PREDICTORS OF DEPRESSION, ANXIETY, AND STRESS AMONG CLERGY. A Thesis Presented to the Faculty of California State University, Stanislaus

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1 PREDICTORS OF DEPRESSION, ANXIETY, AND STRESS AMONG CLERGY A Thesis Presented to the Faculty of California State University, Stanislaus In Partial Fulfillment of the Requirements for the Degree of Master of Science in Psychology By Nathan Lusher II December 2016

2 CERTIFICATION OF APPROVAL PREDICTORS OF DEPRESSION, ANXIETY, AND STRESS AMONG CLERGY by Nathan Lusher II Signed Certification of Approval page is on file with the University Library Dr. Gary Williams Assistant Professor of Psychology Date Dr. AnaMarie Guichard Associate Professor of Psychology Date Dr. Jessica Lambert Assistant Professor of Psychology Date ii

3 2016 Nathan Lusher II ALL RIGHTS RESERVED iii

4 DEDICATION For Chloe and James iv

5 AKNOWLDGEMENTS I want to first thank my thesis chair, Dr. Gary Williams. In working with him, I was able to develop and finish a project that I could be proud of. The completion of this project could not have been done without his guidance and expertise. I want to also thank the rest of my thesis committee, Dr. AnaMarie Guichard and Dr. Jessica Lambert for providing me with valuable insights and resources that only made this project better. I also want to thank my parents, in-laws, grandparents, and other family members for always offering me, not just emotional support and encouragement, but also being there to buy books or pay the bills when I could not do so on my own. The completion of this project could not have been done without you. Lastly, I want to thank my wife Chloe. Through our most difficult times, she has always stood by me and supported me through the completion of this project. We could not have made it without her unwavering support and dedication to myself and our family. Her constant love and encouragement throughout this program and project is something I will cherish forever. v

6 TABLE OF CONTENTS PAGE Dedication... Acknowledgments... iv v List of Tables... viii Abstract... ix Introduction... 1 Psychopathology... 1 Depression... 1 Anxiety... 3 Comorbidity... 6 Clergy... 6 Factors Contributing to Psychopathology in Clergy... 8 Vocational Satisfaction and Stress Social Support Religious Fundamentalism Religious Doubt The Present Study Method Participants Design and Materials Demographics survey Vocational satisfaction Social support Religious fundamentalism Religious Doubt Depression, anxiety, and stress Procedure Results Discussion Limitations Future Research Conclusion References vi

7 Appendices A. A Letter to Participants B. Job Satisfaction Scale C. Medical Outcomes Study Social Support Survey-6 (MOS-SSS-6) D. The Revised 12-Item Religious Fundamentalism Scale E. Religious and Spiritual Struggles Scale; Doubt subscale F. Depression Anxiety Stress Scales-21 (DASS-21) G. Demographics Survey vii

8 LIST OF TABLES TABLE PAGE 1. Descriptive Statistics for all Variables Summary of Multiple Regression Analyses for Variables Predicting Depression, Anxiety, and Stress Scores Correlation Table for Four Predictor Variables and Depression Scores Correlation Table for Four Predictor Variables and Anxiety Scores Correlation Table for Four Predictor Variables and Stress Scores viii

9 ABSTRACT The purpose of this study was to examine the relationship between four predictor variables (vocational satisfaction, social support, religious doubt, and religious fundamentalism) and three outcome variables (depression, anxiety, and stress) among a Christian clergy population. A total of 1,167 surveys were sent out to Christian clergy across the U.S; 115 were returned, and 94 were used in the final analyses. Multiple regression analyses found three significant correlations, (a) a negative correlation between vocational satisfaction and depression scores, (b) a negative correlation between social support and depression scores, and (c) a negative correlation between vocational satisfaction and stress scores. These results are discussed further, including implications for clergy and mental health professionals, as well as areas in need of further research. ix

10 CHAPTER I INTRODUCTION The purpose of this study is to examine the symptomology of depression, anxiety, and stress among a Christian clergy population. Specifically, predictors of depression, anxiety, and stress will be evaluated. Depression and anxiety are major health concerns among the general population, but the rates of these illnesses may be even higher among clergy due to the nature of their profession (Knox, Virginia, & Lombardo, 2002). It is hoped that through this study we may gain a better understanding of what factors contribute to the development of depression, anxiety, and stress among clergy. Depression Psychopathology Depression can be a crippling disease for many in the United States and across the world (National Institute of Mental Health [NIMH], 2016). It is, in fact one of the most common mental disorders that an adult can experience (Waraich, Somers, & Hsu, 2004). By the year 2000, depressive disorders were considered the second most debilitating conditions that brought about disability and an overall lower quality of life (Pincus & Pettit, 2001). What is it about this disorder that makes it so damaging to the individual that suffers from it? People may often wonder how feelings of sadness can be so crippling in a person s life who suffers from this disorder. Depressive disorders are a broad category within the Diagnostic and Statistical Manual of Mental Disorders (5 th ed.; DSM-5; American Psychiatric Association, 2013) encompassing an array of conditions including major depressive disorder, persistent depressive disorder, and disruptive mood dysregulation disorder to name a few. Depressive disorders are most often characterized by deep sadness, loss of pleasure, feelings of guilt and worthlessness, change in 1

