African Americans’ and Black Caribbeans’ Religious Coping for Psychiatric Disorders

Abstract

This study investigates the use of religious coping among African Americans and Black Caribbeans with 12-month DSM-IV psychiatric disorders. Data from the National Survey of American Life is used to examine 3 indicators of religious coping: 1) using prayer and other spiritual practices for mental health problems, 2) the importance of prayer in stressful situations and 3) looking to God for strength. Three out of 4 respondents who had a mental health problem reported using prayer as a source of coping. Agoraphobia and drug abuse disorder were associated with the importance of prayer during stress. Individuals with generalized anxiety disorder were more likely to report that prayer was important during stressful experiences and that they looked to God for strength. These findings contribute to the limited, but growing body of research on the ways that African Americans and Black Caribbeans cope with psychiatric disorders.

Introduction

Religion is an important coping strategy among indiviudals experiencing mental health problems, including psychiatric disorders. Religious coping strategies are common responses to life challenges and difficulties and are practiced across religious and spiritual traditions. Prayer, in particular, is one of the most frequently used types of religious coping. Data on rates of prayer in the U.S. from the Religious Landscape Survey (Pew Research Center, 2018) indicate that most people report praying at least once a day (58% in 2007; 55% in 2014). Prayer remains an important feature of religious life and a common practice even for those who do not frequently attend religious services. For example, 6 out of 10 Americans who never attend religious services indicate prayer is very important during times of stress and that they look to God for strength when facing difficulties (Brown et al., 2013). A very small body of research on religious participation among African Americans explores the use of religious coping in response to problems such as physical illness, financial difficulties and interpersonal problems (Chatters et al., 2008; Ellison & Taylor, 1996; Krause & Chatters, 2005). However, we know less about the degree to which religious coping is used when someone is experiencing severe mental and emotional health challenges such as depression and anxiety.

In examining prayer as a form of religious coping for mental health issues, it is important to understand and account for ethnic differences within the Black U.S. population. Although often overlooked, ethnicity is an important feature of variability within the U.S. Black population. African Americans and Black Caribbeans represent two distinct groups comprising the general category of Black Americans. By way of definition, African American refers to individuals of African descent who are born in the U.S., while Black Caribbean refers to persons of African descent who trace their cultural heritage to the Caribbean region. Throughout this article, the terms African American and Black Caribbean refers to these distinct ethnic groups; the term Black American collectively refers to both groups.

To our knowledge there is extremely little research on African American religious coping and no research that explores the use of prayer for mental health issues specifically among the Black Caribbean population in the U.S. However, both African Americans and Black Caribbeans have low rates of overall mental health services use, and particularly specialty mental health care (Neighbors et al., 2007; U.S. Department of Health and Human Services, 2001). Information on the use of prayer in response to mental health issues among African Americans and Black Caribbeans is useful in delineating potential ethnic differences and similarities in religious coping practices within the U.S. Black population.

The current study addresses these gaps in the literature by investigating the degree to which Black Americans with 12-month DSM-IV psychiatric disorders use religious coping. This research ultimately aims to increase the body of knowledge on Black Americans’ use of religious coping in response to mental health issues to: 1) further our understanding of the utility of religious coping among Black Americans with DSM-IV disorders, and 2) assist social workers and other mental health professionals in efforts to develop and deliver culturally responsive mental health services. We begin the literature review with a discussion of research on the prevalence of psychiatric disorders among Black Americans, followed by a discussion of Black churches and mental health care. The next sections review research on religious involvement and prayer among African Americans and religious involvement and prayer among Black Caribbeans. Finally, we describe the focus of the current study.

Psychiatric Disorders

Psychiatric problems are a significant concern with respect to overall prevalence of disorders and need for and access to services. Recent research based on nationally representative samples of the U.S. Black population indicates that roughly 16% of those age 18 and older meet criteria for any 12-month mental disorder (Vilsaint et al., 2019), while the prevalence among older adults ranges from 6 to 9% (Ford et al., 2007; Jimenez, Alegría, Chen, Chan, & Laderman, 2010). Overall, anxiety disorders are more prevalent (10.8%) than mood disorders (6.8%) (Vilsaint et al., 2019) and range between 1 and 2% for agoraphobia, panic, and generalized anxiety disorder, and between 3 and 5% for social phobia and PTSD (Himle, Baser, Taylor, Campbell, & Jackson, 2009). Twelve-month substance use is 3% for Blacks 18 and older (Vilsaint et al., 2019). Finally, major depressive disorder is prevalent among 5.9% of African Americans and 7.2% of Black Caribbeans aged 18 and older (Williams et al., 2007). Among Black adults 50 and older the prevalence of MDD is 4% and 8%, respectively (Woodward, Taylor, Abelson, & Matusko, 2013).

