How can faith-based mental health care be used to provide care for the emotionally and mentally ill?
CARING FOR THE EMOTIONALLY AND MENTALLY ILL
In this second half of the book, I move away from research on the relationship between religion and mental health, and begin to focus on the role that clergy and religious organizations play in caring for those with emotional problems or severe mental illness. Before discussing the current situation, however, I will provide some historical and theological background information that will provide important insights into the patterns of care provided by faith communities to be discussed later. Then I will examine what words such as faith-based and mental health services mean, and break down these terms into categories.
Faith-Based Social Services
Prior to 1850 in the United States, the family and the church provided all social services.1 As reviewed in chapter 2, the concept of caring for the needy had biblical and early Christian roots: the care of widows and orphans in the Hebrew Testament, the care of the needy in the Book of Matthew and the Book of Acts, the care of ill pilgrims by monastic orders during the Crusades, the care of the poor and lepers by the Franciscans, the care of the mentally ill by religious orders such as the Hospitallers of St. John of God, the care of the poor and sick by female religious orders, and so forth. Beginning in the early 1700s, Catholic Charities was the first example in the American colonies of a faith-based organization caring for the poor, the sick, and other discarded members of society.2
Protestant religious organizations in Europe, such as the Young Men's Christian Association (YMCA) and the Salvation Army, sprang up in the second half of the nineteenth century in response to the growing poor population. YMCA founder George Williams came to London in 1841 as a sales assistant in a draper's shop. He and a group of fellow drapers organized the first YMCA in 1844 to address the unhealthy social conditions in big cities at the end of the Industrial Revolution.3 They offered an alternative to the poor and to young workers: Bible study and prayer instead of life on the streets. By 1851 there were 24 YMCAs in Great Britain with a combined membership of 2,700. The first YMCA was started in the United States in 1851 in Boston. After the end of the Civil War, there were more than 700 YMCAs in full operation in the United States.
About the same time in 1852, William Booth began walking the streets of London preaching the Christian gospel to the poor, homeless, hungry, and destitute.4 Thieves, prostitutes, gamblers, and drunkards became his first converts, and his ministry organized into what later became known as the Salvation Army. To congregations who were desperately poor, he preached hope and salvation and recruited volunteers to help them. In 1867, Booth had only 10 full-time workers, but within seven years, the number had grown to 1,000 volunteers and 42 ministers. In 1879, the first meeting of the Salvation Army in America was held in Philadelphia and rapidly grew from there. The organization had grown to such a degree that President Grover Cleveland received a delegation of Salvation Army officers, giving the organization a warm personal endorsement in 1886. Besides evangelism, the trademark of this organization was, and continues to be, its provision of services to the poor and needy (and mentally ill), especially those located in urban communities.
Another religiously motivated social action program, the Settlement House Movement, originated in England in the early 1880s and spread to the United States in 1890s.5 This began as a religious response to the extreme poverty brought on by the industrial revolution. Volunteers lived and worked in settlement houses (which were often converted buildings in poor, urban neighborhoods) with the goal of improving the lives of poverty-stricken families by providing needed social services. These might include clubs, educational classes, and social gatherings, as well as playgrounds, education in the arts, sports and summer camps, clean-milk stations, well-baby clinics, and other programs. These settlement houses were to become precedent setting for the development of a future U.S. philosophy on providing social services.6
Growth of Government Services
During the 1850s and 1860s, the U.S. government first started to support programs such as the Freedman's Bureau for newly emancipated slaves (a federal program) and mental asylums, poor houses, and orphanages (state programs). In the 1870s the government responded to a major economic depression by giving direct relief to ease the depression's severity. Church and charity workers, however, discouraged direct relief, fearing that it would lead to the moral demise of the poor by encouraging dependency. Instead, they suggested addressing "personal deficiencies" so that people could help themselves. Direct government involvement, however, would soon escalate despite these early warnings.
Between 1900 and 1920, the federal government set up the Children's Bureau and the Maternal and Infant Health Services. Between 1920 and 1930, the states took over many of the services previously performed by private and religious charities. During the Great Depression years of 1930-1940, Democratic President Franklin Roosevelt offered Americans the New Deal, which created many new government-funded social programs, including the Civilian Conservation Corps (to provide jobs for young men), Works Progress Administration (to provide jobs for millions of people in civic construction projects), and especially, the Social Security Act (to provide working people with some economic guarantees and ensure benefits for the elderly and disabled).
