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. Author manuscript; available in PMC: 2019 Feb 1.
Published in final edited form as: Psychiatr Serv. 2017 Sep 15;69(2):154–160. doi: 10.1176/appi.ps.201600457

Prevalence and Predictors of Mental Health Programming among U.S. Religious Congregations

Eunice C Wong 1, Brad R Fulton 2, Kathryn P Derose 3
PMCID: PMC5794513  NIHMSID: NIHMS925958  PMID: 28945177

Abstract

Objective

This study assesses the prevalence of and factors associated with congregation-based programming in support of people with mental illness.

Methods

This study analyzes data from the 2012 National Congregations Study, a nationally representative survey of religious congregations in the United States (N=1, 327), to estimate the proportion of congregations that provide mental health programming. The analysis uses multiple logistic regression to identify congregational characteristics associated with the provision of mental health programming.

Results

Nearly one in four U.S. congregations (23%) provided some type of programming to support people with mental illness. Approximately 31% of all attendees belonged to a congregation that provided mental health programming. Congregational characteristics associated with providing mental health programming included having more members and having members with higher incomes, employing staff for social service programs, and providing health-focused programs. Other significant predictors included engaging with the surrounding community (that is, conducting community needs assessments and hosting speakers from social service organizations) and being located in a predominantly African-American community.

Conclusions

Greater understanding of the role of congregation-based mental health programming within the system of care for people with mental illness is needed to improve coordination between congregations and the professional mental health sector.

Nearly one in five U.S. adults are affected by a mental illness in any given year (1),and roughly 25 percent of these adults turn to religious congregations (e.g., churches, synagogues, mosques) for help with their mental health challenges (2). Despite the substantial number of people who seek out religious congregations for mental health support, little is known about the extent to which congregations are responding to the mental health needs within their communities. Prior studies have focused primarily on the role of clergy and factors that facilitate clergy referrals to mental health professionals (3-6). The relative dearth of studies that examine the extent to which congregations are implementing programs to support people with mental illness is noteworthy given the extensive research on congregation-based social services and physical health-related programs (7-9).

The handful of studies assessing the prevalence of congregation-based mental health programming are mainly limited to studies involving African American churches within specific regions in the United States (5, 10). One recent exception involves a study in which Frenk (2014) analyzes data from the 2006 wave of the National Congregations Study (NCS) to estimate the prevalence of mental health programming among all types of U.S. congregations (11). In the 2006 NCS, congregations were asked to describe any social service programs, groups, meetings, classes, or events that they sponsored; responses were later coded to identify services targeting mental health-related issues. Only eight percent of congregations reported sponsoring mental health programming, the large majority of which focus on addressing substance use disorders (e.g., Alcoholics Anonymous). Separate analyses of the same dataset found that nearly two-thirds of congregations reported providing at least one health-related program (9); thus, the proportion of congregations providing mental health programming is a small subset of those providing health-related programming. Although Frenk's (2014) study analyzes a nationally representative sample of U.S. congregations, its reliance on responses to an open-ended question most likely resulted in an underestimation of congregation-based mental health programming.

In addition to needing a more accurate estimate of the prevalence of congregation-based mental health programming, there is a need to better understand the types of congregations involved in providing such services. Congregations are organizations influenced by both internal and external factors that influence their ability to provide various services (8, 12). Internal factors such as congregational resources (e.g., number of members and paid staff), characteristics (e.g., theological orientation, clergy education), and member composition (e.g., income levels) are associated with a congregation's likelihood of providing social service programs (8, 9, 13, 14). External factors such as a congregation's level of engagement with its surrounding community (e.g., conducting community needs assessment) and community-level characteristics (e.g., poverty level) also are associated with congregations sponsoring social services (8, 13).

To our knowledge, Frenk's is the only prior study that has analyzed data from a nationally representative sample of congregations to identify factors associated with congregations providing mental health programming (11). That study tested whether the provision of congregational-based mental health programming is related to internal factors, but did not examine the influence of external factors. Yet, external factors such as interactions between congregations and their surrounding community may play an influential role in whether a congregation provides mental health programming. External engagement may foster increased knowledge, recognition, and capacity within congregations to respond to the mental health needs within their communities, which may be particularly critical in light of the fact that many clergy have minimal formal training in mental health care (4, 15). Moreover, the racial and socioeconomic composition of the communities surrounding congregations could influence the demand for congregation-based mental health programming given barriers to accessing professional treatment or differential preferences for faith-based mental health care (16).