Black Churches and Mental Health Care

The use of prayer and religious coping specifically for mental health and emotional problems is of interest for several reasons. African Americans are under-served with regard to basic social and health services (Neighbors, 1985; Neighbors et al., 2007), resulting in significant unmet needs and documented racial disparities in overall health status and access to services and care. Further, racial disparities in access to and use of specialty mental health services for psychiatric and emotional problems are particularly acute (Neighbors et al., 2007). Black churches and other religious institutions have traditionally supported African American communities by providing educational, social welfare, economic, and health resources and services. Black churches have been the safe haven, community hub, and spiritual heartbeat of the African American community since the 18th century through the Civil Rights (Lincoln & Mamiya, 1990) to the current health and financial crises. The Black church and prayer were among the few defenses against the harsh realities of the dehumanizing system of chattel slavery. The spirituals and hymns of these churches reminded the enslaved Africans to “take our burdens to the Lord and leave them there.” Since this era, Black churches have provided a range of informal services that evolved into formal services ranging mutual aid societies for health and burial needs (Cnaan et al., 2005; Cnaan et al., 2006; Blank et al., 2002).

Black churches have shouldered the therapeutic responsibility for their community members and are often gatekeepers to services like mental health treatment (Allen et al., 2010). African Americans frequently use religious resources in their overall patterns of help seeking for a wide range of personal and social problems (e.g., health, financial, employment, interpersonal)including consultations with clergy for advice and referrals to formal service providers (Bohnert et al, 2010; Chatters et al., 2011; Chatters et al., 2017; Taylor et al., 2000; Taylor et al., 2011; Woodward et al., 2015; Wang et al., 2003). African Americans may be encouraged by clergy to use prayer in conjunction with their broader help-seeking efforts for mental health and emotional problems.

African Americans, Religious Involvement, and Prayer

African Americans are distinctive among U.S. racial/ethnic groups in having the highest rate of daily prayer, in addition to other religious behaviors such as service attendance and use of religious media (Chatters et al., 2009; Pew Research Center, 2018; Taylor et al., 1996). For example, a study of prayer among older Black and White adults (Krause & Chatters, 2005) indicated that Black elderly were more deeply engaged in various dimensions of prayer including beliefs about how prayer works, the social context and substantive content of prayer, and interpersonal features of prayer. Several studies examine the use of prayer as a source of coping among African Americans. In one of the earliest studies, Neighbors, Jackson, Bowman, and Gurin (1983) found that prayer was used by 44% of African Americans who were coping with a serious personal problem, and further, prayer was the most frequently mentioned coping strategy. Ellison and Taylor (1996) found that prayer as a form of coping was more prevalent among persons facing problems involving poor health and bereavement. Consistent with prior studies, recent investigations using National Survey of American Life data indicate that African Americans and Black Caribbeans both report higher rates of prayer than non-Hispanic whites (Chatters et al., 2009). Longitudinal analysis over a 15-year period also confirmed that private prayer or asking someone to pray on their behalf was the most utilized form of coping with personal problems with 9 out of 10 African Americans indicating this strategy in all 3 waves of data (Taylor et al., 2004). Finally, information from the Pew Research Center similarly indicates that, compared to whites, Latinos, and Asians, Blacks report the highest rates of daily prayer (73%) (Pew Research Center, 2014).

