The Forgotten Factor

Module 1:Charting the Religious Commitment Gap

Utility You will be able to recognize the pervasive and central influence of religious commitment in the lives of many patients and begin to examine how it may be relevant in treatment and therapy.

Contents of this Module


Incidents for Reflection:

  1. One March evening, a tornado swept into the town of Greenville, S.C. hurling trees, smashing homes and inflicting severe injuries. Coloring the trees the next morning were not spring cherry blossoms but pink insulation from the ravaged homes in this religiously conservative, Protestant community. Representatives from the area Mental Health Center interviewed residents who sought federal disaster relief to determine whether any suffered Post Traumatic Stress Syndrome based on the symptom criteria in the Diagnostic and Statistical Manual-III.

    Of the 116 respondents, 69 people, or 59%, qualified for a diagnosis of acute Post Traumatic Stress Syndrome, 19 of whom had a severe form. Not one of these persons, however, came to the area Mental Health Center for help. At a 15-month follow-up 43% were still suffering from the disorder (Madakasira and O'Brien, 1987).
  2. A devoutly religious man entered therapy with a particular psychiatrist who viewed religious commitment differently than his patient. The psychiatrist denigrated his patient's long-standing religious commitment, calling it "foolishly neurotic."

    "Because of the intensity of the therapeutic relationship, the interpretations caused great distress and appeared related to a subsequent suicide attempt" ("Guidelines Regarding Possible Conflict Between Psychiatrists' Religious Commitments and Psychiatric Practice," (1990), American Journal of Psychiatry, 147(4), 542).
What potential reasons might you suggest to explain why none of the disaster victims sought help at the area Mental Health Center?

How does the second incident illustrate discrepant values concerning religious commitment?


At the conclusion of this module, you will be able to:

Identifying Implications

Returning to the victims of the tornado in South Carolina, what reasons might explain why none of those suffering from Post Traumatic Stress Syndrome sought help at the area Mental Health Center?

When presenting his study of the disaster victims at an annual medical meeting, the area Mental Health Center psychiatrist was at a loss to explain why none of those surveyed who were suffering from Post Traumatic Stress Syndrome sought help at the area Mental Health Center. Based upon the research on those who seek help from mental health professionals, another presenter responded that perhaps those people in a religiously conservative Protestant community were reluctant to go to the clinic out of concern for how their personal religious value system might be treated.

A gap between how the majority of mental health professionals view religion - as negative or unimportant - and how the general public's view of religion -as positive and important - can create a barrier which prevents those needing treatment from getting the psychological help that they need. Concerning the man berated for his religious beliefs who then attempted suicide, what discrepancy exists between how the therapist and patient each valued religious commitment?

This particular incident illustrates a "worse case scenario." It was presented as an illustration in the American Psychiatric Association ethics guidelines on religion and psychiatric practice which stated, "Psychiatrists should maintain respect for their patients' beliefs" (APA Board of Trustees 1990, p. 542).


Even when a mental health professional does not overtly criticize religious convictions as negative or neurotic:

What are the implications of ignoring religious commitment in the process of therapy?

What messages does a patient receive when a therapist appears disinterested or declines to inquire further about religious convictions when brought up by the patient?

The Religious Commitment Gap: A Crack or Chasm

Is there a disparity between how the majority of mental health professionals view religious commitment and how the general population views it? How can we objectively answer this question? What does the research say?

Examining the Research


In order to assess the differences in levels of religious commitment among mental health professionals and the general public, surveys of the religious beliefs and practices of each group were compared. How did they contrast?


The U.S. General Public

For more than four decades, the Gallup Organization has conducted scientific polling among Americans. Throughout this time period, the proportion of Americans who believe in God has remained remakably constant: 96 % in 1944 and 94% in 1986 (Princeton Religion Research Center, 1993).

Also, 66% of the general public consider religion to be most important or very important in their lives. Approximately 33% of Americans view religious commitment as the most important dimension of their lives. For another 33%, it is a very important dimension. Furthermore, 72% agree or strongly agree with the statement, "My religious faith is the most important influence in my life" (Princeton Religion Research Center, 1994; Bergin and Jensen, 1990).

Some 40% of Americans attended church or synagogue in the last week, a figure which has remained relatively constant for more than 20 Gallup surveys undertaken between 1939 and 1993 (Princeton Religion Research Center, 1994).

Finally, what percentage of the general population considers religion "not very important?" Some 12% (Princeton Religion Research Center, 1994).

Mental Health Professionals

Bergin and Jensen (1990) polled psychotherapists nationally in order to determine the religious preferences of various groups of mental health professionals.