The purpose of the present study is to analyze the most recent wave of the NCS (2012) to: 1) estimate the percentage of congregations providing programs to support people with mental health problems and 2) identify internal and external factors associated with congregations sponsoring mental health programming. This study's use of the 2012 NCS—the only wave to date that explicitly asks congregations whether they provide mental health-related services—and inclusion of both internal and external factors offer an unprecedented national-scale examination of the role of congregations in providing mental health support.

Methods

Participants and Procedures

The National Congregations Study (NCS) is a nationally representative survey of religious congregations in the United States, which was initiated in 1998 and administered in two subsequent waves in 2006 and 2012 (17). All three waves of the NCS use samples that are derived from the respective 1998, 2006, and 2012 General Social Surveys (GSS), which are nationally representative surveys of English- or Spanish-speaking adults. GSS respondents who reported attending religious services at least once a year were asked to provide the name of their congregation. The congregations named by the respondents were used to establish a representative sample of U.S. congregations (see Chaves et al. [2016] for a detailed description of the NCS data and methods) (18). We analyze data from the 2012 NCS, which was the first wave to ask congregations specifically about their sponsorship of congregation-based mental health programming. Key informants at each congregation (e.g., clergy, staff, leader) were interviewed in person or by phone on a wide range of topics including congregational member characteristics, leadership, programming, and resources. A total of 1,331 congregations participated in the study (73% response rate).All study procedures were approved by the RAND Human Subjects Protection Committee, which determined that this study was exempt from further review given the use of publicly available, deidentified secondary data at the organizational level.

Measures

Our study's dependent variable, the provision of congregation-based mental health programing, is measured using the following item, “Within the past 12 months, have there been any groups or meetings or classes or events specifically focused on the following purposes or activities?” As part of this item, congregational informants were asked to provide responses for 26 distinct groups or activities, which span a wide range of areas (e.g., “To discuss politics?”,“To discuss parenting issues?”). Mental health programming is assessed with the item:“Support for people with mental illness?” Response options were yes (coded 1) or no (coded 0).

The independent variables include measures of congregations' internal and external factors expected to be associated with providing mental health programming based on prior research examining factors associated with congregational involvement in providing health and other social services (8, 9, 12-14). The internal factors include sets of variables related to member composition, congregational characteristics, congregational resources, and involvement with health and human services. Member composition is characterized along three dimensions: age (percentage of members who are less than 60 years old), education (percentage of members with a four-year college degree or more), and income (percentage of members with a household income greater than $140,000 a year). Congregational characteristics include the clergy's age (age of head or senior clergy person), the congregation's theological orientation (theologically conservative=1; moderate or liberal=0), congregational practices (speaking in tongues is practiced; yes=1; no=0), and the congregation's religious tradition (coded 1 for Black Protestant and 0 for Roman Catholic, Mainline Protestant, Conservative Protestant, and Non-Christian). The descriptive statistics provide the percentage of congregations affiliated with each religious tradition. Congregational resources are measured by the congregation's size (number of regular adult participants), whether the congregation employs staff for social service programs (spent more than 25% of work time on social service programs, yes=1; no=0), and whether the congregation owns its building (yes=1; no=0). Involvement with health and human services is measured with two dichotomous items (yes=1; no=0) that indicate whether the congregation provides health-focused education programs and whether the congregation sponsors social service programs.

The external factors include sets of variables related to the congregation's external engagement and community characteristics. External engagement is measured with two dichotomous items (yes=1; no=0) that indicate whether the congregation assesses the needs of its community and whether the congregation had a social service representative as a visiting speaker). Community characteristics are measured with four dichotomous items (yes=1; no=0) related to the racial-ethnic composition of the congregation's surrounding neighborhood (census tract is at least 80% African American), the socioeconomic composition of the congregation's surrounding neighborhood (census tract has at least 30% living below the official poverty level), the congregation's community context (census tract is predominantly urban), and geographic region (located in the South—i.e., South Atlantic, East South Central or West South Central).All of the independent variables are dichotomous, except for the member composition variables, clergy age (years), and congregation size (number of adult participants), which are continuous.

Missing values for the independent variables were multiply imputed using the Imputation by Chained Equations (ICE) package in Stata 14.1 (19). This technique uses the distribution of the observed data to estimate a set of plausible values for the missing data (20). Ten complete imputed datasets were created and pooled using Rubin (1987) combination rules (21). Item nonresponse diagnostics, (i.e., stabilization plots) indicate that the mean and variance estimates for each of the variables with missing values had stabilized and thus do not contain significant nonresponse bias (12). All analyses were performed using Stata version 14.1 (StataCorp LP, College Station, TX).