11 2 appetite, loss of energy, and poor concentration (APA, 2013). Major depressive episodes last for at least two weeks, and during this time can be extremely debilitating. This differs from the common occurrence of sadness by the immense strain placed on the individual s everyday level of functioning. Often, individuals who suffer from a major depressive episode are unable to carry out mundane tasks such as basic hygiene or even getting out of bed. The severity of symptomology inevitably impacts their daily life and contributes to an overall negative quality of life. In the United States, the rate of depression among the general population is approximately 7% within a 12-month period (APA, 2013). However, when expanding the criteria to include lifetime prevalence of anyone that has experienced a mood disorder, the percentage jumps to 20.8% (Kessler et al., 2005). These numbers are alarming and should be a concern to anyone within the field of mental health. There are various explanations regarding the etiology of depressive disorders. Instead of identifying one causal factor that explains why depressive disorders develop in some individuals and not others, researchers have considered a broad range of factors that, when combined, seem to explain why certain individuals develop depressive disorders and others do not. First, there is likely a genetic component involved in the development of depression. For example, when comparing identical and fraternal twins, identical twins were more likely to develop a depressive disorder if their sibling had one, compared to fraternal twins, who were less likely to develop the disorder (Englund & Kline, 1990). In general, individuals who have family members that suffer from depression are more likely to develop the disorder than those who do not have a history of the disorder in their family (Byers et al., 2009). Some estimate the heritability rate of depression to be approximately 31% - 42% (Sullivan, Neale, & Kendler, 2000).

12 3 The genetic research is in its infancy and there is still much more to be learned. However, we do know that genes are not static; they are expressed through a complex interaction with the environment. Even if individuals possessed a gene, or a collection of genes, that predisposed them for the development of a depressive disorder, there is no guarantee that these genes would be expressed. It is the interaction between genetics and environment that may best explain why depression develops in certain individuals and not others (Routledge et al., 2016). In addition to genetic factors, there are a host of environmental contributors that need to be assessed when examining depression, such as negative self-perception, learned helplessness and stressful life events (Alloy et al., 2000). These factors are not necessarily causal, but they may be predictive. Individuals who have negative views of themselves and their life tend to be at greater risk for developing depression (Alloy et al., 2000). There is also evidence that suggests people may feel hopeless after repeated attempts to solve problems in their lives, and these continued failed attempts may lead a person to feel helpless and depressed (Seligman, Weiss, Weinraub, & Schulman, 1980). An individual who experiences many negative life events is more likely to develop depression if they have a pessimistic view of the world, lack social support, and lack effective ways to cope with the situation (Alloy et al., 2000). Negative life events can encompass a broad range of experiences. The stress and anxiety surrounding low job satisfaction, for example, has been linked to higher levels of depression compared to those who experience less vocational-related stress and have higher vocational satisfaction (Mezuk, Bohnert, Ratliff, & Zivin, 2011). Anxiety Anxiety is something that is commonly experienced by people all around the world. It can often be experienced when going in for a job interview, speaking in front of a group, or

13 4 having to be the bearer of bad news. Anxiety differs from fear, in that anxiety can be considered an anticipatory fear, a fear of what is to come; whereas the common feeling of fear is an emotional reaction to real or imagined threats (APA, 2013). A question arises from these facts: When does the experience of fear and anxiety become a matter of clinical concern? Anxiety and fear are the hallmark features of a cluster of disorders known as anxiety disorders. These fears and anxieties can be nonspecific (e.g., Generalized Anxiety Disorder), or they can be focused on objects, animals, or situations (e.g., Specific Phobia). The mere experience of fear or anxiety is not enough to diagnose an individual with an anxiety disorder. There are specific criteria that must be met for each disorder; however, this does not mean that an individual experiencing significant distress will fit into any one category, or any category at all. Anxiety is a rather broad term encapsulating a variety of symptomology. As previously mentioned, anxiety can be thought of as an anticipatory fear. With this fear comes excessive worry, problems concentrating, irritability, fatigue, sleep difficulties, restlessness, and muscle tension (APA, 2013). It is when these symptoms begin to disrupt and impair the everyday functioning of the individual that anxiety becomes a matter of clinical concern. The experience of mundane levels of anxiety is rather common, and unfortunately, the experience of clinical levels of anxiety is also common. The average rate of generalized anxiety disorder in the general population for a given year is approximately 2.9% (APA, 2013), while the lifetime prevalence rate is closer to 5.7% (Kessler et al., 2005). Two important questions to ask are (a) why are these numbers so high, and (b) what factors contribute to the development of clinical levels of anxiety?

