Engaging African American Clergy and Community Members to Increase Access to Evidence-Based Practices for Depression

More than two decades have passed since the landmark U.S. Surgeon General’s report Mental Health: Culture, Race, and Ethnicity documented that African American adults have significantly lower rates of depression treatment than their White counterparts (1). Cultural distrust, poor satisfaction with care, and lack of access to culturally competent providers are among the many contributors to these disparities. African Americans with depression who seek help are less likely than Whites to receive evidence-based care (1). Given these persistent disparities, increasing access to evidence-based practices (EBPs) is a pressing clinical issue.

African American churches may be well positioned to promote the uptake of EBPs because of their cultural influence, accessibility, and clergy-delivered counseling (2). African Americans have the highest rates of church attendance among all racial-ethnic groups in the United States (3). Further, African American churches have a history of disseminating evidence-based health interventions for numerous chronic medical conditions, but provision of evidence-based services for depression is limited (4).

African American clergy are regarded as trusted gatekeepers and have a substantial informal role in providing support for individuals with depression (4). However, seminary education provides limited formal mental health training, and as much as 30% of clergy in African American churches do not have formal seminary training (5, 6). Therefore, training African American clergy in EBPs could increase access to high-quality mental health services.

Few studies report findings from both proposed service providers (i.e., clergy) and service users (i.e., community members). Qualitative research methods (e.g., focus groups) can help identify emerging issues for intervention planning. Thus, the purpose of this column was to explore perspectives on training African American clergy in an evidence-based model of depression management through a qualitative case study.

Qualitative Case Study

This case study illustrates perspectives associated with training clergy in interpersonal counseling (IPC). IPC is an evidence-based, three- to six-session therapy that was derived directly from interpersonal psychotherapy. IPC is designed to be delivered by non–mental health professionals, such as clergy members (7). IPC was selected as the study’s proposed training intervention because it explicitly addresses risk factors for depression (e.g., death of a loved one, relational disputes) that clergy members are most likely to encounter when providing informal counseling.

Study sample.

Participants were recruited from an African American Baptist megachurch (≥2,000 worshippers) in New York City. Inclusion criteria for the study were age 21 years or older, fluency in English, and monthly participation in a church ministry (i.e., a group of volunteers who serve the community at large). Participants were excluded if they had a clinician-assessed medical condition that compromised participation. This study was approved by the New York State Psychiatric Institute Institutional Review Board (6909).

Study procedures.

The study was conducted from April to June 2014. A purposive sample of two full-time clergy members of the church were selected for semi-structured interviews, yielding a 50% participation rate from the clergy. Research personnel conducted interviews, which lasted 30–45 minutes. The selected clergy received $30 compensation.

Focus group participants were recruited from regularly scheduled church ministry meetings. One ministry served as a support group for people with substance use disorders. In the other ministry, church member volunteers conducted outreach to homeless individuals. Each of the two focus groups was facilitated by the study’s primary investigator (S.H.H.), an African American male psychiatrist. Focus groups were conducted onsite at the church in a private room. The first focus group had 18 participants, and the second had seven participants. Each focus group lasted 90 minutes and was audio recorded. Focus group participants received $20 compensation and access to light snacks, which is customary in focus groups. Deidentified content from the interviews and focus groups was transcribed verbatim into Microsoft Word.

Data analysis.

Two master’s-level research assistants coded all transcripts. Thematic analysis was used to analyze data (8). Data from the semi-structured interviews were analyzed first. Emerging themes were identified, and notes were taken on potential codes. The codes were consolidated, given a name, paired with exemplar quotations, and organized in a codebook. This analytic process was repeated with all semi-structured interviews and focus groups. When uncertainty arose regarding code use and terminology, study personnel clarified terminology until consensus was reached.

Results

The demographic characteristics of clergy (N=2) and community members (N=25) were as follows. The two clergy members were a 42-year-old woman and a 27-year-old man. Both self-identified as Black or African American, had a master’s degree or above, had a total household income of ≥$75,000, worked for pay, and had health insurance.

The mean±SD age of community members was 53.2±11.1 years, and most self-identified as Black or African American (N=21, 84%). A majority were women (N=21, 84%), had an education level of some college or technical school (N=10, 40%), had a total household income of $0–$29,999 (N=11, 44%), worked for pay (N=11, 44%), and had health insurance (N=21, 84%).

For this column, we highlight three pertinent themes: mistrust of institutions, depression stigma, and feasibility of training clergy in IPC.

Mistrust of institutions.

Mistrust of institutions was described as feeling unsafe in professional health care settings: “You find people are just very, very guarded and suspicious of health professionals. Distrust of the health institutions in general” (participant 5, semi-structured interview).

The paucity of African American psychiatrists also contributed to institutional mistrust. One community member stated, “For the most part, when I was growing up, nobody spoke of a psychiatrist, and it was never an African American. So, there’s an inability to relate to someone who doesn’t look like you” (participant 12, focus group).

Depression stigma.

Stigma refers to the perceived mark of disgrace felt by a person with depression. We used the code “self-perception” to refer to an individual’s internalized experience of having depression: “There is this particular type of interpreting [depression] that is personalized, I think, in ways that it shouldn’t be—as if there is something inherently wrong with who I am as a person” (participant 5, semi-structured interview).