A collection of recent studies verify that religious involvement and prayer are important devotional practices for African Americans across all age cohorts (Taylor & Chatters, 2010; Taylor, Chatters & Brown, 2014; Taylor, Chatters, & Levin, 2003). Data from the 2007 Pew Religious Landscape Study (Pew, 2008) indicates that across the age spectrum (persons 18-29 and 30 and above), members of historically Black Protestant churches have higher rates of religious involvement and daily prayer than the general population. Further, in contrast to age cohort patterns indicating lower levels of religious involvement among younger people, Black millennials display high levels of various forms of religious involvement and are more likely than non-Black millennials to affirm the importance of religion, belief in God, and to engage in daily prayer (Diamant & Mohamed, 2018).

Black Caribbeans, Religious Involvement, and Prayer

Although systematic investigations of religious involvement among Black Caribbeans is limited, available studies identify several distinctive features regarding religious profiles and communities that are relevant for religious coping. Information from qualitative studies of Black Caribbeans identify churches as important institutions and resources for new immigrants. Waters’s (1999) found that churches play a prominent role in Black Caribbean life. Immigrant churches (institutions that are connected to and comprised of Black Caribbean members) provide important religious functions, tangible social supports, cultural connections, and psychological benefits to their members (Bashi, 2007). Religious communities often function as cultural brokers that assist in the resettlement of immigrants, reinforce ethnic identities and communities, and enhance social capital. These features of church life prove an important coping resource by addressing the psychological, spiritual, social, and material needs of their members.

Research examining religious participation and prayer among Black Caribbeans has yielded several general conclusions. First, Black Caribbeans and African Americans (Chatters et al., 2009; Taylor et al., 2010) are similar in terms of religious participation, viewing televised religious programming, and self-rated religiosity. Black Caribbeans are less likely to be official church members, engage in sponsored church activities (choirs, church clubs) and request prayer from others, but read religious materials more frequently than do African Americans (Chatters et al., 2009). These differences may be a reflection of how the experience of immigration influences social connections to and engagement with religious communities for Black Caribbeans. Prior research based on this data (Chatters et al., 2009) indicates that relatively recent arrivals to the U.S. (5 years or less) are less likely to report being an official member of a church and to have lower rates of participation in church activities than those who have been in residence for a longer period of time (6 years or more). Immigrant resettlement and choosing a place of worship involves an oftentimes lengthy process of exploring several churches and attending services to gain a sense of the congregational climate (i.e., ‘church shopping’). This resettlement process is critical given the pivotal role of religious institutions as a source of social capital, cultural resources, and informal supports for immigrants (Chatters et al., 2009). In these situations while ‘church shopping’, immigrants are attending services, but may forgo formally joining a church and participating in church activities (choir, clubs) until the selection process is completed.

Behaviors such as requesting prayer from church members and other forms of support from church-based social networks requires a considerable degree of relationship building, trust, mutuality, and emotional investment which only accrues over an extended period of time (Taylor, Lincoln & Chatters 2005). The higher rates of reading religious materials among Black Caribbeans may be due to their generally higher levels of education relative to African Americans or a reflection of involvement in a devotional activity in lieu of formal church involvement. Finally, despite these noted differences in religious involvement, as compared to non-Hispanic Whites both groups report higher levels of religious participation in specific activities (e.g., frequency of prayer and frequency of requesting prayer from others) (Chatters et al., 2009) and higher levels of religious coping (Chatters et al., 2008).

The Present Study

Black Americans (African Americans and Black Caribbeans): 1) experience disadvantaged social status and barriers that both create unmet needs for mental health care and limit access to and use of specialty mental health resources and 2) demonstrate high levels of religious involvement and religiously focused coping strategies. Together, these social and religious characteristics underscore the importance of examining religious coping in response to psychiatric disorders. Knowledge about whether and how Black Americans use religious coping, whether it is used in conjunction with formal health resources and alternative therapies, and potential ethnic (e.g., Black Caribbean, African American) differences in these patterns is critical for understanding help-seeking for serious mental health and emotional problems for these groups.

This study focuses on the degree to which African Americans and Black Caribbeans with 12-month DSM-IV psychiatric disorders use religious coping. The data used for this analysis consist of nationally representative samples of native-born African Americans and Black Caribbean respondents from the National Survey of American Life. We focus on both groups in this study in recognition that, in the U.S. context, African Americans and Black Caribbeans, although ethnically and culturally distinct, are typically subsumed under the racial category of “Black.” We recognize that their distinctive ethnic identities and religious profiles are potentially consequential for understanding prayer use for mental and emotional problems.

