Faith Based Organizations and Mental Health Care

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This article was downloaded by: [Universiteit Leiden / LUMC ] On: 20 March 2012, At: 06:42 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK

Mental Health, Religion & Culture
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Finding common ground: the boundaries and interconnections between faith-based organisations and mental health services
Gerard Leavey , Gloria Dura-Vila & Michael King
a a b c

Northern Ireland Association for Mental Health, 80 University Street, Belfast BT7 1HE
b c

Imperial College, London, UK

Department of Mental Health Sciences, University College, London, UK Available online: 07 Jul 2011

To cite this article: Gerard Leavey, Gloria Dura-Vila & Michael King (2012): Finding common ground: the boundaries and interconnections between faith-based organisations and mental health services, Mental Health, Religion & Culture, 15:4, 349-362 To link to this article: http://dx.doi.org/10.1080/13674676.2011.575755

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Mental Health, Religion & Culture Vol. 15, No. 4, April 2012, 349–362

Finding common ground: the boundaries and interconnections between faith-based organisations and mental health servicesy
Gerard Leaveya*, Gloria Dura-Vilab and Michael Kingc
a

Northern Ireland Association for Mental Health, 80 University Street, Belfast BT7 1HE; b Imperial College, London, UK; cDepartment of Mental Health Sciences, University College, London, UK (Received 10 February 2011; final version received 24 March 2011) A perennial theme in the literature of religion and mental health is the need for dialogue between psychiatry and faith-based organisations in the care of people with mental health problems. These worlds are often depicted as oppositional and antagonistic; at times the boundaries are so tightly drawn that it is hard to see where they might share values and concerns. This paper examines the interface areas of religion and mental health care in order to consider where consensus and from where collaboration might emerge. We suggest that while certainly there is a need for dialogue and mutual understanding, there is also a need for psychiatry and faith groups to explore the nature and boundaries of proposed relationships. Keywords: clergy; organisations psychiatry; mental illness; help-seeking; faith-based

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Introduction The importance of religion and spirituality in the context of mental illness can be considered in various ways. First, healing, in theological terms, and from sociological and anthropological theoretical perspectives, is a central function of most religions (Csordas & Lewton, 1998; Durkheim, 1897/1997). In Christianity and other religions, religion-oriented behaviour, individually or collectively, privately or publicly is often directed to the removal, attenuation or endurance of suffering (Church Review Group, 2000; Numbers & Amundsen, 1986). Moreover, a large body of literature, mostly from the USA, suggests that religion and spirituality promote health. These findings have been reviewed comprehensively elsewhere and the various possible mechanisms of the association between health and religion well aired (Koenig, 1988; Levin, 1994). Briefly, these can be understood in sociological or social-psychological terms whereby the individual benefits from community acceptance, belonging and participation. Additionally, religious communities may sometimes provide a moral framework for positively oriented health behaviour (for example, the avoidance of sexual promiscuity and substance misuse). Religion, religious values and practices are also thought to energise healthy coping styles through forgiveness, acceptance, meditation and prayer.
*Corresponding author. Email: [email protected] y This paper is a contribution to the Special Issue on Psychiatrists’ views on the place of religion in psychiatry, and the editors apologise to authors and readers for its delayed appearance.
ISSN 1367–4676 print/ISSN 1469–9737 online ß 2012 Taylor & Francis http://dx.doi.org/10.1080/13674676.2011.575755 http://www.tandfonline.com

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Additionally, ethnic and religious pluralism, for the time being at least, have slowed up the seemingly inexorable progression to secularism within the United Kingdom and other European societies. Correspondingly, in the context of healthcare provision, cultural sensitivity and other concepts such as consumer involvement and choice, holistic care and the expert patient challenge the growth of medical scientific objectivism. In consequence, perhaps, there has been increased demand for partnerships with faith-based organisations (FBOs) in the care of people with mental health problems. However, in the United Kingdom there has been no attempt to examine or test the processes and frameworks in which this relationship might flourish. We have structured the paper in three sections: in the first section, we examine the role of FBOs in mental health care, we suggest that while current mental health is dominated by state provision, it is religious in origin and that faith communities continue to be an important resource. In the second section, we review the role of religion and clergy in helpseeking which we suggest is a vital linkage between FBOs and mental health care. In the final section, we consider the role of religion in psychiatric care and why it has relevance in the care of psychiatric service users. In the discussion, we tie up these themes and suggest that while certainly there is a need for dialogue and mutual understanding, there is also a need for psychiatry and faith groups to explore the nature and boundaries of proposed relationships.

