The Cultural and Religious Complexities of Amish-Focused Mental Health Conditions Research: Insights from an Exhaustive Narrative Review and Case Study of Counseling Controversies

Abstract

Mental health conditions research often relies on reductionist cultural assumptions about the population studied and instruments validated from majority populations. In exhaustively reviewing the limited body of Amish mental health conditions research, we find that studies are well-executed by methodological protocols but that findings are inconsistent or limited in generalizability, instrument validity remains contested, and study investigation into Amish cultural and religious dynamics is limited. A case study from a sizeable Amish community in Ohio illustrates how various ideologies—notably old Amish religious theology, the scientific-psychological, and the Evangelical Protestant—have generated population-internal controversies among the Amish over defining and treating mental health conditions, suggesting that mental health conditions research and diagnosis of ethnic religious adherents should better account for internal cultural-religious dynamics. In order to make some assertions about how Amish culture and religion impacts mental health conditions, future research should include pre-study investigations into the targeted population’s cultural and religious dynamics, consist of more nuanced case reports from therapists and psychiatrists, and include replication studies at different times and places, with deliberate attention to contextual factors.

Introduction

This article benchmarks the state of Amish mental health conditions research by exhaustively reviewing existing research and presenting a case study of Amish-internal counseling controversies. Based on these efforts, we suggest that future research into Amish mental health conditions should better account for religious and cultural contexts, especially when researchers compare Amish outcomes to non-Amish and, thereby, suggest that something about Amishness is predicting or causing mental health outcomes.

Specifically, the first part of this article takes stock of both the aggregate findings of empirical studies about mental health conditions, which span nearly 40 years (1983 to present). This research is the fourth and final installment of a comprehensive effort to conduct narrative reviews of all research about the Amish and health. The larger effort exhaustively analyzes 246 Amish health studies from 1958 to spring 2020, addressing the intellectual history of Amish population health research (Anderson and Potts 2021), the Amish health culture and culturally competent health services (Anderson and Potts 2020), and physical health conditions of the Amish (Anderson and Potts 2022). After reviewing the literature and noting debates and discrepancies in results, we then turn to a case that introduces mental health controversies among the Amish, suggesting that internal cultural and religious nuances may be influencing study outcomes in ways under-addressed in most existing research. The Amish approach to mental health treatment is both diverse and internally controversial. Conflicts among Amish people represent competing understandings of legitimate treatment, between credentialed scientific medicine, American evangelical Christianity, and the Amish people’s own centuries’ old concept of religion. These controversies are not explicitly addressed in Amish mental health conditions research and should be better accounted for, as attitudes may influence clinical evaluations of mental health conditions. Furthermore, these controversies may impact how mental health care providers approach care and treatment for this rapidly growing population.

For this study, we conceptualize “Amish” as an ethnic religious peoplehood identity that, through quotidian activation in people’s lives, produces social structures that reinforce identity The contemporary Amish system of peoplehood descends from late 17^th century Germanic Europe, even as its adherents are now almost entirely based in North America. Salient elements of ethnicity—including language, dress, sense of shared history, and kinship—validate the central religious theme of being a people set-apart to God (Anderson 2017b; Enninger 1979; Enninger 1984; Enninger 1986a; Enninger 1986b; Enninger 1988a; Enninger 1988b). However, Amish people are not literally “separated from the world”; reality is much more complex. Adherents manage multiple identities, both embedded within Amish identity (e.g. specific Amish denominations or family clans) and existing beyond it (e.g. citizen, employee, or consumer lifestyle identity) (Petrovich 2022a; Wimmer 2013, pp. 524–28). Despite these multi-layered identities, Amish-specific social structures have a pervasive centripetal pull, providing strong cohesion and identity for adherents. Membership in the population is largely the consequence of birthright. The North American population is currently approaching 400,000 (Grammich et al. 2022). With a century-long doubling time of just over two decades, the Amish population may well reach a million people by 2050 (Donnermeyer 2015). Given this rapid growth, the Amish population is having an ever-expanding influence on North America. Population health researchers are increasingly interested in how Amish culture and religion predict health outcomes, while healthcare service providers are frequently interested in how health services may be optimally provided for Amish people (Anderson and Potts 2021; Floersch, Longhofer and Latta 1997; Purnell 2021).