14 5 Anxiety, just like depression, does not necessarily have one causal factor that can explain the development of clinical levels of anxiety of one person and not the other. An interaction between a biologically natural response to fear, and learned responses to fear through conditioning and reinforcement may offer a useful model for understanding anxiety. In order to avoid dangerous, possibly lethal situations, we have developed a complex system of threat detection that allows us to navigate through our environment (Lobue, 2014). When an immediate threat is detected we experience a physical response; our breathing changes, our heart rate is increased, and blood flow is directed to the major muscles in our body. This reaction allows us to either make a quick escape, or stand and defend ourselves (Davies & Craske, 2015). This is our body s natural reaction to fear. Anxiety seems to trigger this same response. Classical conditioning is often used to explain anxiety. One of the most famous examples of this is Watson and Rayner s (1920) experiment with Little Albert. Albert was an eleven month old baby that was presented with a rat. The presentation of the rat was accompanied by a loud, fear-invoking sound. Eventually, the researchers only had to show Albert the rat in order to get the fear response. Albert had learned to associate the rat with the fear he experienced when he heard the loud noise. In a similar way, excessive fear and anxiety in the general population could be attributed to this kind of behavioral conditioning. Individuals may learn to associate certain stimuli with fear responses. Looking through a cognitive lens, anxiety is an overestimation of a threat stimulus. This overestimation leads to catastrophizing and overgeneralization (Beck & Emery, 2005). This makes sense not only from a cognitive perspective, but also from an evolutionary one. It is usually more advantageous to overestimate, rather than underestimate a possible threat. The cost of a Type I error (false positive) is much greater than a Type II error (false negative). Therefore,

15 6 one can assume that these specific cognitive patterns would be passed on from generation to generation producing offspring that have preserved this cognitive pattern. Comorbidity A discussion about depression and anxiety would not be complete without addressing the issue of comorbidity. Twenty-six percent of individuals who have a diagnosis of generalized anxiety disorder also meet criteria for major depressive disorder (MDD; Brown et al., 2001). In another study, 17.5% of individuals with a primary diagnosis of major depressive disorder also met criteria for generalized anxiety disorder (GAD; Kessler, DuPont, Berglund, & Wittchen, 1999). This is not surprising considering that there are several overlapping symptoms between GAD and MDD such as problems sleeping, loss of energy, difficulties concentrating, and feelings of restlessness (APA, 2013). According to Kessler et al. (1999), major depressive disorder and generalized anxiety disorder are approximately equal in terms of overall impairment; when combined, symptoms become even more severe. Due to the symptom severity that accompanies comorbidity, individuals who meet criteria for both disorders often experience higher levels of impairment in their daily functioning than individuals with a single diagnosis of either GAD or MDD. Given this information, it will now be important to examine clergy specifically to understand what factors they may face that might place them at risk for experiencing depressive, anxious, and stress-related symptomology. Clergy The term clergy or clergyperson broadly defined refers to the leadership of a particular religious organization ( Clergy, n.d.). This term can refer to leaders in various religious traditions (e.g., Judaism, Christianity, Islam, Buddhism, etc.). In the United States, the term is most often associated with Christianity and its leaders within the tradition. Clergy, within

16 7 the Christian tradition, is a broad term that may refer to a range of different titles within churches such as pastor, minister, bishop, priest, evangelist, or preacher. The specific meaning of these terms will vary according to the specific Christian tradition that utilizes them. Despite the range of terminology, clergy within the Christian tradition carry out similar duties. Most often clergy will lead a group of followers, or congregation. As the leader of these congregations, clergy generally preach a sermon every week informed by specific Biblical passages they wish to focus on for that week; functioning as a religious teacher. Clergy act as spiritual guides for their congregations. Ministers are often required to attend seminary where they earn advanced degrees in Biblical studies or theology. Clergy instruct their congregations in the meaning of their religious tradition and holy book. In addition to preaching every week, clergy often perform a variety of duties outside the confines of their church building. Clergy will often lead a variety of groups during the week, in addition to their weekly service. These groups can vary in purpose (e.g., social, educational, charity), but all have a religious focus. Clergy also conduct various types of ceremonies such a weddings, funerals, and other sacramental activities. Clergy may also act as counselors for members of their congregations. When church members are going through difficult periods of their life, they often turn to a clergyperson leading their church for guidance. For example, families that are having struggles with their personal relationships (e.g., romantic, friendships, or family) will turn to their pastor for guidance and advice. In addition to pastoral counseling, clergy can act as healers. It is not uncommon for a clergyperson to visit ill church members at home or in the hospital in an attempt to heal members or offer comfort. These visits often include words of encouragement to the grieving family, as well as prayer sessions for the ill and their loved ones.

