Should Religious Leaders Help Close Mental Health Care's Gap?

Particularly in rural areas, governments are increasingly turning to them to ease the shortage of providers, blurring the line between religion and medicine.

(David Kidd)
When Randy Simmonds graduated from college and went on to the seminary, he was sure that being a pastor was his calling in life. But in his first job as a youth director at a large church in Louisiana, his confidence was shaken by something that his masters of divinity hadn’t prepared him for. “There were multiple crises every week with these kids and their families,” he says. “Death, substance abuse problems, family issues. I really liked the counseling, but I wasn’t equipped for it -- I only had two classes in counseling while in seminary.” 

Simmonds’ situation is one that’s familiar to clergy across the country. When a person is emotionally distressed and decides to seek counseling, research shows they are much more likely to talk to a faith leader than a psychologist or a psychiatrist. And often that faith leader finds himself untrained and unprepared to properly handle the weighty mental health issues he may be faced with. 

At the same time, governments are confronting a significant shortage of psychologists and other mental health professionals, particularly in rural areas. Thanks to a 2008 parity law, insurers are required to cover mental health on par with primary care services. But until the Affordable Care Act came along, that law was abysmally enforced. Now, more people are thinking about mental health issues in the same way they think about physical ailments, and as a result the federal Substance Abuse and Mental Health Services Administration (SAMHSA) has seen its budget increase over the past couple of years. The National Health Service Corps, which places health professionals in underserved areas, is set to expand its workforce by 60 percent in the coming years. Still, large swaths of rural residents simply don’t have access to proper mental health treatment. 

For some people, the solution to both of these situations is obvious: Train clergy to act as licensed mental health professionals. If there aren’t enough psychologists to go around -- and if most people are more comfortable talking to their pastor anyway -- why not tackle both issues at once? “Look, we’re never going to have enough mental health providers. We just won’t,” says Matthew Stanford, who has spent much of his career studying the intersection of faith and psychology, most recently at Baylor University. “We need to stop pretending that we’re going to get enough people with an expensive degree to move to a rural area and make no money just because they love people. If we know people are going to their pastor first when something is wrong, why wouldn’t we give the pastor tools to make the church a more inclusive environment?”

Not everyone is comfortable with the thought of blurring the line between faith leaders and medical mental health professionals. Directing taxpayer Medicaid dollars to churches, synagogues and mosques is a controversial notion. There’s also an imminent question of how the push for mental health coverage would be affected by President-elect Donald Trump’s plan to repeal and replace the Affordable Care Act. 

But a growing contingent of officials and practitioners believes that leveraging people’s faith -- and their faith leaders -- will be a key component in ending the stigma around mental health and providing people with the treatment they need. When it comes to mental health care, their message seems fairly simple: Have a little faith.

One aspect of using the clergy to provide treatment involves simply training pastors to recognize signs of mental illness in their congregants and connect them with the services they need. “It’s impossible to address any sort of community health disparity without addressing their ‘cultural brokers,’ and often that’s a spiritual leader of some kind,” says Gigi Crowder, the Contra Costa County, Calif., faith coordinator for the National Alliance on Mental Illness. Crowder has spent part of her career training faith leaders in her area to identify potential mental health issues in the people they counsel. If governments want to make genuine inroads with mental health in underserved communities, she says, these cultural brokers are often the only way in.  

State and local funding to implement such an approach has been limited, although Crowder says most counties in California have engaged in some form of training of religious leaders. The federal government, on the other hand, has made significant investments in training. SAMHSA has been actively working with faith-based organizations since 1992, and in 2000 it became the first health and human services department to launch a so-called Faith-based and Community Initiatives program. SAMHSA disperses money specifically to community organizations looking to implement mental health and substance abuse programming rooted in faith. The demand is there and rising, says Acacia Bamberg Salatti, director of faith-based and neighborhood partnerships for the U.S. Department of Health and Human Services. “There certainly has been increasing concern and conversation about mental health in the faith community,” Salatti says. “And getting that referral for a counselor or psychologist from a pastor is really important for some people.” 

But far beyond these efforts to help faith leaders spot signs of mental illness, there’s the bigger -- and thornier -- idea of actually licensing clergy themselves as mental health providers. Last year Kentucky became the sixth state to allow “pastoral counselors” to become licensed mental health workers. A pastoral counselor is someone ordained by their religious group who also has a degree in psychology, counseling or a similar field. Pastoral counselors don’t promote a particular belief system or ideology, but rather are equipped to weave theological thought and teachings into therapy. Pastoral counselors are everywhere, but only Arkansas, Maine, New Hampshire, North Carolina, Tennessee and now Kentucky actually license them with the state. It may still be a nascent trend -- Kentucky was the first state to take up the issue in over a decade -- but it’s absolutely the future of mental health care, says Simmonds, who, after starting at his church in Louisiana, went on to earn a Ph.D. in counseling and become a pastoral counselor. He now serves as president of the American Association of Pastoral Counselors and works as a pastoral counselor in Colorado.  