Methodology

The methodologies of the full Amish health studies literature review are detailed in companion publications (Anderson and Potts 2020; Anderson and Potts 2021; Anderson and Potts 2022). In brief, the Amish health literature includes research focused on “Amish” that addresses physical and mental health. Publications were identified from a snowball sampling of all Amish studies bibliographies (Anderson 2017a). To identify very recent studies from the past decade that are not yet cited, the terms “Amish” and “health” were searched in Google Scholar. Google Scholar offers extensive coverage of many journals not included in selective research databases; it also reflects the research review’s interdisciplinary coverage. A network analysis of citations was performed using all Amish health literature identified. This method revealed how Amish health literature self-organizes into topical areas. For this analysis, two mental health clusters from the citation network analysis are of interest: “mental health diagnosis and culture” and “mental health and deviance” (see figure 1 in Anderson and Potts 2021). The literature was analyzed using a narrative review strategy, which is a scholar-managed synthesis allowing judicious, meta-based interpretation, reflection, and critique across multiple epistemologies; the goal is fresh field insight. All publications were annotated. The authors conducted several joint sessions where they reviewed annotations, developed sub-topical categories into which annotations were classified, and revised categories as needed.

While most publications in the citation network analysis’s two psychology clusters focused on mental health conditions, several from these clusters focused exclusively on practice—that is, program reviews and cultural strategies for working with Amish clients. These studies have already been analyzed in the narrative review of the Amish health culture, which focused on culturally competent healthcare across health professions (Anderson and Potts 2020). This present review focuses solely on mental health conditions, including diagnosis and prevalence of conditions. The review includes pieces both in the mental health cluster and also across the remaining 246 health publications, which have mental health conditions content.

The Amish counseling controversy case study is the product of the first author’s status as an insider-outsider researcher (Dwyer and Buckle 2009). The first author is familiar with the counseling conflict as an adherent of a closely related group to the Amish, and this experience informs his observations and interpretations. The case study pulls data sourced from archival and public sources, as well as notes summarizing discussions from three recent panels at an Amish-themed conference in the community of the case (Bohley, Gasser and Grim 2022; Bright, Gasser and Walkerly 2021; Miller et al. 2022). The purpose of this case study is to provide social context for Amish-focused mental health conditions research and to encourage researchers to consider how this, and other, social contexts impact mental health conditions research.

Results

Results are presented in three sections, the first two representing the exhaustive literature review—including [a] succinct summaries of specific mental health conditions, and [b] methodological issues—while the third offers the case study.

1. Mental Health Conditions

Amish mental health research has addressed seven conditions: anxiety and stress, depression and suicide, body image, bipolar and schizophrenia, dementia, bereavement, and seasonal affective disorder. This review addresses each in turn, identifying the specific Amish denominations and places where researchers conducted studies, such as Holmes County, OH, and Lancaster County, PA. For overviews, readers can consult a companion article that provides profiles of these and other Amish places and denominations (Anderson [forthcoming]).

Anxiety and stress:

An early Holmes County, OH-based study found that, compared to non-Amish subjects, Amish subjects reported higher rates of anxiety “nearly always/always” or “sometimes” interfering with their daily activities (Fuchs et al. 1990). Women and adolescents in particular reported high levels of stress; for women, this may increase with age (Buccalo 1997; Fuchs et al. 1990; Reiling 2002c), especially at menopause (Lehman 1994). However, a Lancaster County, PA, survey revealed that Amish women reported fewer stressors than non-Amish in all areas except pregnancy-related stressors (Miller et al. 2007), and a review article argued that stress among Amish people is generally lower than the U.S. population (Troyer 1994). These findings appear inconsistent and also provide little information about Amish males.

Depression and suicide:

Research similarly offers inconsistent findings for depression rates. In a Holmes County, OH-based study, rates based on self-reports between Amish and non-Amish males were similar while Amish women had significantly higher rates (Fuchs et al. 1990), but in an Adams County, IN, study, Amish males and females were twice as depressive as the general population when measured by the Beck Depression Inventory (Jakubaschk, Würmel and Genner 1994). Inversely, in a Lancaster County, PA, study, Old Order Amish women, compared to non-Amish women, were diagnosed with depression less frequently and fewer rated as at high risk for depression (Miller et al. 2007). In an Illinois study of both Old Order and New Order denominations in different locations, Amish self-reported higher levels of happiness than non-Amish (Biswas-Diener, Vitterso and Diener 2005). Furthermore, suicide rates are consistently lower among the Amish than the non-Amish (Jakubaschk, Würmel and Genner 1994; Kraybill, Hostetler and Shaw 1986; Troyer 1994) and tend to be clustered in family lines (Egeland and Sussex 1985).

