AN EXPLORATORY STUDY OF HOW AFRICAN AMERICAN CLERGY
CONCEPTUALIZED MENTAL HEALTH DISORDERS AND THE UTILIZATION
OF MENTAL HEALTH SERVICES
Charlotte M. Conley
B.A., California State University, Sacramento, 2009
Merita L. Wolfe
B.A., Union Institute & University, 2007
PROJECT
Submitted in partial satisfaction of
the requirements for the degrees of
MASTER OF SOCIAL WORK
at
CALIFORNIA STATE UNIVERSITY, SACRAMENTO
SPRING
2011
AN EXPLORATORY STUDY OF HOW AFRICAN AMERICAN CLERGY
CONCEPTUALIZE MENTAL HEALTH DISORDERS AND THE UTILIZATION OF
MENTAL HEALTH SERVICES
A Project
by
Charlotte M. Conley
Merita L. Wolfe
Approved by:
__________________________________, Committee Chair
Joyce Burris, Ph.D.
Date: ____________________________
ii
Charlotte M. Conley
Students: Merita L. Wolfe
I certify that these students have met the requirements for format contained in the
University format manual, and that this project is suitable for shelving in the Library and
credit is to be awarded for the project.
, Graduate Coordinator
Teiahsha Bankhead, Ph.D., L.C.S.W.
Date
Division of Social Work
iii
Abstract
of
AN EXPLORATORY STUDY OF HOW AFRICAN AMERICAN CLERGY
CONCEPTUALIZE MENTAL HEALTH DISORDERS AND THE UTILIZATION OF
MENTAL HEALTH SERVICES
by
Charlotte M. Conley
Merita L. Wolfe
These researchers interviewed 10 African American clergy who provide counseling
services to members of their congregations, in order to examine participant’s beliefs,
patterns of responses to presenting problems, and level of knowledge about mental
illness. The rationale for this project is to discover how closely the views of the
participants match with those of professionally trained MSW level social workers and
further, to evaluate the clergy member’s ability to provide services. After each participant
reviewed a vignette, she or he was asked questions about the vignette in order to discover
participant’s levels of familiarity with common mental health conditions (i.e. mentally
healthy conditions, depression, schizophrenia, alcohol dependence and substance-related
disorders). Findings indicate that the participants have a common perception that mental
illness is caused by stressful situations and a chemical imbalance in the brain.
The clergy expressed a willingness to make referrals to mental health agencies within
their community when an individual’s need for treatment was serious and beyond their
own capacity for treatment. This project is a collaboration of Charlotte M. Conley and
iv
Merita L. Wolfe. The authors equally worked on the development of the project including
the writing, reviews of the literature, transcribed tapes and coded the data.
__________________________________, Committee Chair
Joyce Burris, Ph.D.
___________________________________
Date
v
ACKNOWLEDGEMENTS
Charlotte M. Conley
First and foremost, I want to thank my Lord and personal savior, Jesus Christ, for
the Bible says “I can do all things through Christ who strengthens me” (Phil. 4:13,
NKJV). Indeed, when I am weak, He is strong, and Scripture reminds me that at times of
trouble, I can lay my burdens at His feet and He will give me rest.
Also, special thanks go to my mother, Alene Washington, who has always
encouraged me and said that I have the ability to do anything and be whoever I want to
be. She has made me laugh when I am sad and wiped away my tears when I am
disappointed. Thanks, mother, for being my mama.
Also, this project would not have been successful without the support of my
project advisor, Dr. Burris, who continually offered a warm smile, a gentle spirit, and
words of encouragement. Thank you for your support through the challenging and
difficult times. Your kindness was truly appreciated. Thank you for walking with me
through my storm. I would not have been able to complete this project if you had not
supported me along my journey
Additionally, I would like to express my sincere appreciation to Dr. John Davis
for his humor and his words of encouragement when he stated, “There is a lot of potential
in you.” Thank you for your support. Also, I want to thank Dr. Dale Russell for his
support through my first year in graduate school as my field instructor. Moreover, I want
to thank Dr Russell for caring. I would like to honor and thank my practice instructor, Dr
Janice Gagerman, a professor who has a passion for her profession and believes in
vi
excellence. With her stern hand of kindness, she helped me to persevere and reach my
goal. Dr. J, I wish many blessing unto you.
vii
Merita Wolfe
Special thanks to the creator of the universe for allowing me to pursue this degree
and hold my peace through it all.
Thanks to my mother, Dr. Hattie B. Gray, for her inspiration, love and support
throughout my life and this journey. Her perseverance and dedication to education truly
motivated me.
I am indebted to Dr. Joyce Burris, for her willingness, flexibility, and invaluable
support both personally and professionally in supervising this collaborative thesis project.
I extend my sincere thanks Dr. Robin Carter, for making herself available and for her
continued interest and support.
Special thanks to my colleagues for their support and assistance. Finally, I extend my
sincere thanks to the following; friends, family, CSUS faculty and administrative staff,
Robertsons’ Adult day Health Center and Women’s Empowerment.
viii
TABLE OF CONTENTS
Page
Acknowledgements ............................................................................................................ vi
List of Figures .................................................................................................................... xi
Chapter
1. THE PROBLEM ........................................................................................................... 1
Introduction ............................................................................................................. 1
Statement of Collaboration ..................................................................................... 3
Background of the Problem .................................................................................... 4
Statement of the Research Problem ........................................................................ 8
Purpose of the Study ............................................................................................... 9
Theoretical Framework ......................................................................................... 10
Definition of Terms............................................................................................... 11
Assumptions.......................................................................................................... 12
Justification ........................................................................................................... 13
Delimitations ......................................................................................................... 13
Summary ............................................................................................................... 14
2. LITERATURE REVIEW ........................................................................................... 15
Introduction ........................................................................................................... 15
African American Clergy as Counselors .............................................................. 16
African American Clergy’s Perception of Mental Conditions ............................. 22
Mental Health Disparity........................................................................................ 25
Stigma and Mental Illness ..................................................................................... 30
Utilization of Mental Health Services................................................................... 34
Summary ............................................................................................................... 37
3. METHODS ................................................................................................................. 38
Introduction ........................................................................................................... 38
Design ................................................................................................................... 38
ix
Research Question ................................................................................................ 39
Participants ............................................................................................................ 39
Instrumentation ..................................................................................................... 40
Validity/Reliability ............................................................................................... 42
Data Gathering Procedures ................................................................................... 42
Protection of Human Subjects .............................................................................. 43
Summary ............................................................................................................... 43
4. FINDINGS .................................................................................................................. 45
Introduction ........................................................................................................... 45
Demographic Profile ............................................................................................. 45
Vignette Results .................................................................................................... 47
5. CONCLUSIONS......................................................................................................... 62
Introduction ........................................................................................................... 62
Review of Findings and Relevance....................................................................... 62
Researcher’s Personal Interest .............................................................................. 63
Limitations ............................................................................................................ 69
Implications........................................................................................................... 70
Recommendation for Further Research ................................................................ 73
Conclusion ............................................................................................................ 74
Appendix A. Letter of Consent ......................................................................................... 77
Appendix B. Interview Structure ...................................................................................... 81
Appendix C. Human Subjects ........................................................................................... 90
References ......................................................................................................................... 91
x
LIST OF FIGURES
Page
1. Figure 1. Formal Education…………………………………………………….. 46
2. Figure 2. Specialized Training…………………………………………………..46
3. Figure 3. Major Depression Vignette A…………………………………………48
4. Figure 4. Causal Factors Vignette A…………………………………………….49
5. Figure 5. Alcohol Dependence Disorder Vignette B……………………………50
6. Figure 6. Causal Factors Vignette B…………………………………………….51
7. Figure 7. Substance Related Disorder Vignette C………………………………52
8. Figure 8. Causal Factors Vignette C…………………………………………….54
9. Figure 9. No Mental Disorder Vignette D……………………………………….55
10. Figure 10. Causal Factors Vignette D……………………………………………56
11. Figure 11. Schizophrenia Vignette E…………………………………………….57
12. Figure 12. Causal Factors Vignette E…..…………………………………….….58
xi
1
Chapter 1
THE PROBLEM
Introduction
When Americans are confronted with severe psychological issues, an individual
can select from among an array of formal mental health professionals, including marriage
family therapist, psychologist, social workers, psychiatrists and counselors (Taylor,
Chatters & Levin, 2004). In recent years, a number of studies have explored where
African Americans seek assistance for mental health problems due to the barriers in the
use of formal mental health providers. Neighbors (2003) suggest that African American
ministers are a pivotal resource for individuals and the African American community.
Historically, clergy have played a significant role in spearheading services to the
community and their congregations through youth-at-risk programs, family counseling,
financial services, HIV/AIDS care, substance abuse counseling and health care screening
(Taylor, Chatters & Levin, 2004).
According to Taylor, Chatters and Levin (2004) 1992 National Survey of Black
Americans (NSBA) Panel Study data investigates the formal service usage in this
population. Respondents of the quantitative data were interviewed to indicate their chose
of organizations for assistance to solve psychological issues consist of , medical clinic,
mental health center, physician office, clergy or members of their church, emergency
room, social services or private therapist. The original respondents of the NSBA were resurveyed in 1987-1988, 1988-1989 and the final re-interviewing was collected in 1992. A
comparison of the participants from the original study with the respondents in the final
2
three stages concludes that respondents frequently selected the minister or a church
member of their place of worship and or a physician as sources for psychological issues
(Taylor, Chatters & Levin, 2004). The data reveal that in the area of mental health service
usage in the African American community, many minority individuals choose the clergy
as their first professional source for help with a psychological crisis (Taylor, Ellison,
Chatters, Levin, & Lincoln, 2000).
Prior research reveals much attention has been paid to the ways in which culture
affects the explanation of mental illness, intervention and expression (Frederick, 2009).
On the other hand, a more current conceptualization of culture, stress as the importance
of examining and understanding the circumstances surrounding how the larger social
sector interacts with the person in a way that seeks to convey a purpose to cultural
experiences (Ivor, Lensworth & Livingston, 2009). Thus, an Institute of Medicine report
documented that Blacks and other racial minorities are subjected to poorer quality of care
amongst a broader area of therapeutic care (Ivor, Lensworth & Livingston, 2009).
According to Surgeons General Report on Mental Health, top priority was
focused on evaluating the mental health issues related to culture, race and ethnicity in the
U.S. Department of Health and Human Services (USDHHS, 2001). The Mental health:
culture, race, and ethnicity- a supplement to mental health. The report highlighted that
Americans do not, in an equal manner, share in the same hope for recovery from mental
illnesses. Specifically, for those individual members of racial and ethnic minority groups,
the lack of care is starkly evident. Additionally, the report notes that from findings of the
science foundation on racial and ethnic minority mental health that is mental health care
3
is insufficient; in short, there is less limited access and ability of this population to obtain
mental health care, and there is a tendency to receive poor and inadequate mental health
services. These disparities create a higher disability burden on minority communities with
unresolved mental health needs (USDHHS, 2001).
The National Survey of American Life (NSAL) is a mental health research
resource that provides a significant outlook for comprehending the mental health of the
Black population (Jackson, Torres, Caldwell, Neighbors, Nesse, Taylor, Trierweiler, &
Williams, 2004). The survey sample consisted of, approximately 1,000 Whites, 2,000
Blacks of non-Hispanic Caribbean ancestry, and sample size of 4,000 native born blacks.
The method selected for the study involved the administration of a diagnostic tool that
uses DSM IV criteria to assess the presenting symptoms of mental illness. The main
purpose of the research is to explore, the barriers to utilization of psychological and
social resources for individuals experiencing stressful life conditions, psychological
issues, multiple stress factors among Blacks and other minority groups, and the various
types of stressors that contribute to psychological distress and mental illness (Jackson,
Torres, Caldwell, Neighbors, Nesse, Taylor, Trierweiler & Williams, 2004).
Statement of Collaboration
In an effort to conduct research the study was collaborated by Charlotte Conley
and Merita Wolfe. Both authors agreed to the nature of the study, conducted interviews
both cooperatively and independently, and shared in the transcription of data and the
writing of this project.
4
Background of the Problem
Leary and Tangney (2002) points out that some historians believe the history of
trauma from slavery transcends generations, producing residual effects that are
manifested in current behavior. Post-Traumatic Slave Syndrome represents the
multigenerational trauma experienced by African Americans as a result of slavery and
their present and past history of discrimination and racism. The experience of oppression
manifested a psychosocial outcome that produced psychological stress and emotional
traumas that transferred intergenerational that which have never healed, and continue to
have mental consequences for African Americans (Leary & Tangney 2002).
According to the Diagnostic and Statistical Manual of Mental Disorders (DSMIV-TR; American Psychiatric Association, 2000) DSM-IV-TR proposes cultural aspects
of Post Traumatic Stress Disorder (PTSD) in regard to immigrants’ memory of
psychological trauma from their homeland of origin. According to Department of Health
and Human Services (2001) cultural and social factors have produced the major impact in
the causation of post-traumatic stress disorder (PTSD) in Asian, Hispanics, Indians and
African Americans. Yet, the study does not examine racism as a trauma, regardless the
fact that the experience of racism can be catastrophic and extreme. Butts (2002) discusses
that the origins of trauma related to PTSD in the DSM-IV-TR are not comprehensive
enough. According to Butts, reactions to experiences of racial and ethnic injustice can
progress to symptoms associated with a PTSD diagnosis.
