Patterns and correlates of contacting clergy for mental disorders in the United States

Partnerships Between Faith Communities and the Mental Health Sector: A Scoping Review

OBJECTIVE

Faith communities are increasingly providing services to address the mental health needs of their congregations and communities. However, many feel limited in their capacity to address serious illness and experience challenges to collaborating with the mental health sector. To inform the development of faith community-mental health sector partnerships, the authors conducted a scoping review to assess the characteristics and evidence base of partnership approaches to addressing mental health needs.

METHODS

A search of four databases identified peer-reviewed articles published between 2010 and 2023 on faith community-mental health sector partnerships in the United States.

RESULTS

In total, 37 articles representing 32 unique partnerships were reviewed. Most partnerships (N=19) used multicomponent approaches, particularly involving training the faith community (N=18), mental health education for the broader community (N=14), and direct counseling (N=11). Many partnerships (N=14) focused on African American communities. Partnerships that included an evaluation component (N=20) showed promising findings for improving mental health symptoms, mental health literacy, stigma, and referrals, among other outcomes. Several articles reported facilitators (e.g., support from faith leaders and reciprocal relationships and equal power) and barriers (e.g., limited time and funding and differing interests and attitudes) to developing partnerships.

CONCLUSIONS

The findings highlight how faith communities can be a critical partner in providing services across the continuum of mental health care and reveal the need for more rigorous evaluations of the effectiveness, feasibility, and sustainability of these partnerships. The results also identify strategies that may facilitate the development and strengthening of future faith community-mental health partnerships.

An Examination of the Impact of Clergy-Involved Mental Health Activities for Their Congregants on Clergy Life Satisfaction, Happiness, and Perceptions of Having a Life Close to Ideal in the USA

Clergy play a crucial role in supporting the mental health of their congregants, but the impact on their own well-being is understudied. A review of 2019-2020 data from 636 U.S. religious leaders using generalized estimating equations analysis found that clergy use prayer, preaching, readings on mental health, and referrals to mental health professionals to support congregants' well-being. Future longitudinal studies are needed to understand the needs of diverse clergy groups.

Spiritual Connectivity Intervention for Individuals with Depressive Symptoms: A Randomized Control Trial

Depression is one of the most prevalent mental disorders worldwide. This study examined the effect of a spiritual connectivity intervention on individuals with depression in a randomized waitlist-controlled trial. Fifty-seven participants with mild or moderate depressive symptoms were randomly assigned to either the intervention group (n = 28) or the waitlist control group (n = 29). The intervention comprised eight weekly sessions focusing on divine connection, forgiveness and freedom, suffering and transcendence, hope, gratitude, and relapse prevention. The outcome measures included depressive symptoms, anxiety, hope, meaning in life, self-esteem, and social support. Participants completed self-administered questionnaires at baseline (week 0), post-intervention (week 8), and 3-month follow-up (week 20). Repeated-measures ANOVA and one-way ANCOVA were used to compare the within-group and between-group differences in the changes in outcome variables. Participants in the intervention group showed significant improvements in depression, anxiety, spiritual experience, hope, self-esteem, and perceived social support after the intervention. Effect size statistics showed small to large differences (Cohen's d, 0.308 to -1.452). Moreover, 85.71% of participants in the intervention group also experienced clinically significant reductions in PHQ-9 scores from baseline to immediate post-intervention. This study highlights the effectiveness of a low-cost, accessible intervention suitable for community implementation by clergy and faith-based organizations.

Mobilizing Meaning: Religion and Spirituality Among Future Generations

Religion and spirituality have long been known to impact both physical and mental health. Considering religion and spirituality as possible additions to social determinants of health, this article examines the current state of religion and spirituality in the United States and also discusses the ways in which they can contribute to the mental health of children and adolescents. Further, this article also discusses new approaches within religion and spirituality to address the changing needs of future generations.

Exploring Faith Leaders' Experiences in Supporting Individuals with Mental Health Challenges in Ottawa, Canada

Faith leaders are often called upon to provide mental health support to their congregants, yet there is limited research on how these leaders experience this aspect of their role. The objective of this study is to understand the experiences of faith leaders who are sought by individuals for mental health support. We report on the findings from a qualitative study based on interviews with faith leaders of different denominations in Ottawa, Canada. The results indicate that faith leaders are asked to provide support for a wide - but not comprehensive - range of mental health issues; that faith leaders experience various challenges in managing role boundaries; and that these leaders believe that training not only in mental health issues, but also on subjects of liability and self-care to maintain their own wellness would be valuable. We address implications for research and practice.

Programming Provided by Religious Congregations in the United States to Address Mental Illness and Substance Use Disorder

Mental health conditions, including substance use disorders, are one of the most commonly occurring yet least commonly treated health ailments in the United States. Religious congregations serve as important providers of mental health services, as they can fill this gap with accessible care. This study provides an up-to-date accounting of mental health service provision by religious congregations, using a nationally representative survey of U.S. congregations collected in 2012 and 2018-19. Half of all congregations in the U.S. provided a program or service targeting mental illness or substance use disorder in 2018-19, and rates of provision increased among Christian congregations between 2012 and 2018-19.

Faith-Based Organizations' Support of Veteran Congregants at Risk for Mental Health Conditions and Suicide: A Qualitative Study of Clergy Experiences in Los Angeles County

Faith-based organizations (FBOs) are often "gatekeepers" to mental health care for congregants at risk of mental illness and suicide, especially U.S. military Veterans, but data to inform better collaboration are needed. We conducted focus groups with clergy in Los Angeles County to understand the mental health support FBOs provide and barriers to collaboration with the mental healthcare system. Clergy detailed strategies used to support the mental health of Veteran congregants. Barriers included stigma, limits in clergy training, and incomplete knowledge about community and VA mental health resources. Results suggest strategies to improve collaboration between FBOs and the mental healthcare system in Los Angeles County.

Mental illness and help-seeking behaviours among Middle Eastern cultures: A systematic review and meta-synthesis of qualitative data

BACKGROUND

Western literature has long explored help-seeking behaviours related to mental health issues. However, this has been relatively neglected in the Middle East despite an increase in mental health needs in the region. The purpose of this review was to conduct a systematic review and qualitative meta-synthesis exploring help-seeking behaviours related to mental health issues in the Middle East.