Body Image:

In a pilot study of women’s attitudes toward body image that compared a convenience sample of Amish, Catholic, and non-religious women, Amish—compared to Catholics—had higher reported body sizes and higher ideal body sizes. While Amish are less likely to report their body image impacted their emotions—perhaps due to religious coping strategies—all groups had a positive correlation between BMI and body dissatisfaction (Davidson et al. 2018).

Bipolar and Schizophrenia:

Geneticists analyzing the Lancaster County, PA, Old Order Amish have suggested links between mental illness and genes. Of all Amish admitted to a psychiatric facility, Bipolar I and II (34%) and Unipolar (37%) were the most common diagnoses, with the number of male cases unusually high compared to non-Amish patients. Schizophrenia rates were particularly low. While researchers attributed these trends to genetic causes (Egeland et al. 2012; Egeland and Hostetter 1983; Egeland and Sussex 1985), others argued that a critical methodological flaw is in falsely assuming Amish cultural homogeneity and then using it as a sort of methodological control (Floersch, Longhofer and Latta 1997).

Dementia:

While non-Amish research has found lower formal education is associated with dementia, Amish elderly in Northern Indiana and Adams County, IN, who uniformly had eight or fewer years of formal education, had lower rates of dementia compared to elderly Americans. While Amish educational attainment was inversely associated with dementia, the effect was not significant when controlling for age and gender. Possible explanations for lower rates of dementia among Amish include genetic resilience to dementia (the decreased frequency of the APOE−4 allele)—as the youngest cohort had exceptionally low rates, and genetically induced dementia affects people earlier—or some sort of rural/Amish lifestyle factors (Johnson et al. 1997; Pericak-Vance et al. 1996).

Bereavement Effect:

An analysis of 10,892 Amish couples born 1725–1900 revealed that risk of death due to bereavement is greater for a widower than widow, the effect diminishes over time and if one remarries, and, contrary to the social support hypothesis, no relationship exists between the number of surviving children and a parent’s mortality (Seifter et al. 2014).

Seasonal Affective Disorder (“SAD”):

An instrument that measures SAD—the SPAQ—was mailed to just over 1,000 Lancaster County, PA, Old Order Amish; results suggest a lower rate of SAD (Patel et al. 2013) and a negative relationship between the occurrence of SAD and adiponectin levels (Akram et al. 2020). While the authors argue for the instrument’s test-retest validity (Kuehner et al. 2013), Amish culture and lifestyle patterns may impact the instrument’s external validity in ways that should be further investigated.

2. Methodological Issues: Instruments and Causes

Amish mental health conditions research is noticeably sparse and, even from what exists, struggles to reach consistent conclusions regarding the range and prevalence of mental health illnesses. Disparities in Amish mental health conditions research may be due to unlike instruments or instruments insensitive to cultural nuances of and within the Amish (Cates and Graham 2002; Egeland, Hostetter and Eshleman 1983; Floersch, Longhofer and Latta 1997; Gershenson and Levine 2016). However, others argue that minimal evidence exists that Amish cultural properties destabilize assessments shown valid for non-Amish (Kuehner et al. 2016). In one study, four psychiatrists achieved high consensus when independently diagnosing 21 medical records and abstracts for mental illness (Hostetter, Egeland and Endicott 1983). In three other studies, the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) (Knabb, Vogt and Newgren 2011), the Millon Clinical Multiaxial Inventory-III (MCMI-III) (Knabb and Vogt 2011), and the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) (Kuehner et al. 2016) produced a similar range of results between Amish participants and general non-Amish rates, and different results between Amish individuals who were and were not psychiatric patients. These studies identified minor vocabulary and language issues that may slightly skew results in some indexes for this bilingual population but suggest that the tools are basically valid.