Carter, Forsyth, Mazzula, and Williams (2004) note that it is more accurate to
assess the outcome of racism as emotional and psychological injury than as a mental
5
disorder, since the effects of racism are a result of sociocultural environment, and not
associated with abnormality that lives within the individual. They also caution mental
health professionals that diagnosing people of color who have experienced race-related
trauma with PTSD may lead to inadequate treatment plans that may overlook the
systemic, institutional and environmental factors of racism.
Research suggests that racism functions at several levels to affect mental health
status. Many studies illustrate that when a person of color perceives an environmental
stimulus as racist, it results in physiological stress and psychological stress responses that
can chronically compromise both physical and mental well-being health. Numerous
investigators have documented that racism is a unique source of stress impacting African
Americans’ mental health. Studies reveal that the stress of racism is connected with major
depression and anxiety (Blitz and Greene, 2006).
According to U.S. Department of Health and Human Services (2001) experiences
of discrimination and racism are also negatively associated with mental and physical
health. Within the medical field, social and institutional racism have had an impact on
quality of services that has continuingly led to inferior treatment for people of color by
the healthcare sector. Disparities in health care have become a major health issue for the
country. A majority of ethnic minority group members do not have equal access to more
formal mental health professionals, even within their own communities. Studies show
that minorities including African Americans are no more likely to suffer from mental
illness, but there are various factors that may prevent them from seeking or receiving the
mental health care services they need.
6
African Americans with mental health needs are unlikely to receive treatmenteven less likely than the undertreated mainstream population. If treated, they are likely to
have sought help from primary care providers or an informal professional. U.S.
Department of Health and Human Services (2001) research notes that African Americans
frequently lack a normal source of health care on a regular basis for treatment. Mental
health care occurs relatively frequently in hospital emergency rooms and mental health
hospitals.
There are disparities in access to mental health services, such as financial barriers
as well as limited health insurance, for seeking mental health care. One-fourth of African
Americans are uninsured, a percentage 1.5 times higher than the Caucasian rate. In the
United States, health insurance is typically provided as an employment benefit. Many of
the working poor, among whom African Americans are at a high percentage, do not
qualify for public coverage and work in jobs that do not provide their workers private
health coverage. Medicaid, a major public health insurance program, subsidizing
treatment for the poor, covers nearly 21 percent of African Americans. Although
insurance coverage is an important determinants for seeking treatment it fails to eliminate
disparities in access to mental health services (USDHHS, 2001).
The availability of mental health services also depends on where one lives.
Studies reveal a high percentage of African Americans live in poor communities
(Whaley, 2001). Evidence indicates that mental health professionals are found mostly in
urban areas and are less likely to be found in the lower socioeconomic communities.
African Americans also may have feelings of shame or guilt when in need of outside help
7
for personal problems for fears of being misdiagnosed and misunderstood by clinicians,
and for having experiences that leave them with a general cultural mistrust of the mental
health care system (Whaley, 2001). Due to these barriers, many African Americans tend
first to seek support from clergy or pastors during psychological crisis, and in some
events they may be the only professionals seen for help (Taylor, 2000).
In times of personal stress or difficulty, many African Americans do not seek help
from professional service providers; instead they seek help from African American
clergy. Neighbors (2003) explained that data from the NSBA show that, when in distress,
African Americans rely heavily on numerous alternative help resources, within social
networks, to compensate for the perceived lack of access to specialty mental health
resources and the reluctance held by many to use the resources. Additionally, the
National Survey of Black American Panel Study (NSBA) conducted by Taylor and
Chatters, which examined mental health and help seeking behaviors among African
Americans, found that when the need for treatment is defined by the presence of
psychopathology rather than in terms of recovery African Americans underutilize mental
health services. Instead the population tends to seek help through informal social
networks. For some, these social networks typically include individuals and settings
considered as informal sources of support, specifically the church and church leaders,
especially African American clergy. Therefore, African American clergy play an
important role in meeting the needs of individuals, families and communities in the
African American population (Neighbors, 2003).
8
Neighbors (2003) discusses that African American clergy are associated with two
critical roles in mental health care. First, clergy are the first and possibly the only
resource that an individual or family may contact for help. Second, clergy are in position
of being counselors or advisors with respect to mental and physical health needs. Thus,
regardless of attempts to make mental health services more cultural awareness, Neighbors
(2003) points out that most African Americans do not seek help through professional
services. Therefore, it is important to establish an accurate description of the role that
African American clergy play in mental health.
The previous literature illustrates that African American clergy are among those
sought out first by African American individuals for help. Acknowledging the importance
of understanding the role that clergy play in mental health, it is important to note that
there is little known about the approach or intervention strategies provided by clergy
when approached for help. Are clergy providing services similar to mental health
professionals? Do clergy emphasize spirituality and religious practices in suggestions for
addressing mental health issues?
Statement of the Research Problem
This study examines how clergy conceptualize and attribute causation of mental
illness and how these factors affect their ability to respond to and provide services to
individuals seeking help with mental illness. Examining their beliefs about causation,
such whether mutual health conditions are attributable to biological or environmental
factors, supernatural causes or biblical beliefs may provide insight into attitudes held by
9
clergy about mental illness and the effects of their ability to strategically engage in an
effective assessment as well as a successful intervention, including appropriate referrals.
In a national Epidemiologic Catchment Area (ECA) study revealed that African
Americans with Major depression expressed their mistrust of treatment and/or
hospitalization as explanations for not seeking mental health treatment (USDHHS, 2001).
Historical persecution such as, the Tuskegee Syphilis study, which was the 40 year
experimental government study of 399 African American men prevented from adequate
treatment of the disease in order to document the natural course of the disease has
affected this community’s ability to trust dominant institutions. Many researchers and
articles have noted the dehumanizing event predisposed African Americans as the major
factor behind the distrust of medical and public health institutions which continues to
plague the African American community (Livingston, 2004).
Purpose of the Study
The main purpose of this research is to discover new strategies to reduce barriers
for those African American individuals seeking assistance with mental health concerns.
The goal of the research is to explore the perceptions of mental disorders among African
American Clergy. The study is designed to investigate the effects that these perceptions
among clergy have on the ability of participants to make effective referrals to appropriate
services, and on the adequacy of assistance to those seeking support with mental health
issues. Research questions that will be explored in this thesis/project include the
following, (1). What may be some the factors that reflect the lack of culturally sensitive
mental health care services? (2). What are barriers that make it difficult for African
10
Americans to receive adequate mental health care? (3). Are there educational levels,
biblical beliefs, demographic characteristics of African American Clergy that influence
their conceptualization of mental illness, (4). Are African American Clergy effectively
recognizing and attributing causal factors associated with psychological concerns?
There is a paucity of documented research exploring the literacy of African
American Clergy in the recognition of mental illness and the causal factors of
psychological distress. It is imperative that investigations, specifically with African
American pastoral counselors, be examined to provide assistance to those seeking help
with psychological concerns. This may provide insight that could allow new ways to be
adopted that will better provide effective tools to serve the African American community
and to better inform formal mental health services about resources and needs in the
African American community.
Theoretical Framework
This research project utilized the Social Constructivist theory (Greene and Kropf,
2009). Greene and Kropf suggest that one’s personal reality is a joint- creation of the
individual and his or her physical and social worlds. The foundation of the perspective
illustrates that everything that affects individuals, communities and groups happens
within a social context. Social constructionists are part of the postmodern movement,
which question the search for universal laws, and theories, acknowledge differences, and
stress localized experiences. The social constructionist perspective of culture is the
formulation of historically shared meanings of a community of people. People, as
biological organisms, manifest a biological imperative to distinguish and categorize the
11
stimuli he or she receives. Thus, the structure of meaning and the use of language help
shape responses and communal action. Individuals create systems of meanings that result
in culture, which is a socio- cultural system that is a meaning-processing. The research is
hoping to determine the various barriers associated with individuals in need of
psychological issues (Greene & Kropf, 2009). The nature of the study is to discover
strategies and tools to assist African Americans who currently receive limited quality
services. The study is hoping to unveil reasons why there are disparities for African
Americans in terms of mental health care
Definition of Terms
African American. A person having origins in any of the Black racial groups of
Africa.
Black church. A Cohesive spiritual and social community that foster the religious
and social well-being of members.
Formal resources: Social service agencies, programs, and professionals in the
secular world.
Help-seeking: Those actions aimed at problem-solving through requesting advice
and/or emotional and material assistance form formal and informal resources.
Informal sources: Include leaders in the community, friends, family, and peers.
Mental Illness: Is considered the development of a complex interaction among
biological, social, psychological and cultural factors.
12
Oppression: The social act of placing severe restriction on institutions, individuals
and groups. The oppressed are usually devalued, deprived privileges and exploited by
individuals and groups of the mainstream which has more power (See, 2007).
Racism: A belief in the superiority of racial groups that produce discrimination
and prejudice toward individual races viewed as inferior.
Stigma: A term that represents negative and false views of mental health.
Assumptions
It is with good intentions that the authors chose to explore mental health in
African American population and utilization of mental health services. Mental illness and
mental health are not polar opposites; they are but two points on a continuum. Mental
health problems are located in the center of the continuum and at the far end of the
continuum are debilitating mental disorders such as schizophrenia, bipolar and major
depression (USDHHS, 2001).
Frederick (2009) Clergy are consulted for numerous psychosomatic concerns;
many issues are consistent with their pastoral training (for instance, marital counseling,
grief and loss, and advising persons with physical infirmity). However, clergy are sought
to address emotional crises and serious mental health concerns. Much of what is known
about African American clergy is that sermons are shared with their parishioners that
provide encouragement, through empowerment, and uplifting messages of hope. Yet
there is a paucity of information as to how African American clergy recognize, provide
services for individuals seeking help for interpersonal crises. It is significant to explore
13
the role of clergy, as well as their expertise as it pertains to their ability to provide
services of the unmet mental health needs of the African American community.
Justification
This research study will contribute to the field of social work and mental health
practitioners who may lack the knowledge of cultural competency when working with
African Americans, or other ethnic groups and individuals with psychological concerns.
It would benefit practitioners and other professionals who may join with others in the
community to advocate for changes in institutions and organizations that negatively
impact the lives of the African American population. It may enlighten those who seek to
collaborate with formal providers in the community to educate and empower for an
effective strategy to eliminate mental health disparities. It is the authors’ intention to
explore perceptions of African American Clergy regarding mental illness, as they are the
gate keepers providing assistance to African American individuals seeking help for
psychological concerns. It also has the potential to build a broader knowledge and
understanding of the culture factors that impact accessibility and poor- quality of mental
health services.
Delimitations
This research was based on answers from face to face taped interviews, conducted
on a random set of African American Clergy in Sacramento County. The findings and
result may not apply to all African American Clergy and the taped structured
conceptualization of mental illness face to face interview was partially created by the
General Social Survey and the current researchers (Powell, 2003). The face to face
14
interview approach was used in effort to gather more information and has not been
administered as a face to face interview on other groups of African American clergy
elsewhere in America or outside of the United States.
Summary
Despite the prominence of clergy providing pastoral counseling, we know little
about, and we have little research on perceptions regarding the basic efficacy of
ministerial assistance. The study will attempt to explore and discover surrounding
conditions involved in using clergy for psychological concerns as well as their utilization
of mental health services and professionals (Taylor, Chatters & Levin, 2004).
15
Chapter 2
LITERATURE REVIEW
Introduction
The African American community has historically relied, to some degree, on the
black church and their clergy to provide assistance in times of stress to meet emotional,
physical as well as spiritual needs. Numerous studies suggest that African Americans
experience more difficulty in obtaining mental health services than their counterparts
among other racial groups. African Americans also encounter greater amounts of strain
and distress as a result of discrimination, racism, health complications and other
disparities (USDHHS, 2001; Snowden, 2001 & Neighbors, 2003).
According to data from the National Survey of Black Americans, 68 percent of
black individuals are affiliated with a church and 92 percent of the parishioners attend a
predominately black church. In fact, the black church has been the catalyst through which
various resources and services are provided as programs that include education, substance
abuse counseling, HIV/AIDS care, life skills, single parenting, and recreational activities
for social support to their parishioners and communities members. Moreover, African
American churches promote empowerment and behavior change through identifying
specific psychological symptoms that are replaced by positive uplifting messages
(Braithwaite, Taylor & Treadwell, 2009). Yet, there is a lack of information about
pastoral counseling work that African American clergy encounter with individuals
presenting with psychiatric problems.
16
This chapter is an initial exploration of potential causes of disparities in usage of
mental health services among African Americans. The chapter begins with a brief
overview of African American clergy as informal support in roles that include counseling
and other supportive services provided to their congregants. This is followed by a review
of research literature on the utilization by African Americans seeking help from mental
health services.
African American Clergy as Counselors
For many Americans, clergy play a pivotal role in their efforts to cope with
personal problems. The pastor is acknowledged as the leader that provides understanding
and direction for mobilizing programs and activities in the church as well representing
the institution’s relationship with formal service agencies in the community. The clergy’s
role is viewed, specifically as an agent of health – related behavioral and social change
(Taylor, Ellison, Chatters, Levin & Lincoln, 2000).