METHODS

We conducted a systematic review and meta-synthesis to gain a comprehensive overview of what is known about mental health and help-seeking behaviours in the Middle East from published qualitative research in the Middle Eastern region. A search of electronic databases (MEDLINE, Embase, CINAHL, PsycINFO and QScience) was carried out from inception to July 2022. The quality of the included studies was assessed using the Critical Appraisal Skills Programme tool, and the review protocol was pre-registered with PROSPERO (Ref: CRD42022311494).

RESULTS

We identified 16 qualitative studies exploring mental health-seeking behaviours in Middle East countries. Facilitators and barriers to help-seeking were captured under six overarching themes. Across all studies, we identified negative attitudes towards seeking help for mental health issues, economic and structural barriers to accessing mental healthcare, and misconceptions surrounding religious beliefs, all of which had a critical role in impacting decisions to seek mental healthcare services. Many sought help from alternative sources, such as traditional healers or family members before consulting a healthcare professional. The role of the family and cultural norms was also identified as key contributors to people's help-seeking behaviours.

CONCLUSIONS

This meta-synthesis indicates the existence of many challenges surrounding mental health-seeking in the Middle East, including public and internalizing stigmas. This suggests an urgent need for an increase in psychoeducation and mental health awareness in the region.

Prevalence and Predictors of Substance Use Support Programming Among U.S. Religious Congregations

We conducted a cross-sectional secondary analysis of data from the 2012 National Congregation Study, a nationally representative survey of religious congregations in the United States ( N = 1,331). Multivariate logistic regression was used to identify congregational characteristics associated with providing substance use support programing. Nearly one-third (38%) of U.S. congregations indicated that they provided substance use support programming; approximately half (52%) of all congregational attendees were in a congregation that provided some type of substance use support. The internal factors associated with a congregation providing substance use programming include having members who are unemployed and younger, being conservative Protestant, engaging in the practice of speaking in tongues, and having the resources to support social services. The analysis also identifies external factors (i.e., assessing community needs and hosting social service speakers) as being associated with a congregation’s likelihood of providing substance use programming. Findings identify factors associated with congregations providing substance use support.

Competencies in Pastoral Counseling: The Lived Experiences of Filipino Diocesan Parish Priests

Pastoral counseling has been a significant part of the priestly ministry in the Philippines. Nonetheless, literature about Filipino priests' lived experiences and competencies in counseling is almost non-existent. Using Interpretative Phenomenological Analysis (IPA), the researcher explored the lived experiences and competencies of Filipino diocesan parish priests in their role as pastoral counselors. The study was framed in Phenomenology, the Philippines Psychology Act of 2009, and the 2009 competencies of the Association for Spiritual, Ethical, and Religious Values in Counseling (ASERVIC), a division within the American Counseling Association (ACA). Data were collected using a semi-structured interview, and the analysis yielded seven (7) themes under three (3) clusters. The findings revealed that the participants lack the prerequisites to be rightfully called pastoral counselors. As priests continue to attend to people in need of counseling, the researcher calls on church leaders, the Psychological Association of the Philippines (PAP), and the Professional Regulation Commission (PRC) to address the practice of pastoral counseling in the country.

Faith-Based Spiritual Intervention for Persons with Depression: Preliminary Evidence from a Pilot Study

Depression is a common, depleting, and potentially life-threatening disorder. This pilot study examined the feasibility and applicability, reported preliminary evidence for effectiveness, and explored the potential healing mechanisms of a faith-based spiritual intervention for people with depression. The intervention consisted of six weekly sessions focused on restoring a connection with the divine, forgiveness and freedom, suffering and transcendence, hope, gratitude, and relapse prevention. Seven adults with mild or moderate depressive symptoms were recruited. A qualitative evaluation was conducted via focus group discussions, and rating scales were administered at baseline, after the intervention, and at the 3-month follow-up. The mean difference scores of the treatment's effect over time were analyzed using Friedman's ANOVA. The themes identified by the focus group included the meaning of the spiritual intervention, the effect of involvement in a spiritual group, and the therapeutic components. The results indicated a significant decrease in the mean scores for depression (PHQ-9) after intervention and at the 3-month follow-up. Participants expressed their improvement in terms of increased knowledge about depression, enhanced coping mechanisms, and improved self-esteem. The preliminary evidence suggested that the faith-based spiritual intervention was effective in reducing depressive symptoms and also helped participants develop a greater sense of connection with themselves, others, and their environment.

The role of stigma and spirituality on mental health help-Seeking behavior: an experimental approach

BACKGROUND

The purpose of this research is to examine how social marketing messages can be developed to reduce the stigma associated with seeking help for mental health conditions. It also explores the role that spirituality plays in an individual's propensity to pursue help for mental health challenges.

METHODS

A two-factor between-subjects experiment (ad message: destigmatizing and control × spirituality: high and low) between-subjects design was conducted with 275 participants from the millennial generational cohort in the United States. Responses were collected using an online consumer panel.

RESULTS

Findings indicate that when presented with an advertisement that reduces the stigma associated with mental illness, individuals have a more favorable emotional reaction toward seeking help for a mental health condition. In addition, spirituality moderates the effect of advertising on mental health help-seeking behavior. Individuals with more intrinsic spirituality are more likely to seek care for a mental health issue, whereas those who report less intrinsic spirituality may need the help of destigmatizing messages. Specifically, individuals who report less intrinsic spirituality have more favorable attitudes toward an advertisement that destigmatizes mental illness, and as a result express greater intentions to seek care for a mental health condition.

CONCLUSIONS

This research contributes to discussions centered on better understanding how to break down barriers to seeking aid for mental illness. Messaging which destigmatizes mental illness might start by targeting those who are less inclined to believe in transcendence. Moreover, since spirituality also includes a search for meaning, connectedness, and growth, such messaging might also be beneficial to those who are less likely to engage in activities which link the mind, body and spirit, such as meditation, mindfulness and yoga.