The role of FBOs in mental health care Social capital and FBOs Among larger religious groups, health care has been accommodated within secular professional institutions; indeed many healthcare systems and hospitals in Western societies have a religious provenance (Koenig, 2005; Numbers & Amundsen, 1986). Although in Western social economies the provision of education, welfare and health has been largely enveloped by the state system, from the latter end of the twentieth century there has been a tendency towards partnership with non-governmental agencies in the provision of welfare services, in part ideological but also driven by pragmatic economics. Latterly, religion and spirituality have re-emerged as part of the discourse around public service provision, albeit for often negative reasons; the conflict between moral perspectives and discriminatory behaviour related to homosexuality, for example. Despite such tensions, in recent years, government departments, public and nonstatutory agencies have warmed to the inclusion of FBOs as partners in health and welfare services. The rationale for this partnership is generally predicated on the latter’s declared commitment to entwined spiritual and social values, and the valued deep-rooted social connections of many faith communities in fostering social cohesion agenda (Putnam, 2000). Thus, the prospect of unbridled materialism, individualism and the corollary of weakened communities has prompted government attraction to the communitarian ideas of commentators such as Putnam (2000) and Etzioni (1993). These emerge in the health literature as the potential public health value attached to notions of social capital (Baum et al., 2000; Baum & Ziersch, 2003; Kawachi, Kennedy, & Lochner, 1997). Religion-based communities, sometimes coterminous with minority ethnic communities, stand as fairly useful exemplars of social capital ideals – reciprocity, integration, socialisation, activism and voluntarism – which solidify the community and benefit the individual. Arising from this counter-anomic vision of religion the incorporation of FBOs as a significant adjunct to statutory sector health and welfare appears as a rational move.

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In our post-enlightenment universe, religion has often been pilloried for being, socially and individually, infantilising, divisive and destructive. As the frontline embodiment of religion, clergy have, of course, been attacked as hypocritical, parasitical and exploitative. Sexual and financial scandals add to the weight of evidence against clergy. However, often overlooked is the vast but seldom quantified amount of community building and cohesion in which clergy and FBOs quietly engage, the long-standing health and welfare patchwork provided as part of ministry, meeting the gaps that the welfare state leave behind or are unable to fill (Davis, Paulhus, & Bradstock, 2008). Also, individual clergy and their institutions have been at the forefront of many social and political causes across Western Europe, the USA, South Africa and Latin America; black civil rights issues, liberation theology, anti-apartheid and various social justice campaigns in the United Kingdom. While the media in the USA has focused on the sex and financial scandals of the religious right, Wuthnow and colleagues (Wuthnow & Evans, 2002) have documented the huge moral and financial commitment to social aid and reform by the Protestant mainstream churches (Olson, 2002). It has been argued that this type of engagement is motivated by proselytisation rather than altruistic concern but the evidence suggests otherwise. However, in any case it would be difficult to argue that state welfare provision is always free of ulterior motives or supplementary outcomes. On the other side of the fence, Government motivation for church involvement is largely a matter of pragmatic economics. It is obvious to any policy-maker that the widespread and embedded presence of FBOs across a diversity of communities, marginal and otherwise, offers readymade structures for the dispersal of welfare goods and services. In the USA during the Bush years, the transfer of welfare dollars to church-based groups may be viewed in more ideological terms, the promotion of a wider neo-conservative strategic alliance with evangelical (or simply religious) populations. There is, of course, deep-seated ideological opposition to an erosion of state secularism. For others the concerns relate simply to the destruction and displacement of long-established non-religious voluntary sector bodies as they lose out to the FBOs. Not simply sour grapes, such changes may have negative consequences in public health and personal life-chances.1 Other critical perspectives on religion emphasise its service to conservatism and the domination or hegemony of establishment values through false consciousness (Bourdieu, 1985; Gramsci, 1971). However, the spread of materialism and capitalist forces have been regularly challenged by clergy from various faith traditions. For instance, liberation theology which emerged in the late 1960s in Latin America produced a revision of the Gospel as a call to end poverty and deliver people from oppressive political systems (Casanova, 1994; Mart|n-Baro, 1990). Elsewhere, where socio-economic deprivation and ethnicity coincide, faith organisations often occupy a key community leadership role for both spiritual and material reasons. Thus, the Black churches in the USA have occupied a central position in the African-American communities from the nineteenth century onwards and have been at the heart of social activism and reform (Chaves & Higgins, 1992). Studies elsewhere reveal that certain religious groups may adopt quite assertive religious approaches to the care of mental health sufferers (Redko, 2003). For instance, black Pentecostal churches, operating within predominantly migrant and inner-city communities throughout Europe and South America, embrace a counter-anomic approach to their mission, working amidst marginalised peoples and urban blight (D’Epinay, 1969; Martin, 2002). This ‘‘branch’’ of Christianity offers support that is not solely compensatory, a spiritual redemption in the afterlife, but provides a vehicle for material change on earth (Droogers, 1994; Martin, 2002). Thus, in addition to spiritual healing they offer work programmes, drug rehabilitation, youth offender initiatives.