Taylor, Chatters & Levin (2004) suggests help-seeking behavior of individuals
may be a result of numerous factors which consist of, convenience of access, history of
relationship with the practitioner and familiarity of the institution. Additionally, clergy
have a distinct gain over other counselors as an inexpensive source of help because, due
to limited fees or no cost for their services. Despite the previous factors mentioned there
are barriers with obtaining adequate assistance from mental health professionals. These
obstacles may be reasons to consider selecting clergy over other mental health services as
a source to assist with psychological concerns. Further, individuals seeking help from
clergy usually do so within the stance of a significant personal relationship with their
17
pastor where trust has already been recognized. Thus, individuals may be more apt to
seek out clergy for assistance in dealing with personal concern because of the universal
philosophy shared with regard to helping others. Incidentally, the commonly shared
worldviews about the sort of issues and established ways of coping with difficult
experiences in life that are specifically religious (Neighbors, 2003).
Thirty-nine percent of Americans who encounter critical personal problems seek
help from clergy. This rate exceeds individuals soliciting help from formal professionals
such as, physicians, marriage family therapist, social workers psychologist and
psychiatrist. Much of the counseling performed by clergy consists of individual pastors
being concerned with emotional and behavioral conditions of parishioners which are
consistent with theological and pastoral training. For instance, helping parishioners with
grief and loss, physical illness, marital conflicts has long been part of the duty of pastors.
Moreover, clergy are sought out to help with critical mental health conditions and
psychological concerns (Taylor, Ellison, Chatters, Levin & Lincoln, 2000).
Several investigators have examined the counseling and referral practices of
clergy, yet few discuss these concerns among black ministers. Mollica 1986 as cited in
Taylor, Chatters & Levin (2004) research is one exception. Of 214 African American and
Caucasian ministers there was a significant difference of African American clergy in the
referral and counseling practices in several respects. Much of the counseling represented
by 70 percent of the participating African American clergy involved greater than 10
percent of their time in conducting counseling. Research illustrates that more often than
18
not African American clergy were involved at a higher degree in crisis intervention and
in counseling individuals with serious personal issues and psychiatric conditions.
Professionals with formal mental health training in most cases are solicited after
receiving a referral from a professional individual or agency. However, clergy usually are
approached directly by individuals and it is less likely that the individuals were referred
by mental health professionals. Individuals who sought clergy for assistance in contrast
with formal mental health professionals were more satisfied with the services provided by
clergy and were more likely to advise others to consider the assistance of clergy (Taylor,
Ellison, Chatters, Levin & Lincoln, 2000).
Young, Griffith and Williams (2003) conducted a recent study of 121 African –
American ministers of whom 99 completed a semi structured interview about pastoral
counseling interventions. The author’s point out, that respondents often encounter critical
issues that do not differ from those handled by secular mental health practitioners. Many
of the clergy reported that they witness and address substance abuse and severe mental
illness in working with their parishioners, and with individuals from the community.
For the past forty years various researchers have shown that tens of millions of
individuals seek assistance from clergy when they are concerned with mental health
conditions. Neighbors (2003) suggested that the idea of clergy providing counseling
services to individuals must be critically explored and analyzed. Neighbors (2003)
proposed that it is unclear whether clergy or mental health professionals are more
competent to provide intervention and treatments for African Americans encountering
psychological concerns, for clergy and mental health professionals or clergy.
19
Furthermore, because the educational requirement is so different, it is difficult to compare
the two groups in terms of counseling, utilizations of service referral practices.
Specialized training in counseling regarding life skills and personal concerns such as,
family conflicts is limited even among clergy who have obtained a postgraduate degree
(Taylor, Ellison, Chatters, Levin & Lincoln, 2000).
A recent analysis of collaboration between clergy and mental health professionals
revealed that perspectives, are different and that clergy play a role as frontline mentalhealth workers. This was noted specifically, more often in secular than in religious
journals (Oppenheimer, Flannelly & Weaver, 2004). The insufficient knowledge or
educational training of clergy was more often viewed as an obstacle to collaboration
(Oppenheimer, Flannelly & Weaver, 2004).
Taylor, Ellison, Chatters, Levin and Lincoln, (2000) note the quality of mental
health interventions provided by clergy is related to their ability to recognize serious
mental health issues and their capability to ensure that people are referred to appropriate
mental health practitioners. Thus, clergy members’ education and level of training may
impact their ability to discern mental health conditions and psychological distress and,
further determine appropriate utilization of or referral to mental health services. For
many, clergy are sought out to address mental health concerns in their pastoral role; in
fact, they may be unaccustomed with numerous forms of psychopathology and the
symptomatology of severe mental health conditions. As a result they may not clearly
understand the criteria of psychotic symptoms and lack the competence to recognize
suicide ideology, as one example (Taylor, Ellison, Chatters, Levin, Lincoln, 2000).
20
Taylor, Chatters and Levin (2004) explain that various studies contend that
characteristics of clergy may have an impact on their counseling and referral activities
with individual parishioners. An important predictor of their range of expertise regarding
mental health problems and services available from professionals and public
organizations will be minister’s level of education. Thus, clergy with higher levels of
education will be more competent in their understanding of mental health problems and
may collaborate more often with the mental health professionals than clergy with less
education.
Moran, Flannelly, Weaver, Overvold, Hess, and Wilson (2005) conducted
research that consisted of clergy (N= 179) who were surveyed about their pastoral care
activities. Researchers found two separate sets of issues presented in pastoral counseling.
The initial first set of factors contain dying and grief, marital problems, as well as anxiety
and, the second factors include domestic violence, depression, HIV/AIDS, suicide,
alcohol/drugs and severe mental illness. It was noted that clergy were significantly less
competent of their ability to deal with the second set of factors regarding psychological
concerns, yet clergy rarely consulted with mental health practitioners about either type of
issues. Of the participants, fewer than half of the clergy had Pastoral clinical educational
training; however, those who obtained educational training felt competent to handle
presenting problems in both factors of one and two categories discussed above.
Kane and Williams (2000) stressed the nature of training received must be
examined regarding the ability of clergy to help individuals in need of psychological
assistance. Further, the research asserts that when clergy are approached by individuals in
21
need of assistance, they must make an initial assessment of the type of intervention that is
most appropriate and determine if the clergy themselves have the competence and the
capability to provide services or make referrals to individual for more appropriate care.
Additionally, Kane and Williams (2000) claim that the type of training that many clergy
receive is a result of denominational requirements of ministry.
Educational obligations for Catholic seminary requires four years of graduate
pastoral and theological education, an internship prior to ordination, clinical counseling
which includes a curriculum of seminary sessions of mental health education, and
students are encouraged to continue pastoral education. Additionally, the educational
background within this population prepare students to recognize mental conditions, but
the perceptions of a priest’s competence and effectiveness is unknown (Kane &
Williams, 2000).
Regardless of these factors, literature also reveals that clergy are very successful
in taking action and responding to the general needs of their congregants and in efforts to
obtain appropriate services (Taylor, Chatters & Levin, 2004). It has also been wellknown that clergy provide an abundance of support to individuals in need, including
basic living, emergency shelter, dealing with personal problems, advising on matters of
educational and job training and are highly involved in a myriad of ways in assisting
members of their congregation (Taylor, Chatters & Levin, 2004).
Collectively, these findings demonstrate that clergy provide direct and valuable
assistance to individuals with particular types of personal issues and situations. The
literature signifies that it is important to encourage communication between clergy and
22
other professionals, such as specialty mental health professionals to enhance access to
other forms of professional’s services (Taylor, Chatters & Levin, 2004).
African American Clergy’s Perception of Mental Conditions
Much of the literature on the conceptualization of African American ministers
relics more assumption and belief than valid documentations (Stansbury & Schumacher,
2008). Furthermore, due to the paucity of research, scores of the issues raised in the
examination of Caucasian ministers that have not been discussed with African Americans
clergy. To increase our understanding of African American clergy’s conceptualization of
mental condition we explored data from studies which focused specifically on pastoral
care and perception of mental health (Stansbury & Schumacher, 2008; Payne, 2009).
Several studies have illustrated the lack of educational training in counseling,
even in post graduate training, received by clergy in assisting individuals who are
experiencing basis problems of daily life circumstances such as, family conflict are
completely unfamiliar with psychopathology and symptoms of severe mental illness.
Previous research has shown that clergy are likely to misinterpret the severity of
psychotic symptoms. In contrast, to other mental health practitioners clergy are less likely
to be familiar with suicide ideations. Religious and ministerial training may cause clergy
to construe mental or emotional issues in purely religious terms or interpret clinical
symptoms as sign of religious conflict (Blevens, Burris, Davis, Kramer, Miller &
Phillips, 2007; Stansbury & Schumacher, 2008; & Snowden, 2001).
Payne (2009) conducted a study on the variations in ministers’ perception of the
etiology of depression by race and religious association. In this study, 204 Protestant
23
pastors in California were queried about their understanding of depression. The results
revealed racial and religious affiliation influenced how ministers perceive and arbitrate in
the area of depression. It was noted that African American ministers in the research were
often open to the idea that depression is defined as a spiritual factor. Moreover, the Black
clergy were more likely to agree that depression was an episode plagued with trials and
tribulations. In short, the participants believed that depression is a result from a deficient
of a limited trust in God. Thus, African American clergy were less likely to agree with
the idea of the causal factor to depression as a biological mood disorder than their
counterparts.
Blevens, Burris, Davis, Kramer, Miller and Phillips (2007) examined in a recent
study of the perceptions of clergy regarding depression. Researchers conducted a focus
group of 42 African American and 19 Caucasian churches. Many of the ministers
acknowledge depression as an illness similar to other physical issues that may require
medical intervention depending on the severity of the condition. Other factors that may
lead to depression include financial conditions, employment satisfaction, limited self –
care, family conflict, and personal expectation. The findings illustrated that clergy
reported a “filtering” process in which they make a distinction between an individual
incident that may be categorized as a mental health crisis, (which may include potential
violence, suicidal ideation, psychosis or a life crisis) and a disruption in faith, resulting
from homelessness and unemployment. It was noted that the clergy evaluated their own
ability to provide adequate assistance. Their previous training and specialized education,
24
as well as legal restriction which are associated with the profession of a counselor were
considered while providing assistance.
Stansbury and Schumacher (2008) explored the mental health literacy of 9
African American clergy that provided assistance to parishioners 60 years of age and
older. The data was coded and classified by Kevin’s typology of pastoral counseling.
Within the model it consists of: Conservative- Theological (C-T), Religious- Community
(R-T), and Theological-Psychological (T-P) models. The models categorizes how clergy
approach counseling a parishioner who may be presenting an issue with a mental
condition. Of the nine clergy all were classified as the typology of R-C model because
their roles as frontline providers of mental health services to older parishioners were
subjective by the issue, level of crisis intervention and their pastoral counseling style.
Moreover, the study explored conceptualization of mental health literacy. Most of
the respondents were associated with the same theme, except one, for all participants.
Counseling intervention included bible study, prayer and scripture reading. The
participants were fairly literate about the risk factors of socio-emotional problems and
only one understood biological causal factors of socio-emotional problems. It is noted
that the lack of recognizing biological causes could affect the pastor’s perceptions and
approach to intervention for socio –emotional issues. The finding reveals that African
American clergy are more likely to recommend a physician over other professions. Yet,
this may be a limitation to African American clergy mental health perception (Stansbury
& Schhumacher 2008).
25
On the contrary, Schhnittker, Freese, and Powell (2000) note, that the mental
health professionals, as well as individuals within the public sector embrace a range of
conceptions about the causes of mental conditions. Those conceptions of causative
factors consist of chemical imbalance, biological causes, environmental factors, genetic
inheritance, social stressors and family history. Yet, some individuals refuse to accept the
“nature vs. nurture” dichotomy but instead believed that the causal factors of mental
disorders are both environmental and biological or conversely by thinking about mental
conditions in terms of individual responsibility or divine judgment.
Previous literature questions the emphasis on the importance of prayer and
willpower in overcoming psychiatric issues by some black religious leaders (Taylor,
Chatters & Levin, 2004). Further, African Americans may be more likely than
individuals outside of their group to attribute mental illness to bad character with some
research illustrating that some African Americans more commonly believe that disorders
including major depression and bipolar disorders are due to lack of willpower
(Schnittker, Freese, and Powell, 2000). Thus, the explanations such as God’s will and bad
character lie outside the nature-nurture continuum, attributing mental illness to either of
those explanations does not prohibit an individual from also believing in casual
influences of biological and /or environmental factors (Schnittker, Freese, and Powell,
2000).
Mental Health Disparity
Substance and Mental Health Services Administration (SAMHSA) (The nation’s
leading mental health service agency), defines health disparity as a strong force that
26
impacts professional organizations that make arguments for policies to increase access,
quality and outcomes for mental health care specifically for a group of individuals
defined as clear ethnic or racial contrast with the general population. The Centers for
Disease Control and Prevention (CDC) considers social determinants to include income,
employment, living situations, which may be factors of mental health and determine
accessibility to care. In a current study by The Harris Interactive and the American
Psychological Association authors discovered that 25% of US of population have limited
access to mental health care (Safran, Mays Huang, McCuan, Pham, Fisher, McDuffie &
Trachtenberg, 2009).