Thus, from 1900 to 1940, social services previously provided by religious organizations or religious volunteers were slowly taken over by federal and state governments. In the 1960s, Democratic presidents Kennedy and Johnson began Job Corps, Vista, Community Action Programs, Head Start, legal services for the poor, Foster Grandparents, Department of Housing and Urban Development for low-income housing, Medicaid, Medicare, and the food stamps program. By the mid-1960s, the role that religious organizations had played in caring for the poor, the needy, the elderly, and the mentally and physically ill had become almost entirely replaced by government programs.
Social Services vs. Evangelism
The decline in social service delivery by religious organizations and religious volunteers was also a response to theological forces. After the latter part of the nineteenth century, a split occurred among religious groups within Protestant Christianity on whether or not to provide social services to the needy.
Walter Rauschenbusch, a liberal Baptist minister and later professor of church history at Rochester Theological Seminary, wrote an influential book entitled Christianity and the Social Crisis.7 In this widely read volume, he described the responsibility and duty of the Christian church to provide for the physical, mental, and social needs of a growing class of poor, disenfranchised people often living in urban areas, who had been made powerless by America's switch from an agricultural to an industrial economy. Rather than emphasizing the traditional goals of evangelism, namely, the spreading of Christianity both at home and abroad through preaching and missionary endeavors with a view toward winning converts, Rauschenbusch claimed that an equal or even greater responsibility of the church should be to meet basic human needs. Rauschenbusch probably saw his "social gospel" as a type of evangelism, seeking to combine Christian faith with committed social action. He believed that Christians were charged with bringing the kingdom of God onto the earth, and one of the chief means of achieving that was through social action (based on the kingdom of God theology of Albrecht Ritschl). Out of this social gospel arose a Protestant theology that focused on the provision of social services to meet the practical needs of people, and to some extent deemphasized conservative Christian teachings on evangelism.
In reaction to the movement that Rauschenbusch championed, the more conservative branches of Protestant Christianity during the early twentieth century began to refocus their mission on maintaining correct doctrine, with a particular emphasis on evangelism. Thus, although evangelical Protestants sought to feed the hungry and clothe the poor, this was done specifically in order to convert them—not simply to provide for their basic needs. Conservative Protestant groups such as the Southern Baptist Convention today focus primarily on evangelism and mission work.8 Although they also provide social services to the needy, this is done largely with the purpose of gaining converts or leading to spiritual transformation.9 The same is true for the Assemblies of God,10 the Church of God, and other conservative Christian bodies, as well as nontraditional movements such as the Church of Jesus Christ of Latter-Day Saints.
In contrast, moderate and liberal Protestants, inspired by Rauschenbusch's social gospel, were beginning to feed the hungry and clothe the poor for its own sake, whether they converted or not. As a result, "mainline" Protestant churches began large social service programs (e.g., Lutheran Services in America and, to a lesser extent, the Methodist General Board of Church and Society and the Episcopal Charities), supported by government funding in recent years.11
The Catholic Church, on the other hand, took a somewhat middleground approach in this regard. While maintaining relatively conservative Christian views (concerning the sanctity of life, and the divinity, birth, death, and resurrection of Jesus) and low-key evangelism, Catholic Charities USA (founded in 1727) has become one of the largest religious social service agencies in the United States.12 Affiliated with it is the Catholic Health Association (founded in 1915), which is composed of more than 2,000 Catholic health care sponsors, systems, facilities, and related organizations.13 By not pushing its evangelical mission, evangelizing by actions not words, and focusing on its social services mission, Catholic Charities has for years received large amounts of federal funds to accomplish its social service goals.
As evident from the historical review above, the divergent priorities of the different theological camps may also be reflected in the political structure of the country, with one party tending to emphasize the responsibility of the central government in providing social services and the other political party wanting to reduce central government in favor of more local control. As noted above, large social programs were instituted during Democratic presidencies following the Depression years (and also earlier in response to abuses of workers by large industries). Christians who advocate more liberal theologies have traditionally found more affinity with the Democratic Party's social agenda. Republicans, on the other hand, have emphasized the role of the individual and conservative Protestant values that tend to de-emphasize government-funded social service delivery (such as welfare, etc.).