Whatever the rates, mental illness among the Amish has social and, possibly, genetic causes, though results are tentative and disputed. Potentially harmful social sources may include:

• farm/business management and debt (Buccalo 1997; Troyer 1994)

• large family size (Buccalo 1997; Troyer 1994)

• a culturally based obsessive compulsive busyness (Buccalo 1997; Troyer 1994)

• demand to live up to religious expectations (Buccalo 1997; Troyer 1994)

• age transitions for the unmarried by mid-20s and aging adults in the late 40s through 60s (Lehman 1994)

• church-based tensions, control, and gossip (Cassady et al. 2005; Reiling 2000)

• an adolescent culture in some churches where the settlement simultaneously prescribes and condemns specific forms of deviance (Reiling 2002c)

• suppression of negative emotions or creative thoughts (Reiling 2000)

• for settlements where schools use outdated health textbooks, the relatively low level of instruction about mental well-being (Oyabu, Ido and Sugihara 2001).

Positive sources may include heightened awareness beyond self, namely of others and God, and personal contentment (Platte, Zelten and Stunkard 2000; Sharpnack et al. 2011). One report, which conjectures that the distribution of Amish mental illnesses probably mirrors non-Amish distributions, argues that neither the glowing social support nor the darker repressive community theses about high or low rates of mental illness are true (Greksa and Korbin 1999).

3. Current Counseling Controversies among the Amish

In the midst of this relatively sparse, somewhat contradictive, and aging body of mental health conditions research, the Amish people themselves have experienced both tremendous expansion in mental health services and profound disagreements over “counseling” and “psychology.” This is crucial context for any future mental health research, because these conflicts suggest that, without factoring in such dynamics, studies may produce aggregately inconclusive results. It also provides a more nuanced picture of Amish attitudes toward psychology and counseling, especially useful for service providers who may want to better understand why Amish people hold various opinions about mental health services.

Counseling Controversies in the Holmes County, Ohio, Amish Community

Amish-focused counseling services are a relatively recent phenomenon, with public, private, and informal practices arising almost entirely since the 1990s. Amish-focused mental health services include the following:

1. Credentialed institutions that employ scientific understandings of mental health, (1a) some with religious-cultural sensitivity and typically operated by Apostolic Christians (Anderson 2018), Mennonites, or other Anabaptist groups (Nolt 2011), (1b) others attempting to be culturally sensitive but operating from non-religious platforms, notably operations funded by the state, including through county boards of mental health (e.g., Miller-Fellows et al. 2018).

2. Non-credentialed institutions or lay counselors employing at least some Evangelical Protestant programs and strategies, (2a) internally endorsed and operated by a segment of Amish, or (2b) operated by related groups, such as Mennonites or Beachy Amish-Mennonites.

3. Non-credentialed, Amish-internal counseling with church leaders or church-appointed laymen, arranged on a case-by-case basis and offering religious and practical advice.

Credentialed institutions include professionally trained staff in licensed facilities. These have arisen specifically to serve the Amish or represent new Amish-focused programs within existing mental health facilities. Examples include Springhaven (Holmes-Wayne County, OH, area), Oaklawn (Elkhart-LaGrange County, IN, area), Philhaven (Lancaster-Lebanon County, PA, area), Apostolic Christian Counseling, and others. Such institutions and programs offer culturally sensitive residential and out-patient services for clients; services are almost entirely offered by non-Amish/plain Mennonites. Residential programs include Amish or plain Mennonite adherents on staff, who serve as intermediaries and help discern how maladaptive behavior is related to religious, social/emotional, and psychiatric dynamics (Bohley, Gasser and Grim 2022; Bright, Gasser and Walkerly 2021; Miller-Fellows et al. 2018; Nolt 2011). The book Holding Out Hope: Mental Health for the Plain Communities generalized the philosophy of these institutions (Byler, Stauffer and Byler 2014). The book is addressed to Amish and Mennonites and is co-authored/co-endorsed by both doctors and Amish/Mennonite adherents. It describes various types of social/church and psychiatric/medical interventions, cultivating appreciation for the line between the two and channeling people to the appropriate places for treatment. It introduces some clinical terminology, as with, for example, personality disorders.