Analyses

To identify the factors associated with congregations providing mental health programming, we began by conducting bivariate analyses on each of the variables measuring the congregations' internal and external factors. Then we performed a multivariate logistic regression that includes all of the variables. All analyses were weighted to the congregational attendee levels, which is considered the appropriate method for studies aimed at assessing the social impact of congregational services (9, 22). Additional analyses (not displayed) indicate that the cases with imputed values do not significantly affect the results of the multivariate analysis.

Results

Descriptive statistics at both the congregation and attendee level are presented in Table 1. Based on data from the 2012 NCS data, nearly a quarter (23%) of U.S. congregations provided mental health programming. Thus approximately 31% of all attendees belonged to a congregation that provided mental health programming.

Table 1. Descriptive statistics of U.S. congregations (N=1,327).

Congregation Levela Attendee Levelb
Variable N % N %
 Provides mental health programming 305 23 376,800 31
Member Composition
 % of members who are less than 60 years old (mean+SD) 63.3 + 24.9 65.1 + 21.4
 % of members with a college degree (mean+SD) 31.7 + 27.4 41.4 + 26.5
 % of members with a high income level (mean+SD) 7.0 + 12.9 14.3 + 18.2
Congregational Characteristics
 Age of head clergy person (mean+SD) 55.0 + 11.5 54.3 + 10.8
 Roman Catholic 73 5 332,640 28
 Mainline Protestant 269 20 206,040 17
 Conservative Protestant 21 46 448,800 37
 Black Protestant 284 21 155,880 13
 Non-Christian 89 7 56,520 5
 Theologically conservative 836 63 70,560 6
 Theologically moderate 332 25 348,000 29
 Theologically liberal 160 12 145,920 12
 Speaking in tongues is practiced 391 29 295,560 25
Congregational Resources
 Number of adult participants (mean+SD) 118.2+325.2 1,012.9+1,840.1
 Employs staff for social services programs 186 14 254,760 21
 Congregation owns its building 1,123 85 1,110,360 92
Involvement with Health and Human Services
 Provides health-focused education programs 373 28 510,600 43
 Sponsors social service programs 1,103 83 1,099,320 92
External Engagement
 Assesses the needs of its community 753 57 811,440 68
 Had a social service representative as a visiting speaker 416 31 574,200 48
Community Characteristics
 Census tract is at least 80% African American 36 3 43,200 4
 Census tract has at least 30% living below the poverty level 226 17 173,160 14
 Census tract is predominantly urban 664 50 873,960 73
 Census tract is predominantly suburban 240 18 147,480 13
 Census tract is predominantly rural 422 32 178,320 15
 Located in the Northeast 160 12 151,200 13
 Located in the Midwest 304 23 312,360 26
 Located in the West 188 14 230,880 19
 Located in the South 675 51 505,560 42
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Source: National Congregations Study, 2012

a

Congregation level weights applied.

b

Attendee level weights applied. Attendee-level estimates are based on the 1.2 million congregational attendees represented among the 1,327 congregations in the sample.

Table 2 presents results of the bivariate and multivariate analyses. The multivariate analysis, which incorporated all the independent variables, indicated that congregations whose members were predominantly younger (odds ratio [OR]=1.01, p<.01) and relatively wealthy (OR=1.02, p<.001) were more likely to sponsor mental health programming. Among the congregational characteristics, sponsoring mental health programming was positively associated with the clergy's age (OR=1.01, p<.05) and the practice of speaking in tongues (OR=1.43, p<.05). With respect to congregational resources, congregations with more attendees (OR=1.11, p<.05) and with staff dedicated to providing social services (OR=1.86, p<.001) were more likely to sponsor mental health programming. Providing health-focused education programs was also positively associated with providing mental health programming (OR=2.03, p<.001).

Table 2. Odds ratios from logistic regression models predicting whether a congregation provides mental health programming.