Research reveals there is a paucity of valid empirical studies examining potential
causes of racial disparities in mental health status. Many of the studies discuss African
Americans who do not gain access and are more likely face barriers to sufficient mental
health diagnosis and intervention which point to a lack of adequate mental health
treatment (Davis & Ford, 2004). According to Davis and Ford (2004) systemic barriers to
effective treatment may be associated with the behavioral health care systems. Clinical
bias, arise when clinicians’ perceptions of African American clients are more negative
when contrasted against the perceptions Caucasians. As a result, such negative
perceptions produce inappropriate or differential interventions and diagnosis of African
American clients. The finding suggests that clinical decisions are influenced by the
perceived race of the client. Thus, clinicians lack the cultural competency to distinguish
symptoms in relation to standard assessment techniques (Davis & Ford 2004).
27
The National Survey of American Life (2004) is a study of racial, ethnic and
cultural influences on mental disorders and represents mental health findings that is the
largest, most detailed examination of serious mental disorders and mental health states
that is conducted on a national sample of the African American population. It provides a
comprehensive study to explore inter and intra-group racial and ethnic differences in
mental health disorders, psychological distress, and it describes various risk factors,
stressors, coping resources within the national adolescent and adult population (Jackson,
Torres, Caldwell, Neighbors, Nessse, Taylor, Trierweiler, & Williams, 2004).
Another recent study also shows that there is evidence that illustrate mental health
is poorer among various ethnic groups. Such as the incidence of schizophrenia is 5-10
times greater among African American populations, even though some authors disagree
that it is possible to attribute this exclusively to ethnicity. Furthermore, racial
discrimination is connected to inadequate mental health conditions, such as, psychosis,
and to increased rates of depression, and stress (Blackwell, 2009). Additionally, it was
noted that the issue is complex and that racism is a reflection of social trauma and limited
opportunities for employment and education. However, there may be other factors that
explain the poor mental health amongst individuals who have been plagued by racism
(Blackwell, 2009).
Snowden (2003) discussed the fact that there may be one possible reason for
disparities amongst clinicians and mental health program directors who make
unjustifiable judgments about minority individuals and that reason is racial bias. In 2001,
then-Surgeon General David Satcher, in a document entitled, “Race, Culture, and
28
Ethnicity and Mental Health”, which he discussed disparities of treatment and access to
services that leave many minority people receiving inadequate treatment and leave many
untreated. Although, Snowden noted gaps in the quality of extend to the elderly and
seriously mentally ill African Americans. He revealed that African Americans were less
likely than Caucasians to receive a treatment plan, as well as guidelines for a follow-up
visits within four weeks after psychiatric hospitalization. Therefore, African Americans
had a higher rate of being provided limited treatment among individuals experiencing
severe mental illness (Snowden, 2003).
According to Snowden (2003) there may be a larger reason for concern about the
existence of racial bias in mental health evaluations and treatment. For some, there is
doubt and uncertainty about the existence of mental disorders, as manifested in
professional disagreements about the labeling of various symptoms as indicators of
mental illness when the issue at hand is no more than experiences that occur in everyday
living. For several decades, researchers have noted Black Americans have increased rate
of being diagnosed as experiencing schizophrenia and have received diagnosis of reduced
rates affective disorders. Thus, these differences have stimulated curiosity and raised
questions about clinicians being in fact biased in their approach of routine interventions
with African American clients. Yet, recent studies illustrate in the complex issues of the
diagnosis of patients based on race how symptoms of mental illness are interpreted by
clinician’s plays a serious role (Snowden, 2003).
Snowden (2003) discussed socioeconomic differences as a form of disparity.
Some researchers considered health insurance coverage as an explanation which would
29
provide a greater access to some and not to others who are seeking treatment. Ethnic
minority individuals who lack individual health insurance are disproportionate in
numbers. However, it appears that even after financial barriers and health insurance
coverage factors have been eliminated, other issues continue to prevent African
Americans individual from seeking mental health treatment (Snowden, 2003).
Mays, Cochran and Barnes (2007) discussed the fact that there are continual and
troublesome health disadvantages that accrue to African Americans despite years of
effort to remove the effects of racial discrimination in the United States. Findings reveal
that persistent experiences with racism and discrimination may be at the root of racedbased health disparities that are associated with this population. The study discussed
social exclusion is a basic term used by social policy makers and social scientists to
consider both to the penalty of being marginalized from mainstream as well as the
method by which it happens.
In a previous study, Williams and Williams-Morris (2000) suggest racism may
affect mental health conditions in the course of a personal experience of discrimination.
A series of studies, reveal that blacks experience discrimination in a wide range of
circumstances in society and that these events can induce substantial anguish (Williams
& Williams-Morris, 2000; Snowden, 2001; & Fredrick, 2009). Much of the documented
studies discuss exposure to discrimination in the clinical setting advances to
psychological and cardiovascular reactivity among African Americans (Mays, Cochran &
Barnes, 2007; Burgess, Ding, Hargreaves, Ryn & Phelan, 2008).
30
The National Study of Black Americans (2004) noted that perceptions of racial
discrimination were related to an increased range of psychological anguish and decreased
range of happiness and life satisfaction, as well as other factors such as adequacy of or
inadequacy of physical health. Williams and Williams-Morris (2000) points out, that the
common perception of unjust treatment includes a response that includes a negative
emotional response and the induction of psychological suffering. Further, the basic
experience of unjust treatment can adversely impact health and can be associated with all
races. However, due to their stigmatized social status, minority groups will encounter
greater levels of unjust experiences.
Stigma and Mental Illness
William- Morris and colleagues insists that the stigma of discrimination and the
label of racial inferiority may impact the treatment of African American patients in the
mental health system. African American clinicians have for some time declared that
accepted misconceptions, incorrectness, and stereotypes of the psychology of African
Americans may perhaps produce inaccurate diagnosis of African American patients. The
evidence reviewed there is an under-diagnosis of affective disorders, such as anxiety and
depression and over-diagnosis of schizophrenia for African Americans (William-Morris
& Williams 2000).
Anglin, Link and Phelan (2006) asserts that the Surgeon General’s report on
mental illness highlighted stigma as a major hindrance to utilizing and receiving adequate
mental health services. Specifically, amongst those that are racial and ethnic minority
populations, there are current studies that support the Surgeon Generals’ views. For
31
instance, in research findings it was revealed that the experiencing of lower alleged
stigma was related to greater medication adherence among adult patients with major
depressive disorder and that heightened stigma was associated with less medication
adherence to prescribed medication orders and treatment discontinuation from mental
health practitioners (Bruce, Have, Reynolds, Katz, Schulberg, Mulsant, Brown, McAvay,
Pearson & Alexopoulos, 2004).
Further, researchers have hypothesized that stigmatizing experiences may
discourage individuals from seeking care, because of social-cognitive processes that
cause people to avoid the label of mental illness that results when people are connected
with mental health care (Corrigan, 2004). In addition, Angin, Link and Phelan (2006)
noted that members of racial minority groups may be more hesitant to seek needed
services because minority populations hold even stronger negative attitudes than
Caucasians. The results of this study revealed that African Americans were more likely
than Caucasians to consider that individuals with severe mental illness would do
something violent to other people. Likewise, African Americans were less likely to
believe these individuals should be held responsible and punished for violent behavior
(Anglin, Link & Phelan 2006).
Anglin, Link and Phelan (2006) reported findings that suggest the importance of
acknowledging racial differences when examining stigma and mental illness. Anglin,
Link and Phelan (2006) conclude, that the stigmatizing attitudes could not explain lower
rates of seeking treatment among African Americans. Anglin, Link and Phelan (2006)
stress that there may be something realistic about the fear of being labeled as violent that
32
prompt African Americans to avoid the label of mental illness linked with receiving
mental health care as opposed to the fear of being liable for punished for their conduct.
In a recent study by Wesselmann and Graziano (2010) it was found that religious
beliefs about mental conditions appear as two separate, but related entities. These entities
focused on beliefs about spiritually-oriented causes/treatment, and sin/morality, and were
linked to negative secular beliefs about mental illness. In addition, the entities were
connected to other individual differences that predict prejudice toward stigmatized
groups. Findings also revealed these religious beliefs are sanctioned differently
depending upon religious association. As a result, data suggest no evidence was found
that female participants (N=144; 47 Christian affiliation) differentiated between types of
mental conditions when indicating their endorsement of these two dimensions. However,
data suggest beliefs are endorsed differently, particularly the Spiritually-Oriented
Causes/Treatments factor. Wesselmann and Graziano (2010) propose that such areas of
negative beliefs about mental conditions may translate into different behaviors and
perceptions. Support of these negative beliefs could have serious penalty for the
willingness to seek help from mental health services.
Alvidrez, Snowden and Kaiser (2008) assert that many African American
individuals do not receive adequate interventions for mental health issues. African
Americans are less likely than Caucasians to seek assistance for psychiatric concerns, and
are specifically under-represented in outpatient mental health settings. The study reports
that African Americans who do enter outpatient treatment receive more limited sessions
of therapy than Caucasians and are more likely to discontinue attending sessions. The
33
research focus was conducted upon stigma concerns, with public – sector African
American mental health consumers (N=34). Alvidrez, Snowden and Kaiser (2008) note
that stigma occurs when socially unwanted characteristics become linked with
stereotypes about a socioeconomic-class of people. The outcome of these dynamics
produces social separation and discrimination towards labeled individuals.
Research indicates that although public perceptions of mental illness have
improved over time, negative labels of people who are mentally ill persist and include the
impression of the mentally ill as unpredictable and dangerous (Alvidrez, Snowden, &
Kaiser, 2008). It is suggested that stigma can deter individuals from mental health care.
In help seeking samples, perceived stigma is connected with treatment discontinuation
and psychotropic medication non- compliance. Numerous qualitative studies, individuals
with mental health conditions identify stigma as primary reason for treatment evading,
dropout and detachment (Alvidrez, Snowden, & Kaiser, 2008).
Alvidrez, Snowden and Kaiser (2008) reveal that there is a paucity of research
investigating stigma among African American or other racial/ethnic minority populations.
The limited studies that have been conducted, explored race/ethnicity and stigma and
have come to specific conclusions. Amongst African Americans and other ethnic
minority groups there appears to be negative perceptions of the mentally ill than among
Caucasians. As previously stated, African American and Caucasians variation may result
from cultural dissimilarity in beliefs about causation of mental conditions (Alvidrez,
Snowden & Kaiser, 2008). Further, numerous beliefs approved by racial /ethnic minority
groups considered immoral lifestyles, and personal weakness or moral transgression the
34
primary cause of mental conditions. Thus, a process of assigning personal accountability
to the development of illness may explain the negative views held by racial minority
groups (Alvidrez, Snowden & Kaiser, 2008).
The study of stigma experienced amongst African American data includes 34
African American mental health consumers who were referred to mental health agency in
San Francisco. The results of the data found (29%) asserts that mental illness was
inappropriate to share within the family due to a mental condition being shameful and
viewed as bad. Of the results (35%) revealed any association with a mental health issue
was viewed as being “crazy” (Alvidrez, Snowden & Kaiser, 2008). In addition, (26%)
noted as a African American values are taught to be resilient, strong, and have religious
faith to conquer any adversity, so mental condition not acceptable, (21%) believed
mentally ill is violent and unpredictable, (24%) viewed mental illness as a bad reflection
on the family, (18%) stated that seeking mental health services was created for White
individuals than for Black Americans, or the Church was the only safe source of support
outside of family. Overall, the finding reveals (76%) admitted stigma was a major factor
in preventing the participants from seeking mental health intervention (Alvidrez,
Snowden & Kaiser, 2008).
Utilization of Mental Health Services
Snowden (2001) discusses the Epidemiologic Catchment Area (ECA) surveys,
African Americans and Caucasians proved no different in mental conditions and
presenting disorders after adjusting for demographics and socioeconomic differences
between ethnic groups. Yet, the National Comorbidity Survey consequently highlighted a
35
different image. Specifically, African Americans had lower lifetime prevalence of mental
conditions than their counterparts. African Americans are overrepresented in elevated
proportions in mental hospitals, homeless populations on the streets, were more likely, to
be incarcerated and subjected to improvised neighbors and rural areas.
As a coping mechanisms African Americans frequently turn to significant others
in the community, especially family, neighbors, voluntary associations and religious
figures. According to traditional wisdom reveal a mutual helping tradition found in
African American communities. Research supports evidence of a larger connection
between members of the community to assist others with mutual resources, for instance,
in African American neighborhoods and extended families. Yet, African Americans are
more likely to have one-on-one assistance from informal community helpers when
individual psychological distress is labeled as mental health (Snowden, 2001).
African Americans indicate a tendency to turn to significant others in the
community specifically, close associates, religious figures and family as sources of help
preferred by Africans Americans, but also to physicians and hospitals have been seen as
the substitute to mental health professionals (Snowden, 2001). The National Ambulatory
Medical Care Survey proposes that among persons with mental conditions their chief
complaint made to a helping professional was estimated 53% of African American visits
were made to medical physicians and 32% to a psychiatrist, in contrast to 44% of
appointments by Caucasians made to primary care doctors and 42% to a psychiatric
doctor (Snowden, 2001).
