J Relig Health DOI 10.1007/s10943-013-9731-0 ORIGINAL PAPER
The Pew Versus the Couch: Relationship Between Mental Health and Faith Communities and Lessons Learned from a VA/Clergy Partnership Project Steve Sullivan • Jeffrey M. Pyne • Ann M. Cheney • Justin Hunt Tiffany F. Haynes • Greer Sullivan
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Springer Science+Business Media New York (outside the USA) 2013
Abstract The history of the relationship between religion and mental health is one of commonality, conflict, controversy, and distrust. An awareness of this complex relationship is essential to clinicians and clergy seeking to holistically meet the needs of people in our clinics, our churches, and our communities. Understanding this relationship may be particularly important in rural communities. This paper briefly discusses the history of this relationship and important areas of disagreement and contention. The paper moves beyond theory to present some current practical tensions identified in a brief case study of VA/ Clergy partnerships in rural Arkansas. The paper concludes with a framework of three models for understanding how most faith communities perceive mental health and suggests opportunities to overcome the tensions between ‘‘the pew’’ and ‘‘the couch.’’ Keywords
Mental health Clergy Pastoral care Veteran Religion Spirituality
Introduction ‘‘It is doubtless true that religion has been the world’s psychiatrist throughout the centuries (p. 393).’’ Karl Menninger (Menninger 1938).
S. Sullivan (&) J. M. Pyne A. M. Cheney J. Hunt T. F. Haynes G. Sullivan South Central Mental Illness Research, Education and Clinical Center, Central Arkansas Veterans Healthcare System, 2200 Fort Roots Drive (152/NLR), Building 58, North Little Rock, AR 72114, USA e-mail:
[email protected] S. Sullivan J. M. Pyne A. M. Cheney J. Hunt T. F. Haynes G. Sullivan Center for Mental Health Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, AR, USA J. M. Pyne A. M. Cheney T. F. Haynes G. Sullivan Division of Health Services Research, UAMS Psychiatric Research Institute, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
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The Greek ‘‘psyche’’ from which we derive ‘‘psychology’’ and ‘‘psychiatry’’ is translated in most English versions of the New Testament as ‘‘soul’’ and is considered to be the focal point of most Christians’ spirituality as well as that of the world’s major religious traditions. This shared nomenclature suggests common ground between religions (particularly Christianity) and mental health sciences. While religion and psychiatry use different vocabularies and methodologies to understand human experiences, their goals overlap and are often congruent. For example, both religion and mental health services seek to provide emotional well-being and emphasize the importance of relationships for their parishioners or clients (Levin and Chatters 1998). Humans are fundamentally bio-psycho-social-spiritual beings (Sulmasy 2002). This is not to say that all people share the same spiritual ideals, institutionalized forms of religion (e.g., Christianity, Islam), or belief in God. Rather we raise this point to emphasize that spirituality, properly understood, is an integral part of the human condition. In addition, we want to point out that the philosophical underpinnings of religion and psychiatry are similar: both can be conceptualized as frameworks to understand and describe ‘‘the human experience and human behavior’’ (Boehnlein 2000, p. xvi.). There has been a long-standing relationship between religion and psychiatry across the world’s major religions (Kinzie 2000). In many cultures, religious healing and rituals have been integrated into medical traditions or served as complimentary practices (Baer 2001; Hughes and Wintrob 2000; Neighbors et al. 1998; Snowden 1999), and individuals have sought care from both medical providers and spiritual leaders. For instance, in the Buddhist and Hindu traditions, patients often seek care from Western-trained clinicians after seeking guidance from religious elders or gurus. These spiritual leaders are akin to a chaplain or pastoral counselor in a Western setting and listen to and offer advice to individuals experiencing emotional and psychological distress (Josephson and Peteet 2004). The relationship between religion and mental health is complex, however. For example, mental health treatment recommendations may conflict with a patient’s religious/spiritual beliefs or faith community teaching causing the patient to choose to follow one or the other. More subtle conflicts can occur when a mental health provider fails to acknowledge or appreciate the important role that a patient’s religious or spiritual beliefs and practices play in illness and treatment experiences (Josephson and Peteet 2004). Thus, an understanding of these relationships can prepare spiritual leaders and mental health providers to address these conflicts and overcome potential barriers to care. Religion can play a tremendous role in helping patients cope with the stress of illness. In one study, as many as 40 % of those admitted to general medical services indicated that their religion was the most important factor that enabled them to cope with the stress of their illness (Koenig 1997) In this article, we focus on the Christian tradition and the role of religion, spirituality, and psychiatry in the lives of our clients who are from rural areas of the southern United States. In this context, Judeo-Christian worldviews and powerful religious beliefs and practices are interwoven into personal and familial histories and shape understandings of health and illness (e.g., Cheney et al. 2013). Regardless of one’s religious tradition, coordinated spiritual and mental health care are important to holistic treatment. Mental health providers are largely unaware of how to address the spiritual needs of their clients. Similarly, clergy are untrained in how to address many of the mental health needs of their parishioners. For this reason, collaboration between clergy and mental health providers is a natural strategy and of paramount importance. For many of our patients, to ignore Christian values and beliefs in our mental health treatment is to be, at best, culturally incompetent and, at worst, can potentially both devalue and cut off a significant source of support and personhood for our clients (Kleinman 1980).