They found that on average, mental health professionals have somewhat higher rates of atheism and agnosticism than the general population: approximately 16% vs. 6% (Gallup, 1989). Rates of atheism and agnosticism among mental health professionals were combined as follows:

Likewise, 80% of the mental health professionals surveyed expressed a religious preference compared to 91% of the general population. For the professionals, Protestant was the most common religious preference (38%). However, the next largest group was atheist, agnostic, humanist or none (20%).

On the other hand, Bergin and Jensen found that while "the professionals' rates of conventional religious preferences were lower in some respects than the public at large", there was, nonetheless, "an unexpected, sizeable personal investment in religion." For example, 77% of the professionals agreed with the statement, "I try hard to live by my religious beliefs." In comparison, on a similar Gallup survey item, "I try hard to put my religious beliefs into practice in my relations with all people...," some 84% of the general public agreed.

Furthermore, 41% of the mental health professionals indicated that they attend religious services on a regular basis. A rate that is virtually the same as that found for the general population.

In their survey, Bergin and Jensen asked respondents to agree or disagree with the statement, "My whole approach to life is based on my religion." Mental health professionals who agreed or strongly agreed were as follows:

Bergin and Jensen, as noted above, refer to a similar Gallup survey item, "My religious faith is the most important influence in my life." 72% of the general public agreed or strongly agreed with this statement. A comparison of these figures suggests that there may be significant differences in the extent to which members of the general population and mental health professionals - particularly clinical psychology and psychiatry - endorse a religious view of life.


What do you think the implications of this religious commitment gap are in addressing religious issues in therapy?

Since 72% of the general public claim to be influenced significantly by their religious faith, religious commitment may be an important factor to draw upon in therapy.

By excluding religious commitment issues from the therapeutic setting, there remains a denial of an aspect of life which has shown to be of central importance to nearly two thirds of the U.S. population.

The Religious Commitment Doorway

The general public appears to view and value religion as a central factor in their lives, whereas many mental health professionals do not. There is a gap in how each values religion, which may potentially lead to harmful misinterpretation and mishandling of religious issues in the therapeutic setting.

In addition, some therapists who value religion in their personal lives may set aside their personal perception and refrain from inviting the patient to deal with religious commitment in therapy.

Do they keep that doorway shut, closing off the opportunity of addressing a potentially significant factor for the patient?

Examining the Research


Two surveys were compared to determine whether there is an open or closed door between how therapists value religion in their own lives and the way they perceive the role of religious commitment in the lives and mental health of their patients.


In a 1990 survey of Mental Health Professionals, Bergin and Jensen found that although nearly half did not base their whole approach to life on their religion, some 77% agreed with the statement, "I try hard to live by my religious beliefs."

This figure showed "an unexpected, sizeable personal investment in religion," the authors noted.

The authors then compared this figure with a survey of what factors therapists believed were important to mental health. Surprisingly, only 29% of therapists rated religious content as important in treatment with all or many clients or patients (Jensen and Bergin, 1988).


Do you think religiously committed therapists should open this doorway or keep it closed? What do you think would be the consequences of opening the doorway and addressing religious issues in therapy?

What undercurrent of pressure within the mental health profession might contribute to the suppression of religious issues in therapy?

Who's Dangling in the Gap

A majority of psychotherapists - even those who personally value religion - often fail to recognize the potential significance of dealing with religious commitment in therapy. Does this failure have an impact on who religiously committed patients might turn to for help with psychological problems?

Examining the Research


In order to examine whether people with mental health disorders sought help from mental health professionals, clergy or both, data from a national study was analyzed.

Data for the analyses came from the Epidemiological Catchment Area (ECA) Survey which sought information on demographics, health and mental health services utilization, and psychiatric diagnosis among a sample of adults at five sites.

Psychiatric status was determined by interviewing people in the communities with the Diagnostic Interview Schedule, a research instrument used to assess psychiatric disorders. The five sites were New Haven, Conn.; eastern Baltimore, MD.; St. Louis, Mo.; five counties in the Durham, NC area; and the Venice and East Los Angeles areas of Los Angeles County, CA.


The analysis focused on people with psychiatric symptoms who had sought help for problems with emotions, nerves, drugs, alcohol or mental health at any time in their lives.

Perhaps the most striking finding was that in a similar manner across the five sites, persons with serious psychiatric disorders were just as likely to seek hlep from clergy as they were to seek help from mental health professionals.

Those seeking help from the clergy were just as likely to have major psychiatric disorders as those seeking help from mental health professionals. Sometimes, those with severe disorders such as major depression, schizophrenia and bi-polar disorder sought help from both. However, some with severe disorders only sought help from the clergy.

Exceptions were individuals with a history of alcohol or drug abuse who preferred to seek help from mental health specialists rather than clergy. Persons with those disorders tend to be non-religious (McDonald and Luckett, 1983).

