Jean S pann A nthony , PhD, RN,
A pril Jo hnson , BSN, RN, John S chafer, PhD
Abstract: Nearly 40% o f African Americans use clergy as their primary source
o f help with depression. However, less than half o f African American clergy are
trained in counseling. Objectives: 1) to examine how African American clergy
recognize depression and 2) identify what they need to more effectively identify
and address depression in their congregants. Design: This was a descriptive,
quantitative study using a Personal Profile Questionnaire and a M ental Health
Counseling Survey. Results: Sixty-five clergy completed the data collection tools;
approximately 50% had some training in counseling. The majority could identify
signs o f depression. Eighty-one percent stated they needed additional education
about depression and access to referral resources. Conclusions: I f clergy take an
active role in addressing the issue of depression and establishing liaisons with
mental health professionals the stigma associated with depression could be greatly
reduced, and individuals might enter into treatment earlier thus improving their
quality o f life.
Key Words: African American Clergy; Depression; Congregants; Depression
Cues. Circles A frican A merican C lergy and
D epression: W hat they know;
W hat they want to know
epression is a serious medical illness affecting
more than 19 million American adults each
year but one that can be effectively treated
(Report of the Surgeon General, 2001). In fact, more
than 80% of people with depression can be treated
successfully with medication, psychotherapy or a
combination of both. However, in the African Ameri­
can community depression is often untreated (Mental
Health America Fact Sheet, 2006). Factors that con­
tribute to fewer African Americans being diagnosed
and treated for depression include: 1) a mistrust of the
medical profession based on historical experiences; 2)
cultural barriers, influenced by language and value
differences between the health care provider and the
patient; and 3) reliance on the support of family and
the religious community during periods of emotional
distress (Brown, Ndubuisi, & Gary, 1990; Dupree,
Watson & Schneider, 2005). D Jean Spann Anthony, PhD, RN, corresponding au­
thor, is an Associate Professor in the College of Nursing,
the University of Cincinnati in Cincinnati, OH. Dr.
A nthony may be reached at: Jean.Anthony@uc.edu.
April Johnson, BSN, RN, is a Graduate Student in
the College of Nursing at the University of Cincinnati.
John Schafer, PhD, is a Statistician in the College of
Nursing at the University of Cincinnati. Journal of Cultural Diversity • Vol. 22, No. 4 BACKGROUND
The lifetime prevalence of Major Depression Disor­
der (MDD) is estimated to be higher for Whites than
for African Americans (Earl, Williams & Anglade,
2011). A study by Pratt & Brody (2008) reported that
the percent of non-Hispanic adult blacks suffering
from symptoms of depression was 10.4% compared
to Whites (17.9%). However, Earl et al, (2011) found
significant differences in the measures of persistence/
chronicity and severity in depressed African Ameri­
cans (56.5%) compared to Whites (38.6%). A similar
study by Williams, Gonzales, Neighbors, Nesse,
Abelson, Sweetman, & Jackson, (2007) found that on
average African Americans had higher scores on all
correlates of depression including those of Caribbean
Blacks. Outcomes of their research show that dispari­
ties in mental health status can and do exist across the
continuum of mental health. Living in an environment
of oppression, injustice, discrimination, high crime
levels, decreased access to goods and services and rac­
ism can lead to feelings of unhappiness and dissatis­
faction with life leaving one more vulnerable to stress
and thus the onset of depression and other mental
disorders (Earl et al, 2011). However, in the study cited
earlier by Pratt & Brody (2008), only about 29% of all
ersons with depression reported contacting a mental
ealth professional and only 39% of those making the
contact actually kept the appointment (Whaley, 2001;
Sussman, Robins, & Earls, 1987). In addition, African
Americans are less likely than other groups to receive
Winter 2015 adequate mental health treatment due to factors includ­
ing racial bias, inadequate financial resources and lack
of access to care (Amour,Bradshaw, & Rosenborough,
2009; Ford, 2003).