Bivariate Multivariate
Congregational internal and external factors OR 95% CI OR 95% CI
Member Composition
 % of members who are less than 60 years old 1.01*** 1.01 – 1.02 1.01** 1.01 – 1.02
 % of members with a college degree 1.01** 1.00 – 1.01 1.00 0.99 – 1.01
 % of members with a high income level 1.02*** 1.01 – 1.03 1.02*** 1.01 – 1.03
Congregational Characteristics
 Age of head clergy person 1.01 1.00 – 1.02 1.01* 1.00 – 1.03
 Black Protestant 1.66** 1.21 – 2.29 0.95 0.60 – 1.52
 Theologically conservative 0.77* 0.60 – 0.97 1.04 0.78 – 1.37
 Speaking in tongues is practiced 1.88*** 1.45 – 2.44 1.43* 1.03 – 1.99
Congregational Resources
 Number of adult participants (logged) 1.32*** 1.22 – 1.43 1.11* 1.00 – 1.23
 Employs staff for social service programs 2.84*** 2.15 – 3.75 1.86*** 1.36 – 2.54
 Congregation owns its building 1.22 0.77 – 1.94 0.80 0.47 – 1.35
Involvement with Health and Human Services
 Provides health-focused education programs 3.02*** 2.37 – 3.85 2.03*** 1.53 – 2.67
 Sponsors social service programs 3.53*** 1.95 – 6.37 1.77 0.93 – 3.36
External Engagement
 Assesses the needs of its community 2.92*** 2.20 – 3.87 1.98*** 1.46 – 2.70
 Had a social service representative as a visiting speaker 2.20*** 1.73 – 2.79 1.41* 1.07 – 1.86
Community Characteristics
 Census tract is at least 80% African American 3.11*** 1.82 – 5.33 2.20* 1.12 – 4.33
 Census tract has at least 30% living below the poverty level 1.33 0.97 – 1.82 1.28 0.88 – 1.87
 Census tract is predominantly urban 1.81*** 1.37 – 2.39 0.80 0.56 – 1.13
 Located in the South 0.79 0.63 – 1.01 0.79 0.60 – 1.04
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Source: National Congregations Study, 2012

Note: The diagnostic tests recommended by Winship and Radbill (1994) indicate no misspecification related to the probability-proportional-to-size feature of the sample; thus, we present the results from analyzing unweighted data.(41)

*

p < .05,

**

p < .01,

***

p < .001 (two-tailed tests)

Regarding the external engagement indicators, congregations that assessed the needs of their communities (OR=1.98, p<.001) and those that had hosted a social service representative as a visiting speaker (OR=1.41, p<.05) were more likely to sponsor mental health programming. In addition, congregations in neighborhoods with predominantly African-American residents (OR=2.20, p<.05) were more likely to have mental health programming. The most notable correlations indicated that employing staff for social services, providing health-focused education programs, assessing the needs of the congregation's community, and being located in a predominantly African-American community each increased the odds of a congregation providing mental health programming by approximately a factor of two.

Regarding the external engagement indicators, congregations that assessed the needs of their communities (OR=1.98, p<.001) and those that had hosted a social service representative as a visiting speaker (OR=1.41, p<.05) were more likely to sponsor mental health programming. In addition, congregations in neighborhoods with predominantly African-American residents (OR=2.20, p<.05) were more likely to have mental health programming. The most notable correlations indicated that employing staff for social services, providing health-focused education programs, assessing the needs of the congregation's community, and being located in a predominantly African-American community each increased the odds of a congregation providing mental health programming by approximately a factor of two.

Discussion

This study examined the prevalence of congregation-based mental health programming and factors associated with providing such services by analyzing data from the 2012 NCS. The 2012 NCS was the first survey conducted with a representative sample of U.S. congregations that specifically asked congregations whether they provided mental health programming. Approximately one-third of all congregational attendees were in a congregation that provided programming support for people with mental illness. At the congregation level, nearly a quarter of congregations reported providing such support, which is approximately three times greater than the estimate derived by a prior study that used the 2006 NCS (11).

Although the higher rate found in this study may partly reflect the general trend of congregations to become more involved in providing social services (14),it is also likely that this study was better able to detect the provision of congregation-based mental health programming because congregations were specifically asked about providing such services. Furthermore, the large majority of mental health–related services identified in the 2006 NCS study were related to substance use disorders (11).The 2012 NCS, which asked separate questions about programs for mental illness and substance use disorders, allowed for a more precise estimate of congregational programming focused specifically on supporting people with mental illness. We note that in the 2012 NCS data, the proportion of U.S. congregations providing programming for substance use problems (38%) was greater than that providing mental health programming.

The 2012 NCS enabled a more accurate test of factors associated with congregations' sponsorship of programs targeting mental illness because it did not comingle mental health services with services for substance use disorders. We found that several internal factors were associated with providing mental health programming. Congregations with younger and more affluent members had slightly higher odds of providing mental health programming. Given that younger adults and people with a higher socioeconomic status tend to hold less stigmatizing views of mental illness (23-25),it is possible that congregations with younger and wealthier members may foster a more supportive environment for people with mental illness. In addition, the odds of providing mental health programming increased slightly in congregations with older clergy and in congregations with the practice of speaking in tongues. Older clergy may have greater exposure to and experience with caring for people with mental illness. Speaking in tongues is a spiritual practice similar to other practices, such as prayer with the laying on of hands and memorizing scripture, that many Pentecostal Christians view as being effective methods for treating depression (26). Because congregations that practice speaking in tongues tend to correlate mental health with spiritual health, they may be more inclined to provide support for mental health issues.