The data showed that clergy - with or without the help of mental health professionals - were coping with a broad spectrum of psychiatric disorders which they may or may not have been prepared to handle (Larson, et. al., 1988).


What are the implications of the fact that persons with severe mental health disorders may choose to seek help from a member of the clergy rather than a mental health professional?

What could be done to educate and assist members of the clergy who might be hesitant to recommend a mental health professional for a parishioner?

Spanning the Gap

Some persons with serious mental health disorders only seek help from the clergy. How might they be encouraged to also seek professional psychological help which may be needed as well? Who might help bridge the gap - or open the doorway?

Examining the Research


A survey was undertaken to find out how mental health professionals who personally value religion choose to integrate a patient's religious commitment into therapy?


According to survey results published in the American Journal of Psychiatry, a growing number of religious psychiatrists actively promote new approaches to psychotherapy based on conventional religious commitment (Galanter, Larson and Rubenstone, 1991).

The survey, which polled psychiatrists who were members of the Christian Medical and Dental Society, found that these psychiatrists believed that prayer and the Bible could be used effectively to help patients deal with grief reactions, suicidal intent, sociopathy and alcoholism However, acute manic episodes or acute schizophrenic episodes were believed to be best dealt with by psychotropic medication.

The results showed the average Christian psychiatrist to be a prominent member of his profession: 59% held faculty appointments at a medical school, 68% were board certified and 88% were members of the American Psychiatric Association.

These religious psychiatrists have integrated aspects of conventional religious commitment into therapy with religiously committed patients. Is it only possible for therapists who personally value religion to bridge the gap and use religious content in therapy?

Examining the Research


A carefully controlled study was designed to examine whether using religious content in therapy - conducted by either religious therapists or non religious therapists - would be more or less effective in the treatment depressed patients.


A study of clinically depressed patients compared the effectiveness of treatment when using a cognitive behavioral therapy either with religious content or without. Religious and non-religious therapists were used in each treatment.

Depressed patients receiving treatment involving religious content did better than patients with whom religious content was omitted. This was determined by using the measures of post- treatment depression and adjustment scores on standardized tests. Of note was the fact that the non-religious therapists, using the religious approach, had the highest level of treatment effect (Propst, 1992).

Four Quadrants of Therapists in Treating Religiously Committed Patients

  1. Across the Gap: Therapists who personally do not value religious commitment and ignore it or primarily see it as harmful for their patients.
  2. The Collaborative: Therapists who personally are not religiously committed but respect and deal positively with religious commitment in therapy.
  3. Behind the Door: Therapists who personally hold religious values but ignore or refrain from dealing with religious commitment and religious values in therapy.
  4. The Conjoint: Therapists who personally are religiously committed and who deal with religious commitment in therapy.
Please see figure on the following page.

Identifying Implications

Our education has made us increasingly sensitive to prejudice against race, gender, ethnic groups and socio-economic levels. However, how sensitive have we become to respecting religious commitment and the role it plays in the lives of the majority of our patients?

For the more than 70% of the population for whom religious commitment is a central factor, "secular approaches to psychotherapy may provide an alien values framework," state Bergin and Jensen. They continue:

A majority of the population probably prefer an orientation to counseling and psychotherapy that is sympathetic, or at least sensititve, to a spiritual perspective. We need to better perceive and respond to this public need (Bergin and Jensen, 1990).


Would you agree or disagree with Bergin and Jensen's statement? What do you think might contribute to therapists, at times, failing to take into account the religious dimension of a patient's life?

Review Check

Directions: There are seven questions presented to reinforce your knowledge of the preceding information. In Part A, please fill in the blanks with the correct answer. Then, in Part B, match the term with the appropriate definition.

Part A

  1. A series of Gallup polls have determined that % of the U.S. population believe in God, while a much lower % of the U.S. population does not consider religion to be very important.
  2. _____ % of the general public endorsed the statement in a Gallup survey, "My religious faith is the most important influence in my life." In contrast, responses for mental health professionals to the statement, "My whole approach to life is based upon my religion" included a low of ______ % for clinical psychologists and a high of _____% for marriage and family therapists.
  3. In one of the reviewed surveys, non-religious persons were those who called themselves: atheist, agnostic, humanist or had no belief. The range for mental health professionals who fall into this category went from a low of 7% for clinical social workers to a high of 28% for _____________ .
Part B


4. Across the Gap

5. Behind the Door

6. The Conjoint

7. The Collaborative

a) Therapists who personally are not religiously committed but respect and deal positively with religious commitment in therapy.

b) Therapists who personally hold religious values but ignore or refrain from dealing with a patient's religious commitment as a component in therapy.

c) Therapists who personally do not value religious commitment and ignore it or see it as harmful to their patients.

d) Therapists who personally are religiously committed and who deal with religious commitment in therapy.

Review check answers here.

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