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Before delving into the long-standing history between the pew and the couch, we would first like to note that God and the church play a vital role in the rural South parishioners’ mental health and emotional well-being (Blank et al. 2002; Campbell et al. 2002; Mitchell and Weatherly 2000). The church and leaders within the faith community shape the way many parishioners understand society in general (Lee 2003) and influence their perceptions of mental health in particular (Stanford 2007). Pastoral care is also integral to the lives of those in rural, southern communities where formal mental health services are sparse (Hendryx 2008; Thomas et al. 2009, 2012). It is important to note though that differing viewpoints of illness and approaches to healing can impact the individual seeking help and possibly increase tension and mistrust between the clergy and healthcare providers (Neighbors et al. 1998, 1999). Similarly, leaders in the faith community who tend to ignore or demonize the biomedical model for mental health treatments run the risk of delaying or blocking access to available mental health resources. Despite the common goals of the church and the mental healthcare community, the history between religion and mental health includes conflict, mistrust, and even antagonism (Meissner 2000; Pruyser 1966). Decreasing tension and increasing collaboration between clergy and mental health providers may improve treatment adherence for patients who are accessing both spiritual and MH support (Bonner et al. 2013).Thus, recognition and resolution of this ongoing conflict are necessary for effective collaboration to occur.
The History of the Pew Versus the Couch: The Background of the Conflict Any serious attempt at communication between the mental health community and the faith community must take seriously the history of their perceptions of each other. The conflict between psychology and religion is usually considered to be a modern phenomenon; however, its roots are much deeper. The conflict emerged during the rise of Enlightenment thinking and the subsequent Darwinian and Freudian revolutions, which raised the debate between matters of the soul, mind, and body (Reed 1997). Thus, the struggle between the pew and the couch dates back to the Enlightenment period of the 17th and 18th centuries when scientific and rational theories began to explain the world (Bristow 2011). Prior to that point, it was difficult to distinguish religion, spirituality, and medicine. The Pew’s Attitude Toward the Couch Historically, healthcare was synonymous with spiritual care (Magner 2005). The earliest documented institutions seeking to provide cures for ailments were ancient Egyptian temples. Muslim hospitals emerged in a similar religion-inspired fashion in the eighth century. In ancient Greece, temples associated with the healer-god Asclepius were the centers of medical advice, prognosis, and healing (Risse 1999). The earliest in-patient hospitals on record date to the Byzantine period shortly after the acceptance of Christianity and the conversion of Constantine in the early part of the fourth century, when each town with a cathedral soon also had a hospital (McClellan and Dorn 2006). In general, most early hospitals, including those in the United States, came about as a result of religious charity and impetus. Illness was understood in a spiritual context until the beginning of the Enlightenment or Age of Reason (circa 1650–1700). The rise of modern science, medical explanations for behavior, and the fields of psychiatry and psychology drove a wedge between the church and science with regard to mental health in particular and resulted in increased tension
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between ‘‘spiritual’’ and science-based understandings of mental and emotional well-being (Fulford 1997). With the Enlightenment and the development of the scientific method, a gradual territorial struggle began between the religious and the scientific communities that had tremendous impact on the nature and delivery of healthcare. The institutionalization of medicine and what Foucault (1973) refers to as the ‘‘medical gaze’’ fundamentally changed the explanation of emotional distress from a religious one to a medical one, as the Cartesian dualism of biomedical philosophy separated the mind and body and the individual became subject to the expert knowledge of those in positions of power (i.e., doctors) (Lagrange 2008). The body became the object of analysis and explanations were no longer found in the spiritual being of the person, but rather in the biological and physiological makeup of the body. Whereas priests (in the Catholic tradition) had been mediators of spiritual and health care, a new paradigm emerged in which physicians were entrusted with the care of patients’ health. Historians have argued that subtle traditions developed in medicine that served to challenge the previous authority of the church. For instance, the use of traditional white laboratory coats for physicians challenged the traditional black priestly attire in hospital settings (Brumberg 1988). This paradigm shift in the understanding of health and illness had tremendous effects on the understanding of mental health in particular. The medicalization of mental health gradually devalued and alienated many in the faith community, particularly clergy. They perceived that the importance of faith and the role of clergy in the treatment of emotional and spiritual problems had been undermined. In addition, many in the church community perceived the rise of psychiatry and psychology as a direct threat to the Biblical understanding of the human condition (Powlison 1993). This mentality exists today and some of the language has become vitriolic: ‘‘Modern psychiatry is as anti-Christian, dangerous and satanic as evolution’’ (The Interactive Bible, n.d.). In this quote we see how psychiatry is linked to evolution and viewed as part of the modern attack of science on religion. Furthermore, psychiatry is not just perceived as untrue or irrelevant, but it is also ‘‘anti-Christian’’ and even ‘‘dangerous.’’ While the use of such strong language from a Christian group concerning psychiatry is not universal, it does point to the suspicion and even antagonism of many in the faith community toward those in mental health fields. Much of the distrust and suspicion on the part of certain faith communities comes from certain subjective interpretations of Biblical scriptures. Although all scriptures are subjectively interpreted, the meanings certain interpretations evoke can play a powerful, though sometimes implicit, role in how Christians perceive mental health services. For example, the story of the Gadarene demoniac recounted in Luke 8:26–35 (New American Standard Bible Update 1995) can be used to support a Christian view of mental illness as something to be feared, shunned, and/or exorcised (Neugebauer 1978; Pfeifer 1994). In this story, Jesus encounters a man, ‘‘possessed with demons’’ that had ‘‘seized him many times.’’ The man could not be restrained and was isolated, living ‘‘in the tombs.’’ Jesus spoke to the demons or unclean spirits inside the man and cast them out of the man into a near-by herd of swine. When the demons left the man, the townspeople found the man restored, clothed, ‘‘and in his right mind.’’ Biblical accounts like this one have influenced Christian beliefs about emotional and psychiatric distress connecting it with demon possession, the influence of Satan, or the effects of sin. Within this framework, prayer, repentance, faith, conversion, and exorcism were solutions to rid the body of evil and restore the soul. Exorcism played a large role in the history of Christianity and continues to a lesser degree in the present (Goodstein 2010).
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Other Biblical passages are interpreted as a direct warning about the dangers of mixing psychological and Biblical principles. This is evident in the King James Version of the Bible when Paul says, ‘‘O Timothy! Guard what was committed to your trust, avoiding the profane and idle babblings and contradictions of what is falsely called knowledge. By professing it, some have strayed from the faith. Grace be with you. Amen.’’ (I Timothy 6:20, King James Version). This passage has been interpreted as a caution against the modern medical understanding of mental illness and support for a spiritual understanding (Powlison 1993). The Couch’s Attitude Toward the Pew Antagonism in the relationship between the couch and the pew is not limited to the church. Science, in general, and the fields of psychiatry and psychology, in particular, have done their fair share of demonizing religion. While the critique of religion in science peaked in the wake of the Enlightenment, inflammatory remarks from philosophers against religion date back to long before the birth of Christ. For instance, Heraclitus, writing in approximately 500 BCE, wrote, ‘‘Religion is a disease, but it is a noble disease.’’ Titus Lucretius Carus was not as generous in his assessment of religion in the first century BCE: ‘‘Religion is a disease born out of fear and a source of untold misery … Fear is the mother of all gods.’’ In the last few centuries, criticism of religion emerged in the realm of the behavioral sciences. The following table illustrates some of the long-standing tensions between many Christians and those speaking from a secular, philosophical, or behavioral science perspective (Table 1). The use of such vitriolic language toward the church by those in the mental health profession is particularly significant. It reveals how deeply anti-religious sentiment is historically imbedded in the beliefs of many of those who seek to treat mental illness (Pargament and Saunders 2007). No small wonder that, historically, mental health providers were hesitant to engage spiritual and religious perspectives with their clients, if many of them considered religion as a primary source of their client’s suffering. Koenig et al. (2001) identify several concerns about religion’s potential negative impact on medical care in general, some of which pertain directly to mental health, including failure to seek timely medical care and replacing mental health care with religion. Further, MH clinicians may identify a causal relationship between religion and delusion, whereas patients may be using religion as a framework for understanding their illness. More recently, however, faith is being recognized by the fields of psychology and psychiatry as an important component of health and one that might contribute to a patient’s recovery. The American Psychological Association’s Society for the Psychology of Religion and Spirituality (Division 36) (http://www.apa.org/about/division/div36.aspx) now promotes the application of psychological research methods to diverse forms of religion and spirituality, as well as incorporating research results into clinical practices. This group fosters constructive dialogue between psychology and religious perspectives and institutions. Similarly, the American Counseling Association through its endorsement of the Association for Spiritual, Ethical, and Religious Values in Counseling (ASERVIC) (http://www.aservic.org) has identified and disseminated six spiritual competencies to assist in addressing spiritual and religious issues in counseling. Even so, clinicians who may appreciate their patients’ faith are constrained in their ability and willingness to address a patient’s faith by professional boundaries and uncertainty about the effectiveness of integrating faith and mental health treatment. In addition, lack of knowledge, training, and/or understanding about the diversity of religious practice often create barriers for