17 8 Clergy also play an administrative role within their church. Often they must raise money every week, in the form of tithes, to continue regular church operations. Clergy have the responsibility of paying church bills, ensure proper church property maintenance, and plan and schedule church events. Clergy not only act as spiritual leaders within their church, but play the role of counselors, motivational speakers, managers, business owners, and even janitors. The list of various vocational responsibilities for a clergyperson is broad and long. With such a wide range of responsibilities, clergy often experience job related stress (Wells, 2013; Wells, Probst, McKeown, Mitchem, & Whiejong, 2012; Lee, 1999; Morris & Blanton, 1998; Berry, Francis, Rolph, & Rolph, 2012; Dewe, 1987). The question naturally arises: does the stress produced by vocational demands on clergy put them at greater risk for developing depression and anxiety compared to those in the general population? The question is rather complex with a variety of different factors that need to be assessed. Factors Contributing to Psychopathology in Clergy Clergy can experience a variety of stressors that are a consequence of the demands of the profession they are in. A key factor involved in the development of depression in clergy is low levels of vocational satisfaction (Knox et al., 2002; Knox, Virginia, Thull, & Lombardo, 2005; Raj & Dean, 2005). Based on these findings, it seems that the demands associated with work in the ministry may lead clergy to have high levels of stress and low levels of vocational satisfaction. Clergy may also have difficulty finding appropriate social support and deal with feelings of isolation. Heavy demands are often placed on clergy by their congregations, but often lack the support they themselves need in their times of crisis (Berry et al., 2012; Virginia, 1998; Knox,

18 9 Virginia, & Lombardo, 2002; Knox et al., 2005). During moments of significant stress, depressive episodes can occur in people who lack sufficient social support (Leskelä et al., 2006). The way in which a person understands and practices their religion may also play a role in the development of depression, anxiety, and stress in clergy. It is known that Pentecostals (a conservative, fundamentalist Christian tradition) commonly view persistent mental health issues as spiritual problems that can be explained by sin or a troubled relationship with God (Trice & Bjork, 2006). Keating and Fretz (1990) suggest that the more fundamentalist a Christian is, the more apprehensive they are about seeking mental health services. They may fear their religious beliefs will not be taken into consideration. On the other end of the spectrum, religious doubt may play a role in the development of psychological distress in members of the clergy. Studies indicate that there is a strong negative correlation between religious doubt and mental well-being (Krause, 2006; Ellison, Fang, Flannelly, & Steckler, 2013; Galek, Krause, Ellison, Kudler, & Flannelly, 2007). Clergy are often well-educated and may wrestle with much deeper philosophical and theological issues regarding their religious beliefs compared to the average member of their congregation. Clergy may also not feel comfortable discussing their doubts about their religion due to their position of leadership in the church. As previously mentioned, clergy often lack social support. This lack of social support can lead to isolation and feelings of loneliness (Staley, McMinn, Gathercoal, & Free, 2013). Religious doubt may also act as a means of further internal isolation from church members if the clergyperson is doubting the very core doctrines that define the group as a whole. There is little doubt that stress can have an effect in the development of certain psychopathologies within this population. Due to the nature of their work, clergy face a variety of stressors on a daily basis. In a sample of depressed participants (non-clergy), Rojo-Moreno

19 10 and colleagues (2002) found that a stressful life event preceded the development of depression in 68% of the people they sampled. Clergy who may be experiencing religious doubts may also be experiencing additional stressors that their low-doubting colleagues do not face. Belief in a god for many Christians is more than a belief in a proposition. These believers feel as though they have a personal relationship with this deity. When doubts or even disbelief occur in the believer, there may be a profound sense of loss regarding their relationship with God. Hammen (2005), in a review of stress and depression studies, noted that negative changes in a relationship status, particularly the loss of an important relationship often came before the development of depression. Vocational Satisfaction and Stress Vocational satisfaction can be defined as a pleasurable or positive emotional state resulting from the appraisal of one's job or job experiences (Locke, 1976, p. 1304; as cited in Park, Y., Seo, Park, J., Bettini, & Smith, 2016). The degree to which an individual is vocationally satisfied depends, in part, on the level of demand and stress experienced from their vocation. Job-related stressors can be a daily occurrence in some professions. These stressors that are experienced can greatly influence vocational satisfaction, as well as the individual s overall level of psychological well-being. For example, Mezuk et al. (2011) found that older workers who were experiencing high levels of job-related stress and low levels of vocational satisfaction had a much higher risk of experiencing depressive symptomology than those older workers who were experiencing lower job-related stressors and higher levels of job satisfaction. Due to the wide range of responsibility in the ministerial profession, clergy experience a range of work related demands and stressors. Berry et al. (2012) examined various job-related stressors as described by a sample of Anglican clergy from Great Britain. Clergy reported that

20 11 demands of a heavy work-load with not enough time to accomplish required duties greatly contributed to their overall level of stress. Clergy from this sample also reported issues related to unreasonable expectations by members of the congregation as well as leaders within the hierarchical structure of the church organization. Another potential stressful area of ministry was dealing with conflict within the church. The stress that these clergy experienced left them feeling tired, anxious, exhausted, and feeling as though they did not have enough support to carry out their duties. Dewe (1987) found similar results regarding stressors experienced by ministers in New Zealand. Stressors identified by this sample were church conflict and church conservatism, and stress involved with working with members of the congregation. Ministers reported various levels of distress involved in ministerial activities, such as conflicts between church teachings and their own beliefs, prejudice within their congregation, feeling as though they were not meeting the needs of their congregation, and emotional exhaustion. The experience of job-related stress seems to be a leading contributor to low vocational satisfaction in clergy. In a sample of Catholic clergy, Knox et al. (2002) found low vocational satisfaction to be predictive of higher rates of depression, as well as higher levels of anxiety overall. When clergy experienced higher levels of vocational satisfaction, rates of depression and anxiety were much lower. This has been a consistent finding among samples of Catholic clergy in terms of vocational satisfaction being predictive of depression (Knox et al., 2002; Knox et al., 2005; Raj & Dean, 2005). The overall rate of depression for this population of clergy has been shown to be higher than individuals of the general population, in some cases being seven times higher than the average rate in the general population (Virginia, 1998; Knox et al., 2002; Knox et al., 2005; Knox, Virginia, & Smith, 2007).