The Gap in Mental Health Service Utilization Among United Methodist Clergy with Anxiety and Depressive Symptoms

Clergy are tasked with multiple interpersonal administrative, organizational, and religious responsibilities, such as preaching, teaching, counseling, administering sacraments, developing lay leader skills, and providing leadership and vision for the congregation and community. The high expectations and demands placed on them put them at an increased risk for mental distress such as depression and anxiety. Little is known about whether and how clergy, helpers themselves, receive care when they experience mental distress. All active United Methodist Church (UMC) clergy in North Carolina were recruited to take a survey in 2019 comprising validated depression and anxiety screeners and questions about mental health service utilization. Bivariate and Poisson regression analyses were conducted on the subset of participants with elevated depressive and anxiety symptoms to determine the extent of mental health service use during four different timeframes and the relationship between service use and sociodemographic variables. A total of 1,489 clergy participated. Of the 222 (15%) who had elevated anxiety or depressive symptoms or both, 49.1% had not ever or recently (in the past two years) seen a mental health professional. Participants were more likely to report using services currently or recently (in the past two years) if they were younger, had depression before age 21, or "very often" felt loved and cared for by their congregation. The rate of mental health service use among UMC clergy is comparable to the national average of service use by US adults with mental distress. However, it is concerning that 49% of clergy with elevated symptoms were not engaged in care. This study points to clergy subgroups to target for an increase in mental health service use. Strategies to support clergy and minimize mental health stigma are needed.

Faith Leaders' Views on Collaboration with Mental Health Professionals

When faced with experiences of mental struggle, Americans often turn to faith leaders as their first recourse. Although studies have explored religious leaders' mental health literacy, few studies have investigated how religious leaders believe faith communities and mental health professionals should collaborate. The data gathered for this research is from in-depth and focus group interviews with faith leaders from Christian, Jewish, Buddhist, and Sikh communities in South Texas and the Mid-Atlantic region between 2017-2019 (n=67). This research analyzed faith leaders' response to the question "How can mental health professionals and faith communities better work together" by utilizing the flexible coding approach (Deterding and Waters 2018). Four distinct themes emerged from the faith leaders' responses: education, relationship building, external factors, and dismissal. By learning about how faith leaders believe they can better work together with mental health professionals we can help bridge the gap between religion and mental health further by fostering a much-needed dialogue between these two groups.

US Religious Leaders' Views on the Etiology and Treatment of Depression

Importance

Religious leaders commonly provide assistance to people with mental illness, but little is known about clergy views regarding mental health etiology and appropriate treatment.

Objective

To assess the views of religious leaders regarding the etiology and treatment of depression.

Design, Setting, and Participants

This cross-sectional study used the National Survey of Religious Leaders, which is a nationally representative survey of leaders of religious congregations in the United States, with data collected from February 2019 to June 2020. Data were analyzed in September and October 2022.

Main Outcomes and Measures

Views about causes of depression (chemical imbalance, genetic problem, traumatic experience, demon possession, lack of social support, lack of faith, and stressful circumstances) and appropriate treatments (seeing a mental health professional, taking prescribed medication, and addressing the situation through religious activity).

Results

The analytic sample was limited to congregations' primary leaders (N = 890), with a 70% cooperation rate. Clergy primarily endorsed situational etiologies of depression, with 93% (95% CI, 90%-96%) endorsing stressful circumstances, 82% (95% CI, 77%-87%) endorsing traumatic experiences, and 66% (95% CI, 59%-73%) endorsing lack of social support. Most clergy also endorsed a medical etiology, with 79% (95% CI, 74%-85%) endorsing chemical imbalance and 59% (95% CI, 52%-65%) endorsing genetics. A minority of clergy endorsed religious causes: lack of faith (29%; 95% CI, 22%-35%) or demon possession (16%; 95% CI, 10%-21%). Almost all of the religious leaders who responded to the survey would encourage someone with depressive symptoms to see a mental health professional (90%; 95% CI, 85%-94%), take prescribed medication (87%; 95% CI, 83%-91%), and address symptoms with religious activity (84%; 95% CI, 78%-89%). A small but nontrivial proportion endorsed a religious cause of depression without also endorsing chemical imbalance (8%; 95% CI, 5%-12%) or genetics (20%; 95% CI, 13%-27%) as a likely cause. A similar proportion would encourage someone exhibiting depressive symptoms to engage in religious treatment without also seeing a mental health professional (10%; 95% CI, 5%-14%) or taking prescribed medication (11%; 95% CI, 8%-15%).

Conclusions and Relevance

In this cross-sectional survey, the vast majority of clergy embrace a medical understanding of depression's etiology and treatment. When clergy employ a religious understanding, it most commonly supplements rather than replaces a medical view, although a nontrivial minority endorse only religious interpretations. This should encourage greater collaboration between medical professionals and clergy in addressing mental health needs.

Exploring the lived experience of Long Covid in black and minority ethnic groups in the UK: Protocol for qualitative interviews and art-based methods

Some people experience prolonged symptoms following an acute COVID-19 infection including fatigue, chest pain and breathlessness, headache and cognitive impairment. When symptoms persist for over 12 weeks following the initial infection, and are not explained by an alternative diagnosis, the term post-COVID-19 syndrome is used, or the patient-defined term of Long Covid. Understanding the lived experiences of Long Covid is crucial to supporting its management. However, research on patient experiences of Long Covid is currently not ethnically diverse enough. The study aim is to explore the lived experience of Long Covid, using qualitative interviews and art-based methods, among people from ethnically diverse backgrounds (in the UK), to better understand wider systems of support and healthcare support needs. Co-created artwork will be used to build on the interview findings. A purposive sampling strategy will be used to gain diverse experiences of Long Covid, sampling by demographics, geographic locations and experiences of Long Covid. Individuals (aged >18 years) from Black and ethnic minority backgrounds, who self-report Long Covid symptoms, will be invited to take part in a semi-structured interview. Interviews will be analysed thematically. A sub-sample of participants will be invited to co-create visual artwork to further explore shared narratives of Long Covid, enhance storytelling and increase understanding about the condition. A patient advisory group, representing diversity in ethnicity and experiences of Long Covid, will inform all research stages. Stakeholder workshops with healthcare professionals and persons, systems or networks important to people's management of Long Covid, will advise on the integration of findings to inform management of Long Covid. The study will use patient narratives from people from diverse ethnic backgrounds, to raise awareness of Long Covid and help inform management of Long Covid and how wider social systems and networks may inform better healthcare service access and experiences.