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Regardless of how we might interpret their motivations, political or otherwise, the sociologist Martin (2002) points to the work of Pentecostals in Latin America in transforming the lives of women, providing them with secular aspirations (in tandem with spiritual change) and the practical and emotional supports to realise these. Other ethnographic research in urban Brazil has examined Pentecostal involvement with patients with schizophrenia (Redko, 2003). While not, strictly speaking, fundamentalists,2 Pentecostals believe in the inerrancy of the bible and the omnipresent threat of satanic power (Cox, 1996). Ritual healing, including deliverance from possession, is an essential part of Pentecostal life. Pentecostal welfare provision appears to draw little attention in countries such as Brazil or Chile where health inequalities are severe and state welfare is weak. Where they compete head to head with more developed health and welfare systems, the potential for conflict is likely to be greater.

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The role of clergy in mental health care As noted in the previous section, clergy in many communities, particularly among recently arrived and minority ethnic (Jarvis, Kirmayer, Weinfeld, & Lasry, 2005) play a pivotal role as gatekeepers for services, community advisers and mediators between government and people. Moreover, there is a considerable evidence (in the USA, at least) that communitybased religious leaders have significant contact with people from their congregations who suffer from emotional and mental health problems; indeed many people experiencing what appears to be psychiatric illness look to clergy rather than psychiatric professionals (Wang, Berglund, & Kessler, 2003; Weaver, 1995; Weaver, Samford, & Kline, 1997). However, while the scope of pastoral care is considerable, in essence it attempts to deal with the problems, concerns and suffering of people within a theological or religious framework (Mollica & Streets, 1986). Thus, the core ingredients of pastoral activity described by church historians are those of guidance, healing, reconciliation and sustenance of the community. However, it is argued within a Christian context that pastoral care cannot be simply ‘‘applied theology’’, a term which suggests that clergy rely on biblical text to guide their relationships with troubled congregants (Hiltner, 2000). Thus, clergy in order to have contemporary relevance must engage with and learn from an increasing range of modern disciplines and methods including secularist disciplines of psychiatry, psychology and anthropology (among others). Various studies suggest that although many clergy see mental health pastoral care as a large part of their work, some obtaining specialist training in counselling and psychotherapy, many others have poor understanding of mental health problems and lack confidence in referral to professional services (Wang et al., 2003). In concurrence with this view other studies suggest that clergy may be unable to discern between various disorders and have poor training to assess needs and offer appropriate pastoral care (Domino, 1990; Wylie, 1984). Studies in the USA consistently reveal that across all major religious groupings between 50% and 80% of clergy considered their seminary training in pastoral counselling to be deficient and reported being inadequately prepared to deal with the severe mental problems and marriage counselling issues to which they were asked to respond (Weaver, 1995). There is also concern that so many people obtain ‘‘help’’ from clergy, without additional contact from professionals, in the absence of evidence as to the efficacy of whatever it is they provide. Significantly, Wang and colleagues found that suicidal thoughts and behaviours increased contact with clergy and suicidal individuals were as likely to contact the clergy as other providers. Previous research indicates that