21 12 Other factors that may contribute to low vocational satisfaction for clergypersons are intrusive demands of church members. Various studies (e.g., Morris & Blanton, 1998; Lee, 1999; Wells et al., 2012; Wells, 2013) have shown that clergy are often on call 24 hours a day for congregation members. These demands can be seen as intrusive or invasive to clergy, as well as by their families. It is important to note that these stressors may not only have negative impacts on clergy, but also have deleterious effects on their families. Social Support Social support is defined as an individual s feeling that they are cared for and loved esteemed and valued [and] belongs to a network of communication and mutual obligation (Cobb, 1976, p. 300; as cited in Carr, Wohn, & Hayes, 2016). Social support has not only been linked to higher levels of mental health (Holden, Dobson, Ware, Hockey, & Lee, 2015), but has also been shown to have beneficial effects for our physical health (Uchino, 2006). When social support is lacking, coupled with unfavorable life events, the risk of a depressive episode occurring is higher than when social support is high (Leskelä et al., 2006). The sample of Anglican clergy examined by Berry et al. (2012) reported various stressors related to their profession, many of which were discussed in the preceding section. One factor that these clergy described as contributing to their overall level of stress was a lack of social support. Clergy often reported feeling as though they did not have enough support to carry out their required duties; either from church members or members from the church hierarchy. Staley et al. (2013) sampled ministers from the Evangelical Friends and Nazarene denominations and examined factors that contributed to social isolation and lack of social support among these ministers. Minsters reported that there were barriers that prevented them

22 13 from developing close relationships. Six core barriers were identified: time, expectations, transparency/vulnerability, relational boundaries, relocation, and trust/confidentiality. Due to the nature of their work, ministers stated that they often felt they did not have the time necessary to foster close and supportive relationships. Ministers also struggled with the expectations placed on them by members of their congregation. They often felt as though they were held to a different standard and most often viewed as an authority figure holding a different rank in the social hierarchy than those in their congregation. Because of this standard placed on clergy, ministers often dealt with issues related to transparency; they had difficulty opening up and being themselves (Staley et al., 2013). Relocation was another issue described that prevented the development of close relationships. Ministers reported that they often had to move in order to pastor another church, forcing them to uproot and start fresh. This made it difficult to hold on to any relationships they had previously formed. The last theme they described was an issue related to trust and confidentiality. Ministers struggled with knowing how much of their personal issues to disclose for fear that this information would make its way around the church and other social circles (Staley et al., 2013). In Virginia s (1998) study examining burnout and depression in secular order (clergy within the community, acting as leaders of a church), religious order, and monastic order clergy (clergy living within a priestly community and generally not overseeing a congregation) in the Catholic Church, lack of social support was thought to be related to burnout and depression among secular order clergy compared to their religious and monastic order colleagues. Knox et al. (2002) found similar results, finding lack of social support to be predictive of state and trait

23 14 anxiety in their sample of secular Catholic clergy. Social support was suspected of having a kind of buffering effect against anxious and depressive symptomology in their sample. Findings have not all been conclusive. In a pilot study looking at general rates of psychopathology, Knox et al. (2007) found social support not to be a significant predictor of emotional exhaustion or depression. These findings are open to interpretation considering the small sample size (N = 45) compared to similar studies (e.g., Virginia, 1998; Knox et al., 2002). In a study looking at rates of depression and burnout in Indian Catholic priests, Raj and Dean (2005) also found that social support was not predictive of depression and burnout. Despite these findings, these results should be interpreted with caution. The generalizability of these findings is questionable considering the cultural differences in the expression of psychopathology. They may not provide an accurate representation of the role played by social support in clergy as a whole, especially those serving in the United States. Religious Fundamentalism Religious beliefs are not uniform across all populations, and vary considerably, even among adherents of the same religious tradition. Some believers may take stories from their religious traditions as literal, historical accounts preserved within their sacred texts, while others may interpret the same passages as metaphorical and possessing a much deeper meaning. Some more conservative or fundamentalist believers may hold that their specific tradition is the only true means of understanding and connecting with the Divine, while other, more liberal or progressive believers may view their religious tradition as one of many pathways to understanding God. Fundamentalist believers tend to hold more literalistic beliefs regarding their religion. Altemeyer and Hunsberger (1992) provide a particularly useful definition of religious fundamentalism,