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J Relig Health Table 1 Historical perspectives on religion and mental health tensions Clergy perspective on mental health
Mental health/societal perspective on religion
Dangerous threat ‘‘Modern psychiatry is as anti-Christian, dangerous, and satanic as evolution.’’ (‘‘The Fraud of Modern Psychiatry’’ http://jpfinn7.com/2012/03/30/ psychiatry-is-bogus/)
‘‘Religion is a disease, but it is a noble disease.’’— Heraclitus, circa 500 BCE
‘‘Psychoheresy is the integration of secular psychological counseling theories and therapies with the Bible. Psychoheresy is also the intrusion of such theories into the practice of Christianity in terms of the nature of man, how he is to live and how he changes.’’ (PsychoHeresy 2012) (Psychoheresy-aware.org)
So potent was religion in persuading to evil deeds Only religion can lead to such evil. (Book I, line 101) Titus Lucretius Carus, circa 55 BCE (Titus Lucretius Carus 2008) Religion is a disease born out of fear and a source of untold misery… Bertrand Russell (Russell 1930)
Social support/organization ‘‘…I myself am fully convinced that you yourselves (local church) are full of goodness, filled with all knowledge, and able also to counsel one another.’’ (Romans 15:14) (italics added)
‘‘Religion is a disease. It is born of fear; it compensates through hate in the guise of authority, revelation. Religion, enthroned in a powerful social organization, can become incredibly sadistic. No religion has been more cruel than the Christian.’’—Dr. George A. Dorsey, Anthropologist (Dorsey 1868–1931)
Source of suffering ‘‘For all have sinned and fallen short of the glory of God…the wages of sin is death.’’ (Romans 3:23, 6:23)
‘‘The most deadly form of insanity is the Obsessional Neuroses commonly called ‘religion’. This aggressive and contagious mental health disorder has caused more death and suffering than any other communicable disease.’’—Emmett F. Fields (Atheism: The Struggle against Superstition (30 complete rare books on CD-Rom) 2002
‘‘…problems are because of what is in us, not because of what someone did to us.’’ (David Powlison) (Powlison 1993)
‘‘Anyone who engages in the practice of psychotherapy confronts every day the devastation wrought by the teachings of religion (p. 127).’’— Nathaniel Branden 1930, objectivist psychologist (Lane 2008)
Source of wisdom ‘‘As the heavens are higher than the earth, so are my ways higher than your ways and my thoughts than your thoughts.’’ (Isaiah 55:9)
‘‘At bottom God is nothing more than an exalted father (page 147).’’ Sigmund Freud, Totem and Taboo (Freud 1962)
‘‘For the foolishness of God is wiser than man’s wisdom, and the weakness of God is stronger than man’s strength.’’ (1 Corinthians 1:25, ital. mine)
‘‘Divine wisdom is human wisdom (page 267).’’ (Ludwig Feuerbach The Essence of Christianity. (Feuerbach was a philosopher that heavily influenced Freud) (Feuerbach 1854)
Source of knowledge ‘‘O Timothy! Guard what was committed to your trust, avoiding the profane and idle babblings and contradictions of what is falsely called knowledge- By professing it, some have strayed from the faith. Grace be with you. Amen.’’ (KJV)
‘‘Religion is an illusion and it derives from the fact that it falls in with our instinctual desires (Page 239).’’ Sigmund Freud, New Introductory Lectures on Psychoanalysis. (Freud 1933)
‘‘Faith is the substance of things hoped for, the evidence of things not seen.’’ (Hebrews 11:1, KJV)
‘‘…there are no sources of knowledge of the universe other than what we call research’’ (Freud, quoted in Nicholi, p. 20B) (Nicholi 2003)
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clinicians. The complexity of this problem is highlighted by psychiatric physicians generally being personally less religious than non-psychiatric physicians and at the same time being more open to addressing religious/spiritual issues with their patients than other physicians (Curlin et al. 2007a, b; Larson et al. 1986). Adding to the complexity is the possibility that psychiatry residents are more religious than psychiatrists in practice, and therefore, there may be shift underway toward psychiatrists’ personal religious beliefs becoming more similar to those of other, nonpsychiatrist physicians (Waldfogel et al. 1998). These recent shifts toward openness by mental health providers may not be as evident to the faith community as the historical antagonism of psychiatry and psychology toward religion, given the sound-bite quality and traction of the above quotes. Many church goers and their clergy are well aware of the historical and possible current negative perceptions that mental health professionals have about religion, and these perceptions continue to exacerbate the tension between the couch and the pew.