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clergy have been relatively unprepared to assess suicidality or indeed manage the needs of people bereaved by suicide (Domino, 1990; Holmes & Howard, 1980; Leavey, Rondon, & McBride, 2011). What then do religious people value about their religious leaders? One study examined the help-seeking beliefs and attitudes of committed UK Christians (Mitchell & Baker, 2000). Secular professionals were generally trusted in terms of their professional standards and confidentiality but were nevertheless regarded as ‘‘cold, impersonal and theoretical’’ and rejecting of the spiritual dimension. Secular professionals were regarded as providing fairly safe but limited, short-term and possibly superficial help. At worst, professional help conflicted with religious beliefs and were a last resort for help. Importantly too, the research pointed to a desire among the informants for the ‘‘definitive directiveness’’ offered by religious guidance and not by secular professionals. This point is also made by religious leaders who suggest that while psychotherapists can explore issues of guilt, morality and conscience they are generally limited in their resolution of such problems and unable to engage with the ‘‘guilty’’ person in acts of atonement, confession or ‘‘offer dispensations’’ (Bar-Ilan & Hoffman, 2003; Leavey, 2008). To a degree, secular therapy is considered amoral in that it is thought to take a neutral, value-free stance to what are clearly, from the religious viewpoint, problems of sinful behaviour and thought. However, these presumed positions are much more likely to be on a continuum than polarised. The recognition and interpretation of disorder by religious leaders are likely to have important implications for patient pathways to appropriate care and their relationship with psychiatric services, compliance with treatment and outcomes. They will also affect their subsequent relationships with their respective religious communities (Leavey, 2008). Thus, psychiatric problems identified as spiritual or supernatural in origin by clergy may lead to delays in reaching professional psychiatric help and/or difficulties in the patient’s relationship with mental health workers. Of course, acculturation by clergy of secularist beliefs is likely to be influential. Thus, the willingness to accommodate biomedical and naturalist explanations of disease may in some part be conditioned on exposure to psychiatry and psychiatric knowledge and some clergy will have had some training, or at least exposure to this discipline, as part of their work as hospital chaplains. Others will have had a medical, nursing or psychotherapy training (Leavey, Loewenthal, & King, 2007) but this should not be considered as a rejection of supernatural connections with health and illness but rather, the likelihood of maintaining more complex explanatory models. The openness to holding in tension both religious and medical beliefs about aetiology and treatment may be crucial in the care of patients who are uncertain about the origins of their suffering (Dura-Vila, Hagger, Dein, & Leavey, 2011).

The role of religion in psychiatry Individual narratives and recovery Since the 1960s, in Western healthcare systems, the emergence of ‘‘customer primacy’’ and the notion of the patients’ voice has permitted a challenge to the biomedical model. In the midst of wider social discourses about the nature of mental illness and the role of the state, psychiatry came to be variously regarded as misguided or repressive and, more strongly, a fake or pseudo discipline (Laing, 1960; Szasz, 1960, 2008). Liberalising reforms in the mental health system have attempted to reframe the patient as an active consumer of, or collaborator in, health care. Moreover, since the 1960s social science perspectives of medicine have promoted the salience of the patient’s biography and context; a need for