Our analyses examine 12-month DSM-IV psychiatric disorders differences in reports of: 1) the use of prayer and other spiritual practices for mental and emotional problems, 2) the importance of prayer in stressful situations and 3) turning to God for strength among African Americans and Black Caribbeans. This analysis has several significant strengths. First, this is the first analysis that we are aware of that examines religious coping and DSM level clinical disorders among African Americans and Black Caribbeans. Prior analysis on religious coping for mental health issues is limited to investigating mental health symptoms such as depressive symptoms (CES-D) as opposed to clinical psychiatric disorders. Second, our analysis is based on a large national probability sample of African Americans and Black Caribbeans which allows for the generalizability of findings. Given these strengths, study findings will make a meaningful contribution to the very small body of literature on religious coping among African Americans and Black Caribbeans.

Methods

Sample

This study analyzed data from the National Survey of American Life: Coping with Stress in the 21^st Century (NSAL). The NSAL was collected by the Program for Research on Black Americans at the University of Michigan’s Institute for Social Research (Jackson et al., 2004). The fieldwork for the study was completed by the Institute for Social Research’s Survey Research Center, in cooperation with the Program for Research on Black Americans. The NSAL is part of the Collaborative Psychiatric Epidemiology Studies (CPES) funded by the National Institute of Mental Health and designed to be representative of Blacks (both African Americans and Black Caribbeans) in the US. The data collection was conducted from 2001 to 2003. A total of 6,082 interviews were conducted with persons aged 18 or older, including 3,570 African Americans, 1,621 Black Caribbeans, and 891 non-Hispanic Whites. The current analysis utilizes the African American and Black Caribbean sub-samples and the analytic sample is 5,179.

The NSAL includes the first major probability sample of Black Caribbeans ever conducted. For the purposes of this study, Black Caribbeans are defined as persons who trace their ethnic heritage to a Caribbean country, but who now reside in the United States, are racially classified as Black, and who are English-speaking. The overall response rate was 72.3%. Response rates for individual subgroups were 70.7% for African Americans, 77.7% for Black Caribbeans, and 69.7% for non-Hispanic Whites. Final response rates for the NSAL two-phase sample designs were computed using the American Association of Public Opinion Research (AAPOR) guidelines (AAPOR, 2006).

The African American sample is the core sample of the NSAL. The core sample consists of 64 primary sampling units (PSUs). Fifty-six of these primary areas overlap substantially with existing Survey Research Center’s National Sample primary areas. The remaining eight primary areas were chosen from the South in order for the sample to represent African Americans in the proportion in which they are distributed nationally. The Black Caribbean sample was selected from two area probability sample frames -- the core NSAL sample and an area probability sample of housing units from geographic areas with a relatively high density of persons of Caribbean descent.

In both the African American and Black Caribbean samples, it was necessary for respondents to self-identify their race as Black. Those self-identifying as Black were included in the Black Caribbean sample if they answered affirmatively when asked if they were of West Indian or Caribbean descent, if they said they were from a country included on a list of Caribbean area countries presented by the interviewers, or if they indicated that their parents or grandparents were born in a Caribbean area country (see Jackson et al., 2004 and Heeringa et al., 2004 for a more detailed discussion of the NSAL sample). After providing a complete description of the study to participants, informed consent was obtained. The NSAL data collection was approved by the University of Michigan Institutional Review Board. Respondents were compensated for their time.

Measures

Dependent Variables. There are three dependent variables in this analysis: 1) the use of prayer and other spiritual practices for mental and emotional problems, 2) the importance of prayer in stressful situations and 3) looking to God for strength. For the first dependent variable, respondents were provided a list of commonly used alternative therapies and asked to indicate which ones they used in the past 12 months “for problems with your emotions or nerves or your use of alcohol or drugs.” This dependent variable is a dichotomous indicator for whether respondents use ‘prayer or other spiritual practices’ in the past 12 months to cope with their mental health problems. Because this dependent variable was only asked of a subset of respondents, the analytic sample for this analysis only consisted of the 736 African Americans and Black Caribbeans who reported using any alternative therapies, including prayer, for addressing a mental health need in the 12 months before the interview. This sub-sample included 519 African Americans and 217 Black Caribbeans.