36
The Surgeon General’s Report on Mental health (2001) illustrated that service use
was limited within the minority population. Findings confirm that African Americans
exhibited an underutilization of outpatient treatment services and an overrepresentation in
inpatient treatment services. In addition, African Americans were more likely to use
emergency department services, seek treatment from primary care provider, rather than
seeking treatment from a mental health practitioner, or choose to use other sources of
support, including family, clergy, friends, and the church.
The National Mental Health Association (2000) feature lower prevalence of help
seeking treatment to factors, which include a general mistrust of medical professionals,
misdiagnosis and inadequate treatment, socioeconomic factors, co-occurring disorders,
cultural barriers and primary dependence on family and the religious community in times
of distress. Furthermore, researchers have discussed the lack of community mental health
resources, stigma, and low levels of information in understanding the etiology of mental
conditions (Pickett-Schneck, 2002).
Snowden (2001) asserts the possibility of racial differences in assignment to
individual outpatient psychotherapy has been a cause of concern to researchers and
activists that there may be a possibility of a fear that African Americans were deemed to
be deficient in sufficient maturity and intelligence to profit from this form of treatment.
Snowden (2001) notes that there were public mental health systems studies that
conducted research data over years, which found that African Americans were in fact less
likely than Caucasians to receive individual outpatient therapy, and that those who
participated attended 20% fewer sessions. Yet, findings were outstanding for Asian
37
American and Latino clients, who proved more likely than Caucasians to have received
individual outpatient therapy.
Literature reveals African American usual sources of care in mental health
services may be determined less by administrative and clinical decision making and more
by social structures and community traditions. African Americans frequently visit
psychiatric emergency care and hospitals (Neighbors, 2003). The usual source for
treatment differentiates African Americans not only from Caucasians but also from other
ethnic minority groups. Reliance on emergency care might help to determine other
factors of African American utilization: continual crisis treatment may preclude
engagement in continuance outpatient treatment as well as make a possible admission
into psychiatric hospital (Snowden, 2001).
Summary
The literature shows that African American clergy are viewed as agents of health.
Many of the studies reveal that there are barriers that hinder access to mental health
services. Some of the literature illustrates that African American ministers lack the
educational training in counseling. For many African Americans, their preference of
choice is treatment by informal sources, such as clergy. This review highlighted
information with regard to the role of African American clergy in treating mental illness
and identified mental health barriers for the parishioners and the African American
community at large.
38
Chapter 3
METHODS
Introduction
This chapter provides an overview of the research design utilized in this study.
The research design used for this study is exploratory in nature. This project examines
African American clergy's beliefs about the descriptions, causes and interventions
required in the treatment of mental illness.
Design
This research study is conducted using a qualitative, explorative design. The
authors selected this design because of the paucity of research on the ability of African
American clergy to interpret mental illness. The study consists of voluntary research
participants who were individually interviewed, face-to-face by the authors of this
research project. The purpose of the interviews is to gain an understanding of each
individual’s experience, perception of mental illness, and utilization of mental health
services in the community. A semi-structured questionnaire is developed by the
researchers for this research study. The interview guide approach which for use in this
research project is one explained by Rubin and Babbie (2008). They describe the
interview guide approach as one that aims "to ensure that all respondents are asked the
same questions in the same sequence to maximize the comparability of responses and to
ensure that complete data are gathered from each person on all relevant questions".
(Rubin & Babbie, 2008, p.444). One advantage of using the interview guide approach is
that it simplifies the researchers' assignment of systematizing and analyzing interview
39
data. This type of design also helps readers of the researchers' to critic the quality of the
interviewing methods and tools used. One of the disadvantages that Rubin and Babbie
(2008) discuss is that it lessens the natural, conversational environment of interviewing.
Research Question
This study is designed to explore how these factors might affect the ability of
clergy to respond to and to provide services to individuals seeking mental health services.
The rationale for this design is to identify the ability of the participants to (a) provide
insight into decision making about treatment needs, (b) to examine the process utilized
for providing referrals to other sources, (c) to evaluate the clergy’s ability to provide
services, and (d) to analyze their ability to provide alternative recommendations to
individuals in need of service. Additionally, this study investigates the participants’ selfperceived ability to recognize and understand the causes of mental illness.
Participants
Participants for this study include a convenience sample of African American
clergy. Clergy recruited for this study are leaders of African American churches in the
Sacramento area. The sample (N=10) are clergy who provide pastoral counseling to
congregants within the church organizations. The interview guide approach is used to
ensure topics and issues that need exploration would be discussed in the interview
sessions. This approach also allowed the researchers to adjust the order and phrasing of
the questions to each specific interview (Rubin & Babbie, 2008). Clergy are recruited
through the internet and based on personal knowledge on the part of the researchers of
churches of Apostolic, Baptist, African Methodist Episcopal, Non-denominational and
40
Church of God in Christ (C.O.G.I.C) faiths. The researchers began an initial contact
through formal letters requesting permission to interview the aforementioned.
This exploratory study consists of interviews with 10 African American pastoral
leaders with no specific denomination selected by the researchers. Subjects were selected
upon meeting the criteria that included clergy and youth ministers must be18 years or
older, African American origin, pastoral counseling, and of a religious biblical based
denomination. A total of 10 interview structure packets are prepared for participants.
The letter of consent introduced the researchers, described the purpose of the study,
potential benefits, risks of participation, possible outcomes, based upon findings as well
as, an explanation of risks or potential discomfort, the right to refuse/ withdraw from
participation without penalty, issues regarding confidentiality, and the opportunity to
offer feedback. The letter also provided contact information of the Sacramento County
Division of Mental Health, Adult Access Team (see Appendix A).
Instrumentation
Interview Session Part I consist of a total of (3) three open-ended questions (see
Appendix B). Each question is open-ended so that each participant is able to discuss in
detail his or her life experiences, length of service in ministry, any specialized training
and his or her level of Theological orientation.
Session Part II focused on contemporary experience: The participants are asked to
share what it is like to provide assistance to individuals seeking help with psychological
issues. In addition, clergy are asked if there are others within the congregation who act as
assistants to the pastors in the capacity of counseling members. Section II of the
41
interview process consists of five vignettes in which psychological problems are
presented. The participants are asked to give their opinion of what presenting problems
exist and the causal factors involved in these presenting problems. The descriptions of
presenting problems ranged from schizophrenia, alcohol dependence, major depression,
substance-related disorders to vignette subjects having no problem at all. The causal
factors referenced in the interview structure are; a chemical imbalance in the brain, the
way a person was raised, his or her own bad character, stressful circumstances in life, a
genetic or inherited problem, God’s will, a nervous breakdown, a mental illness, a
physical illness or a crisis in faith (see Appendix B).
Session Part III focused on what it means to each participant to be a provider of
spiritual and emotional guidance. These subjects are also asked about the individual
process for discerning the symptomatology and causal factors of mental illness. These
questions are developed in an effort to give participants a deeper sense of the importance
and the need to make appropriate referrals to mental health professionals in situations in
which members are in need of emotional/psychological support- being aware of
necessary resources and having the ability to refer to the persons/agencies most qualified
to handle these types of individuals.
Section Part III is designed to gain knowledge about the clergy’s personal
approaches when dealing with mental illness and the counseling and the utilization of
mental health services. Participants are asked when providing help, whether they provide
counseling in a spiritual, pastoral or psychological manner. In addition, the clergy are
asked to share at what level they feel they are qualified to handle certain situations
42
whether or not they feel adequately prepared to assist with mental illness. Clergy are also
asked if the church currently has an outreach program for individuals with mental health
issues, about their awareness of community mental health services, and the level of
comfort in making referrals to community based agencies. The interviews are then
conducted in a place in which the participant felt comfortable.
Validity/Reliability
The validity of this study is unknown and the findings of this research study
cannot be generalized because of the small sample size, and the researcher’s choice of
sample members reflects a particular ethnic group of clergy. The instrument used in this
study has not been administered on the current population to establish statistical validity,
but it has face-validity and is logical to the researchers. These findings must be accepted
with caution and cannot be generalized beyond the study’s conditions.
Data Gathering Procedures
Recruitment of participants includes scheduling interviews both by phone and in
person by meeting with administrative staff. The preliminary contact with staff is
scheduled to present research ideas, and request cooperation to interview clergy
providing pastoral counseling. No inducements are offered for the subjects’ participation
in this study.
Upon meeting with prospective subjects for the qualitative study, the researchers
and participant review the consent form. The document is signed by each interviewee and
researchers begin the interview process. The letter of consent and letter of permission
43
both assist in lending credibility to the study and to the researchers as well as to
encourage participation in the study.
The interviews are tape recorded, transcribed and analyzed for any recurring
themes. Specifically, clergy was asked to respond to three open-ended questions, five
vignettes and five questions related to clergy’s ability to counsel and utilize community
services (see Appendix B). In order to assist in maintaining participants’ confidentiality,
the researchers are not naming the participants in the recorded interview sessions.
Protection of Human Subjects
Prior to the beginning of interviewing or data collection, a Request for Review for
the Protection of Human Subjects was submitted to the Sacramento State Committee in
the Division of Social Work for approval. The human subjects form explained the
purpose of the research study, the risks involved for participating, and how the researcher
insured the participants’ involvement would be voluntary and remain protected and
confidential. The confidentiality and right to privacy of the participants was ensured
throughout the course of this study by the absence of any identifying information, such as
name, address, or phone numbers, as any part of the study. The interviews were protected
in a locked box in the researchers’ homes. The questionnaires were kept separate from
the recorded tapes. The Human Subjects committee approved this research study as
involving minimal risk (see Appendix C #10-11-072).
Summary
The interviews of the African American clergy in this study is to assess the beliefs
and understanding of clergy based upon the types of mental illnesses that they deal with
44
among their congregants who seek assistance and the type of intervention that they (the
clergy) provide. The researchers are specifically interested in assessing the ability of the
clergy to provide insight into the types of treatment they perform; their ability to make
proper referrals; their ability to provide the appropriate services, and their ability to
recommend alternative actions or make alternative recommendations.
Although the sample is small and it is not possible to generalize, nevertheless the study
has face validity and is logical.
45
Chapter 4
FINDINGS
Introduction
This chapter contains the analyses of the data that was transcribed for the research
study. An examination of the clergy participant’s educational background is described,
consisting of level of formal education, type of degree, level of theological orientation,
and specialized education or training. The participants who were interviewed gave
responses to situational issues and determined how they would respond to problems
presented in five vignettes. The instrument was developed to provide data insight into
how clergy recognize and attribute the cause of mental illness. The instrument design is a
combination of questions and vignettes about mental illness from the General Social
Survey (GSS) that include specific questions regarding severity of the presenting problem
(see Appendix B) and possible causal factors of mental illness (Powell, 2000).
Demographic Profile
Of the 10 clergy participants, 9 were male and 1was a female. The average
number of years serving as a minister ranged from 10 years to 60 years. The results of the
participants level of formal education is reflected in the chart below. Ten subjects
participated in this research study. Three of the participants have earned Doctoral
degrees, 4 have earned Bachelor degrees, and 2 have Associate degrees. One of the
participants has attended college but has not yet received a formal degree. Two of the
subjects have attended Bible College. Several of the participants have earned more than
one college degree (see Figure 1).
46
4
Bachelor's Degree
4
Ph.D
Associate's Degree
Some college
Bible College
2
Master's Degree
3
1
2
Note. Several participants’ have more than one degree
Figure 1. Formal Education
4
4
Pastoral Care Counseling
Seminars
Bible counseling
None
1
Figure 2. Specialized Training
1
47
The result found that four or 40% of the 10 respondents have participated in
specialized training in the area of Pastoral Care counseling. 40% have no specialized
training. Ten percent of the respondents have attended seminars and 10% have had some
form of training in counseling. (see Figure 2).
Vignette Results
Five vignettes (see Appendix B) coded as A, B, C, D and E presented various
psychological problems. Vignette (a) presenting a character with major depression;
participants averaged 90% of the correct response Vignette (b) presented the problem of
alcohol dependence, and clergy participants averaged 70%. Vignette (c) presents a
problem regarding substance-related disorder; participants averaged 60%. Vignette (d)
presented no mental illness, yet the clergy selected on a average 60% for Major
depression, and vignette (e) showed schizophrenia; the clergy averaged 90% of the
correct response. Overall, the clergy reported the causal factors of mental illness to be a
stressful situation in their constituent’s life or a chemical imbalance in the brain. A
summary of all the data is included in figures 3-12.
Bible counseling (see figure 2).
48
10%
No Response
Major Depression
90%
Figure.3 Major Depression Vignette A
Description A: Rebecca is a 33 year old, Asian American female with an associate
degree. Rebecca’s career title is a Data Analysis. For the last three weeks, Rebecca has
been feeling hopeless. She has withdrawn from mostly all social habits, nearly every day.
There is a decrease in her appetite and significant weight loss. Rebecca has had difficulty
sleeping, and she has problems with completing her project reports due to a diminished
ability to think or concentrate. Rebecca feels very discouraged, and worthless. Rebecca
just does not seem to feel like her normal self, and she has had thoughts of death. The
presenting problem reveals that 90% of the respondents attributed the presenting problem
as Major depression. 10% of respondents had no response (see Figure 3).