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patient-clinician engagement with meaning (Bury, 1982; Good, 2003). From this subjectivist or phenomenological perspective, patients could not be viewed merely as a bundle of symptoms neatly sealed with a diagnosis. Thus, it was hoped that eventually a mechanistic view of the irrevocably damaged patient would give way to a more holistic, perhaps collaborative, reconstruction of self. Such aspirations are reflected in the literature on recovery approaches in mental illness whose advocates argue that the lives of people with mental illness have significance beyond illness; much neglected, they have social identities and personal resources which can be supported and directed towards a fulfilling and meaningful existence (Shepherd, Boardman, & Slade, 2008). Religion and spirituality, for many, are foundational aspects of identity and central resources. Thus, religion and increasingly, spirituality, provide structures for meaning, action and coping with suffering (Berger & Luckman, 1966; Pargament, 1997). A secular-oriented professionalism that paid little attention to the religious beliefs of the individual, or in some circumstances challenged and insulted such beliefs, could hardly be surprised when the religiously oriented patient shunned services which they found demeaning.

Ethnicity, religion and cultural competence The presence of ethnic and cultural diversity within Western societies became increasingly evident within health care and other public services (Parekh, 2000). In the United Kingdom and other Western healthcare systems, research continued to show elevated rates of depression and schizophrenia among migrant and minority ethnic patients (King, Coker, Leavey, Hoar, & Johnstone-Sabine, 1994). The issues of racism, discrimination and misdiagnosis increasingly demanded examination as evidence emerged that black and minority ethnic (BME) patients experienced differential access and poorer outcomes than their white majority counterparts3 (Coid, Kahtan, Gault, & Jarman, 2000; Littlewood & Lipsedge, 1989). Supported by an informal coalition of service users, community groups and mental health professionals, the NHS and local providers slowly began to incorporate within their service frameworks, usually implicitly, the need for cultural competency (Sue, Arredondo, & McDavis, 1992), promoted in various recent policy documents (National Institute for Mental Health in England, 2005). However, the cultural competency approach, however laudable, implicitly offers a fairly benign view of mental health services, suggesting that any discordance between providers and users arises through ignorance and stereotyping. Thus, somewhat crudely expressed here, an alien cultural expression of distress may be misinterpreted by Western-trained professionals and the person misdiagnosed (Fernando, 1991; Littlewood & Lipsedge, 1988). Consequently, contact with services is poor, ineffective and offensive due to the provision of culturally inappropriate services (Gerrish, Husband, & Mackenzie, 1996). Religious belief and practice often appear to be the sensitive interface of poor services to people from minority ethnic backgrounds rather than of intrinsic value to the general population as a whole. Thus, generally, the rites and diets of this or that ethnic group are the focus of attention in hospital settings. However, religious patients regardless of ethnocultural background, argue that their beliefs and values are either disregarded or seen as further evidence of pathology among atheistic mental health professionals and as a result, such patients and their carers suppress cherished beliefs. This type of self-censorship is experienced by some as distressing and harmful (Leavey, 2004). While much of the evidence is anecdotal there remains a widespread perception of services as religio-phobic among patients and carers (Mayers, Leavey, Vallianatou, &