Non-licensed facilities and lay counselors are run by Amish and plain Mennonites and use religiously framed methods for counseling (e.g., Blair and Hurst 1997, p. 42). Examples include Hoffnung Heim and Whispering Hope—which are Amish-owned and operated—and Freedom Hills Ministries near Walnut Creek village in eastern Holmes County, OH.

The Amish congregations centered in Holmes County, OH, have been the epicenter for counseling controversies. The Holmes County, OH, Amish community represents the largest existing cluster of Amish congregations, and the Freedom Hills controversy, in particular, is perhaps hottest in the “Isaac Church” (or Old Order-mainline), the largest local denomination of Amish, currently numbering over 200 congregations in the region (Petrovich 2017). Religious counseling is the Isaac Church’s single most divisive issue, even above the controversial, uneven adoption of Smartphones (variously discussed in Ems 2014; Ems 2015; Jantzi 2017; Neriya-Ben Shahar 2020; Petrovich 2017) and battery-powered bikes, which are replacing regular bicycles. The potential for a religious schism seems to loom. At least three small schisms of one to two congregations have occurred in the past several years (Miller et al. 2022).

Freedom Hills is largely run by evangelically oriented Mennonites on the relatively progressive end of plain Mennonite denominations—that is, even as some formal sanctions remain, these congregations have relatively little formal influence on members’ daily decision-making in group identity-salient areas such as grooming and garment patterns, media consumption, home styles, and consumer behavior (Anderson 2013; Scott 1996). Freedom Hills also has substantial support from a segment of Amish. Freedom Hills’ counseling methods are primarily sourced from evangelical Protestant counselor John Regier. Jeremy Chupp, a central figure at Freedom Hills who was, until recently, affiliated with an Isaac Church congregation, offered counseling and public seminars. Among his public seminars was “Crippled Hearts to Golden Crowns,” which was transcribed into a 183-page book (Chupp 2017). In this book, he takes up Regier’s evangelically rooted concepts. Chupp leaves little question that all listeners and readers are experiencing heart-level emotional hurts and abuses—many sin related. While he steers readers away from focusing on others’ dysfunctionalities, he also insinuates that, though Amish congregations have some good qualities, they are not able to truly deal with people’s deeper problems. Congregational leaders and members may emphasize religious legalism (that is, more concerned about superficial rules and visual form than true “heart” needs) and, as such, give people a false sense of moral standing. For individuals to address hurts, they need to pray directly to Jesus for healing, forgive with compassion and personal repentance, and help redeem the family and church institutions by entering into interpersonal relationships with love. The book contains no scientific, psychological jargon, and it makes intermittent reference to Bible passages and stories.

One relatively young Isaac Church minister, Delbert Shetler, in an unpublished but widely distributed position paper, critiqued Freedom Hills and other Regier-based lay efforts, therein capturing the sentiments of Amish people suspicious of Freedom Hills. Shetler stated that he had once “fully supported the counseling movement” with all of its “terms” that “help people effectively deal with their struggles.” And while he still feels that many supporting the counseling movement “want nothing but what’s right [...] to help the struggling,” this counseling movement is “one of the most deceiving things that has ever come into our plain churches” because “the church is rapidly losing its authority.” When “an issue arises you first consider what does the counselor think about this [...] HE IS NOT OUR SOURCE OF TRUTH!!” This loss of the local congregation’s authority, he says, is evidenced by many interpersonal tensions among individual members who are divided in opinion about Freedom Hills. The writer then asks church people to treat the source of broader problems—i.e., at the collective level, a “lukewarm” religious apostatizing—rather than treating symptoms—i.e., too-readily outsourcing individual needs to counselors (Shetler 2015 [circa]). Ultimately, Shetler captured a widely held suspicion that a new social movement dressed as counseling/helping people is introducing heterodoxy to Amish members while robbing congregations of their chance to help individuals with needs.

Shetler’s concerns were buttressed by a widely distributed anonymous booklet—Is the Counsel of God’s Word Sufficient?—which endorsed a congregation-internal approach to counseling. The text cites Bible passages heavily and incriminates counseling approaches that (1) make emotional healing foundational at the expense of a religious transformation, (2) regularly probes the subconscious past, or (3) provides “freedoms” alienating one from his/her home church. The book was freely available through the “Old Order Amish Literature Fund” (Anonymous 2014). This booklet and Shetler’s paper express concerns about the relocation of religious authority from the church to counseling institutions, and the disregard counseling movement supporters show toward the Amish church’s practices. At the same time, both sets of authors seem distressed at how counseling co-opts many of the church’s emphases, including the importance of personal moral depravity before God, stable family life, and restoration after sin.