Study protocol: A randomized controlled trial of Raising Our Spirits Together, an entertaining, group-based technology-assisted cognitive behavioral therapy for depression, tailored for rural adults and delivery by clergy

This paper presents a methodological description of a randomized controlled trial (RCT) testing the effect of Raising Our Spirits Together (ROST), a technology-assisted cognitive behavioral therapy (T-CBT) for depression, tailored for the rural context and for delivery by clergy, compared to an enhanced control condition. Depression is among the most common mental health conditions; yet the majority of adults with depression do not receive needed treatment due to limited access to mental health professionals, treatment-associated costs, distance to care, and stigma. These barriers are particularly salient in rural areas of the United States. T-CBT with human support is an accessible and effective treatment for depression; however, currently available T-CBTs have poor completion rates due to the lack of tailoring and other features to support engagement. ROST is a T-CBT specifically tailored for the rural setting and delivery by clergy, who are preferred, informal providers. ROST also presents core CBT content in a simple, jargon-free manner that supports multiple learning preferences. ROST is delivered virtually in a small group format across 8 weekly sessions via videoconferencing software consistent with other clergy-based programs, such as Bible studies or self-help groups. In this study, adults with depressive symptoms recruited from two rural Michigan counties will be randomized to receive ROST versus an enhanced control condition (N = 84). Depressive symptoms post-treatment and at 3 months follow-up according to the Patient Health Questionnaire (PHQ-9) will be the primary outcome. Findings will determine whether ROST is effective for improving depression symptoms in underserved, under resourced rural communities.

Mental health policy reactions during the first year of the COVID-19 pandemic in two worst-hit WHO European countries: a narrative review and lessons for the aftermath of mental health care

Introduction: The COVID-19 pandemic has been challenging the health care systems and public wellbeing unprecedentedly. The United Kingdom and Turkiye were the countries worst hit by the pandemic in the World Health Organization European region. Purpose: This review investigated the mental health policies in these countries which draw a contrasting pattern of mental health care, sociodemographic background, and income level. Following the investigation, we recommended the possible directions to be pursued by European policymakers Methodology: The documents were picked from the health policy sections from the websites of international organizations (European Parliament, OECD, WHO, UN), online data and policy reports of national ministerial bodies, and general web search. Later, the papers were reviewed and the author identified the main concepts of the responses to discuss after policy review. The study was designed as a review; therefore, no statistical framework was conducted. Results: Identified concepts were as follows: a) continuing service provision for people with mental health conditions, b) digital mental health care interventions, c) building psychological resilience for citizens. Conclusions: A strategy only focusing on treating mental health conditions will not be sustainable during the post-pandemic era. It is essential to address mental health in all policies to foster a strong mental health care system

Experiential Avoidance Mediates the Relationship between Prayer Type and Mental Health before and through the COVID-19 Pandemic

The practice of prayer has been shown to predict various mental health outcomes, with different types of prayer accounting for different outcomes. Considering the numerous stressors facing seminary students, which have only intensified throughout the COVID-19 pandemic, prayer may be a common coping strategy for students who study theology, spiritual growth, and leadership. The present study investigates the role that different types of prayer may have in reducing anxiety, depression, and work burnout among seminary students. Experiential avoidance is proposed as a mediator such that specific types of prayer contribute to greater spiritual and characterological formation through staying engaged in the midst of struggle. Longitudinal data was collected from 564 graduate seminary students from 17 institutions accredited by the Association of Theological Schools. Based on previous research, we hypothesized that experiential avoidance would mediate the relationship between colloquial, liturgical, meditative, and petitionary prayer types and the negative mental health outcomes of anxiety, depression, and work burnout. Results confirmed significant negative relationships between colloquial, liturgical, and meditative prayer types and all three mental health indicators, fully mediated by experiential avoidance. Petitionary prayer was not significantly related to lower levels of mental health. These results indicate that engaging in certain prayer practices may be a protective factor by facilitating experiential engagement.

Religion and Help-Seeking: Theological Conservatism and Preferences for Mental Health Assistance

Religious affiliation and attendance have been shown to affect various facets of mental health, including the willingness to seek mental health assistance; however, little is known about how theological beliefs influence people’s assessments of religious and secular mental health assistance options. Prior research using theological conservatism (beliefs about scripture, sin, and salvation) has conceptualized this perspective as being a schema in which the dimensions operate in tandem. Nonetheless, given the personalized nature of mental health, this study has conceptualized this perspective as three interrelated, but distinctly different dimensions of a religious belief system. Using data from the NORC General Social Survey’s (GSS) 2006 and 2018 waves (N = 2563), this study enlists a fruitful but underutilized approach to gauging perceptions of mental health assistance through the use of situational vignettes that prompt survey respondent appraisals of different sets of circumstances and various possible solutions. This study finds some support for the hypothesis that predicted theological conservatism would be associated with a more favorable view of religious support for mental health as opposed to secular sources of assistance; there was also considerable support for the hypothesis that the salvation dimension of this worldview would exhibit an influence apart from the scripture and sin dimensions. This investigation sheds light on an understudied facet of religion in relation to receptivity toward distinctive forms of mental health treatment and highlights potential directions for future research.

Factors Influencing Military Personnel Utilizing Chaplains: A Literature Scoping Review

Chaplains have been embedded in military settings for over a millennium. In recent years however, the decline in spiritual/religious (S/R) affiliation of military personnel across Western cultures has led to some commentators questioning the utilization of religious chaplains by defence personnel. This scoping review maps the literature on S/R and non-S/R factors that influence utilizing military chaplains-with a particular emphasis on the Australian military context. A systematic scoping review of tertiary literature databases using Arksey and O'Malley (2003) and Joanna Briggs Institute methodologies (JBI, 2021), revealed a total of 33 articles meeting the inclusion criteria. Results fell into three broad categories: (i) how personal religious views influence utilization of military chaplaincy, (ii) barriers and enablers to personnel utilizing military chaplains, and (iii) the impact of chaplaincy. Despite the current reduction in religiosity in Western society, findings from this scoping review suggest there is little evidence that low religiosity among military personnel forms a significant barrier to utilizing chaplaincy services. To the contrary, the literature revealed that chaplains provide trusted, confidential, and holistic support for military personnel that if diminished or compromised would leave a substantial gap in staff well-being services.

The role of religion in mitigating the COVID-19 pandemic: the Malaysian multi-faith perspectives

Social distancing is crucial in breaking the cycle of transmission of COVID-19. However, many religions require the faithful to congregate. In Malaysia, the number of COVID-19 cases spiked up from below 30 in February 2020 to more than a thousand a month later. The sudden increase was mostly linked to a large Islamic gathering attended by 16,000 near the capital, Kuala Lumpur. Another large COVID-19 cluster was from a church gathering in Kuching, Sarawak. Within a few weeks, Malaysia became the worst hit country by COVID-19 in Southeast Asia. While religious leaders have advised social distancing among their congregants, the belief that "God is our shield" is often cited for gathering. There is a need to promote sound decision-making among religious adherents so that they will not prioritize their loyalty to the subjective interpretation of religion over evidence-based medicine. Malaysia, a multi-cultural and multi-faith country, is an example of how religious beliefs could strongly influence health behaviours at individual and community levels. In this article, we detail the religious aspects of COVID-19 prevention and control in Malaysia and discuss the possible role of religious organizations in encouraging sound decision-making among religious adherents in mitigating this crisis. We make recommendations on how to promote a partnership between the healthcare system and religious organizations, and how religion and faith could be integrated into health promotion channels and resources in the response of COVID-19 and future communicable diseases.