24 15 the belief that there is one set of religious teachings that clearly contains the fundamental, basic, intrinsic, essential, inerrant truth about humanity and deity; that this essential truth is fundamentally opposed by forces of evil which must be vigorously fought; that this truth must be followed today according to the fundamental, unchangeable practices of the past; and that those who believe and follow these fundamental teachings have a special relationship with deity (p. 118). Narrowing our focus to members of the Christian tradition that may be considered fundamentalist in their system of belief, it may be helpful to examine how fundamentalist beliefs may contribute to increased levels of psychopathology, but more specifically depression and anxiety. Fundamentalist Christians are generally wary of the secular world that exists outside of their religious organization. This caution most likely comes from the interpretation of various Biblical passages that discuss believers being separate from secular society (e.g., Ezra 10:11, Romans 12:2, 1 Peter 1:14, 1 John 2:15; NRSV). As it relates to mental health services, this ingroup/out-group distinction is apparent in a study conducted by Keating and Fretz (1990). They found that Christian participants were far more likely to choose a Christian counselor than one whose religious orientation they did not know, suggesting that their trust in the counselor s abilities was directly tied to the counselor s religious affiliation. Fundamentalists are also more likely to attribute psychological distress to issues related to spirituality. In a sample of 126 Australian Christians, Hartog and Gow (2005) found that 38.2% of participants thought that demonic activity or possession was a likely cause of depression, and 37.4% thought the same was true in the development of schizophrenia. Pentecostals, a conservative, fundamentalist denomination of Christianity, were sampled by Trice and Bjorck (2006) to assess their views about depression. Results indicated that psychological distress was not immediately explained as a spiritual issue, but if symptoms did not dissipate, they were more likely to attribute the cause of the problem to a spiritual issue

25 16 related to a damaged relationship with God, or related to demonic activity. Payne (2009) also found similar results regarding Pentecostal minsters. In a sample of minsters from various Christian denominations, Pentecostal minsters were more likely to view depression as the result of spiritual or moral problems, as opposed to biological or psychological factors. These results may explain the findings of previous studies that indicate rates of depression are much higher in Pentecostals than other Christian denominations (Meador, Koenig, Hughes, & Blazer, 1992; Trice & Bjorck, 2006). Views regarding the efficacy of treatment may also play a role in the rates of depression experienced by more fundamentalist denominations. Trice and Bjorck (2006) found that the majority of their sample thought the most effective form of treatment for depression was spiritual (e.g., reading the Bible, confessing sins, praying), as well as doubted the benefits of traditional mental health services. Loewenthal and Cinnirella (1999) in a sample of believers from varying traditions, found that prayer was considered to be just as effective, if not more effective, in dealing with depression than medication and psychotherapy. This perception of treatment, coupled with cautious suspicion of secular treatments and their views regarding the etiology of various mental disorders may leave fundamentalist Christians more vulnerable to the development of these disorders than those believers who are more likely to seek out traditional mental health services. Religious Doubt Religious doubt can be defined as the uncertainty, or questioning of teachings and doctrines of the religious tradition to which you belong (Hunsberger, McKenzie, Pratt, & Prancer, 1993; as cited in Krause, 2006). There are various reasons why a person might begin to doubt the teachings and doctrines of the religious tradition they belong to. As Krause (2006)

26 17 describes, there are certain teachings and doctrines within Christianity that seem to be in the realm of scientific implausibility or even impossibility, such as the belief in beings that one cannot see, that people can walk on water, a virgin can give birth, or deceased individuals can come back to life. Doubts can also be centered on more emotionally-driven concerns such as the contradiction inherent in the coexistence of an omnipotent, omnibenevolent deity, and the presence of evil and suffering in the world. Due to these issues related to belief, these teachings and doctrines may be difficult for some believers to accept. For a Christian who has been a believer his or her entire life, the experience of doubt may be an extremely stressful event. Doubt may even be preached against in some Christian circles. The story of Doubting Thomas (John 20:24-29) is a prime example of why doubt is often discouraged among Christian believers. In this story, one of Jesus disciples, Thomas, doubts that Jesus has been resurrected from the dead, and says that until he sees Jesus he will not believe. When Jesus returns he scolds Thomas, telling him to stop doubting and believe. Jesus goes on to say that those that did not see him, but still believed he had risen, were blessed. It is easy to see why the experience of doubt can be unwanted and cause significant distress for believers; but, can this distress lead to more significant problems related to mental health? Galek et al. (2007) examined a nationwide sample of American adults 18 years and older (N = 1,629) to try and understand the relationship between doubt and mental health. Their findings show that doubt was positively associated with higher levels of depressive and anxious symptoms. Ellison et al. (2013) assessed the degree to which spiritual struggles had an effect on mental health. Spiritual struggles were divided into two categories; divine struggles, and struggles with belief, i.e., religious doubt. Divine struggle was defined as a perceived problem in the individual s relationship with God (e.g., feeling distant from God, or feelings of