In 2018, the Holmes County-area Isaac Church senior bishops (those holding this highest leadership position the longest) and their support committee endorsed a report from a “Counseling Research Team” that investigated 18 counseling services—from the professionally licensed to Amish church-operated institutions and self-trained Amish lay-workers. The nine-page research report cautiously condoned most credentialed institutions, or else noted the institution declined to participate in the investigation. Where the report specifically singled out certain operations were those—including Freedom Hills—using the Evangelical Protestant materials of John Regier. Based on this report, at a 2019 meeting of Isaac Church leaders, senior Amish church leaders banned involvement with Freedom Hills and several other counseling services (Troyer et al. 2018). Thereafter, Freedom Hills purchased full-page ad space in the local paper, advertising an auction fundraiser that was well attended by many Amish individuals. Today, a sizeable minority of Amish continue supporting Freedom Hills, if attendance at public fundraising events is any indication, and it is unclear whether local church leaders universally endorse and enforce the senior bishops’ position.

Religious and Cultural Dynamics

Three concepts of Amish-specific mental health programs exist because three distinct bodies of knowledge each convincingly offer, to some degree, treatments made relevant for Amish contexts. Because the three approaches have cases of success, each enjoys some level of support. Consequently, mental health treatment has become a matter of power, between accepting scientifically credentialed practitioners, lay-counseling based on Evangelical Protestant theology, or an old Amish approach privileging the local church. At the same time, even as each body of knowledge competes with the other, individuals and leaders may blend the approaches.

These competing bodies of knowledge represent subtle unevenness in religious theology among the Amish. Until recently, little of the sizeable body of research on the Amish investigated Amish theology (Anderson 2017a). Fortunately, Christopher Petrovich’s recent studies of Amish theology, ecclesiology, and Scripture interpretation are filling this gap. His detailed studies provide clues as to why the Amish have tended to prefer non-credentialed, Amish-internal counseling and how theological shifts are informing counseling controversies.

Petrovich explains that, while Amish theology includes the “justification by grace” doctrine familiar to Protestants, it primarily emphasizes the transformation of one’s life in a religious-interpretive community (i.e. the Gemeinde). To this end, Amish theology suggests a literal and localized reading of Scripture. Adherents first routinely seek moral instruction vis-à-vis Bible commands and story examples. Adherents then strive to become like Scriptural examples but within their own familiar cultural contexts, where status quo and the precedents of older generations hold much sway. Localized contexts of Amish lived religiosity is contingent on any given local church’s historical trajectory, which references a series of past ecclesiastical separations that brought the church to where it is today. Competing values do arise, such as, is it better for dairy farmers to forgo bulk milk tanks as the prior generation did, who saw their adoption as inconsistent with a humble life? Or is it preferable to adopt bulk milk tanks to keep people from abandoning farm work, which is good for family life (Petrovich 2013b; Petrovich 2022a)?

Following this religious outlook, the local Gemeinde (church-community) has naturally become the key institution for working out what it means for adherents to embody Scriptural examples of faithfulness and God-mindedness (Enninger and Raith 1982; Rumsey 2010). Amish theology frames the Christian church as the continuation of God’s people into New Testament times and beyond, but that churches are also local contexts that may differ one from another, and that individuals and families have the responsibility to commit themselves to a church they feel represents Godliness. The Gemeinde is locally governed by a plural leadership, theologically untrained men who have been nominated by the laity and selected from among nominees by lot. Because leaders are chosen by both the church and God (via the lot), they have a God-sanctioned responsibility for steering policy. Their influence varies depending on group and church, from being near-authoritarian to being a mere reflection of adherents’ collective opinions. Ultimately, the practices recognized as “Amish” are more than cultural carry-overs but have been shaped by Amish adherents’ critical attitude toward the industrial-economic complex of the past century and its long-term impact on each Gemeinde (Petrovich 2022b).