Technology-Assisted, Group-Based CBT for Rural Adults' Depression: Open Pilot Trial Results

Purpose

This pilot study assesses the association of Raising Our Spirits Together (ROST), a technology-assisted, group-based cognitive behavioral therapy for depression, with rural adults' depressive symptoms and anxiety.

Method

Nine adults from rural Michigan participated in an open pilot of ROST. Clergy facilitated pilot groups. The pilot began in February 2020 in-person. Due to COVID-19, the pilot was completed virtually.

Results

Mean depressive symptom scores, based on the PHQ-9, significantly decreased from pre-treatment (M = 14.4) to post-treatment (M = 6.33; t (8) = 6.79; P < .001). Symptom reduction was maintained at 3-month follow-up (M = 8.00), with a significant pattern of difference in depressive symptoms over time (F(2) = 17.7; P < .001; eta-squared = .689). Similar patterns occurred for anxiety based on the GAD-7. Participants attended an average of 7.33 of 8 sessions. Fidelity ratings were excellent.

Discussion

ROST is a potentially feasible intervention for rural adults' depressive symptoms. ROST offers a promising model for increasing treatment access and building capacity in rural areas.

Negotiating Safety and Wellbeing: The Collaboration Between Faith-Based Communities and Public Health During the COVID-19 Pandemic

The COVID-19 pandemic led to lockdown measures where congregational faith-based activities were prohibited. With time, the collateral impacts of confinement emerged as priorities, and impositions had to be balanced with the collaboration of the population. In this process, faith-based organizations played a key role in encouraging their congregations to adhere to lockdown measures while fostering their mental wellbeing and resilience. This paper describes the process of establishing a collaborative negotiation among the Montreal Regional Public Health Unit, the police, and the Muslim and Jewish communities, examining the role of mediation in this context. Despite some obstacles, such as communication difficulties and decision-making limitations, the collaborative approach seems to buffer the escalation of intercommunity tension and to promote communities' commitment to physical distancing measures and should be considered in times of pandemic for a more inclusive public health approach.

Clinical Recognition of Substance Use Disorders in Medicaid Primary Care Associated With Universal Screening, Brief Intervention and Referral to Treatment (SBIRT)

OBJECTIVE

Screening, Brief Intervention and Referral to Treatment (SBIRT) programs have been effective for moderate reductions of alcohol use among participants in universal settings. However, there has been limited evidence of effectiveness in referring individuals to specialty care, and the literature now often refers to screening and brief intervention (SBI). This study examines documentation of substance use disorder (SUD) diagnoses in a low-income Medicaid population to evaluate the effect of universal SBIRT on healthcare system recognition of SUDs, a first step to obtaining a referral to treatment (RT) for individuals with SUDs.

METHOD

SBI patient data from Wisconsin's Initiative to Promote Healthy Lifestyles (WIPHL) were linked to Wisconsin Medicaid claims data. A comparison group of Medicaid beneficiaries was identified from a matched sample of non-SBIRT clinics (total study N = 14,856). Hierarchical generalized linear modeling was used to assess rates of SUD diagnosis in the 12 months following receipt of SBIRT in WIPHL clinics compared with rates in non-SBIRT clinics. Analysis controlled for clinic, individual patient's health status, demographics, and baseline substance use diagnoses.

RESULTS

SBIRT was associated with greater odds of being diagnosed with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), alcohol abuse or dependence as well as drug abuse or dependence over the 12 months subsequent to receipt of the screen. The overall diagnostic rate for any DSM-IV substance abuse or dependence was 9.9% at baseline and 12.2% during the follow-up year. SBIRT patients had 42% (p = .003) greater odds of being diagnosed with a substance use disorder within 12 months relative to comparison clinic patients. However, there were very few claims for specialty SUD services.

CONCLUSIONS

The presence of SBIRT in a primary care clinic appears to increase the awareness and recognition of patients with SUDs and a greater willingness of healthcare providers to diagnose patients with an alcohol or drug use disorder on Medicaid claims. Further research is needed to determine if this increase in diagnosis reflects integrated care for SUDs or if it leads to improved access to specialty care, in which case abandonment of the RT component of SBIRT may be premature.

Clinical Recognition of Substance Use Disorders in Medicaid Primary Care Associated With Universal Screening, Brief Intervention and Referral to Treatment (SBIRT)

OBJECTIVE

Screening, Brief Intervention and Referral to Treatment (SBIRT) programs have been effective for moderate reductions of alcohol use among participants in universal settings. However, there has been limited evidence of effectiveness in referring individuals to specialty care, and the literature now often refers to screening and brief intervention (SBI). This study examines documentation of substance use disorder (SUD) diagnoses in a low-income Medicaid population to evaluate the effect of universal SBIRT on healthcare system recognition of SUDs, a first step to obtaining a referral to treatment (RT) for individuals with SUDs.

METHOD

SBI patient data from Wisconsin's Initiative to Promote Healthy Lifestyles (WIPHL) were linked to Wisconsin Medicaid claims data. A comparison group of Medicaid beneficiaries was identified from a matched sample of non-SBIRT clinics (total study N = 14,856). Hierarchical generalized linear modeling was used to assess rates of SUD diagnosis in the 12 months following receipt of SBIRT in WIPHL clinics compared with rates in non-SBIRT clinics. Analysis controlled for clinic, individual patient's health status, demographics, and baseline substance use diagnoses.

RESULTS

SBIRT was associated with greater odds of being diagnosed with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), alcohol abuse or dependence as well as drug abuse or dependence over the 12 months subsequent to receipt of the screen. The overall diagnostic rate for any DSM-IV substance abuse or dependence was 9.9% at baseline and 12.2% during the follow-up year. SBIRT patients had 42% (p = .003) greater odds of being diagnosed with a substance use disorder within 12 months relative to comparison clinic patients. However, there were very few claims for specialty SUD services.