49
Chemical Imbalance in
the brain
The way he/she was
raised
Physical Illness
6%
6%
24%
Stressful situation in
his/her life
6%
Mental Illness
0%
6%
6%
0%
Genetic/Inherited problem
His/her own bad character
46%
Crisis In Faith
No Response
Figure 4. Causal Factors Vignette A
Vignette A-Causal Factors: The following table represents study participant responses for
vignette A and is in a similar order of the interview structure questionnaire. The pie chart
below depicts the responses of causal factors to scenarios presented to ten subjects.
Please note that several respondents selected more than one answer. Forty-six percent of
the ten subjects responded that the causal factor was due to stressful situation in his/her
life. A chemical imbalance in the brain was selected by 24%. While 6% attributed the
cause to be the way he/she was raised. Another 6% selected the way he/she
50
was raised, and the remaining 6% of study participants felt that the causal factors were
due to a genetic /inherited problem, a crisis in faith or had no response (see Figure 4).
Chemical Imbalance in
The brain
No Response
10%
20%
Major Depression and
Substance Related
Disorder
70%
Note. Several respondents selected multiple answers.
Figure 5. Alcohol Dependence Disorder Vignette B
Description B: Brian is a 51 year old, Caucasian male, Mechanical Engineer. He has a
wife and four children. During the last 9 months, Brian has begun to have drinks after
work with his colleagues. In fact, he has noticed that his drinking has progressed to
consuming alcohol on his lunch break. On two occasions he has had black-outs, and
could not remember how he arrived at various locations. His wife noticed that his
drinking has increased and has created financial hardships, martial conflicts as well as
51
family disagreements. Brian has tried to stop, but he became irritable, shaky, and unable
to sleep, so to stop the symptoms he would consume another drink to alleviate the
withdrawals. Of the ten clergy participants 70% selected alcohol dependence as the
presenting problem. While 20% chose no response. Only 10% attributed Major
depression and a substance related disorder as the presenting problems (see Figure 5).
Chemical Imbalance
in the brain
The way he/she was
Raised
Genetic Problem
0%
10%
10%
10%
0%
20%
0%
0%
Stressful situation in
his/her life
Mental Illness
Physical Illness
50%
His/her own bad
Character
Crisis in Faith
No Response
Figure 6. Causal Factors Vignette B
Vignette B-Causal Factors: Fifty percent of the respondents suggested that the common
causal factor for this vignette was due to stressful circumstances in his/her life. In
52
addition, 10% of the subjects answered that the causal factor was due to a genetic or
inherited problem. No response, a chemical imbalance in the brain and his/her own bad
character was selected by three of the respondents (see Figure 6).
10%
10%
10%
No Response
Substance Related Disorder
10%
Major Depression and
Substance Related Disorder
60%
Alcohol Dependence and
Substance Related Disorder
Alcohol Dependence
Figure 7. Substance Related Disorder Vignette C
Description C: Steven is a 37 year old, African American male, Tax Accountant. Steven
states, he is not aware of any mental health issues in his family, but reports having an
aunt being addicted to alcohol and his father being an addict. Steven reveals, his father is
now in recovery. Steven started using marijuana and alcohol as a teenager. Currently, he
uses crack cocaine and reports he used crack cocaine for the first time in college. Steven
lost his job two months ago, after missing too many days of work. Steven has lost weight
53
and often isolates in his home for days. His family has noticed missing items and suspects
Steven has stolen the possessions. His family is suspicious about him frequently visiting a
house that was raided by the police for drugs. When Steven’s family tries to talk about
his behavior changes, he becomes agitated and verbally abusive. Steven has attempted to
stop, but began to have symptoms of a increase heart rate, tremors, drooling and fever
Results show 60% of participants agreed that a substance related disorder was the
primary presenting problem. While 30% selected the dual issues- Major depression and a
substance related disorder, only 10% of the respondents had no response (see Figure 7).
54
Chemical Imbalance in the
brain
The way he/she was raised
Genetic Problem
0%
5%
5%
20%
Stressful situation in his/her
life
Mental Illness
10%
Physical Illness
10%
25%
25%
His/her own bad character
No Response
Figure 8. Causal Factors Vignette C
Vignette C- Causal Factors: Twenty percent attributed the causal factor to be a chemical
imbalance in the brain. While 25% selected both a genetic or inherited problem and the
way he/she was raised as the final answers. In addition, 20% of respondents selected
stressful situation in his/her life and mental illness the causal factors. Additionally, 10%
selected his/her own bad character and a physical illness as the casual factors (see Figure
8).
55
30%
No Response
10%
Major Depression
No Problem
60%
Figure 9. No Mental Disorder Vignette D
Description D: Dorothy is a 27 year old Native American. She has been married for six
years. Dorothy is a Graphic designer. Much of Dorothy’s designs are created in her
home- based business. She spends time with her friends, shopping and eating out. At
times, Dorothy has become irritated and upset with her husband not spending enough
time with her on a regular basis. She argues with her husband about watching sports, and
tampering with his classic Chevy convertible. On occasions, Dorothy may have
headaches, but will isolate in her room and sleep for a couple of hours to alleviate the
discomfort. Clergy responses show that Major depression was selected by 60% of the
respondents as the presenting problem. In addition, 30% percent of respondents attributed
no problem. Only 10% had no response (see Figure 9).
56
9%
18%
Chemical Imbalance in
the brain
Stressful situation in
his/her life
No Response
73%
Figure 10. Causal Factors Vignette D
Vignette D-Causal Factors: More than half or 73% of the respondents attributed the
causal factor to be stressful circumstances in his/her life. In addition, 18% of the
participants responded that the causal factor was due to a chemical imbalance in the
brain. No response was selected by 10% of the subjects (see Figure 10).
57
10%
No Response
Schizophrenia
90%
Figure 11. Schizophrenia Vignette E
Description E: Sophie is a 41 year old, Hispanic female Attorney. She is a partner of a
prestigious Law firm. She has thoughts that the lawyers in her firm are plotting to kill her
and she was convinced that her family is involved in the scheme. Sophie is hearing
voices, even though no one else was around. These voices have told her how to escape
her death and what to think. Sophie spends much of her time isolated at home. Neighbors
of Sophie has witnessed her talking and responding to material objects. Sophie has been
living this way for 8 months. Of the 10 clergy 90% of study participants’ selected
Schizophrenia as the presenting problem. Only 10% selected no response (see figure 11).
58
Chemical Imbalance in
the brain
The way he/she was
raised
Genetic Problem
6%
His/her own bad character
18%
34%
0%
Mental Illness
Physical Illness
6%
0%
Nervous Breakdown
0%
24%
0%
12%
Crisis In Faith
Stressful circumstances in
his/her life
No Response
Figure 12. Causal Factors Vignette E
Vignette E-Causal Factors: A chemical imbalance in the brain was selected by 34% of
study participants as the causal factor. Mental Illness was selected by 24% of
participants. While 18% attributed the causal factor to be due to stressful circumstances
in his/her life. A genetic /inherited problem was select by 12% of participants. Six
percent selected a nervous breakdown. No response was given by 6% of the respondents
(see Figure 12).
59
The clergy who were participants for this study were asked an open-ended
question: when presented with an individual experiencing a psychological issue, do you
advise or counsel in a spiritual manner, or from a psychological approach? One of the
participating ministers stated that he initially may proceed in a spiritual manner, but in
some cases would determine that the problem is one that will require a psychological
intervention. For instance, the parents may have a problem with an adolescent child
having behavior issues. The intervention will become more of mapping out a plan to
determine what is happening in the home and school, as well as other issues that may be
the result of the behavior problems.
Another question presented to the clergy participants was used to determine their
ability to recognize mental health conditions. This was reflected in the question: How do
you discern the symptomatology of mental illness? The key word in this question is
discernment; it is a biblical term based upon the ability to distinguish between good and
evil spirits. Overall, 90% of the clergy tended to attribute symptomatology of mental
disorders to the individual appearance, behavior, language, chemical imbalances, genetics
and the state of mind of the individual. Another minister revealed that individuals have
the ability to mask their conditions; they are masters of disguise, saying, “at times it may
take me two or three times to determine if the individual has a mental condition… If at
any point I feel it is beyond my scope of expertise, I will refer the individual to a license
professional.” The research findings revealed that many of the clergy participants agreed
that when providing assistance, they would determine if the individual in need of
60
psychological help had recently had a physical examination from a physician to rule out
any physical illness before proceeding with their counseling session.
The interviewers also asked the following question: In your opinion, what is the
causal factor of mental illness? Across the board, the response regarding the causal factor
of mental illness in the five vignettes was chemical imbalance in the brain and/or stressful
circumstances in his or her life. One of the demographics featured a question that asked
the subject if he or she ever received specialized psychological education or training. Of
the 10 clergy, 70% responded that pastoral counseling was associated with their academic
courses, while approximately 30% of the 10 clergy acknowledged that they received
specific mental health education. 90% of the clergy viewed themselves as spiritual
advisors, and could provide minor assistance to those seeking help, along with the
assistance of a mental health professional. In short, the findings from the study show that
the clergy are not adequately trained to provide mental health treatment for individuals
seeking assistance.
Previous literature supports this claim, through the suggestion that the
characteristics of clergy have a potential impact on their counseling and referral activities
with individual church members and their community (Taylor, Chatters, & Levin, 2003).
One minister stated “I have had sexual predators amongst my congregation. I have to
contact police officials, locate housing for the individual, limit the duties of that person in
the church, place background checks, and dismiss an individual from the church.”
Taylor, Chatters and Levin (2003) note that clergy with more education will likely
be more confident in their ability to acknowledge mental health issues and engage with
61
the parishioner or community member. Another minister who participated in this study,
described an experience with a female who lived in the community near the church. The
individual was screaming and speaking rapidly, saying “someone is after me; they are
trying to hurt me.” The minister stated, after observing and listening to the woman, “I
knew there was more to the story than what she was willing to disclose. I referred the
individual to the church’s resource center to assist with locating the proper service
needed for her condition.”
Overall, 80% of the 10 clergy agreed that if the issue was beyond their level of
expertise, he or she would be comfortable referring the individual to a more competent
professional, and 10% stated a preference for the referral to be made by an outside
source. They would only refer the individual to a more experienced member of clergy if
the individual was beyond their level of expertise. The remaining 10% stated that
individuals seek their help when social services and secular professionals have depleted
all resources, and are unable to solve the person’s issues.
The interviewers also inquired about the clergy participant’s awareness of
community mental health service agency locations and resources. Approximately 40% of
10 participants were familiar with mental health agencies in the Sacramento area. Some
acknowledged the use of a community resource book that references local services.
Others mentioned the reliance on mental health professionals in the church to recommend
a mental health service.
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Chapter 5
CONCLUSIONS
Introduction
This chapter summarizes the conclusions of the findings for the project. It
includes a discussion of how African American clergy conceptualize mental health
disorders. In addition, it also includes the participants’ views and their attempt to advise
individuals that present concerns, as well as an evaluation of their ability to provide
assistance. This chapter discusses one of the researcher’s previous experiences with a
minister who had a severe emotional problem. Finally, this study provides a personal
statement of an actual event of an interview conducted with the African American pastor
that provided a statement of the crisis intervention he experienced with one of his
associated ministers. This chapter also discusses the limitations and implications of this
study for social work practice, as well as suggestions for future research and
recommendations on how African American ministers can effectively meet the needs of
individuals seeking assistance for mental health problems in their surrounding
community.
Review of Findings and Relevance
This research study examined the clergy’s understanding of mental illness and
their ability to provide referrals to other mental health sources. The study explored the
clergy’s beliefs about causation, such as biological or environmental causes or biblical
ideology. The researchers found a significant relationship between the clergy’s limited
education in mental health disorders and a need for professional mental health
63
practitioners to collaborate with clergy in recognizing and treating serious mental
conditions.
The results of this project study are consistent with findings of other studies that
stated a number of individuals seek clergy support for treatment of mental conditions.
However, not much is known about how the clergy provide services regarding mental
illness. This study attempted to examine African American clergy’s ability to recognize
mental health illness by presenting five case vignettes of individuals who sought their
care and have presented problems of major depression, substance-related disorders,
unspecified diagnoses, schizophrenia, and alcohol dependence. The study explored the
clergy participants’ utilization of mental health services.
Many of the clergy who participated in this study felt inadequately trained in
recognition and treatment of mental illness. However, the findings revealed that a
majority of participants correctly recognized many of the indicators of mental illness
presented in the vignettes. Much of their ability to determine the presenting problem of
mental illness was based upon life experiences. One minister responded, “You cannot
give what you don’t have when you counsel someone, if you have not experienced such a
thing before. This cannot come from reading a textbook. [It’s not as effective if] you only
give textbook knowledge; it is easier to counsel someone when you have seen or
experienced it.”