Described in this way, Amish religion has informed outlooks on Amish-internal counseling in at least three ways. First, counseling for one’s deep and personal struggles should occur within the context of the Gemeinde, where elders and leaders who have cultivated humility and devotion, who know the recipient best, can provide fitting guidance. Second, mental health conditions may be viewed as the product of unresolved or unrepentant sin. To receive healing, individuals must confront habitual sins and change their direction. Third, certain mental health conditions, such as depression, may be understood as part of life’s lot, which is characterized by suffering (Petrovich 2022a).

In addition to articulating themes of Amish religiosity, Petrovich also identifies two prevailing assumptions about Amish theology that are incorrect. These assumptions map well on the two other forms of mental health intervention—modern/scientific and Evangelical Protestant—and suggest why these alternative modes may at once both resonate with some Amish people (whose theologies are not totally informed by the Amish system) and simultaneously cause controversy.

The first assumption is that because the Amish are “traditional” (loosely referencing the rational-traditional dichotomy of Weber’s economic typologies), Amish are incapable of rationalizing their theology and, therefore, do not really have religious theology. Their religion (as misconstrued) represents a traditionally oriented knee-jerk reaction to science and the “modern” world, which Amish either resist or negotiate with solely to the end of community perpetuation. Indeed, the Amish explicitly prohibit nearly all secondary and post-secondary education options, so receive no training in the scientific method. The bodies of knowledge of professionally credentialed mental health treatment are primarily transacted in post-secondary educational institutions. Consequently, Amish populations, in engaging mental health knowledge and institutions, face power disparities in knowledge. They are asked to commit the core of the patient’s social-psychological being to knowledge bodies that Amish individuals cannot officially (i.e. credentialed) know, nor can its practitioners offer empathy for their culture (Reiling 2002a; Reiling 2002b; Reiling and Nusbaumer 1997).

Hence, some Amish shy from scientific mental health institutions. Notwithstanding, substantial evidence suggests that Amish feel confident evaluating scientific claims and giving or withdrawing their endorsement (Martin 2021; McConnell and Loveless 2018; Welk-Joerger 2019, Ch. 7). While Amish cannot have the credentialed psychological knowledge of counselors, and while they tend to be skeptical of the scientific establishment (McConnell and Loveless 2018; Trollinger and Trollinger 2015), they can still choose to confidently accept it. Scientific knowledge that maps well on Amish understandings of the world and is endorsed by fellow co-adherents is more likely to be accepted (Sauder 2020). Accordingly, credentialed counseling programs sensitive to Amish religiosity have witnessed some success legitimizing their scientific approach to treating Amish patients.

The second misconception of Amish theology that Petrovich (2023) describes is Amish theology as a “works” religion (as articulated in Oyer 1996), i.e., Amish individuals believe they can earn salvation through their lifestyle. This, Petrovich argues, superimposes an American Protestant evangelical theology on the Amish and fails to understand Amish theology on its own terms. Given the strong emphasis on regeneration through a “born again” confession and testimony (Geiger 1986), Evangelical Protestant theology is liable to cast Amish people as trying to do “works” to “earn” their salvation, which means Amish people are either not trusting in their “born again” experience for justification or have never had one. Ultimately, Amish people may be neglecting what really matters, the deep condition of one’s heart, so to say.

This evangelically oriented misconception of Amish theology is not just endorsed by evangelicals; many Amish have come to interpret their own religion from this framework (Anderson and Anderson 2016; Miller 2019; Petrovich 2013a; Pride 2003; Stoltzfus 2019; Waldrep 2008). The subtle slippage in theology is understandable, as the commonalities between Evangelical Protestantism and Amish theology are many, including an emphasis on an adult-level confession and spiritual transformation, the totality of one’s Christian commitment, and justification by faith. Notwithstanding, Amish theology is localized while Evangelical Protestant theology is outwardly oriented toward proselytization. Hence, Evangelical Protestants lean toward reducing barriers to potential converts, stressing the conversion experience over the lifelong, community training and accountability provided in the Amish Gemeinde (Geiger 1986). Evangelical-style counseling programs, including Freedom Hills, base their counseling strategies on responsiveness to the spiritually deep “heart issues,” which is as much at the crux of one’s being as the born again experience itself. “Getting right with God,” then, is vital to successful therapy, as is non-reliance on “my own strength” (i.e. religious “works”). Given this positioning, individuals holding to old Amish theology are liable to be suspicious of evangelical counselors, who are not part of the Gemeinde, who are deeply involved in bringing about change via probing the patient’s inner spiritual being (the property of the Gemeinde), and who devalue or even denounce localized Amish lifestyle practices as trust in false “works.” Yet, the God-invoked totality of this counseling method may appeal to Amish people who are skeptical of overly science-ifying treatment and/or who are distrustful of their church leaders’ abilities to really understand the root issues.