27 18 abandonment). Results showed that individuals who experienced high levels of these two spiritual struggles experienced not only higher levels of depressive and anxious symptoms, but also higher levels of phobic and somatic symptoms. The relationship between spiritual struggles and psychopathology was much stronger for individuals who had a strong sense of religious identity compared to those individuals who did not have as much of their identity wrapped up in their religious ideology. Clergy may be an especially vulnerable population in terms of religious doubt and psychopathology. Krause and Wulff (2004) found that individuals from congregations that experienced high levels of doubt tended to have lower levels of health satisfaction and were more likely to experience depressive symptoms. The results of this study also showed that symptoms were exacerbated for individuals who held formal positions within the church such as a church board member, worship leader, or Sunday school teacher. In other words, individuals who were more invested in their religious identity by holding a formal position in the church, were more likely to be negatively affected by religious doubts. The experience of doubt in clergy is often met with a sense of uneasiness from congregation members. Staley et al. (2013) share the response of a clergyperson that was part of their study. This minister recounted an experience he had during a church book club. During this meeting, the group was discussing the fact that the author of the book they were reading experienced many religious doubts in his youth. The pastor then divulged to the group that he could relate to many of the struggles the author discussed. Immediately following the book club meeting, a friend of the pastor began to criticize him for sharing his doubts, reiterating that pastors were held to a different standard and his doubts should not be shared with members of the congregation.

28 19 It is clear that clergy face a unique set of challenges, not only in terms of experiencing doubt, but also in their expression of doubt. As religious leaders within their communities, clergy are expected to be the ones that can be turned to for the answers to the tough questions. Despite this expectation, clergy seem to be the most at risk in experiencing the negative effects of doubt; holding a place of leadership within the church, they stand to lose the most. As intimated by Galek et al. (2007), the reason doubt seems to have such negative effects on depressive symptomology is because the individual s religious beliefs have provided them with a framework to understand and encounter the world. When one begins to doubt these core beliefs about the natural and the supernatural, they have lost pieces of that framework that had previously offered them comfort due to its explanatory power. This liminal period between certainty and uncertainty creates significant distress in the life of the religious doubter, making them prone to depressive and anxious symptomology. The Present Study There is evidence from the literature that clergy may be at risk for the development of stress, depression, and anxiety. The high work demands and the stress involved in the everyday functioning of a minister puts ministers in a precarious situation and place them at risk for developing depressive and anxious symptomology. Ministers are also at risk for lacking supportive social relationships. Because ministers are held to a different standard compared to other members of their congregation, they often do not feel comfortable being themselves and connecting with people on a deeper level, or reaching out for help. The nature of their belief also seems to play a role in the development of their psychopathology. Individuals from more fundamentalist traditions seem to have higher rates of depression than their more religiously liberal peers. This may be in part due to their views of the etiology and treatment of mental

29 20 disorders. Doubt has also been associated with higher levels of psychological distress due to a disrupting or questioning of the existential framework that allowed the believer to make sense of the world. This disruption of belief, or liminal period can be distressing and lead to the development of depressive and anxious symptomology in clergy that are experiencing doubts. This evidence and theoretical framework provided by the relevant research provide the basis for the following hypotheses: H1: Vocational satisfaction will be negatively correlated with the (a) depression, (b) anxiety, and (c) stress subscales of the DASS-21 for clergy. H2: Social support will be negatively correlated with the (a) depression, (b) anxiety, and (c) stress subscales of the DASS-21 for clergy. H3: Religious doubt will be positively correlated with the (a) depression, (b) anxiety, and (c) stress subscales of the DASS-21 for clergy. H4: Religious fundamentalism will be positively correlated with the (a) depression, (b) anxiety subscales of the DASS-21 for clergy.

30 21 CHAPTER II Participants METHOD Participants were 94 Christian clergy from the United States that were contacted from publicly available contact information provided by their church websites. A total of 1,167 surveys were sent out through a link, via . Of this total, 115 were returned. Due to incomplete or partial responses, only 94 surveys were used in the final analyses. Participants were sent an with an attached letter (Appendix A) inviting them to participate in the study through an online link to the Qualtrics survey. Participants were not compensated for their participation in this study. Informed consent was obtained from all participants. Participants were both male (82.2%) and female clergy (17.8%) between the ages of 27 and 73 years (M = 49.7, SD = 11.8). Time involved in active ministry ranged from 2 to 48 years (M = 20.3, SD = 11.9). There was also a broad range of denominational affiliation among participants: Baptist (23.8%), Other (16.8%; Church of Christ, Evangelical Covenant, Disciples of Christ), Non-denominational (13.9%), Presbyterian (11.9%), Episcopalian (10.9%), Catholic (6.9%), Methodist (5.9%), Pentecostal (5%), Lutheran (2%), Orthodox (2%), Adventist (1%). In terms of sexual orientation, 91.1% of participants identified as heterosexual or straight, 5.9% identified as gay or lesbian, and 3% identified as bisexual. Clergy were mostly White (90.1%); however, 3% identified as Hispanic or Latino, 3% identified as Black or African- American, 2% identified as Asian/Pacific Islander, and 2% identified as Other. Regarding marital status, clergy were mostly married (81.2%); however 12.9% were single/never married, 1% were divorced, 2% were widowed, and 3% were in a relationship, but not married.