Progress Fortunately, over the last several decades, progress has been made in the tension between the pew and the couch (Aten and Worthington 2009; Koenig 2009; Pargament and Saunders 2007). In many ways, we are moving from a period of ‘‘antagonism’’ to ‘‘mutual ignorance.’’ Increasingly, practitioners in the fields of mental health are realizing the important roles that spirituality and faith play in the lives of their clients. Much of this growth in interest began in the 1980s in the United Kingdom. Interest in the intersection of psychiatry and religion in Britain grew rapidly until the formation of the Spirituality and Psychiatric Interest group in 2000. In 2007, this group claimed 13 % of the membership of the Royal College of Psychiatrists in the United Kingdom (Sims 2009). In the United States, Larson and colleagues’ 1993 study of religious examples in case studies of serious mental illness in the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) (Larson et al. 1993) prompted culturally sensitive changes in the DSM-IV. Other mental health providers are people of faith themselves and see this intersection as a natural way to bring social and spiritual benefits into their treatment of others who come from a faith background (Wade et al. 2007). A large body of literature and research has begun to emerge over the last couple of decades that seeks to address this delicate topic of the relationship between spirituality and mental health (Koenig 2009) (Pargament and Saunders 2007; Post and Wade 2009). Research centers studying the relationship between religion and health exist at a number of universities, e.g., Duke’s Center for Spirituality, Theology, and Health (http://www.spiritualityandhealth.duke.edu/) and the University of Chicago Program on Medicine and Religion (https://pmr.uchicago.edu/). Many of these academic institutions such as the Institute for Spirituality and Health at Texas Medical Center (http://www.ishtmc.com/) concentrate their efforts fostering spiritual awareness and clinical integration for physicians. Less attention has been given to studying collaboration between clergy and mental health providers. The Department of Veteran Affairs and Department of Defense have begun initiatives to encourage collaboration between chaplains and mental health providers in the care of service members and veterans through their Integrated Mental Health Strategy (Nieuwsma et al. 2013) and the establishment of VA Mental Health and Chaplaincy (http://www.mirecc.va.gov/mental healthandchaplaincy). Despite these positive trends, mental health providers who are open to this kind of collaboration are uncertain about how to understand and incorporate the
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faith perspectives of their clients into treatment programs, or how to collaborate with resources in their faith communities (Aten and Worthington 2009; Post and Wade 2009). As suggested by Koenig et al., additional randomized controlled trials are needed in addition to qualitative studies to inform the design of religious/spiritual intervention studies (Koenig et al. 2012). From the perspective of the ‘‘pew,’’ many faith communities have recognized the need to connect with local mental health providers and have made concerted efforts to encourage parishioners to address their mental health needs. Progress in mental health relations with the faith community has come in several ways. Many mainline denominations have adopted specific mental health resolutions into their mission statements and denominational statements of belief. Some have established ‘‘mental health networks’’ within their denominations. Ecumenical groups such as ‘‘Pathways to Promise’’ have produced awareness and educational materials to promote mental health ministries in churches and encourage collaboration with mental health organizations on a national scale (http://www.pathways2promise.org). There has also been a movement away from antagonism toward integration of mental health principles within many evangelical denominations, including those in the more rural South (Johnson 2010). In recent decades, many of those providing pastoral care in more conservative churches are integrating psychological and counseling principles into their Biblical understanding of faith and/or referring parishioners to mental health or substance use services (Sexton et al. 2006). This has led to a plethora of ‘‘Christian counseling’’ educational programs and professional programs across the country (Buckholtz 2005; Paul 2011). A number of churches now employ ‘‘pastoral counselors’’ or ‘‘Christian counselors’’ who use mental health principles and techniques in counseling. In some cases, they make referrals to outside mental health professionals (Paul 2011). Although these faith-based counselors are quite selective in what mental health principles they accept and use (Paul 2011), their existence shows an openness to ‘‘the couch’’ and a movement away from antagonism. The progression from antagonism to awareness of the benefits of mental health treatment in some churches illustrates the current variety of attitudes that exist in the faith community.