CONCLUSIONS

The presence of SBIRT in a primary care clinic appears to increase the awareness and recognition of patients with SUDs and a greater willingness of healthcare providers to diagnose patients with an alcohol or drug use disorder on Medicaid claims. Further research is needed to determine if this increase in diagnosis reflects integrated care for SUDs or if it leads to improved access to specialty care, in which case abandonment of the RT component of SBIRT may be premature.

Hospitality Towards People with Mental Illness in the Church: a Cross-cultural Qualitative Study

Mental illness is a prevalent concern that affects Christian churches in North America in significant ways. Previous studies on the relationship between mental illness and the church have found that beliefs and practices within the church can contribute to stigma towards people with mental illness. Yet, the typical experience of people with mental illness who attend church has been found to be positive, suggesting that there are considerable resources within the church for supporting those who experience mental health problems. One such resource is the concept of hospitality, which promotes a sense of belonging for those with mental illness in the church. This qualitative study advances the construct of hospitality as a helpful paradigm for addressing mental health needs within the church, capturing perspectives and practices that are currently in place or seen as necessary by church attendees. The study methodology also emphasized the need to incorporate cultural considerations that are appropriate for the racial and ethnic make-up of particular churches. Semistructured focus group interviews were conducted with participants from eight churches that were either predominantly African American, Asian American, Latinx, or multi-ethnic. Findings resulting from content analysis of transcripts indicated that hospitality was a broadly helpful construct for addressing mental health concerns in the church, though some cultural differences existed in the understanding and application of hospitality. Both the interface of the findings with the existing scholarly literature and the relevance of findings for church leaders are discussed.

Religious Coping Amidst a Pandemic: Impact on COVID-19-Related Anxiety

Religious coping is one potential strategy to manage stressors. Positive religious coping has been linked to better physical and mental health outcomes, while negative religious coping has been associated with increased stress and anxiety. The primary objective of this study was to examine individuals' use of religious coping during the COVID-19 pandemic. We examined the relationship between COVID-19 anxiety and religious coping in a national sample of 970 individuals located within the USA recruited via Amazon's Mechanical Turk (MTurk) between September 12, 2020, and September 25, 2020. Findings indicate negative religious coping is most strongly associated with COVID-19 anxiety, as higher levels of negative religious coping were positively related to COVID-19 anxiety. In a moderated multiple regression wherein positive religious coping and negative religious coping were included in an interaction term, only negative religious coping was significantly associated with COVID-19 anxiety. This may have been due, in part, because individual's typical religious engagement was disrupted by social distancing and isolation measures. When accounting for participant age, sex, religious beliefs and behaviors, and negative religious coping, positive religious coping was negatively, although weakly, associated with COVID-19 anxiety. These findings suggest that negative religious coping has a stronger association with COVID-19 anxiety than positive religious coping.

Second Victims: Aftermath of Gun Violence and Faith-Based Responses

In the aftermath of gun violence, those impacted and left to mourn are regarded as second victims. These individuals experience and are often burdened by mental and physical sequelae while attempting to cope with the trauma. The objective of this report is to highlight the support and resources of congregational and faith-based leaders available in an urban city with a high prevalence of gun violence. We describe information and insights presented during a symposium uniting medical-religious partners to discuss actions and programs to address trauma from gun violence. Faith-based persons from various Abrahamic religions, ranging from imams to reverends to hospital-based chaplains, discussed key strategies to allocate resources to second victims. These strategies included religious rituals meant to cope with trauma, memorials, and providing insight into resiliency for difficult times. Resources were identified for both within the hospital and community. Such medical-religious resources should be considered for future interventions which aim to attenuate the consequences of gun violence for second victims.

Clergy as Suicide Prevention Gatekeepers

801 U.S. Catholic, Jewish and Protestant clergy reported on their suicide gatekeeping activities. Using vignettes, they identified suicide risk and selected interventions for three risk levels. Two-thirds of the sample who provide counseling reported at least one contact from a suicidal person per year. Clergy were significantly more concurrent with experts in identifying risk and selecting interventions with high risk but deviated more from the experts with low and medium risk. Most reported needing more training.

Views of Catholic Priests Regarding Causes, Treatments and Psychosocial Consequences of Schizophrenia and Depression: A Comparative Study in Italy

This study explored views of Catholic priests about schizophrenia and depression in Italy. Participants completed a questionnaire on their views about either schizophrenia (N = 282) or depression (N = 277). The depression group was surer than the schizophrenia group that: the disorder was due to psychosocial causes; curable; non-requiring long-term pharmacotherapy; the persons with depression could participate in religious activities. The older priests were more convinced than the younger priests that: the prayer and long-term pharmacotherapy are useful; the persons with mental disorders had affective difficulties, are recognizable and kept at distance. Priests should receive education on stigma in mental disorders, particularly schizophrenia.

Examining Associations With Mental, Well-Being and Faith in Nurses (LIFT)

OBJECTIVE

The aim of this study was to explore the association between religion/spirituality (r/s) and mental health outcomes in hospital-based nursing staff.

BACKGROUND

The relationship between r/s and health has been studied extensively. Most frequently, r/s has been studied in association with mental health outcomes, including depression, anxiety, and distress among patients. However, hospital-based nurses suffer from the mental health effects of working in high-stress work environments. To date, little research has focused on the relationship between r/s and mental health outcomes in nurses.

METHODS

A cross-sectional online survey was completed by 207 nurses from 6 community hospitals.

RESULTS

Approximately half of the nurses sampled identified as religious, whereas nearly 75% identified as spiritual. There were significant associations between measures of r/s and mental health outcomes such as depression, anxiety, and mental well-being.

CONCLUSIONS

This whole-person assessment of nurses may inform future retention and engagement strategies focused on faith-based interventions.

African Americans' and Black Caribbeans' Religious Coping for Psychiatric Disorders

This study investigates the use of religious coping among African Americans and Black Caribbeans with 12-month DSM-IV psychiatric disorders. Data from the National Survey of American Life is used to examine three indicators of religious coping: 1) using prayer and other spiritual practices for mental health problems, 2) the importance of prayer in stressful situations, and 3) looking to God for strength. Three out of four respondents who had a mental health problem reported using prayer as a source of coping. Agoraphobia and drug abuse disorder were associated with the importance of prayer during stress. Individuals with generalized anxiety disorder were more likely to report that prayer was important during stressful experiences and that they looked to God for strength. These findings contribute to the limited, but growing body of research on the ways that African Americans and Black Caribbeans cope with psychiatric disorders.