31 22 Design and Materials This study employed a correlational design examining the relationship between predictor variables and outcome variables. Within the confines of this study, four predictor variables were examined, (a) vocational satisfaction, (b) social support, (c) religious fundamentalism, and (d) religious doubt. Along with these four predictor variables, three outcome variables were also measured, (a) depression, (b) anxiety, and (c) stress. Demographics survey. A survey was used to assess various demographic information in this sample of clergy. Participants were asked questions regarding their age, gender, sexual orientation, income, level of education, marital status, years in active ministry, and religious beliefs. Participants were also asked questions about their racial/ethnic identity, as well their denominational affiliation. Vocational satisfaction. Vocational satisfaction was measured using a portion of the Job Satisfaction subscale from a 1996 survey of United Church of Christ and Disciples of Christ ministers that was originally conducted by McDuff and Mueller (as cited in the Association of Religion Data Archives, 2015), that was meant to assess various kinds of vocational satisfaction among ministers. The job satisfaction subscale consists of four items. While the subscale only contains four items, two of these items are reversed phrased, e.g., one item reads I find real enjoyment in my job, while another item reads, I definitely dislike my job. The phrasing of these items gives a better indication of whether or not the participant fully understood the construct being measured. Four other items were added to the subscale from other subscales within the instrument in order to make the subscale more applicable to clergy specifically. Items are scored using a fivepoint Likert scale, the lowest score (1) indicates the participant strongly disagrees with the item,

32 23 while the highest score (5) indicates that the participant strongly agrees with the item. Item scores are totaled and the highest scores on positively phrased items (e.g., I find real enjoyment in my job) indicate high job satisfaction, while high scores on negatively phrased items (e.g., I definitely dislike my job) indicate low job satisfaction (see Appendix B). Reliability analyses of this instrument show it to have strong internal consistency (α =.78). Social support. Social support was measured using the Medical Outcomes Study Social Support Survey-6 (MOS-SSS-6). The MOS-SSS-6 is a six-item instrument used to assess the level to which one experiences social support. The MOS-SSS-6 was first used within a much larger survey, the Australian Longitudinal Study on Women s Health, and was developed to offer a shorter and more concise version of the original 19-item MOS Social Support Survey developed by Sherbourne and Stewart (1991). Participants are asked how often certain kinds of social support are available to them, presented with an item, and then asked to rate how often they experience that kind of social support. Examples of items include, [Someone to] do something enjoyable with, and [Someone to] share your most private worries and fears. Items are scored on a five-point Likert Scale. The instrument is scored by calculating a total that will range from 6 to 30. Higher scores indicate higher levels of social support, while lower scores indicate lower levels of social support (see Appendix C). The MOS-SSS-6 has been shown to have strong internal consistency (α =.81) and good concurrent validity (rs =.97) (Holden, Lee, Hockey, Ware, & Dobson, 2014). Reliability analyses conducted for this study show strong internal consistency (α =.88). Religious fundamentalism. Religious fundamentalism was assessed using the 12-item Revised Religious Fundamentalism scale, developed by Altemeyer and Hunsberger (2004). Items are scored using an eight-point Likert scale, with the lowest score (-4) indicating that the

33 24 participant very strongly disagrees with the statement, to the highest score (+4) indicating that the participant very strongly agrees with the statement. For items 1, 3, 5, 6, 8, and 11, the selection of -4 is given a score of 1, -3 is given a score of 2, -2 is given a score of 3 and this pattern continues until +4 which is scored as 9. For items 2, 4, 7, 9, 10, and 12 the scoring is reversed (e.g., -4 is scored as a 9, while +4 is scored as 1). If a participant selects 0 or fails to answer the question, the item is given a score of 5. These scores are then totaled and will range from 12 to 108; higher scores indicate higher religious fundamentalism. Questions cover a range of assertions such as, to lead the best, most meaningful life, one must belong to the one, fundamentally true religion, and it is more important to be a good person than to believe in God or the right religion (see Appendix D). The Revised Religious Fundamentalism scale has been shown to have strong internal consistency (α =.91 for students sampled, and α =.92 for parents sampled). Reliability analyses show a higher degree of internal consistency in this study (α =.94). Religious doubt. Religious doubt was measured using the 4-item Doubt subscale from the Religious and Spiritual Struggles scale (RSS; Exline, Pargament, Grubbs, & Yali, 2014). The RSS was developed to measure the degree to which one struggles with their religious beliefs. Participants are given a statement and asked to what extent they agree on a five-point scale. Participants are asked to what extent they identify with the item (e.g., not at all [1], a little bit [2], somewhat [3], quite a bit [4], and a great deal [5]). The subscale is scored by calculating the mean of the four items. Examples of items from the Doubt subscale include, [I] struggled to figure out what I really believe about religion/spirituality, and [I] felt confused about my religious/spiritual beliefs, (see Appendix E). Initial examination of the RSS Doubt subscale

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