Several studies on attitudes and beliefs about depres­
sion have shown that approximately 63% of African
Americans believe that depression is a personal weak­
ness, and almost two-thirds said they believe that prayer
and faith alone w ould successfully treat depression
(Wang, Lane, Olfson, Pincus, Wells & Kessler, 2005;
Chamberlain, Muntaner, Walrath, Nickerson, LaVeist, &
Leaf, 2001; Neighbors, 1985). Nearly 40% of the African
American population use clergy as their primary source
of help for mental health issues, with less than 10% being
referred on to mental health specialists (Openshaw &
Harr, 2009; Farris, 2006; Kales, Blow, Bingham, Roberts,
Copeland & Mellow, 2000; Levine, 1986). Further, Afri­
can Americans who saw clergy first were less likely to
contact other mental health professionals, were more
satisfied w ith the help they received from clergy, and
were more likely to refer others to clergy rather than
to mental health professionals (Jett, 2000; Neighbors,
Musick, & Williams, 1998).
The African American church has historically been
the central institution in the black community, "giving
rise to religious traditions, education, music, dramatic
and artistic opportunities, economic stability and po­
litical involvem ent" (Lincoln & Mamiya, 1990, p. 9;
McAdoo & Crawford, 1990). African American clergy
are intim ately involved in the lives of congregants
providing counseling for bereavement, marital issues,
pregnancy, employment, violence/abuse, drug abuse
and legal problems (Taylor, Ellison, Chatters, Levin, &
Lincoln, 2000; Mollica, Streets, Boscarino, & Redlich,
1986). Studies have shown that while clergy do not
differ significantly from mental health practitioners in
terms of types and severity of psychiatric disorders
they see, less than half of African American clergy have
training in clinical pastoral counseling (Battle, 2006;
Moran, Flannelly, Weaver, Overvold, Hess & Wilson,
2005). At a very early age African Americans are taught
to lean on God when one endures hardships and dif­
ficult situations (Pew Forum on Religious & Public Life,
2006; Millet, Sullivan, Schwebel, & Meyers, 1996). Many
African Americans believe that clergy are that bridge
to God w hen they are facing hardships and need sup­
port. Research conducted by Cooper, Gonzales, Gallo,
Rost, Meredith, Rubenstein, Wang & Ford, (2003) also
show ed that African Americans were less likely to
seek help from mental health specialists and m uch less
likely to continue with follow-up visits. When personal
problems arise, often resulting in depression, African
A m ericans are significantly more likely to contact
their clergy than a mental health professional (Payne,
2008; Anthony, 2007; Ellison, 1993). Because depressed
congregants w ith a range of problems and levels of
severity seek help from their pastors, religious leaders
need to be able to differentiate between problems they
are prepared to counsel and manage from those that
w arrant consultation from mental health professionals
(Wylie, 1984).
Involvement in spiritual and church based activities
provides a source of support for many African Ameri­
cans. In order to identify and respond more readily to
congregant health issues some churches assign m em­
Journal of Cultural Diversity • Vol. 22, No. 4 bers to smaller groups called "m issions or circles."
Membership in these smaller "circles" provides many
congregants an opportunity to develop a support
system within the church, particularly larger churches
where it is sometimes difficult to get to know others.
The members of the "circle" are often the first to notice
that an individual needs attention from the pastor or
a mental health professional (Stansbury, Harley, King,
Nelson, & Speight, 2010; Becker, Gates, & Newsom,
2004; Carter, 2002; Blasi,Husaini, & D rum w right 1998;
Caldwell, Greene & Billingsley, 1992).
Several studies explored preferences of African
A m ericans for m ental health care and found that
they were 2 Vi times more likely to select a member of
clergy for treatment than a mental health professional
(Lewis & Green, 2000; Schnittker, Freese, & Powell, 2000;
Snowden, 1998). The findings from these studies and
the dearth of literature in this area demonstrate a need
for more research to better understand the role of African
American clergy in the recognition and management
of depression in their congregants. The research shows
that many African American congregants, regardless of
age, expect their clergy to assume a role that provides
support and solutions for their depression (Jackson,
Torres, Caldwell, Neighbors, Nesse, Taylor, Trierweiler,
& Williams, 2004; Wimberly, 1979).
While the research is clear that African American
clergy are intimately involved in all aspects of their
of their congregants lives including providing mental
health services, little is known about their knowledge
of depression and the actual counseling services and
strategies that they use to address depression care needs
of their congregants. Clergy have acknowledged their
role(s) in counseling congregants with depression symp­
toms, averaging over 6 hours per week (Stansbury &
Schumacher, 2008; WesfiTanamly, Novgood, & Williams,
2006). However, several studies revealed that African
American clergy lack knowledge about the biological
and psychological causes of depression (Young, Griffith,
& Williams, 2009; Neighbors, Musik & Williams, 1998;
Lincoln & Mamiya, 1990). African American clergy
overwhelmingly state that their pastoral counseling
approaches are theologically grounded in the beliefs that
depression is the result a of spiritual poverty, demonic
oppression, personal sin and a lack of faith (Stansbury,
et al, 2010; Payne, 2009; Carter, 2002; Kelcourse, 2002;
Blasi, et al, 1998; Mollica, et al, 1994; Chalfont, Roberts,
Heller, Briones, Aguirre-Hichbaum, & Farr, 1990; Levine,
1986).