Mental Health Stigma Among Black Immigrant Women in An Urban Setting

BACKGROUND

Mental health stigma results in unmet mental health needs. Research describing predictors of stigma remains limited among Black immigrants. We aim to examine stigma associated with mental illness among a group of Black immigrant women.

METHODS

We examined data from 22 women from two Black immigrant community centers. We collected surveys on demographics, cultural beliefs, migration status, religiosity and mental health stigma. Simple linear regression was used to model the unadjusted association between each component variable and overall stigma scores. All analyses were conducted using R and assumed a two-sided, 5% level of significance.

RESULTS

A linear relationship was found between author-generated scale, the Stigma and Culture Survey (SCS) and the Depression Self Stigma Scale (DSSS). Among respondents, use of religious resources was associated with less stigma (p-value: 0.04). Whereas spirituality and morality was associated with greater stigma (p-value: 0.003). United States citizenship was associated with less stigma (p-value: 0.0001).

DISCUSSION/CONCLUSION

Religion and spirituality are critical to understanding mental health stigma among Black immigrants. Studies aimed at assessing and reducing stigma need to critically engage with cultural and religious factors.

Challenges to welcoming people with mental illnesses into faith communities

Faith communities are important to the psychiatric care of people with mental illness. I distinguish the effects of two principles of becoming welcoming communities: compassion, in which the community accommodates members with mental illnesses so they are fully included, and dignity, which rests on the essential worth of everyone.

Attitudes About Mental Illness Among Seminary Students: a Qualitative Analysis

Tragically, a majority of people with mental illness never seek treatment; however, people may be more likely to seek help from religious clergy than from mental health professionals. In the current study, 25 Protestant seminary students were interviewed. The majority of students considered there to be biological, spiritual, and environmental causes of mental illness and favored psychological, medication, or spiritual treatments. Some participants reported stigma of mental illness, including avoidance and "dangerous" stereotypes. Religious clergy are frontline mental health providers, and their attitudes about mental illness are critical in reducing stigma and increasing treatment seeking among people with mental illness.

The Association Between Prosocialness, Relational-Interdependent Self-construal and Gender in Relation to Burnout Among Swedish Clergy

Serving as a clergyperson is a highly variable profession and in recent decades, the role has evolved and expanded even further. Consequently, the demands have increased and with it the risk for stress-related ill-health and absenteeism. The aim of the current study was to evaluate, in a larger sample of Swedish clergy (N = 871), two possible antecedents of burnout, namely prosocialness and relational-interdependent self-construal. A further aim was to explore potential gender differences in the investigated associations. The direct and indirect relationships of prosocialness and relational-interdependent self-construal to two dimensions of burnout, exhaustion, and disengagement were investigated in a structural equation-modelling framework. The results showed that clergy who reported higher prosocialness experienced more stress in their work, in terms of both quantitative and emotional demands, which in turn was associated with higher levels of exhaustion and disengagement. But prosocialness was also found to be directly associated with lower levels of disengagement, as well as indirectly associated with higher levels of role clarity. However, no direct or indirect associations were found between relational-interdependent self-construal and any dimension of burnout. Regarding gender differences, female clergy reported higher levels of prosocialness and job demands, less role clarity, and in turn more exhaustion compared to male clergy. This indicated a more stressful situation for female clergy. Our study contributes new insights into the role that personality plays in different dimensions of burnout in clergy, as well as insights into an understanding of gender differences in burnout among clergy.

Are changes in positive mental health associated with increased likelihood of depression over a two year period? A test of the mental health promotion and protection hypotheses

This paper investigates the mental health promotion and protection (MHPP) model of reducing depression. Data are from the Clergy Health Initiative Longitudinal Survey of United Methodist ministers in North Carolina that included the Mental Health Continuum Short Form (MHC-SF) for positive mental health and the Patient Health Questionnaire (PHQ-9) for depression in 2014 and 2016 (N = 955). The promotion hypothesis predicts reduced risk of depression in 2016 among clergy whose mental health increased to flourishing and the increased risk of depression in 2016 for clergy who stayed not flourishing. The protection hypothesis predicts increased risk of depression in 2016 for clergy who were flourishing in 2014 but went down to 'not flourishing' in 2016. The reference group is clergy who stayed flourishing. We used modified Poisson regression models for binary outcomes to estimate Prevalence Ratios (PR) and to estimate Incidence Rate Ratios (IRR) of depression in 2016 associated with changes in mental health status. Results support both hypotheses. Compared to clergy who stayed flourishing, clergy who improved to flourishing were as likely, while clergy who stayed not flourishing were nearly seven times more likely, to have depression in 2016. Clergy who declined to not flourishing were six times more likely to have depression in 2016 compared to those who stayed flourishing. Similar patterns were observed when the sample was restricted to clergy without depression in 2014. These findings suggest focusing on MHPP as a complementary approach to treatment to reduce the incidence, prevalence and burden of depression.

Bringing Psychiatry into the Mosque: Analysis of a Community Psychoeducation Intervention

OBJECTIVE

Mental health care in the growing US Muslim population is a relevant topic given ongoing discrimination and self-stigma similar to that seen in other racial and religious communities. Data concerning efforts to integrate religious practice or spiritual concepts into mental health education are limited. Therefore, the objective of this study was to analyze views about psychiatric illness and treatment before and after a mental health symposium at a community mosque led by faith leaders and mental health professionals.

METHODS

A total of 31 matched presurveys and postsurveys were collected from participants at the symposium to assess attitudes about psychiatric illness and treatment before and after the intervention. The surveys were analyzed using SAS.

RESULTS

At baseline, the highly religious and educated population that participated in the survey had high levels of agreement with the conceptualization of psychiatric illness as a biological problem and less so as a spiritual problem. Even so, at baseline, only approximately half of the participants indicated that they would talk to a medical doctor about mental health problems, and participants were significantly less positive about taking psychotropic medication for illness, compared with after the intervention. Educational attainment was positively associated with the conceptualization of psychosis as a biological problem, with willingness to speak to a medical doctor, and with willingness to take antidepressant medications.

CONCLUSIONS

The findings of this study suggest the potential effectiveness of coordinated interventions by religious leaders and mental health professionals to address the reluctance of Muslims to use psychotropic medication treatment when indicated. Limitations of this study include the self-selection of a highly-educated subset of the greater Muslim population that may already have been interested in a mental health symposium. For the future, research should consider the use of psychoeducation in general religious services to reach a more representative sample of practicing Muslims.