Researcher’s Personal Interest
According to Oppenheimer, Flannelly, and Weaver (2004) one of the most
common themes was the clergy’s role as front-line mental health workers, which was
64
mentioned significantly more often in secular than in religious journals. Forty percent of
Americans who experience serious interpersonal issues sought help from a minister,
surpassing rates of those seeking assistance from secular helping professionals. Despite
the apparent importance of clergy, there is limited knowledge concerning the mental
health services provided by clergy. Ministers are often sought to address serious mental
health concerns, although they may be uncertain of the symptoms of severe mental illness
and the different forms of psychopathology. In an actual account of an incident
experienced by Charlotte M. Conley one of the authors, the following interview was
conducted as a personal interest in the topic with an African American minister who
faced a life-threatening crisis event.
This interview is presented to explore an actual mental health crisis intervention
provided by an African American clergy member. The minister states, “I have been a
pastor for 27 years and served at three different churches, and have been preaching for 30
years, ever since I was 17 years of age. My educational background consists of a
Bachelor of Christian Education/Theology, Masters of Christian Education and 2
Honorary Doctorate degrees and specialized education in Pastoral counseling of couples
and families.”
The pastor stated, “Much of my counseling experience has been developed
through life experiences. It was my professor in college that claimed, “We have not made
all the necessary preparation, there is a classroom perception of what to expect, but there
is a life experience you will encounter as a pastor when you begin to walk in the shoes or
path of others which I have not prepared you for in the classroom.” The interview
65
focused on a mental health crisis intervention that the Pastor carried out with one of his
associated ministers. The pastor was asked an open-ended question: Could you talk about
a mental health event that occurred with one your ministers? The pastor responded:
“I had known the minister for a couple of years, and he was born with a Puerto
Rican and African American heritage. He was born in the state of New York. The
minister was close to both sides of his family. He had a past history of serving a
jail term and was released on probation. The church has a ministry called “Friends
helping Friends” that helps individuals rehabilitate and transition from substance
abuse and incarceration to successful living. He joined the Friends helping
Friends ministry and became an active participant. The minister was dating a
woman who had a teenage daughter in the church. After some time, their
relationship grew and the two decided to get married. Under my leadership he
became an ordained minister under the Baptist religion. I remember the minister
had a strong Catholic background and a different belief about family life than his
wife’s views about what a family resembles. As time passed, the minister and his
wife began to have marital problems, and discussed separation and divorce. I
counseled the couple. There were issues of jealousy on both sides, he more so
than she. I remember him saying to his wife, “If I can’t have you, than no one else
can.” After the church service, the minister pulled a gun out on the church
campus.”
He believed the minister knew he had crossed the line in terms of the agreement
of his parole. As it pertains to his thoughts, he knew that he had messed up his parole.
66
The troubled minister said, “I cannot go back to jail, I cannot spend any more time in jail,
and my life is over.” One of the other associate ministers with the church tried to talk to
him, but the minister went home and entered the home in a rage. The stepdaughter was
there at the time. He held her hostage during the incident, and the minister poured
gasoline fluid around the lower level of the home. He proceeded to the top level of the
home. As the minister approached the crisis, the police official stated that the person he
was really inclined to speak with was the pastor. The pastor stated that he called him on
his cell phone. The minister informed the pastor that at midnight he was going to end it
all.
The researcher asked the pastor if there were red flags or behavior indicators
and/or a possible plan that may have been in place. The pastor stated that no, there were
no red flags other than their marital issues, about which the pastor was counseling them.
The researcher asked, “Can you recall if he was depressed?” The pastor said, “No, he was
always upbeat and happy.” The researcher asked, “Did you know he had a gun?” The
pastor replied, “No. It was something that took place on the weekend that led up to the
event. The minister was willing to only speak with me.” The pastor stated that he asked
the minister to surrender and let the girl go, “let her go for me.” After 2 or 3 hrs the
minister released the girl.
The researcher asked, “how did that make you feel, knowing at that time that someone is
about to take their life?” The pastor replied:
I began to question; did I do everything I could? Was there something I could
have said differently or done to change the outcome? I began to reflect that this
67
was a minister that would pray for me on a regular basis. As I continued to speak
with him, the minister continued to say that there was no changing his mind, he
was not going to jail, so the minister and I began to put a time frame on when it
would take place over the phone. I continued to try and discourage the minister
from setting the house on fire, but he said, “I put a lot of work into this house, and
nobody will enjoy this home.” But, I shared with him, saying that “the home was
her home before you became a part of her life.” Meanwhile, time had passed, and
at 11:00 p.m. I called the minister as we began to share final words. I said, man, I
wish you would change your mind. [The pastor paused, and began to shed tears
as quietness filled the room.] The other minister said, “I want you to know that I
love you; I do love you because you have been a blessing to me in my life. But, I
cannot go back to jail.” At that very second I could hear him lighting the match,
and the lower level of the house began to catch on fire and burn. Next, there was
the cocking of the gun shaft and the sound of the gun being shot.”
The researcher then asked the pastor, how did all this affect your life? Did you have
remorse or guilt? Has it changed your view of counseling? The pastor replied:
It has to do with the tragedy that took place in my own life. My wife, son and I
were involved in a fatal car accident. I received the news that my son had died
from the accident, and was later informed that my wife was on life support in a
different hospital and not progressing well. I gave them permission to pull the life
support plug that was keeping my wife alive. It was that crushing pain that began
to transition me. That transition took place with God, who told me, “If you trust
68
me with this, I will rebuild your life over.” It was after that encounter, that several
psychiatrists, cardiologist and other medical professionals began to assess me and
could not understand why I was not experiencing trauma from the effects of the
tragedy that had just taken place as a result of that incident in my life. In terms of
the minister committing suicide, it was not that I was careless with his death, but I
had already experienced death. It was the pain and loss I had endured from the
tragic death of my wife and son, the pain and crushing that had broken me, to the
point that I don’t sympathize - no, I empathize, because I have experienced their
pain far more, from a place of deeper love and tragedy.
The research asked if the pastor had any final words. The pastor said,
One of things that I would like to mention that is so important for those that are
providing assistance is that for individuals who have been highly trained and
prepared, but have not been broken, their words of encouragement come from
some book or passage he or she has learned or something that was memorized
from the internet that is shared, but there is no compassion because the person has
not experienced being crushed or broken.
This interview provides a snapshot of a serious mental health crisis intervention with a
minister who attempted to address a critical incident. It is unclear if there were additional
psychological issues. The interview sheds light on an important area of investigation,
showing how little is known about clergy and mental health practices. Clergy, in
comparison with other mental health practitioners, tend to underrate the severity of
psychotic symptoms and are less likely to discern suicidal lethality. In terms of religious
69
and pastoral training, clergy may interpret psychological and/or emotional issues and
symptoms of mental disorders in merely religious terms (Taylor, Ellison, Chatters, Levin,
and Lincoln, 2000).
Limitations
The researchers’ selected a small convenient sample size for this project study.
The location of the data collected was in Sacramento County. One of the major
limitations identified in this study was the efforts of the researchers to increase the
response rate of churches. The researchers attempted to improve the response rate of
potential clergy participants by eliminating the initial pre-interview phone calls to
schedule an appointment with the clergy, and instead used a strategy to communicate
with the church staff by conducting an on-site visit during church office hours to present
the nature of the study.
Another limitation was the views and attitudes of some clergy’s perceptions of
previous studies that published negative views and ideas of ministers as religious fanatics
with abnormal beliefs of demonic spirits, and who viewed mental illness as being
possessed by an evil spirit. There were clergy who declined to avoid being bashed or
highlighted in an inappropriate way.
One other limitation of the vignettes presented during the interview was that they
provided the clergy with limited information. It is also important to mention that the
vignettes presented did not present mental disorders such as obsessive-compulsive
disorders, bipolar and dissociative identity disorder or attachment disorders; these may
70
have been more challenging to identify unless the clergy was educated in mental health
disorders.
Implications
The goal of this study was to gain a better understanding of African American
clergy members’ perception of mental illness, pastoral counseling and utilization of
mental health services. The researcher’s goal was to provide strategies and innovative
tools to assess the African American clergy by exploring mental health barriers, attitudes
of pastoral counselors, mental illness stigma, racial disparities and the utilization of
mental health sources.
The field of social work could benefit from the findings of this study. The
findings show that the most commonly identified barrier in our study was a lack of
mental health education for clergy in their training, but also that there are limited, if any,
educational courses for social workers regarding an awareness of spiritual concerns. It
would benefit the African American community if social workers recognize the
importance of gaining information about both the positive and negative role of religion
and spirituality in the fight for social justice of numerous groups, and could be sensitive
to this history in working with members of oppressed populations. It is important that
social work students acquire information about these areas as they prepare to work with
communities, individuals and families.
Another implication to consider in the African American community is that the
Black church is a mini-social service agency; the institution is a huge resource for nursery
care, activities for youth groups, after school tutoring, single-mother groups, assistance
71
for homeless, health ministry, youth groups, and substance abuse outreach programs. It
may benefit faith institutions to collaborate with social work educational programs and
consider incorporating student interns in assisting individuals and families with
resources. This could help educate the community, as well as provide a way to bridge the
gap between faith-based community settings and the provision of psychological
resources. In addition, the collaboration would assist their informal support systems by
creating a pathway to formal support groups between the African American community
and mental health services.
More importantly, Neighbors (2003) suggests that collaboration requires
dedication and an effort on the part of the service delivery systems, pastors and policy
makers in order to create a change. In terms of the collaboration to reach its potential, the
pastor must displace feelings of disinclination to form a partnership. This is a result of the
history of mistrust of the formal institutions based on previous patterns of both
discrimination and prejudice by health professionals in their assistance with the African
American community. In addition, health professionals must consider their own biases
and attitudes regarding religion and religious institutions, and their willingness to work in
a unified effort to support the Black church (Taylor & Ellison, 2000).
The research study accomplished more than what the author set out to
accomplish. Several of the clergy participants gained insight and considered
incorporating mental health information and programs in their organizations. After the
study, one clergy participant decided that he would consider becoming a potential partner
with the university and collaborate in a mental health program for the church. Another
72
clergyman declared that reading the nature of the study piqued his curiosity. According to
Franklin (2003) the third leading cause of death amongst African American males is
suicide. This clergy participant shared that in his church, a teenager committed suicide.
This episode was difficult for the family and the church congregation.
After reading the nature of the study, the pastor pulled together a team of doctors
and nurses that were members of his church. The team of health professionals and clergy
reviewed the vignettes. As a result of the research study, the church now has a health
program for the members of the church. The researchers were also asked by another
clergy participant about assistance in implementing a mental health program in the
church.
In terms of research, this study may provide the insight that social work
practitioners are in a position to collaborate by mutually assisting the African American
community through increasing educational resources and providing support to clergy,
consumers and families. For many African American consumers and caregivers, mental
health needs are unmet. It is important to recognize that the role of the pastor is
harmonious with the literature presented and recommendations from U.S. President
Bush’s New Freedom Commission on Mental Health (2003). The literature and findings
of this study reveal that the Black church has been a source of support for African
American families and communities faced with disparities in health care; specifically,
that African American pastors have the most potential for connecting the African
American community and mental health services.
73
It is imperative that social workers become more involved in mental health care
advocacy boards in order to support consumer’s rights. Social workers could talk with
community leaders who are associated with politics or support legislative policy, in order
to better serve the community or minority groups of people in need of mental health care.
Social workers could promote the change of policy laws by initiating policy that would
specifically address the injustices of mental health care, in order to provide effective
services that recognize the need to develop culturally competent assessments, as well as
early screening programs and assistance in the expansion of federal and state plans.
Recommendation for Further Research
The purpose of the study was to discover new strategies to reduce barriers for
those African American individuals seeking assistance with mental health concerns. Both
authors sought to explore the role of the African American clergy as front-line mental
health providers. The research participants have provided both authors the opportunity to
investigate reasons why some barriers make it difficult for African Americans to receive
adequate mental health care. In addition, the researchers also explored how clergy
effectively recognize and attribute causal factors associated with psychological
conditions.
The following recommendations are for mental health professionals and social
workers working in the mental health sector and human service institutions.

Providers should learn to be culturally aware of community resources,
such as local churches and community-based organizations.
74

Pastoral education programs may benefit from providing clergy with a
mental health course, in order to broaden knowledge regarding
recognizing mental health conditions, provide them with some
psychological tools to help them make more appropriate referrals, and
offer counseling that will effectively provide interventions to assist the
emotionally distressed parishioners and community members.

Educate professionals such as mental health providers, medical social
workers, psychologist, and marriage and family therapists about values
and beliefs that might undermine or show contempt for the faith of
individuals who might be referred for services.

Mental health programs and health professionals could organize seminars
or discussion groups to broaden perspective.

Mental health agencies, hospitals and medical schools could promote
educational workshops to familiarize clergy with facilities and services
available to their parishioners and community members.

Mental health professionals should advocate for policy change through the
political and legislative arena to promote the rights of oppressed
populations.
Conclusion
Overall, the project illustrates the need of increasing awareness of mental health
professionals regarding the role that African American clergy play in the mental health
sector. From the clergy’s perspective, there is a perceived need to improve the education
75
of mental health professionals to increase their sensitivity to racism, religion and
spirituality, as well as disparities in the utilization of mental health services. Clergy and
mental health professionals acknowledged that the training and education of clergy would
benefit the clergy profession, helping clergy members distinguish various psychological
disorders and providing the ability to make appropriate referrals to mental health services
and professionals. While there were some limitations in this research study, both authors
hope that more studies will be conducted that reveal the benefits of a mutual
collaboration between clergy and the helping profession; hopefully this will help such
professionals to unite, educate one another and close the gap to promote and improve the
unmet mental health needs of a population that continually is faced with obstacles
hindering the health of the African American community.