Discussion and Conclusion

This study has presented an exhaustive review of existing Amish mental health research and a case study about contemporary Amish counseling controversies. On the one hand, the current body of Amish-focused mental health studies—assuming methodological robustness—is not generalizable beyond the local Amish population studied at that time. Compared to non-Amish, Amish stress/anxiety and depression may be higher or may be lower depending on study, and while bi-polar and unipolar are argued to be higher and schizophrenia lower than non-Amish populations, critiques of these studies’ methodology remain unaddressed. Studies finding that Amish women are more accepting of their body image, that Amish dementia rates are lower than non-Amish, and that Amish experience lower rates of SAD are geographically localized and invite extensions in methodology and population coverage. Finally, arguments about instrument validity are unresolved, largely due to the question of Amish culture and religion’s impact on measurement. Indeed, mental health studies have rarely incorporated Amish culture and religion into predictions of mental health conditions. In such a research climate, even cautious assertions about relationships between the Amish culture/religion and mental health are difficult. We have only a thin understanding of why Amishness should predict mental health conditions and how to incorporate it into study methodologies.

On the other hand, the counseling controversy case suggests that Amish people themselves have their own sets of disagreements about which bodies of knowledge and institutions should interpret and address mental health conditions. These controversies suggest internally competing understandings of Amish theology, between those adhering strictly to an old Amish understanding of the church’s responsibility to guide members through deep internal struggles, those willing to accept scientific interpretations of mental health as distinct from spiritual struggles, and those embracing an Evangelical Protestant emphasis on being born again, rejecting a works religion, and getting your heart right with God as the path to healing—and those who in some way synthesize two or all three perspectives. How would mental health researchers even identify and diagnose maladaptive behaviors in this volatile context? And then, what institutions will have authority over which individuals to interpret and work with maladaptive behaviors? An entirely church-sponsored and staffed, accredited, scientifically based institution would provide an ideal pathway to a scientific and culturally/religiously informed understanding of mental health conditions, but given Amish restrictions on post-secondary education, this scenario is unlikely.

The impact of context on instrument accuracy is not a methodological challenge unique to Amish research. As with other ethnic and religious minorities, Amish individuals have not been included in classic psychological research and therefore have been largely excluded from the development of diagnostic tools and treatment strategies. When assessment tools developed by society majority members are used to measure attributes of individuals in minority cultures, the population should be defined and justified, the social and temporal environment including ideological conflicts described, and the individuals under study, whose psychological and social selves are so intertwined, be assessed.

We conclude with three suggestions for future research. First, because it is impossible to account for all potential cultural and religious variables, mental health conditions research should include pre-study observation to understand contexts, disclose all potential limitations, and discuss ways to improve generalizability. Second, what would especially help inform clinical studies are case observations of practitioners working with Amish populations. The Amish mental health literature has only several published case observations, in spite of the fact that many therapists and psychiatrists are working with Amish clients. Published cases would be extremely useful in revealing how cultural and religious dynamics influence diagnosis and, ultimately, if, how, and why diagnostic tools should be revised. Finally, given that several sets of methodologically similar studies (albeit not replication studies) have produced irreconcilable results, researchers should engage in more replication studies across time, place, and Amish groups that carefully and reflexively detail context. Replication efforts will provide insight into differences across the Amish population and collectively inform some cautious generalizations about psychological tendencies and variations.

Mental health conditions research among Amish is both needful yet challenging. Notwithstanding, contexts of mental health conflict have the potential to re-orient and inform mental health conditions research, away from models of cultural homogeneity and biological reductionism and toward a careful and flexible assessment of culturally and religiously informed mental health conditions diagnosis and treatment.