The VA/Clergy Partnership: A Case Study Literature on the importance of the intersection between spirituality and mental health is plentiful. What has been woefully lacking, however, is a model or template for how to go about collaboration between clergy and mental health. Very few case studies exist describing what collaboration might look like. In an effort to address this question, we began a community-based pilot project in August of 2009 with funding from the VA Office of Rural Health. The Department of Veterans Affairs (VA) South Central Mental Illness Research Education and Clinical Center began a project aimed at training clergy as first responders to veteran mental health issues and to help veterans in rural areas gain greater access to care by developing partnerships between churches and mental health providers (Sullivan et al., accepted). Briefly, a team of VA psychiatry researchers and chaplains identified several rural Arkansas towns as sites to establish partnerships. Next, we identified at least one local clergy member who was interested in being involved in, and potentially leading, a program related to mental health of military veterans. With the help of this clergy member, we established local advisory boards in each community site, consisting of members of the clergy, veterans, and local service providers, including the mental health provider at the local VA community-based outpatient clinic. These local advisory boards
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partnered with the VA researchers and chaplains, met regularly, and together decided on a series of local activities. This partnership grew very slowly for the first 18 months in the initial site but has since grown rapidly and the project has expanded over the last 3 years. There are now four rural communities in Arkansas and one in Oklahoma that are developing partnerships between churches, military support services, and mental health providers. These community-based partnerships are all organized around the needs of veterans and their families. Because we used a community-based approach, each partnership is unique in its makeup, its dynamics, and its specific goals. However, certain themes emerged from these efforts to partner the ‘‘pew’’ and the ‘‘couch.’’ VA/Clergy Partnership Methods We informally gathered information on the process of developing partnerships with faith and mental health communities through observations at community advisory board meetings and discussions with board members (Bernard 2002). This approach allowed us to immerse ourselves in the local context to gain knowledge of social phenomena in the natural setting (DeWalt and DeWalt 2011). We participated in the community advisory boards and other communitybased activities such as ministerial alliance meetings, VA/Clergy-sponsored community events, luncheons, clinician presentations, and informal surveys to establish rapport with community members and to develop relationships with pastors, parishioners, and providers. We recorded our observations and informal conversations with community members in the form of handwritten notes and then transcribed them into field notes. As the field notes were developed, we read them line by line to identify emergent themes and relationships between them (Strauss and Corbin 1998). Below we report on the patterns that emerged for the current tensions between clergy and mental health providers (Table 2). While some of these tensions may represent a more extreme perspective, they were present in our discussions. Current Tensions 1. Lack of trust that clergy/clinician collaboration can happen. Efforts by outsiders to bring together spiritual and clinical mental health resources are often perceived by pastors and chaplains as being uni-directional (i.e., the clergy are encouraged to refer parishioners to mental health, but mental health providers do not refer patients to the clergy). Some of the participating clergy fear mental health providers may drive parishioners away from God and the church. Some pastors and chaplains perceive mental health providers as not valuing the unique benefits of spiritual care enough to reciprocate referrals. Clergy also interpreted healthcare privacy rules as a lack of clergy trust on behalf of health professionals. Similarly, some mental health providers think that if they refer a patient to clergy then the clergy will convince the patient to no longer participate in mental health treatment and instead rely solely on spiritual support for treatment. Mental health providers may also believe that clergy are not adequately trained or credentialed to address mental health problems. 2. Stigma undervalues the contribution of clergy and mental health clinicians. Goffman described stigma as a visible or invisible ‘mark’ that disqualifies a person or group from full acceptance (1963). As described above, there is a long history of stigma and distrust between clergy and mental health providers. Based on our interaction with both clergy and mental health providers, there are those in their respective communities
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J Relig Health Table 2 Current perspectives on clergy and mental health tensions Clergy
Mental health
Trust
People may not need MH care, they need more of God to help with their problems. Referring to MH providers may drive people away from God and the church
Some clergy are not capable of or properly credentialed to address MH problems. The clergy may convince patients not to take their mental health medications
Stigma
Physical health providers are seen as ‘‘blessings from God,’’ but MH providers are not. Clergy therefore become de facto MH counselors
Religion remains undervalued in the context of evidence-based therapies—both in terms of training and in terms of the scientific literature. Historically, religion has been equated with delusion
Knowledge
There is no dialogue between clergy and MH providers so they do not know what each other has to offer. Clergy are often not aware of veterans in their congregations, do not know how to refer to MH, and assume that HIPPA rules will make the sharing of information nearly impossible
MH providers have minimal knowledge and training in how to talk about spiritual issues. MH providers are uncomfortable talking with patients about religion or spiritual issues for fear that doing so will reveal too much of themselves and compromise the patient/provider working alliance