Clergy w ith a more theologically based view about
depression and other mental illnesses are less likely to
recognize the symptoms and levels of severity of m ental
illnesses and therefore render less effective counseling
(Hong & Wiehe, 1974). Further, the research by West
et al (2006) and Openshaw & Harr, (2009) found that
the lack of understanding of the causes of depression
significantly altered clergy's perceptions and treatment
approaches. Clergy w ithout previous exposure and
understanding about depression were more likely to
use spiritual interventions such as prayer, reading of
scriptures and a counseling focus on God as the only
one who can relieve the symptoms.
Studies by Stansbury et al, (2010) and Stansbury
& Schumacher (2008) showed that clergy w ith previ­
ous exposure to depression via personal experience or
Winter 2015 Figure 1. Mental Health Counseling Survey
Mental Health Counseling Survey
Adapted from: Wylie, W.E. (1984) Health counseling competencies needed by ministers.Journal of Religion and
Health. 23: 237-49
1. Describe the characteristics of congregants who seek counseling from you.
Age range:_________
Gender:____Male Income range:_______________ _____ Female Educational Level________ _____both Do they come in as:____Individuals _____Couples______Family____Parent/child
2. Do any of your congregants seek your help when dealing with the following issues?
(Check all that apply).
__Anxiety
__Depression
__Suicidal Ideation
__Bereavement/Grief
__Other (please specify)_________________________________________________ 3. In the past 4 weeks, estimate the number of people whom you have counseled for any reason:
Total number:____________________________ 4. In the past 4 weeks estimate the number of people whom you have counseled for each of the following
mental health problems:
Depression_____________________ Anxiety_______________________ Suicidal ideation_____________
5. Why do you think most people come to you instead of going to mental health professionals for help with
depression? Rank in order of importance below
(1= lowest, 4 = highest).
____Their spiritual values and beliefs may not be respected by health care professionals
____Health insurance does not cover visits to a mental health professional
____Clergy integrate their spiritual values and beliefs into the counseling
____Other (Explain)______________________________________________ 6. What cues make you suspect that a congregant might be depressed? 7. How does your depression counseling compare to your spiritual counseling experiences? (Check all the
answers below that are true for you)
___Issues brought up in depression counseling almost never overlap with those addressed in spiritual
counseling. Journal of Cultural Diversity • Vol. 22, No. 4 Winter 2015 ___The methods I use in depression counseling are distinctly different from those I use in spiritual
counseling.
___Depression counseling is very dissimilar to spiritual counseling.
___Depression counseling is somewhat different from spiritual counseling.
___Depression counseling is somewhat similar to spiritual counseling.
___Depression counseling is very similar to spiritual counseling.
___Issues brought up in depression counseling are identical to those addressed in spiritual
counseling.
___
8. The methods I use in depression counseling are no different from those I use in spiritual counseling. Do you refer depressed congregants to any of the following?
Check all those that you refer to):
__Mental health specialist
__Hospital emergency room ___Primary care provider
___Psychiatric hospital __Other (describe)__________________________
9. What factors influence your decision to make a referral?
Congregant's signs & symptoms
Your level of comfort 10. 11. Individual request
Other (Explain) As you think about your experiences in counseling individuals suffering with depression, is there
anything that would help you do a better job? In your opinion, is formal training in depression counseling skills appropriate for
clergy?
Yes No If no, why not? Is formal training in depression necessary for clergy?___Yes No If not, why not? Journal of Cultural Diversity • Vol. 22, No. 4 Winter 2015 education/training are more knowledgeable about the
risk factors and symptoms of depression. These clergy
often suggest self help interventions for congregants
and encourage them to seek professional help with
primary care providers being the first choice. However,
many clergy remain uninformed about the causes and
symptoms of depression (Eng & Hatch, 1991; Wylie,
1984). This lack of knowledge leads to clergy failing to
recognize depression, their inability to initiate effective
counseling strategies, increased inability to manage their
depressed congregants. Additional research is needed
to identify the types of mental health problems encoun­
tered, the counseling strategies used and the resources
and educational needs of African American clergy so
they can better meet the depression care needs of their
congregants.