76
APPENDICES
77
APPENDIX A.
Letter of Consent
Dear Potential Study Participant:
Purpose of Study
You are being invited to participate in a research study, which will be conducted by
Charlotte Conley and Merita Wolfe, graduate students at California State University,
Sacramento. We are under the advisement of Professor Joyce Burris who can be
contacted, if needed at (burrisj@csus.edu or phone 278-7179) at California State
University, Sacramento. As Master of Social Work, students in the Department of Social
Work, our study will focus on the perceptions of mental illness among African American
clergy. The study is design to understand the effects of these perceptions on the ability of
participants to make effective referrals (to appropriate services) and on the adequacy of
assistance to those seeking support with mental health issues. The main purpose of this
research is to discover new strategies to effectively serve the African American
community, and to develop innovative ways that will reduce barriers of those seeking
assistance for mental health concerns.
Procedures
Much of the literature reveals that within the context of Black churches, that African
American clergy have a significant role in the delivery of mental health services for
community members within the African American community. And as such, we believe
it is imperative to learn more about the perceptions of clergy providing counseling. We
request your permission to participate in a face-to-face interview that will take
78
approximately 45 minutes to 1hour of your time. As a prospective participant,
specifically, you will be asked to respond to vignettes. The taped interviews will be
transcribed, but the information contained in the tape will be presented in the thesis as
patterns that emerge from all of the 10 interviews being conducted. In other words, these
authors will not report any personal information that would allow a reader to trace
information directly to any particular participants. After you read the consent form, you
will be encouraged to ask any questions you may have about the research. If you choose
to participate in the study, and after you sign this consent form, the form will be slipped
into an envelope that is kept separate from the tape on which the interview is recorded.
All materials will be stored in a locked box in the locked private home of the authors and
both will be destroyed upon completion of this research project. To protect the privacy
and confidentiality of participants, names and other identifiable information, will not be
asked. The collected taped interviews will be also analyzed in private to maintain
confidentiality. The audio tapes, audio tape transcripts, consent forms, notes, and other
identifying information will be destroyed at the end of the study period.
Risks
The researchers of this project consider this study to pose “minimal risk” in terms of
potential harm. The nature of study will not involve any greater harm than that
encountered in everyday lives. In the event, you feel discomfort due to the nature of some
of the questions encountered or decide that you do not wish to continue participation, you
have the right to discontinue the interview session or skip any questions to prevent harm.
Again, please understand that if you should feel any discomfort resulting from your
79
participating in this study, please contact the Sacramento County Division of Mental
Health, Adult Access Team for a referral at (916) 875-1055 or notify The Effort North,
Mental health services at (916) 679-3925.
Benefits
Potential benefits that individuals may experience from participating in this study may
include the following: 1.) You have a chance to reflect on the work you do with the
parishioners and community members in ways that allow you to see new ways to work
better with them, 2.) You may discover new insights that allow new strategies to work
with parishioners or community members, 3.) You may think of ways achieve better
linkages between faith-based communities and formal mental health care, and 4.) You
may find ways to establish a more culturally sensitive assistance for the African
American community.
Right to Withdraw
As a prospective participant, please understand that your participation in this research is
entirely voluntary. You may decline your participation now or you may discontinue your
participation at anytime during the interview session without any penalty. You will not be
receiving any compensation from neither the researchers nor California State University,
Sacramento. To protect your privacy and confidentiality, your name and other
identifiable information, will not be asked. All raw data obtained from you will be
destroyed upon completion of the project.
80
Thank you for the opportunity. If you have questions about this research, you may
contact Charlotte Conley and Merita Wolfe. By signing this form you agree to participate
in this research study.
_______________________________________
________________
Signature of Participant
Date
81
APPENDIX B.
INTERVIEW STRUCTURE
Conceptualization of Mental Illness
The nature of the interview is not designed to test hypotheses; rather it is designed
to ask Clergy to reconstruct his or her experience as it pertains to parishioners, and
community members seeking assistance with mental health concerns. The study is to
explore their ability to serve the help seeking behaviors of individuals with psychological
issues, and the utilization of mental health services in the community. The interview
schedule will consist of a three- part structure (1.) The first section is an open-ended
question interview (2.)The second section of the interview the participants will be given
five vignettes. This will involve the participant to read the situational issue, and
determine the presenting problem. Each participant will mark the response by placing a
circle around the answer and (3) Mental health community services.
Open-ended question section
Interview Session Part One (life history): How did the participant come to be a clergy?
(i.e., life history, education, number of years in the ministry, specialized training, and
level of theological orientation).
Interview Session Part Two (contemporary experience): What is it like for the participant
to provide counseling? For example, take me through a day in your work life, and talk
about the experience of assisting an individual seeking help for a psychological issue?
Are there others that may assist with counseling parishioners and community members
within the church?
82
Interview Session Part Three (reflection on meaning): What does it mean to the
participant to be a provider of the spiritual and emotional needs of individuals seeking
help? How do you discern the symptomatology of mental illness? In your opinion, what
is the causal factor of mental illness?
Vignettes
This instrument was developed to provide data that will examine how clergy
recognize, attribute cause of mental illness, and ability to provide services to individuals
with mental health concerns. The tool is design to explore the decision-making ability
regarding how clergy would attempt to refer to formal services. The instrument design is
a combination of questions and vignettes about mental illness from the General Social
Survey (GSS) that includes specific questions regarding severity of the presenting
problem, possible causal factors, and the attempt to provide assistance or a referral
(Powell, 2000).
Instructions: The following situations describe various individuals presenting problems.
In your opinion, what is the presenting issue? Circle the answer below.
Presenting Problems
Description A: Rebecca is a 33 year old, Asian American female with an associate
degree. Rebecca’s career title is a Data Analysis. For the last three weeks, Rebecca has
been feeling hopeless. She has withdrawn from mostly all social habits, nearly every day.
There is a decrease in her appetite and significant weight loss. Rebecca has had difficulty
sleeping, and she has problems with completing her project reports due to a diminished
83
ability to think or concentrate. Rebecca feels very discouraged, and worthless. Rebecca
just does not feel herself and she has had thoughts of death.
In your opinion, what is the presenting problem?
(1). Schizophrenia
(2). No problem
(3). Alcohol dependence
(4). Major depression
(5). Substance Related Disorder
In your opinion, what is the causal factor of the presenting problem?
a. A chemical imbalance in the brain
b. The way he or she was raised
c. His or her own bad character
d. Stressful circumstances in his life
e. A genetic or inherited problem
f. God’s will
g. A nervous breakdown
h. A mental illness
i. A physical illness
j. Crisis in faith
Description B: Brian is a 51 year old, Caucasian male, Mechanical Engineer. He has a
wife and four children. During the last 9 months, Brian has begun to have drinks after
work with his colleagues. In fact, he has noticed that his drinking has progressed to
84
consuming alcohol on his lunch break. On two occasions he has had black-outs, and
could not remember how he arrived at various locations. His wife noticed that his
drinking has increased and has created financial hardships, martial conflicts as well as
family disagreements. Brian has tried to stop, but he became irritable, shaky, and unable
to sleep, so to stop the symptoms he would consume another drink to alleviate the
withdrawals.
In your opinion, what is the presenting problem?
(1). Schizophrenia
(2). No problem
(3). Alcohol dependence
(4). Major depression
(5). Substance Related Disorder
In your opinion, what is the causal factor of the presenting problem?
a. A chemical imbalance in the brain
b. The way he or she was raised
c. His or her own bad character
d. Stressful circumstances in his life
e. A genetic or inherited problem
f. God’s will
g. A nervous breakdown
h. A mental illness
i.
physical illness
85
j. Crisis in faith
Description C: Steven is a 37 year old, African American male, Tax Accountant. Steven
states, he is not aware of any mental health issues in his family, but reports having an
aunt being addicted to alcohol and his father being an addict. Steven reveals, his father is
now in recovery. Steven started using marijuana and alcohol as a teenager. Currently, he
uses crack cocaine and reports he used crack cocaine for the first time in college. Steven
lost his job two months ago, after missing too many days of work. Steven has lost weight
and often isolates in his home for days. His family has noticed missing items and suspects
Steven has stolen the possessions. His family is suspicious about him frequently visiting a
house that was raided by the police for drugs. When Steven’s family tries to talk about
his behavior changes, he becomes agitated and verbally abusive. Steven has attempted to
stop, but experienced an increase heart rate, tremors, drooling and fever.
In your opinion, what is the presenting problem?
(1). Schizophrenia
(2). No problem
(3). Alcohol dependence
(4). Major depression
(5). Substance Related Disorder
In your opinion, what is the causal factor of the presenting problem?
a. A chemical imbalance in the brain
b. The way he or she was raised
c. His or her own bad character
86
d. Stressful circumstances in his life
e. A genetic or inherited problem
f. God’s will
g. A nervous breakdown
h. A mental illness
i. A physical illness
j. Crisis in faith
Description D: Dorothy is a 27 year old Native American. She has been married for six
years. Dorothy is a Graphic designer. Much of Dorothy’s designs are created in her
home- based business. She spends time with her friends, shopping and eating out. At
times, Dorothy has become irritated and upset with her husband not spending enough
time with her on a regular basis. She argues with her husband about watching sports, and
tampering with his classic Chevy convertible. On occasions, Dorothy may have
headaches, but will isolate in her room and sleep for a couple of hours to alleviate the
discomfort.
In your opinion, what is the presenting problem?
(1). Schizophrenia
(2). No problem
(3). Alcohol dependence
(4). Major depression
(5). Substance –Related Disorder
In your opinion, what is the causal factor of the presenting problem?
87
a. A chemical imbalance in the brain
b. The way he or she was raised
c. His or her own bad character
d. Stressful circumstances in his life
e. A genetic or inherited problem
f. God’s will
g. A nervous breakdown
h. A mental illness
i. A physical illness
j. Crisis in faith
Description E: Sophie is a 41 year old, Hispanic female Attorney. She is a partner of a
prestigious Law firm. She has thoughts that the lawyers in her firm are plotting to kill her
and she was convinced that her family is involved in the scheme. Sophie is hearing
voices, even though no one else was around. These voices have told her how to escape
her death and what to think. Sophie spends much of her time isolated at home. Neighbors
of Sophie has witnessed her talking and responding to material objects. Sophie has been
living this way for 8 months.
In your opinion, what is the presenting problem?
(1). Schizophrenia
(2). No problem
(3). Alcohol dependence
(4). Major depression
88
(5). Substance –Related Disorder
In your opinion, what is the causal factor of the presenting problem?
a. A chemical imbalance in the brain
b. The way he or she was raised
c. His or her own bad character
d. Stressful circumstances in his life
e. A genetic or inherited problem
f. God’s will
g. A nervous breakdown
h. A mental illness
i. A physical illness
j. Crisis in faith
Below is a list of additional questions that will be addressed upon the completion of the
vignettes.
Counseling and Utilization of Services
If you are approached for help with the various situations, would you attempt to advise
the individual in a spiritual manner?
If you are approached for help with the various presenting problems, would you attempt
to advise, counsel in a psychological or pastoral manner?
If you are approached for help with the presenting problems, at what level do you feel
that you would be able to provide assistance?
89
1. I can handle this situation alone (I have adequate training to handle presenting
concerns of this sort).
2. I could provide major assistance with the collaboration of a properly trained
mental health professional.
3. I could provide minor assistance with the collaboration of a properly trained
mental health professional.
4. I am not adequately trained to handle presenting problems of this sort other than
to refer to a mental health professional.
5. Not sure
Do you feel that you are adequately prepared to assist individuals with mental illness?
In your church, do you have an outreach program devoted to assisting individuals with
mental health issues?
Are you aware of community mental health services that are available?
Are you comfortable in referring individuals in need of assistance to agencies within your
community?
90
APPENDIX C.
Human Subjects
CALIFORNIA STATE UNIVERSITY, SACRAMENTO
DIVISION OF SOCIAL WORK
TO:
Charlotte Conley & Merita Wolfe
Date: December 20, 2010
FROM: Committee for the Protection of Human Subjects
RE: YOUR RECENT HUMAN SUBJECTS APPLICATION
We are writing on behalf of the Committee for the Protection of Human Subjects from
the Division of Social Work. Your proposed study, “An Exploratory Study of How
African American Clergy Conceptualize Mental Health Disorders and Utilization of
Mental Health Services.”
__X_ approved as _ _
_EXEMPT __ __ NO RISK _X__ MINIMAL RISK.
Your human subjects approval number is:10-11-072 Please use this number in all
official correspondence and written materials relative to your study. Your
approval expires one year from this date. Approval carries with it that you will
inform the Committee promptly should an adverse reaction occur, and that you
will make no modification in the protocol without prior approval of the
Committee.
The committee wishes you the best in your research.
Professors: Jude Antonyappan, Maria Dinis, David Demetral, Susan Eggman, Serge Lee,
Kisun Nam, Maura O’Keefe, Sue Taylor, Santos Torres
Cc: Dr. Joyce Burris
91
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