But even Simmonds acknowledges the challenges of blending faith and health care. “It’s just such a tightrope with Medicaid and Medicare reimbursement -- how do we fit into that mix? How do we make clear to insurance companies that we’re not proselytizing? These are things we’re going to have to deal with for years.” 

That tightrope is cause for concern, says John Rigney. As the immediate past vice chair of the Kentucky Board of Licensed Professional Counselors, he says he agrees with the basic idea of licensing pastoral counselors. “It’s an effort to provide better quality for those patients where faith is a central consideration when choosing a therapist,” he says, “and [Kentucky’s] qualifications for licensed pastoral counselors are stringent.” The problem, he says, is with enforcement. There are currently 28 licensed pastoral counselors in Kentucky, and Rigney suspects that there are many more out there without certification operating under the guise of a pastoral counselor. “The public doesn’t know, when they go to Pastor Smith for counseling, whether he’s had the proper training according to the state.” 

Indeed, there’s a growing number of groups and associations dedicated to various forms of religious-based counseling. The American Association of Christian Counselors, for example, more than tripled in size from 1999 to 2005. There’s also the Association of Biblical Counselors, not to be confused with the Association of Certified Biblical Counselors or the Biblical Counseling Coalition. These and other associations may require “counseling trainings,” but they don’t require education credentials like pastoral counselors do.  

That’s why it can be tricky to mix religion and mental health care, says Stanford, the Baylor professor. Pinning down exact figures is tough, but he says he’s seen a dramatic rise in ministries operating under the guise of a counseling center. “It’ll market itself as place where girls can recover from eating disorders, for example, but then they get there and it’s a spiritual intervention,” he says. “It’s disturbing because these appear to be based in psychology at first glance.”   

Stanford also notes an increase in addiction ministries, which offer sober houses for recovering addicts. He says they can be beneficial, but “they sometimes don’t understand how relapse works, and how typically it’s just part of the recovery.”     

Even in regular counseling sessions, Stanford says, religion can color a patient’s experience. “My research found that 30 to 40 percent of people who go to faith leaders for a mental health problem have a negative experience,” he says. “They are told things like, ‘You need to pray more,’ or, ‘It’s a weakness of faith.’ They see something like depression as a moral failing.”  

For that reason, Stanford believes it’s more imperative than ever to de-stigmatize mental health within a religious community and to train religious counselors to know when an issue might require help that goes beyond prayer. Stanford, like Crowder in California, also trains faith leaders on the basics of mental health. He is CEO of the Hope and Healing Center, which offers community leaders educational seminars and programs on how to best treat someone with a mental illness. “Most faith communities want to help, but they don’t have a clue,” he says. “And they often just want to know how they can fit something into a particular spiritual paradigm.”   

That may be changing, says Crowder. As the mental health stigma ebbs slowly away, she says she’s seen faith leaders come to appreciate that mental health problems are an illness rather than a moral defect. “We’re getting them to realize that if you can accept diabetes as a medical condition, you can accept depression as one too,” she says. “A lot of progress has been made. I’ve had faith leaders apologize to their congregation for things they’ve said about mental health problems in the past.”  

There’s a possibility that this shift toward incorporating clergy into mental health care could be slowed or halted by Donald Trump. Depending on how he goes about repealing and replacing the Affordable Care Act, it could end the push to integrate mental health into more of a primary care setting. Georgia Rep. Tom Price, Trump’s pick to lead the Health and Human Services Department, has been critical of the Obama administration’s efforts to move away from a fee-for-service model. That may mean that funds for SAMSHA to create integrated care programs could be wiped out in the coming year. Conversely, it’s possible that a Republican administration, paired with overwhelming Republican control in the states, could push the integration of faith-based mental health services even further.  

Either way, most experts say that mental health parity is the direction the field is ultimately heading. “The integrated approach to health care is the future,” says Simmonds. “It’s going to be incumbent for everyone to figure out the best ways to treat people as a whole person.” 

And for some patients, the best treatment means incorporating elements of faith, says Crowder. “When I was just working in the mental health space, I never vocalized my faith because I felt like we weren’t supposed to. But it’s important to people and it can be talked about,” she says. “If we’re going to truly treat the whole person, then addressing someone’s faith is just a part of doing culturally responsive work."

Mattie covers all things health for Governing.