RESEARCH QUESTIONS
For many African American clergy the origin of men­
tal illness is still associated with spiritual weakness, a
lack of faithfulness, and / or demonic influences (Young
et al, 2003; Millett et al, 1996). The lack of knowledge
about depression demonstrates the need for more re­
search to clearly identify the training and resource needs
of African American clergy in order to improve their
ability to successfully recognize and manage depressed
congregants (Eng & Hatch, 1991; Larson et al., 1988).
Without special training, clergy may be ill-equipped to
deal with mental illness resulting in an escalation of
symptoms being experienced and possibly prolonging
recovery. Few studies have explored the role of African
American clergy in counseling congregants with de­
pression. This study examined four research questions:
• •
•
• What is the association between the African
American clergy's demographic factors (age, edu­
cation, gender, marital status) and their ability to
recognize and address depression?
What are the cues / behaviors that African Ameri­
can clergy look for that starts them thinking that
a congregant may be depressed?
How does depression counseling differ from spiri­
tual counseling among African American clergy?
What do African American clergy identify as their
resource and training needs in order to develop
their skills in recognizing and managing depres­
sion in their congregants? METHOD
Research Design
This descriptive, quantitative research study was
approved by the University of Cincinnati Institutional
Research Review Board. There were two sources of data:
Personal Profile Questionnaire and a Mental Health
Counseling Survey (Figure 1). Criteria for inclusion in
the study were African Americans who self-identified as
clergy, 18 years of age or older, able to read, understand
and sign the Informed Consent Form and complete
the Personal Profile Questionnaire and Mental Health
Counseling Survey. The recruitment criteria were broad
in order to maximize recruitment.
Sample
Purposive sampling was used to recruit participants
for this study. A list of African American churches was
Journal of Cultural Diversity • Vol. 22, No. 4 obtained from the local Interdenominational Ministe­
rial Alliance. The names of the churches were placed
in a box and 300 names of churches were selected to
receive the survey and questionnaire. The Personal
Profile Questionnaire and Mental Health Counseling
Survey were mailed to 300 African American clergy in a
Mid-western city. The sample represented churches of
the Baptist, Catholic, and Methodist, Apostolic and Non­
denomination faiths. Participation criteria required
that the participant 1) self-identify himself/herself as
African American clergy, 2) be 18 years of age or older,
and 3) be able to read and complete the Personal Profile
and Mental Health Questionnaire. The completion and
return of the data collection tools were interpreted as
consent to participate in the study.
The Mental Health Counseling Survey (MHCS) is
an eleven item questionnaire designed to identify the
knowledge, beliefs and counseling experiences of Afri­
can American clergy (Figure 1). The MHCS is adapted
from the Health Counseling Competencies Needed for
Ministers Survey designed to determine the competen­
cies ministers need to feel competent in counseling
congregants (Wylie, 1984).
Recruitment
Recruitment procedures included attending several
of the local meetings of African American clergy in­
cluding the Baptist Ministers Convention meetings, the
Martin Luther King, Jr. Coalition, the Faith Community
Alliance and the Women of the Word Conference. At­
tending these meetings of clergy allowed the principal
investigator (PI) to be introduced to the clergy, describe
the significance of the study and answer any questions.
The PI also distributed flyers as a reminder to the clergy
to expect to receive the survey and questionnaire in the
mail within a week of the meeting and as encourage­
ment to share information about the study with their
colleagues. Several clergy had questions about the
research procedures, particularly about confidential­
ity and how their responses would be reported. The
clergy were reassured that the data would be reported
in aggregate and that no names would be used. The PI
also assured the members that the data would be kept
secure in a locked cabinet in her office and on the secure
university server.
At these meetings a number of the clergy agreed
that there was a need for additional training about de­
pression. In addition, several clergy gave the principal
investigator (PI) their cards and contact information so
that the questionnaires could be mailed to their homes
or church offices.