Congregational resources, including the congregation's size, having staff for social services, and providing health education and social service programs, were positively associated with congregation-based mental health programming. These findings are consistent with previous studies demonstrating a connection between congregational resources and the provision of health-related programs (8, 22),but they counter findings from the 2006 NCS, which did not identify any significant relationships between a congregation's resources and provision of mental health programming (11).This contradictory finding could be partly due to the fact that most mental health–related services identified in the 2006 NCS study targeted substance use disorders; many of the corresponding services involved activities such hosting Alcoholics Anonymous meetings, which do not require substantial congregational resources. Future studies that examine differences among congregations sponsoring mental health–related versus substance abuse–related services could provide a better understanding of how congregations view and address these needs and reveal potential avenues for collaboration with professional care providers.

We also found that external factors were associated with congregations' sponsorship of mental health programming. Congregations that engaged with their external environment by assessing the needs of their surrounding communities and hosting speakers from social service agencies were more likely to sponsor mental health programming. This finding is consistent with prior research on congregations' provision of health programs (8, 13). A congregation that interacts with its surrounding community may become more aware of mental health needs and its capacity to provide support for people with mental illness (8). In addition, congregations in predominantly African-American neighborhoods were more likely to sponsor mental health programming. Given that African Americans are less likely to access mental health treatment (27), it is possible that congregations located in predominantly African American neighborhoods are responding to this unmet mental health need by providing support services. Although it is known that many African Americans turn to congregations for help with personal needs (28, 29), little research has been conducted on congregation-based mental health programming within predominantly African American communities (30). A few preliminary studies, however, suggest that building collaborations between African American congregations and the mental health sector is a promising strategy to increase access to needed services (31-33).

Our findings should be considered in light of certain study limitations. Associations for certain congregational factors (that is, clergy age and congregational members' age and income), although statistically significant, should be interpreted with caution given the small ORs, which suggest minimal effects in actual practice. In addition, although the 2012 NCS included a specific question about providing support for people with mental illness, it did not collect data on the mental health conditions addressed. Congregations may regard a wide range of programs as being mental health related—from issues that are more typical of clinical disorders, such as depression, to less clinically defined conditions, such as marital counseling. Similarly, little is known about the type of mental health programming that congregations offer, which could vary from more spiritual forms of support (for example, prayer) to more education-based support or counseling. In addition, the congregational factors associated with providing mental health programming may differ depending on the type of programming offered. Furthermore, because the 2012 NCS did not collect data on why congregations decided to offer particular services, we could not determine whether congregations offered mental health programming as a collaborative continuum with professional mental health care providers or as an option to rely exclusively on religious care(34).

Overall, more detailed information about congregation-based mental health programming is needed to better understand the role and functioning of congregations within the broader system of care for people with mental illness. For example, even though a sizable proportion of congregations offer programming to support people with mental illness, it is unclear whether this programming was complementing, supplanting, or filling in gaps with respect to professional mental health treatment. Currently, more than 60% of U.S. adults with a mental illness do not obtain the professional treatment they need (35). Furthermore, over half of U.S. adults who seek help from congregations for a mental disorder do so at the exclusion of other healthcare providers (2).For instance, although racial-ethnic minorities and young adults are among the least likely to obtain professional mental health treatment (36, 37), they are among the most likely to seek mental health care from religious congregations (2, 29). Further research is needed to examine whether interventions designed to foster greater collaboration between congregations and the mental health service sector can significantly improve access to treatment among groups with the greatest levels of unmet mental health needs (38).

Conclusions

Given that congregations are often the first and only point of contact for many people seeking help with mental illness (2), they can play an important role in providing support and in facilitating connections to professional treatment. A growing number of mental health professionals view congregations as potential collaborators in helping to address unmet mental health needs (38-40).Greater coordination between mental health providers and congregations with programs that support people with mental illness could foster more integrated and holistic care, which in turn may lead to improved recovery outcomes.

Contributor Information

Dr. Eunice C. Wong, RAND Corporation, Santa Monica, California

Dr. Brad R. Fulton, School of Public and Environmental Affairs, Indiana University, Bloomington, Indiana

Dr. Kathryn P. Derose, RAND Corporation, Santa Monica, California

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