who undervalue the services provided by members of the other group. These judgments usually stem from a lack of understanding and are perpetuated by negative anecdotes that rapidly spread through the respective group. 3. Lack of knowledge about how clergy and mental health clinicians can collaborate Because of the history of minimal dialogue between these groups, they do not know about the potential benefits of collaboration or how best to achieve effective collaboration. Clergy stated that they were not aware of veterans in the congregations or of families that may be directly affected by post-deployment mental health problems because it has not been an issue brought to their attention before. Clergy were also not familiar with mental health referral options or procedures, including the impact of healthcare privacy rules. Mental health providers stated that they had minimal training or were discouraged from talking with patients about spiritual issues with the rationale that spiritual issues were not in their scope of practice. Mental health providers also stated that they did not want to disclose too much about themselves or impose their beliefs on their patients. Based on our experience to date with the VA/Clergy Partnership study and more than 30 cumulative years of providing ministerial services in the rural South, we identified three prevailing attitudes among clergy toward the intersection of faith and mental health. These attitudes represent different approaches to the current tensions summarized above. A. Spiritual Problem, Spiritual Solution Individuals with the ‘‘spiritual problem, spiritual solution’’ perspective would begin by questioning the existence of ‘‘mental illness.’’ They would likely view all mental and emotional problems as purely spiritual issues. From this perspective, ‘‘psychological’’ problems are merely manifestations of demon possession, evil spirits, or the work of the devil. Healing can only come through faith and prayer. Use of psychotherapy and medication demonstrates a lack of faith and may even hinder healing. Orientation toward a medical model of mental illness (e.g., biopsychosocial etiology) or a spiritual model (mental illness is due to a spiritual or moral problem) tends to be a reflection of ethnic, cultural, and geographic beliefs. In Latino faith-based communities, for instance, mental
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illness is commonly perceived as a spiritual or moral problem, and the cure might involve exorcism or faith healing (Dossett et al. 2005). Similarly, some African Americans in the South perceive their substance use to be the work of the devil, evil spirits, or a poor relationship with God, and sobriety is possible through their relationships with God (Cheney et al. 2013). Healing from such ailments comes through faith, prayer, and involvement in the church community (Brown 2006). B.
Mental Problem, Spiritual Solution
The ‘‘mental problem, spiritual solution’’ perspective probably has the widest acceptance among Christian faith communities in the South. This perspective holds that mental illnesses and emotional problems may be real, but that they require a primarily or exclusively spiritual solution. Individuals who hold the ‘‘mental problem, spiritual solution’’ perspective, like the first group, believe that all mental and emotional issues are still fundamentally spiritual in nature. But unlike the ‘‘spiritual problem, spiritual solution’’ perspective, mental illness from the ‘‘mental problem, spiritual solution’’ perspective is less likely to be seen as a direct result of evil spirits or the devil, but instead, as resulting from a loss of faith, lack of prayer, stress, or ‘‘getting away from the Lord.’’ Based on our experiences, we believe that individuals and faith communities with the ‘‘mental health, spiritual solution’’ perspective would be more likely to engage in Christian counseling when necessary, which would use the benefits of professional treatment within a Biblical perspective. To this group, treatments such as psychotherapy and medication are not necessarily evil and probably will not hurt, but they are not usually seen as necessary except in extreme cases and will not heal mental or emotional problems without an accompanying spiritual solution in the individual’s life. C.
Mental Illness, Spiritual AND Mental Solution
Pastors and laypeople who approach mental illness from the ‘‘mental illness, spiritual AND mental solution’’ perspective believe that mental illness is real and benefits from the use of mental health services. They believe that mental and emotional issues are both mental and spiritual. Mental problems may be the result of biopsychosocial risk factors (Bender and Alloy 2011; Bolton et al. 2007; Garcia-Toro and Aguirre 2007; Schotte et al. 2006). In this view, treatment and healing come through spiritual practice as well as medication, psychotherapy, and other mental health services. Mental illness stigma is likely lower among churches and members of these faith communities who hold this view of mental illness (Johnson 2010). They would likely refer to and seek professional help either from those in ‘‘Christian’’ counseling or clinicians practicing from a secular perspective. They believe that the church is called to work alongside mental health providers to increase the mental and spiritual health of their churches and communities by accessing mental health services in addition to emphasizing spiritual practices such as prayer, meditation, study, and community. Current Opportunities The historical and current tensions between clergy and mental health exist but most of the clergy and churches that we have engaged are not hostile to the notion of mental health services for their parishioners. They are more likely to plead ignorance of these issues and to express a feeling of inadequacy in addressing mental health issues. Most clergy have not had education on identifying serious mental health problems and the criteria or protocol for making referrals. They often requested such training and welcomed the shared responsibility for the mental health of their congregation after some of the mental health issues