Interestingly, the current Republican administration's emphasis on faith-based and community initiatives is viewed by some as a way to avoid government responsibility for providing social services by putting this responsibility back on the churches. This effort has been opposed by both ends of the religious spectrum, including even some conservative Christian elements (i.e., Pat Robertson) threatened by the possibility that their primary mission of evangelism might be affected by government regulations. On the other hand, Catholic Charities and Lutheran Social Services and the Salvation Army have long been receiving federal funds under both Democratic and Republican administrations. In 2000, these three religious groups alone received over $4 billion in government money to provide a range of services from assisting pregnant teens to helping the dying through hospice services.14 In fact, federal funding of faith-based organizations goes back to just after the Revolutionary War in the 1780s, when the government paid the Philadelphia Bettering House, a Quaker hospital, to provide care for wounded soldiers.15
The general lack of enthusiasm for social programs by fundamentalist and some evangelical Protestant groups is a bit surprising given that it is from the lower social classes that a significant proportion of their membership often has come. Alcoholics, drug addicts, the mentally ill, and other social outcasts are often prime targets for evangelism by these groups. This may be particularly true for those with emotional problems and severe mental illness. A Duke University study of 853 "baby boomers" and 1,826 "non-boomers" participating in Wave II of the NIMH Epidemiologic Catchment Area Survey compared mental disorders in persons from conservative and mainline Protestant affiliations with those in persons from Pentecostal affiliations.16 This study showed that Pentecostal baby boomers had higher current and lifetime rates of mental disorder across the board, and a similar although less striking trend was also seen among middle-aged and older adults (see Tables 7.1 and 7.2).
Further analysis, however, revealed that the differences between religious groups on rates of psychiatric disorder were found primarily among those who attended religious services less frequently. In fact, low-attending Pentecostals had the highest rates of lifetime psychiatric disorder of any religious group (52%). Even more important, and especially relevant to the discussion here, is that despite high rates of lifetime psychiatric disorder, not a single (0%) low-attending Pentecostal baby boomer had seen a mental health professional within the previous six months. This raises the concern, then, that such Protestant groups may go to great lengths to "save" such people, but then tend not to follow up to ensure that they are included in the faith community and that their mental health needs are met.
Some conservative Protestant groups, such as the Mennonites and the Salvation Army, have maintained more of a balance between providing social services and evangelism. Likewise, the African American church in America has traditionally maintained both a conservative doctrine that emphasizes personal regeneration and evangelism while supporting progressive social service efforts in the community as well.
Bear in mind, also, that now in the twenty-first century the lines of division between the evangelical Christian and the mainline Protestant religious traditions have become less distinct. There are many fundamentalist groups and strongly conservative Christian congregations today that provide social services by sponsoring inner-city programs for the poor, soup kitchens, shelters for the homeless, while at the same time many mainline Protestant groups are now placing a renewed emphasis on evangelism as their memberships have dwindled. Nevertheless, while many of the differences described above have softened over the years, they still have considerable influence on the kinds of faith-based efforts toward mental health service delivery that I will describe below.
Finally, while many persons with severe and persistent mental illness and their families have experienced rejection from traditional religious communities (as noted in chapter 1 and elsewhere), studies do indicate that the attitudes of religious congregations toward the mentally ill are less negative and rejecting than attitudes of the general population.17 No doubt, though, much work remains to be done in educating faith communities about these illnesses and also allaying concerns about dangerousness and unpredictability that prevent many people of faith from reaching out to those with mental illness.
Before going on, I would like to define what I mean by terms such as mental health services and faith-based organizations.
Mental Health Services
Under mental health services (see Table 7.3) I include counseling and support for anyone experiencing emotional distress. That distress could be from depression, anxiety, or stressful circumstances such as bereavement, divorce, job problems, or economic loss. Counseling and support may be for time-limited emotional problems, or may be directed at severe, persistent, long-term mental illness. Mental health services also include both outpatient and residential treatment programs that provide psychotherapy, pharmacological therapy, or other biological treatments for mental illness, as well as case management and social services needed by those with serious mental illnesses. Social services include housing, food, job search, health care, and family services. Finally, mental health services also involve education of service providers, education of the general public, organization and networking of groups that provide mental health services, and advocacy for those with mental illness (at local government, national government, and health organization levels).
A faith-based organization (FBO) is either a religious organization or a group with administrative or financial ties to a religious organization or organizations. I include groups that support and coordinate faith-based delivery of mental health services by providing contacts and educational resources to religious congregations. I also include here organizations that are not religious organizations and are not administratively tied to a religious organization, but that have as their primary mission the delivery of health services from a faith perspective. That faith perspective, however, must be rooted within an established and recognized religious tradition (Christianity, Judaism, Islam, Hinduism, Buddhism, etc.). FBOs should be distinguished from secular organizations that provide health services sensitive to the religion of clients or that utilize the religious beliefs of patients as part of the treatment they offer, although their primary mission is not faith based.
FBOs that deliver mental health services may or may not include religion as part of the treatment they offer, and this helps to distinguish the various categories of FBOs that I will describe below. There are also two levels of services that FBOs provide: (1) direct care services, or (2) educational, professional, organizational, and networking services at a local or national level. Based on these considerations, I have categorized FBOs into five major groups, drawing heavily on the work of Roger Fallot. Note, however, that any particular organization may have characteristics of more than one group and that overlap is probably more the rule than the exception:
(A) Local churches, synagogues, mosques, and temples that provide counseling and other mental health and social services to members and sometimes to the broader community.