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Barker, 2007). However, a recent qualitative study of UK psychiatrists and their views on religion suggests that engaging with the religious beliefs of patients is to open a Pandora’s box, to be avoided at all costs (Dura-Vila et al., 2011). Moreover, the same study suggested that psychiatrists with religious beliefs also self-censor because they fear being seen as ignorant. Indeed, some of the reluctance of religious people to consult psychiatry, psychotherapy or counselling services may be explained by what Shafranske and Gorsuch (1984) and others have termed the ‘‘religiosity gap’’ between the religious patient and mental health. For instance, a UK study of evangelical Christians and help-seeking indicated deep-seated anxieties about the beliefs and values of mental health services. Fearing that secular therapists might try to challenge or attempt to alter their beliefs and values they preferred to consult clergy or religious counsellors (McLatchie & Draguns, 1984). Some of the anticipated antagonism of psychiatry towards religion may be traced to Freud’s views of religion as delusional (Freud, 1961). Other commentators in psychiatry consider religion to be communally and individually problematic and divisive (Ellis, 1986). However, while psychiatrists tend to be less religious than the general population (Neeleman & King, 1993), there is little evidence that religious patients are penalised or discriminated against because of their beliefs or that they experience relatively worse outcomes than non-religious patients (Mayers et al., 2007). Nevertheless, it is plausible that religiously devout patients may be viewed by secular mental health professionals in a negatively stereotypical way as ignorant, neurotic and superstitious or have concerns about clergy interference in treatment. Moreover, religious beliefs and experiences tend to be negatively interpreted by mental health professionals. For example, some descriptions of religious belief, expression or spiritual experience bear a resemblance to psychotic symptoms or those of compulsive obsessive disorders (Jackson, 1991). While the articulation of spiritual or religious views may indicate the existence of genuine pathology, among mental health professionals, greater knowledge of background, beliefs and context is vital. For instance, among some religious people, in charismatic groups, for example, profound religious or ecstatic mystical experience may be considered desirable and beneficial (Cox, 1996; Hathaway, 2003; James, 1902). Similarly, the experiential and exuberantly expressive behaviour among Pentecostal groups and other charismatic Christians, although relatively harmless and perhaps, even beneficial to adherents, have tended to provoke anxieties among outsiders. Thus, the cognitive and behavioural dimensions of religion may be relevant to the issue of misdiagnosis among BME patients. For example, among African and African-Caribbean communities where religious and spiritual beliefs appear more prevalent and readily expressed, acute psychotic episodes with a rich religious flavour may reflect culturally determined expressions of distress (Littlewood & Lipsedge, 1988). And, although misdiagnosis is largely discounted as an explanation for the high rates of schizophrenia among African Caribbeans in the United Kingdom, it is, nevertheless, the case that religious beliefs may impact in other ways on such patients’ experiences of mental health services.

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Explanatory models, religion and help-seeking During our research on ethnicity and psychotic illness we attempted to explore the association between pathways into care and causal attributions of patients and carers (Cole, Leavey, King, Sabine, & Hoar, 1995). We asked the participants about their religious and other beliefs related to the supernatural. Forty-four per cent of the patient

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group believed in witchcraft and also spirit possession. Indeed, 18% of patients claimed to have personally experienced the effects of spirit possession. Many of these patients and their relatives ascribed the occurrence of mental illness to these ‘‘spiritual’’ phenomena (unpublished data). This study indicated that more than 10% of patients and their carers during a first episode of psychotic illness contacted religious and spiritual leaders prior to psychiatric contact. More strikingly, in a community-based study in Haringey (N ¼ 428) more than a quarter of participants reported a belief in supernatural forces (Cole, Leavey, & King, 1994). Twenty-three per cent stated a belief in spirit possession, while 18% believed in Witchcraft. Of the Black group (N ¼ 101) 40% claimed to believe in Witchcraft. A similar proportion of Asians believed in spirit possession. These findings are supported by other studies on explanatory models and pathways into care for patients (McCabe & Priebe, 2004). Some of the reasons for the valued position of religion in help-seeking are associated with religious or spiritual conceptualisation of illness and suffering and the perceived need for religious resolution. Thus, for some people, symptoms of anxiety and depression may arise from a spiritual conflict, moral transgression and guilt, a damning spiritual selfevaluation; they have sinned or have weak faith. When these occur clergy may be sought for expiation, spiritual guidance and healing. Alternatively, other people rely on their faith as a means of coping with suffering (Pargament, 1997). Additionally, help-seeking behaviour may be considered as culturally derived in a number of intersecting ways. Stigma related to mental illness in closed communities has both widespread and profound consequences for the individual’s (and his or her family’s) marital, social and economic ties and prospects. Behaviour that is conceptualised as spiritual in origin may be accorded greater social latitude. Thus, in ways that parallel the relationship between the patient and doctor as theorised in Talcott Parson’s ‘‘sick role’’ (Parsons, 1951), the individual (or more usually, the family) seeks assessment and legitimacy from the priest and in return, consenting to treatment.4 It is probably safe to suggest that within most communities the stigma of mental illness remains potent (Angermeyer, Link, & Majcher-Angermeyer, 1989; Link, Cullen, Mirotznik, & Struening, 1992) and the attribution of psychiatric symptoms to a religious causation may be of ‘‘help’’ to the individual and/or her family (Galanter, 1997; Redko, 2003). Therefore, in some circumstances, a spiritual conceptualisation of the problem may deflect suspicion or blame away from the individual and the wider family. Whereas, the collateral damage of the psychiatric label, in terms of blighted job and marital prospects, may be too dire for the family to accept. A religious solution, such as possession or deliverance, to a spiritually conceptualised, if not derived, ‘‘problem’’ may represent the possibility of a dramatic and immediate fix; it may also confer upon the individual, and by association, the family, exceptional qualities or ‘‘gifts’’, reversing the negative into a special degree of spiritual connection. Where there is some acceptance of psychiatric diagnosis by families there often remains, some reluctance to relinquish an intervention of healing through faith and the close involvement of the local church or temple. However, there are considerable differences between and within religions, and the extent to which clergy encourage religious or spiritual explanations and healing is likely to be predicated on several interrelated factors such as cultural background and degree of acculturation, education and training for mission, ‘‘church’’ theology and adherence to doctrinal orthodoxy and an acceptance of bio-medical illness models (Leavey, 2008). It is therefore important to consider clergy utility in promoting spiritual healing. Does it increase their standing within their own congregation or likely to bring them into disrepute with the wider religious