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were demystified, and they found out how to refer people to formal mental health services. Concern over the tremendous needs of veterans in our rural communities provided a strong motivation and unifying factor in planning and implementing such mental health trainings. Competing with other demands on clergy time and energy seemed to be a greater barrier than an attitudinal unwillingness to cooperate with mental health providers. Another somewhat surprising observation was how eager many mental health clinicians were to engage in a partnership with the faith community. Many reported that they were engaged with clients whose faith played a major role in their lives and were eager to seek out ways to collaborate with the faith community. Clinicians who treat patients with posttraumatic stress disorder recognize that addressing the moral significance of a traumatic event may be critical to recovery (Thielman 2011) and there is recognition that the issue of moral injury associated with being a combat veteran may not be adequately addressed by our current evidence-based mental health treatments (Litz et al. 2009). Similar to what others have found, the mental health providers also identified a need for additional training for both how to discuss spiritual issues and access potential spiritual resources during a clinical encounter and for understanding any legal or ethical limitations to the extent of this discussion (Hodge 2005; Miller 1999). One of the largest barriers to collaboration seemed to come from the fact that clergy and mental health providers do not know each other. We found that simply introducing community clergy and mental health providers to each other during an informal lunch meeting where barriers to collaboration were often discussed resulted in a series of referrals both to and from the clergy. In addition, clergy and mental health providers collaborating on community events (e.g., providing breakfast for soldiers during drill weekend) provided another opportunity to increase trust and decrease stigma. Simply having a trusted face and name to call on when serious spiritual or mental health concerns occurred greatly enhanced the collaboration between the ‘‘pew’’ and the ‘‘couch.’’ This observation is consistent with the anti-stigma literature which identifies direct contact interventions as the most effective method for reducing general population stigma (Corrigan and O’Shaughnessy 2007). Given competing time demands, these informal gatherings also provided an efficient opportunity for the pew and the couch to brainstorm about how best to meet the needs of rural veterans. We also provided ‘‘Pew versus Couch’’ presentations to audiences that included clergy and mental health providers to address both decreased stigma and increased knowledge. Lack of clarity and trepidation about the referral process among clergy led us to create a ‘‘mental health referral protocol for veterans’’ consisting of a practical one-page decision tree that guides clergy through the process of what to do with a person in crisis. We are currently in the process of collecting qualitative data from VA patients receiving mental health services, VA chaplains and mental health providers, and community clergy about how best to enhance clergy/clinician collaboration. In the process of recruiting community clergy for this study, we observed increased interest when the clergy perceived respect for their services from the mental health community. We interpreted this observation as an indication of the barriers to clergy/clinician collaboration that continue to exist and some of the communication that is necessary (respect for what each other can contribute to veteran mental health and the value of their respective contributions) to address these barriers. Rather than continuing to engage clergy by inviting them to come learn what we know about mental health, we have discovered a more effective way of recruiting might focus on our need for clergy expertise in helping veterans with issues like guilt, shame, and moral injury.
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Conclusion There has been an explosion of interest in recent years on the importance of integrating spirituality into medical practice (Koenig et al. 2004, 2012) including results from a recent VA survey which indicated that 47 % of veterans with depression reported they would be ‘‘very’’ or ‘‘somewhat likely’’ to seek help for emotional problems from spiritual counselors such as clergy (Bonner et al. 2013). Less has been written on how to make spiritual integration work. There is almost no literature that looks at why this integration between spirituality and health has been so slow in coming and so difficult to achieve. We have addressed this complex question through a summary of the historical perspectives of both medical science and religion. This long-standing tension has roots in biblical interpretation and in secular bio-medical explanations of illness. The tension is particularly significant when it comes to mental health as the goals and clientele of the faith community and mental health often overlap. Three broad categories of mental health perspectives among faith communities offer insight into the current landscape of the ‘‘the pew’’ versus ‘‘the couch.’’ Some lessons learned from our VA/Clergy Partnership for Rural Veterans give clues as to the best ways for us to move forward. Much research is yet to be done on the efficacy and implementation of collaboration between mental health providers and faith communities. The VA/Clergy Partnership for Rural Veterans provides a case study and model for both the importance and the difficulties of trying to form this collaboration. Plans are under way to collect data both on the best practices for clergy/clinician collaboration with the goal of improving access to services and on the outcomes for returning veterans. Acknowledgments The authors would like to acknowledge VA South Central Mental Illness Research, Education, and Clinical Center (MIRECC) and the VA Office of Rural Health for support and funding for this project. We also recognize Elise Allee and Carrie Edlund for editorial and research contributions, as well as the Chaplains of the Central Arkansas Veterans Healthcare System. Finally, we recognize the many community clergy and mental health providers who came together at places like Western Sizzlin of Russellville to begin the process of honest dialogue and collaboration between ‘‘the pew and the couch.’’
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