The code “societal perceptions” reflected how the community at large views a person with depression: “Sometimes people have those strong reactions because other people in the community say things like, ‘Oh there’s something wrong with you’” (participant 6, semi-structured interview).

Feasibility of training clergy in IPC.

Clergy and community members expressed strong interest in IPC training among clergy members. The code “training need” highlighted the clergy’s desire for more in-depth training in depression counseling: “I [clergy member] don’t necessarily feel the most prepared to do [depression counseling]. I do it, but yeah, I don’t necessarily feel as prepared as I should be” (participant 11, semi-structured interview). Another clergy member noted, “Because sometimes you wind up like, ‘Did I give the right advice?’ And living under the weight of people who are trusting me with their issues and being a steward of all these stories makes you ask, ‘Did I say the right thing?’” (participant 3, semi-structured interview).

Although the clergy members in our study wanted training in IPC, they were not interested in counseling a greater number of people. The code “counseling barrier” was used to describe clergy’s reluctance to provide counseling to more people: “So, if [training in IPC] can help me as I talk to folks, I think that would be wonderful. What I’m not interested in is it increasing my counseling load or doubling it” (participant 11, semi-structured interview).

Community members identified the “benefits of training clergy” in evidence-based depression models: “I think [training clergy] is an excellent idea because we come to the pastor anyway, and if you can’t trust our pastor, why would you bother to come to church?” (participant 24, focus group).

More importantly, community members underscored the need for clergy to have “training certification” to demonstrate proficiency in IPC skills: “I like the piece about [clergy] having training. I’ll get counseling from the pastor, as long as they’re qualified” (participant 20, focus group).

Discussion

This case study assessed clergy and community members’ perspectives on training clergy in IPC in one African American church. Church-based mental health services may address sociocultural barriers that contribute to treatment disparities. Given the small sample size and single study location, we interpret the results cautiously and discuss potential next steps.

Our results underscore some African Americans’ distrust of health care settings. Psychiatrists in clinical practice could build trust with church leaders by providing a brief church-based workshop on depression or by serving as a referral source for clergy. This type of two-way resource sharing could lay the foundation for a more long-term partnership. We encourage psychiatrists to embrace cultural humility when seeking to engage church leaders and to learn about the historical factors that may contribute to mental health disparities in their local community (9).

Participants in our study described stigma as both an internal and a community-level process. African Americans with depression have intersecting, highly stigmatized identities (e.g., racial minority group, mental illness) that highlight the importance of culturally tailoring anti-stigma interventions for this population. Contact is an anti-stigma intervention that involves planned communicative interactions between people with mental illness and key groups (10). These narrative approaches may include stories, drama, personal experience, and others’ experiences. Given the strong tradition of oral history in Black churches, future studies could evaluate the impact of church-based contact interventions on attitudes toward depression help seeking.

Participants in the clergy were eager to receive training in IPC. This is an important finding because, in other studies, clergy members have resisted mental health training because of perceived philosophical conflicts between psychological constructs and religious doctrine (2). However, because of multiple competing demands, the clergy in our study were not interested in counseling more people. Thus, training clergy in IPC at this church was not a feasible approach by which to reduce racial disparities in depression care. An alternative task-shifting approach is to train community health workers (CHWs) in EBPs for depression. CHWs are trusted, culturally concordant lay health personnel from the local community who have been trained to provide health literacy and evidence-based interventions for chronic medical conditions (11). Exploring the feasibility of training CHWs to deliver mental health literacy programs and depression-focused interventions would be a novel way to address the limited number of providers available in churches.

Community members had positive views about the prospects of clergy being trained in IPC. Before seeking depression services from clergy, however, community members wanted clergy members to have certification that they had completed IPC training. A clergy member’s outward display of IPC certification may alleviate community members’ cultural mistrust when seeking mental health services. However, despite a strong evidence base and established fidelity measures, no standardized national certification process for training in IPC currently exists. Alternatively, proof of certification may be a way for community members to differentiate the clergy’s role as spiritual leaders from their role as mental health providers.

Our small aggregate sample size and recruitment from a single church in New York City limited the generalizability of our findings. The findings may not translate to small- or medium-sized churches, those in rural communities, or different denominations. Because views about a specific depression intervention (i.e., IPC) were assessed, we cannot comment on participants’ perceptions of other interventions. Another limitation was that community members’ positive views of training clergy in IPC may be influenced by the church’s preexisting ministry programs that address mental health conditions (i.e., substance use disorders). Thus, our results may not translate to other places of worship that do not provide these types of ministry opportunities. Last, because the lead author (S.H.H.) facilitated all focus groups, participants’ responses may have been affected by social desirability bias. However, our team decided that the risk of desirability bias would be outweighed by visibility and engagement with community members, leading to a more trusting long-term relationship.

Conclusions

This case study highlights how cultural mistrust and depression stigma impede the use of traditional psychiatric services among African Americans. Clergy in our study were interested in learning the skills of IPC but did not want to increase their counseling caseloads. Implementing mental health literacy interventions for church members may be a more feasible and scalable approach to promoting help seeking for depression in African American communities.