(B) Mainline and conservative Protestant groups that provide support and educational resources to religious congregations to enhance faith based delivery of mental health services.
(C) Mainline religious groups that have set up relatively autonomous national agencies to provide social and mental health services that are largely secular in nature, but are provided because of religious mission or values.
(D) Trained religious counselors that utilize a combination of both secular and religious treatment strategies depending on the religious orientation of the patient.
(E) Conservative and/or evangelical groups within Protestantism, as well as similar kinds of groups in other religions (Islam, Judaism, etc.), who focus on the religious beliefs of patients and utilize them as a primary way of treating mental illness.
Integrating Religion into Mental Health Treatments 171
Table 7.4 places these five FBO groups that deliver faith-based mental health services into four major categories and describes the kinds of services that they provide.
In this chapter, I have provided historical and theological perspectives on how social services once delivered by faith communities became taken over by government agencies, a change that took place in the United States during the past 150 years. I then define terms such as mental health services and faith-based organizations as they will be used in the rest of this book. This chapter is rounded out by a description of five different categories of faith-based organizations that deliver mental health services. In the following chapters, I will focus on each category of FBO, providing details on their organization and mission and examples that illustrate their functions.
- See Web site: http://bkaw.bravepages.com/socsci/0202/HistorySumm.doc.
- See Web site: http://www.catholiccharitiesinfo.org/.
- See Web site: http://www.ymca.net/index.jsp.
- Mission statement: "[The Salvation Army is] an evangelical part of the universal Christian Church. Its message is based on the Bible. Its ministry is motivated by the love of 324 References God. Its mission is to preach the gospel of Jesus Christ and to meet human needs in His name without discrimination." See Web site: http://www.salvationarmyusa.org/WWW_USN.nsf/vw_dynamic_arrays/
- Mankiller, Wilma, ed. 1998. Reader's Companion to U.S. Women's History. Boston: Houghton Mifflin. See Web site: http://college.hmco.com/history/readerscomp/women/html/ wm_033300_settlementho.htm.
- Rauenbusch, W. 1908. Christianity and the Social Crisis. New York: MacMillan.
- See Web site: http://www.imb.org/core/default.asp. The mission statement is: "The International Mission Board (formerly Foreign Mission Board) is an entity of the Southern Baptist Convention, the nation's largest evangelical denomination, claiming more than 40,000 churches with nearly 16 million members. The board's main objective is presenting the gospel of Jesus Christ in order to lead individuals to saving faith in Him and result in church-planting movements among all the peoples of the world."
- See Web site: http://www.sbc.net/bfm/bfm2000.asp#xv. No specific arm exists for providing social services.
- See Web site: http://ag.org/top/about/about.cfm. The mission is: (1) To introduce the lost to Christ; (2) To provide an environment for worshiping God and fellowshipping with others who hold similar values and love for God; (3) To effectively train and nurture believers. No specific arm exists for providing social services.
- Jewish groups in America, which usually do not actively proselytize but rather focus on the needs of the family and the community, formed several organizations including the Association of Jewish Family and Children's Agencies (1972), Association of Jewish Aging Services (1960), and United Jewish Communities to provide needed services to the poor and disadvantaged Jews in America.
- See Web site: http://www.catholiccharitiesinfo.org/. Its mission is: "Catholic Charities USA is a national network of agencies, institutions and individuals who aim to reduce poverty, support families and empower communities."
- See Web site: http://www.chausa.org/DEFAULT.ASP. Its mission is: "Catholic Health Association represents the combined strength of its members, more than 2,000 Catholic health care sponsors, systems, facilities, and related organizations. Founded in 1915, CHA unites members to advance selected strategic issues that are best addressed together rather than as individual organizations."
- Wineburg, Bob. July 31, 2003. The underbelly of the faith-based initiative. Sightings See website: http://marty-center.uchicago.edu/sightings/archive_2003/0731.shtml.
- Koenig, H. G., L. K. George, K. G. Meador, D. G. Blazer, and P. Dyke. 1994. Religious affiliation and psychiatric disorder in Protestant baby boomers. Hospital and Community Psychiatry 45:586-96.
- Gray, A. J. 2001. Attitudes of the public to mental health: A church congregation. Mental Health, Religion and Culture 4 (1): 71-79.
From Harold G. Koenig, M.D., Faith & Mental Health: Religious Resources for Healing (Philadelphia: Templeton Foundation Press, 2005), 161-72.