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community? For example, the issue of demonic possession is treated with great caution in the established, conservative branches of the mainstream (Catholic and Anglican) churches which remain fearful of bad publicity, while evangelical or charismatic Christian churches perceive supernatural forces as seminal in much human suffering and willingly work towards demonic eradication. In Pentecostal and some African faith traditions, the concept of demonic possession is integral to the belief system and promoted among adherents (Ensink & Robertson, 1999; Meyer, 2001). Clergy in highly boundaried communities such as the Orthodox Jewish or Muslim communities may be pivotal in the problem definition period of patients’ help-seeking, strengthening or challenging religious health beliefs and in effect, advocating spiritual or secular intervention. Some recent studies in the United Kingdom point to a preference among Muslims and African-Caribbeans for spiritual care rather than psychiatric services, a preference influenced by their health beliefs (Hatfield, Mohamad, Rahim, & Tanweer, 1996). Dein’s ethnographic study among the Hasidic Jews of north London highlighted the central and adjudicatory role of the rabbi on matters of health and suffering (Littlewood & Dein, 1995). Greenberg and Witzum provide insightful views on providing mental health services to Hasidic Jews in Israel (Greenberg & Witzum, 2001). More generally, our knowledge on the role of clergy in mental health help-seeking is limited.

Conclusions Professional boundaries and competencies In the USA various studies indicate that clergy currently play an important role in the provision of mental health services and their involvement may not be limited to common or minor mental health disorders (Gurin, Veroff, & Feld, 1960; Larson, Hohmann, & Kessler, 1988; Reiger, William, & Narrow, 1993; Sorgaard, Sorensen, Sandanger, Ingebrigtsen, & Dalgard, 1996; Wang et al., 2003). This leads many commentators and researchers, mostly American, to argue for greater collaboration between psychiatry and clergy (Koenig, 1988, 2008) and greater spiritual competency among mental health professionals (Bergin, 1980; Knox, Lynn, Casper, & Schlosser, 2005). While psychiatry in the United Kingdom appears more reluctant to co-opt a religious dimension into mental health care, some commentators argue that the neglect of spirituality, in patient care and in research, may be improvident (Culliford, 2002; Poole et al., 2010). Recent publications and correspondence in a British psychiatric journal (Koenig, 2008) revealed the residual sensitivities around any engagement of the spiritual in psychiatric services. However, while often sounding reasonable the adopted positions tend to polarise along established fault lines that may be less concerned with the beliefs and values of patients but rather to be located within a broader culture war on the position of religion in society generally. Although observed by some as sharing similar concerns, the relationship between psychiatry and religion is often regarded as oppositional and quarrelsome (Bhugra, 1997) and despite their long historical involvement in healing and health care, clergy, tend to be ignored by Western mental health services as potential partners in healing (Larson et al., 1988). Mindful of the strategic and symbolic importance of clergy in many minority ethnic communities, there is continued demand, based on multicultural and equal opportunities perspectives, that psychiatry should develop partnerships with FBOs which one assumes would then facilitate the provision of culturally sensitive community-based services, public health education and offer advice to community members consonant with the formal healthcare strategies.