Two other dependent variables (asked of the entire African American and Black Caribbean sample) reflect general attitudes and opinions about religious coping. The first provides an assessment of the significance of prayer in difficult circumstances and asks: “How important is prayer when you deal with stressful situations?” Very Important (1), Fairly Important (2), Not Too Important (3) or Not Important At All (4). The second question reflects an overall orientation towards God as a resource and queries respondents’ level of agreement with the statement: “I look to God for strength, support, and guidance.” Respondents indicate whether they: Strongly Agree (1), Somewhat Agree (2), Somewhat Disagree (3), or Strongly Disagree (4) with this statement.

Psychiatric Disorders

Psychiatric disorders were assessed with the World Mental Health Composite International Diagnostic Interview (WMH-CIDI), a fully structured, lay-administered diagnostic interview based on the definitions and criteria of ICD-10 and DSM-IV. The WMH-CIDI is an expanded version of the World Health Organization CIDI that includes a greater number of disorders (Kessler & Ustun, 2004). Anxiety disorders included panic, agoraphobia without panic, social phobia, generalized anxiety disorder, and post-traumatic stress disorder; mood disorders included major depression, dysthymia, and bipolar I & II; and substance disorders included alcohol abuse, alcohol dependence, drug abuse, and drug dependence. Dichotomous measures were created to indicate whether respondents met criteria for a disorder in the 12 months prior to the interview. In addition, a variable was created for the number of disorders.

Control Variables. Sociodemographic variables included ethnicity (African American, Black Caribbean), gender, age (18 to 34 years, 35 to 54 years, 55 and older), marital status (currently married, previously married, never married), years of education (0 to 11, 12, 13 to 15, or 16 or more), household income in quartiles ($0 to $14,999, $15,000 to $27,999, $38,000 to $46,999, and $47,000 and higher), and region (Northeast, Midwest, South, or West).

Frequency of religious service attendance is measured by combining two items—one that indicates frequency of attendance and one that identifies respondents who have not attended services since the age of 18. The categories for this derived variable are: attend nearly every day, at least once a week, a few times a month, a few times a year, less than once a year (except for weddings and funerals) and never attended services since the age of 18. This variable ranges from 6=nearly every day to 1=never attended religious services since the age of 18. The distribution of the demographic. psychiatric disorder, religious service variables is presented in Table 1.

Table 1:

Demographic description of Sample

	n	%
Race/ethnicity
African American	3562	93.02
Black Caribbean	1617	6.98
Gender
Male	1905	44.46
Female	3274	55.54
Age
18-34	1854	36.24
35-64	2190	42.39
55 and older	1135	21.37
Education
0-11	1223	23.99
12	1838	37.24
13-15	1249	23.99
16 or more	869	14.78
Marital status
Currently married	1904	42.23
Previously married	1545	26.24
Never married	1710	31.53
Household income
0-14,999	1325	24.08
15,000-27,999	1305	23.57
28,000-46,999	1304	25.46
≥47,000	1245	26.90
Region
Northeast	1543	18.52
Midwest	605	17.78
South	2780	54.32
West	251	9.38
Psychiatric Disorder
Major depressive disorder	320	6.82
Panic disorder	121	2.35
Agoraphobia without panic	57	1.06
Social phobia	225	4.57
Generalized anxiety disorder	113	2.47
Posttraumatic stress disorder	176	3.90
Dysthymia	101	2.52
Bipolar I and II disorders	109	2.41
Alcohol abuse	87	2.26
Alcohol dependence	46	1.28
Drug abuse	54	1.31
Drug Dependence	26	0.67
Number of disorders
None	4218	83.66
One	464	9.22
2 or more	327	7.12
Frequency of Service Attendance1	3.78	1.04

Frequencies are unweighted, Percentages are Weighted

¹For Frequency of Service Attendance, mean and standard deviation are presented.