Professional service use among older African Americans, Black Caribbeans, and Non-Hispanic Whites for serious health and emotional problems

This study examined racial and ethnic differences in professional service use by older African Americans, Black Caribbeans, and Non-Hispanic Whites in response to a serious personal problem. The analytic sample (N = 862) was drawn from the National Survey of American Life. Findings indicated that African Americans and Black Caribbeans were less likely to use services than Whites. Type and race of providers seen varied by respondents' race and ethnicity. Among respondents who did not seek professional help, reasons for not seeking help varied by ethnicity. Study findings are discussed in relation to practice implications.

Differences in Distress and Utilization of Mental Health Services between 2005 and 2018: a Potential Trend?

This study examined possible differences in self-reported psychological distress and need of treatment in two samples of well-educated adults, which were obtained from two larger studies that were conducted separately in 2005 and 2018. Psychological distress and need for treatment were reported using the Langner Symptom Survey, a psychometrically robust measure of nonspecific distress that provides validated cutoff scores for those in need of receiving mental healthcare services. Treatment utilization was examined through self-report in which respondents indicated whether they had never received treatment, previously received treatment, or were currently receiving treatment. Results suggested that a larger percentage of respondents from the 2018 sample reported current counseling (11.8%) compared to the 2005 sample (4.0%), and they were almost twice as likely to be classified as distressed and in need for treatment than their 2005 counterparts (51.9% compared to 33.2% in 2005; odds ratio = 2.17, 95% CI: 1.59-2.97). Implications for these findings are discussed at length.

Do religious patients need religious psychotherapists? A naturalistic treatment matching study among orthodox Jews

Religion is professed by the majority of the general population, but a minority of mental health practitioners. We evaluated whether religious patients benefited more from treatment with religious psychotherapists in a naturalistic study among adult Orthodox Jewish (n = 117) and control patients (n = 91) receiving psychotherapy from Orthodox Jewish (n = 15) and other (n = 7) psychotherapists at a New York based outpatient clinic. Groups did not differ with respect to diagnoses (χ²(200) = 7.5, p = .76), likelihood of having an Orthodox Jewish therapist (χ²(200) = .06, p = .81), or number of therapy sessions (t(206) = .73, p =  .47). Multilevel regression modeling revealed that Orthodox patients reported lower initial anxiety (t(198) = 3.71, p < .001, d = .54) and depression (t(198) = 3.71, p < .001, d = .54, d = .50), but were equivalent to controls at termination (Anxiety t(189) = .36, p =  .72; Depression t(182) = 1.00, p =  .32). Interactions between patient and therapist religious affiliations were not significant. These results suggest that religious (and non-religious) patients may benefit equally from treatment delivered by religious and non-religious therapists.

Rural Residents' Depressive Symptoms and Help-Seeking Preferences: Opportunities for Church-Based Intervention Development

This study examines rural residents' depressive symptoms, helps seeking preferences and perceptions of a church-based group depression intervention, informing feasibility of adapting evidence-based treatment for delivery in rural churches. A cross-sectional survey was administered to 100 members of 2 churches in a rural Midwestern community; 63 congregants responded. Depression was assessed via the Patient Health Questionnaire-9. Descriptive analyses were performed, and 12.9% of respondents screened positive for depression. Another 25% reported mild symptomatology. Respondents preferred informal help seeking, although reported more openness to formal providers to address others' depression. Results suggest receptivity to church-based treatment. Almost two-third of respondents reported they would consider attending a church-based group depression intervention, 80% would recommend it to a friend in need, and 60% indicated it would benefit their community. Delivering evidence-based depression treatment within church settings may provide a viable option for increasing access to care in this rural community.

The religion variable in community health promotion and illness prevention

Religion is a source of beliefs and practices, which can in turn influence health behaviors. Therefore, religious communities represent potential public health partners to improve well-being across economic and ethnic diversity. This issue of the Journal of Prevention & Intervention in the Community presents six empirical studies with a breadth of methodologies, and a range of subjects. The associations of religion with cancer fatalism, prenatal substance abuse, bereavement, suicide prevention, clergy mental health and attitudes toward the Affordable Care Act are reported here. These research findings support the key importance of community. Like community, religion is complex. This issue's studies demonstrate the need to include ethnicity in analyses as well as the necessity to measure both religious belief and practice. Consistently, religious community participation predicted more positive outcomes than one's level of belief.

Urban Religious Congregations' Responses to Community Substance Use: An Exploratory Study of Four Cases

Faith-based drug treatment programs are common, and many are implemented through congregations; however, little is documented about how congregations conceptualize and implement these programs. We use case study analysis to explore congregational approaches to drug treatment; qualitative findings emerged in three areas: (1) religion's role in congregational responses to substance use, (2) relationships between program participants and the broader congregation, and (3) interactions between congregational programs and the external community. Congregational approaches to drug treatment can be comprehensive, but work is needed to evaluate such efforts. Congregants' attitudes may influence whether program participants become members of a sustaining congregational community.

Beliefs About Etiology and Treatment of Mental Illness Among Korean Presbyterian Pastors

This descriptive study explored pastors' beliefs about etiology and treatment of mental illness. Surveys were completed by mail by 202 Korean and Euro-American Presbyterian clergy. Nearly one-third of Korean pastors viewed bad parenting and demon possession as very important causes of mental illness, in contrast to the more than two-thirds of Euro-American pastors who viewed genetics and chemical imbalances as the most important causes. Compared with their Euro-American counterparts, Korean pastors soundly endorsed spiritual treatment of mental illness. The findings of this study suggest the value of understanding the views of pastors working with populations that underutilize formal mental health services.

Attitudes and behaviors that differentiate clergy with positive mental health from those with burnout

Clergy provide significant support to their congregants, sometimes at a cost to their mental health. Identifying the factors that enable clergy to flourish in the face of such occupational stressors can inform prevention and intervention efforts to support their well-being. In particular, more research is needed on positive mental health and not only mental health problems. We conducted interviews with 52 clergy to understand the behaviors and attitudes associated with positive mental health in this population. Our consensual grounded theory analytic approach yielded five factors that appear to distinguish clergy with better versus worse mental health. They were: (1) being intentional about health; (2) a "participating in God's work" orientation to ministry; (3) boundary-setting; (4) lack of boundaries; and (5) ongoing stressors. These findings point to concrete steps that can be taken by clergy and those who care about them to promote their well-being.