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However, while there is possible cause for suspicion or anxiety on both sides, these generalisations have seldom been empirically explored. More perplexingly, however, it should be pointed out that most of the debate takes place within psychiatry rather than between religion and psychiatry. While some denominations or sects such as the Scientologists remain antipathetic, most ministers of religion do not see themselves as rivals or enemies with any branch of medicine (Numbers & Amundsen, 1986). It may be the case that many clergy would, if they could, avoid dealing with mental illness among their communities. In part, like their psychiatrist counterparts, some clergy regard this as a blurring of role boundaries. However, most are simply ill-equipped. Pattison suggests that the adoption of professional role has had a profound influence on pastoral care in the twentieth century. Two divergent changes occur. First, through processes of professional differentiation, clergy begin to focus more narrowly on religious and spiritual role functions, forsaking more general aspects of their work which have been appropriated by medicine, welfare and education. Second, clergy shift towards ‘‘professionalist’’ and personalised stance, placing emphasis upon an individual clientprofessional relationship. This approach lends itself to the increasingly adopted concept that religion is an essentially personal and private matter. . . ‘‘an important predisposing factor towards pastoral care which is psychologically, spiritually and individually orientated’’ (Pattison, 2000, p. 85). While the former is unsatisfactory, the latter, as some see it, may be stepping further towards secularisation. Nevertheless, while the discussion of clergy involvement in mental health care is generally presented as one of voluntary engagement, this is not the case. It has been noted before that clergy are de facto mental health workers in the community and that this aspect of their role is challenging to the point of stress and burnout (Louden & Francis, 2003). Moreover, it appears that the churches put no resources in either training or pastoral support to clergy in order to manage such problems (Leavey et al., 2008; Weaver, 1995). The ideal model of mental health partnerships between FBOs and psychiatry, tend to be presented by individuals, not unreasonably, with overlapping religious and professional interests; clergy with a background, interests and vocational training in counselling or mental health professionals with strong religious convictions (Sims, 1993). However, while the demand for collaboration is well placed it may be that the barriers between the two sides have been minimised. While there appears an obvious need for knowledge, let alone assessment and evaluation, about the extent, and nature about clergy involvement in mental health care these areas are seldom explored. For example, there is scant information on the referral patterns of clergy to psychiatric services or to what extent clergy are instrumental in assisting or directing patients and families to professional medical or psychiatric help. In the United Kingdom, particularly, the evidence as to the capacity, confidence and willingness of faith groups and clergy to engage in this care is unavailable. Additionally, while some psychiatrists advocate an engagement with religion and spirituality, there is a clear need to articulate what this means for mental health professionals. Religion spans a vast spectrum of beliefs and practices, many of which will not be easily accommodated.

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Notes
1. For example, in the case of sex education, the promotion of religious/moral values (such as the silver ring thing) may be at the cost of genuinely effective programmes aimed at reducing sexualtransmitted diseases and teenage pregnancies.

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2. In fact, fundamentalist Christians and evangelicals generally, have tended to view the emotionalism and experientialism of Pentecostalism with suspicion and distaste. 3. Of interest, the concept of institutional racism has dominated the NHS agenda relating to mental health and ethnic minority patients often hinging on involuntary admissions to services. The assumption of NHS racist practice is currently being challenged and reassessed to allow for a more complex view of social and cultural factors. 4. Of course, the religious treatment (healing, deliverance) may be considered ineffective or failed, opening the way for secular healing modalities. More usually, there is an engagement with both medical and religious systems.

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