Analysis

All percentages reported were weighted and frequencies were unweighted. Logistic regression was used with the dichotomous dependent variables and linear regression analysis was used with the two continuous dependent variables. For the logistic regression analysis, odds ratio estimates and 95% confidence intervals are presented. For the linear regression analysis, unstandardized coefficients and standard errors are presented. All analyses were conducted in SAS. Standard error estimates were corrected for unequal probabilities of selection, nonresponse, poststratification, and the sample’s complex design (i.e., clustering and stratification). Results from these analyses are generalizable to the African American and Black Caribbean adult populations.

Results

Use of prayer for a mental health problem was only asked of individuals who reported a mental or emotional problem (n=736). Of these 736 adults, three-quarters (78.6% n=570) reported using prayer or some other spiritual practice. The other two dependent variables were asked of all African Americans and Black Caribbeans in the NSAL. Roughly 9 out of 10 of both African Americans and Black Caribbeans indicated that 1) prayer is very important when coping with stress and 2) “strongly agree” that they look to God for strength, support, and guidance.

Table 2 presents percentages for use of religious coping for specific 12-month DSM-IV disorders. A higher proportion of respondents with agoraphobia (95.3%) and social phobia (89.5%) reported using prayer for a mental problem. Note that although 100% of respondents who had 12-month alcohol dependence and 12-month drug dependence indicated that they use prayer, the number of respondents is too small to provide reliable estimates. With regards to use of prayer for stressful situations, respondents who had Agoraphobia, PTSD and Generalized Anxiety Disorder have a higher likelihood of reporting that prayer was very important. Lastly, respondents with Generalized Anxiety Disorder have a higher likelihood of strongly agreeing with the statement that God is a source of strength, support and guidance.

Table 2.

Use of Religious Coping by 12-Month DSM-IV Disorders

	Percent using prayer for mental problems (n=736)	Percent state Prayer for Stress Very Important (n=5005-4987)	Percent Strongly Agree God Source of Strength (n=5012-4999)
Disorders
Panic disorder	69.70	91.24	87.39
Agoraphobia without panic	95.27	99.28	92.69
Social phobia	89.53	90.70	90.35
Generalized anxiety disorder	81.60	94.15	96.15
Posttraumatic stress disorder	82.81	95.11	90.69
Major depressive disorder	73.58	88.41	84.30
Dysthymia	72.23	88.16	78.99
Bipolar I and II disorders	80.62	86.85	82.90
Alcohol abuse	75.85	82.98	83.25
Alcohol dependence	100	77.20	77.20
Drug abuse	68.53	85.53	79.49
Drug dependence	100	73.23	69.56

Table 3 presents the multivariate analysis of the three indicators of religious coping on DSM-IV psychiatric disorders, and the number of disorders. Each multivariate regression model controls for age, gender, education, marital status, household income, and region. Two separate models are presented for each regression analysis; the second model in each instance controls for frequency of service attendance. An examination of Table 3 revealed no significant differences between African Americans and Black Caribbeans in any of the multivariate models of religious coping. Panic disorder and drug abuse are significantly associated with use of prayer for a mental or emotional problem. However, neither of them remain significant when controlling for frequency religious service attendance (Model 2). Models 3 and 4 in Table 3 present the regression analysis of the importance of prayer for stress. Respondents with agoraphobia and generalized anxiety disorder are more likely to report that prayer is important in both models. Respondents with drug abuse are more likely to report that prayer is important when controls for service attendance is applied (Model 4), but this relationship was marginal in the model that did not control for service attendance (Model 3). Generalized anxiety disorder is positively associated with agreeing that God is a source of strength, both with and without controls for religious service attendance (Models 5 and 6). That is, persons with generalized anxiety disorder are more likely to agree that God is a source of strength than those who do not meet the criteria for this disorder. Individuals who have one disorder, as well as those with two or more 12-month disorders are less likely to believe that God is a source of strength than those who do not have any disorders (Models 5 and 6). In addition, Black Americans who attend religious services more frequently have significantly higher levels of all three indicators of religious coping—prayer use for mental and emotional problems, prayer during stressful circumstances, and a view of God as a source of strength.

Table 3.