FINDINGS
A total of sixty-five (n=65) clergy completed and
returned the Mental Health Counseling Survey and
Personal Profile Questionnaire. The participants in this
study were predominantly middle aged, male and
highly educated. The majority of respondents were male
(n=48); ninety- five percent (n=62) identified themselves
as African American and n=3 identified themselves as
being of mixed race (African American and White);
seventy-six percent were married (n=43). The mean age
of participants was 55 years. The educational levels of
the participants included: twenty-five percent (n=16)
having earned a doctorate degree, forty-five percent
Winter 2015 (n=29) had m aster's degrees, one (n=l) had a Juris
Doctorate , and twenty-one percent (n=14) had com­
pleted some church-sponsored training. Seventy-eight
percent (n=51) had completed some level of training in
pastoral counseling. The types of training in counseling
varied from that obtained as part of the curriculum in
seminary, m aster's a n d /o r doctoral programs, peer
counseling, on-line counseling programs, and comple­
tion of continuing education programs. The majority
of participants identified themselves as Baptist (n=38)
or non-denominational (n=18) (Table 1).
Demographic factors (gender, age, education) were
not associated with the clergy's ability to identify signs
of depression. Each of the participants was able to list
two or more of the most frequently recognized signs of
depression. The most frequently cited signs of depres­
sion were crying, isolation, insomnia, changes in activi­
ties (a lack of attendance at church activities) and mood
swings. Participants stated that as much as 50 - 80% of
their time was spent in counseling congregants. Table 2
shows the types of mental health conditions the clergy
stated they had counseled in the four weeks prior to
completing the questionnaire. The most frequently seen
symptoms were those associated with depression in 243
congregants. Other conditions included:
•
•
• The majority of participants (n=54) stated that the ma­
jority of their congregants sought individual counseling
for these mental nealth conditions. Almost half of the
participants (n=33) stated that they were being asked
to counsel more children during this same four week
time period. Clergy also stated that what began as an
individual (adult or child) counseling session frequently
led to family (n=25) and couple (n=41) counseling ses­
sions.
The most frequent issues for which congregants
sought counseling from their clergy were: bereave­
ment/grief, depression, anxiety and suicidal ideation/
attempts.
The data also showed that having a master's degree
was moderately and positively associated with hav­
ing had some training in pastoral counseling, r =.311*
and with counseling depressed and anxious persons, r
=.337** and r =.384** respectively. There was a strong,
positive association between those clergy with an as­
sociate degree and the counseling of congregants with
suicidal ideation or attempts r = .655**. This strong
association could be a result of the senior pastor del­
egating the counseling needs/requests of individual
congregants on to an associate pastor because of his /
her demanding schedule.
Table 3 compares the clergy's beliefs about depression
counseling versus spiritual counseling. The majority of
clergy in this study had a clear understanding of how 243 with symptoms of depression
41 with expressions of suicidal ideation
195 with symptoms of anxiety. Table 1. Demographic Profile of Participants (n=65)
N % Gender
Male
Female 49
16 75.38 %
24.61 7
51
1
6 10.76
78.46
1.54
9.23 16
29
1
23
2
4
3
14
10 24.61
44.61
1.54
35.38
3.07
6.15
4.61
21.53
15.38 26
12
10 38.46
18.46
15.38 M arital status
Single
Married
Widowed
Divorced
Education
Doctorate (PhD, ThD, Dmin)
Masters
JD
Bachelor degree
Associate degree
Seminary
Undergraduate student
Church training
Other
Church denomination
Baptist
Non-denominational
Methodist Journal of Cultural Diversity • Vol. 22, No. 4 Winter 2015 Table 2. Frequency of mental health conditions for which congregants seek help from their clergy
F re q u e n c y P e rc e n t D e p r e s s io n 47 64.4 A n x ie ty 42 57.5 S u ic id a l id e a tio n /b e h a v io r 23 31.5 Table 3. Clergy's descriptions o f depression counseling compared to spiritual counseling
F re q u e n c y P e rc e n ta g e Is s u e s b r o u g h t u p in d e p r e s s io n
c o u n s e lin g a lm o s t n e v e r o v e rla p
w ith th o s e a d d r e s s e d in s p iritu a l
c o u n s e lin g n= 50 79.3 T h e m e th o d 1 u s e o n d e p r e s s io n
c o u n s e lin g a re d is tin c tly d iffe r e n t
fr o m th o s e 1 u s e in s p iritu a l n= 48 76.2 n=52 82.5 n=49 77.7 n=32 50.7 c o u n s e lin g
D e p r e s s io n c o u n s e lin g is v...

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