Regressions of the Use of Religious Coping and 12-Month DSM-IV Psychiatric Disorders

	Use of Prayera		Prayer for Stressb		God Source of Strengthb
	Model 1	Model 2	Model 3	Model 4	Model 5	Model 6
Variable	OR(95% CI)	OR(95% CI)	b(SE)	b(SE)	b(SE)	b(SE)
Ethnicity
Black Caribbean	1.0	1.0	0.0	0.0	0.0	0.0
African American	1.48(0.92-2.37)	1.53(0.92-2.55)	0.02(0.03)	0.02(0.03)	−0.01(0.04)	−0.01(0.04)
Psychiatric Disorder
Major depressive disorder	0.31(0.09-1.13)	0.31(0.09-1.14)	0.03(0.07)	0.01(0.07)	0.05(0.08)	0.03(0.08)
Panic disorder	0.25(0.07-0.96)*	0.31(0.08-1.13)	0.09(0.07)	0.09(0.06)	0.08(0.09)	0.08(0.08)
Agoraphobia without panic	1.75(0.15-20.94)	1.54(0.14-16.62)	0.13(0.04)**	0.14(0.05)*	0.10(0.09)	0.11(0.09)
Social phobia	1.80(0.40-8.05)	2.06(0.51-8.31)	0.04(0.06)	0.03(0.06)	0.09(0.05)	0.08(0.05)
Generalized anxiety disorder	0.60(0.11-3.16)	0.76(0.13-4.36)	0.13(0.04)***	0.13(0.04)**	0.19(0.06)**	0.19(0.06)**
Posttraumatic stress disorder	0.88(0.23-3.30)	0.88(0.28-3.78)	0.09(0.06)	0.09(0.06)	0.09(0.07)	0.10(0.07)
Dysthymia	0.43(0.08-2.23)	0.75(0.16-3.59)	−0.04(0.07)	−0.01(0.07)	−0.09(0.10)	−0.06(0.10)
Bipolar I and II disorders	0.98(0.26-3.67)	0.94(0.24-3.65)	0.01(0.12)	−0.01(0.12)	0.02(0.09)	0.00(0.10)
Alcohol abuse	0.19(0.02-1.56)	0.19(0.03-1.29)	0.02(0.07)	−0.01(0.07)	0.11(0.09)	0.07(0.08)
Alcohol dependence	>999(>999->999)†	>999(>999->999)†	−0.04(0.12)	0.01(0.12)	−0.11(0.13)	−0.06(0.13)
Drug abuse	0.10(0.01-0.72)*	0.16(0.03-1.02)	0.21(0.11)#	0.22(0.10)*	0.18(0.15)	0.20(0.12)
Drug dependence	>999(>999->999)†	>999(>999->999)†	−0.30(0.24)	−0.29(0.22)	−0.22(0.24)	−0.21(0.21)
Number of disorders
None	ref	ref	ref	ref	ref	ref
One	2.71(0.93-7.86)	2.93(0.97-8.86)	−0.10(0.06)	−0.07(0.05)	−0.12(0.05)*	−0.09(0.04)*
2 or more	6.34(0.51-79.29)	4.44(0.45-43.97)	−0.14(0.07)	−0.11(0.07)	−0.25(0.10)*	−0.22(0.10)*
Frequency of Service Attendance	--	1.45(1.17-1.79)***	--	0.10(0.01)***	--	0.10(0.01)***
Wald Chi-Square	181.07***	231.47***	---	---	---	---
F	---	---	13.84***	44.99***	27.58***	93.51***
N	736	736	4977	4976	4981	4979

^aLogistic Regression

^bOrdinary Least Squares Regression.

OR=Odds Ratios CI=Confidence Intervals b=regression coefficient SE=standard error, Ref=Reference Category

All analysis controls for age, gender, education, marital status, household income and region.

^†Due to the small number of respondents in these categories, these estimates are not stable and not discussed in the paper.

^#p<.07

^*p<.05

^**p< .01

^***p<.001

Discussion

This study investigated the degree to which African Americans and Black Caribbeans with 12-month DSM-IV psychiatric disorders use various forms of religious coping. Although there is a small body of literature on African Americans’and Black Caribbeans’ religious coping, this is the first investigation of religious coping for serious mental health problems including psychiatric disorders. Our analysis found that prayer was a frequently used coping response when experiencing 12-month psychiatric disorders. In particular, 3 out of 4 (76.5%) respondents reported that they used prayer to cope with their mental and emotional problems. In terms of more general attitudes concerning religious coping, roughly 9 out of 10 respondents reported that prayer was very important when coping with stress and “strongly agreed” that they look to God for strength, support, and guidance. Collectively, these percentages are consistent with previous research indicating that African Americans and Black Caribbeans have high rates of religious involvement including high rates of prayer and other indicators of religious participation (e.g., service attendance) (Brown et al., 2013; Chatters et al., 2009; Ellison & Taylor, 1996; Taylor et al., 2014; Taylor et al., 2010).

Our analysis found that the use of religious coping by African Americans and Black Caribbeans was not significantly different across any of the dependent variables (Table 3). This is consistent with previous research which also finds very few differences in the frequency of prayer (Chatters et al., 2009) and religious coping (Chatters et al., 2008) for these two populations.

Several significant relationships between the psychiatric disorder variables and measures of religious coping were found. Panic disorder (PD) and drug abuse (DA) were significantly associated with use of prayer for a mental or emotional problem, but both disorders failed to achieve significance when controlling for frequency of religious service attendance. Both panic disorder and drug abuse were negatively associated with the use of prayer indicating that respondents with those disorders prayed less frequently than those who did not have these disorders. However, because these disorder-prayer relationships were insignificant after controlling for service attendance, leads us to believe that they were confounded with service attendance. That is, people who have panic disorder and drug abuse are less likely to use prayer for emotional and mental problems because they are generally less religious which is evident in their lower frequency of attending religious services. Consequently, these relationships were actually due to the level of religious involvement and not the disorders themselves. It is important to remember that these findings are based on the analysis of the subsample of people (n=736) who experienced a mental or emotional problem. The remainder of the discussion section focuses on analysis which utilizes the entire NSAL African American and Black Caribbean sub-samples.

Agoraphobia (AG) and drug abuse disorder were associated with respondents’ beliefs about the importance of prayer during stress. The most consistent finding in our analysis was that individuals with generalized anxiety disorder (GAD) were more likely than their counterparts to report that prayer during stressful experiences was important and that they looked to God for strength and support. To help understand these findings, it is important to further examine these three disorders (i.e., DA, AG & GAD) in terms of their defining clinical criteria.

DSM-IV drug abuse is defined as substance use that leads to clinically significant distress or impairment. Diagnoses for drug abuse required respondents to meet at least one of the following 4 criteria: 1) failure to fulfill major obligations at work, school or home, 2) engaging in physically hazardous situations (e.g. operating machinery, driving when impaired), 3) legal problems (e.g., arrests for drug associated disorderly conduct) and 4) interpersonal problems caused by drug use (e.g., arguments, physical fights with family and friends) (APA, 2000). Adults experiencing AG avoid places that makes them feel trapped or helpless and tend to feel unsafe in any public place, particularly places with crowds. This includes public transportation, being in open or enclosed spaces, or standing in line. In some cases, this fear is so great that individuals never leave their homes (Mayo Clinic, 2017). Finally, individuals with GAD have excessive, exaggerated and persistent worry about everyday life including health, work, education, families and money. GAD sufferers worry excessively even though there is no obvious reason to worry and the degree of worry is out of proportion. For people with GAD, daily life can become so fearful that it interferes with healthy functioning including work, family life, and romantic relationships (ADAA, 2018).

Common to all three of these psychiatric disorders is that each is associated a significant level of distress. For instance, African Americans and Black Caribbeans with these disorders have 2 to 5 times higher rates of suicidal attempts and suicidal ideation (Joe et al., 2006). Additionally, relatively few adults with DA, AG and GAD have received any mental health treatment for these disorders (Neighbors et al., 2007). For instance, among African Americans less than 6 out of 10 adults have received any treatment for these disorders. Even fewer Black Caribbeans have received treatment, with 9 out of 10 Black Caribbeans not receiving any formal therapy or treatment for GAD or AG (Neighbors et al., 2007). Given the clinical features, distress, and under-treatment of AG, DA and GAD, prayer and other forms of religious coping may be particularly important for those experiencing these serious psychiatric disorders.

The role of prayer and religious coping strategies in relation to these psychiatric disorders is advantageous in that they are practices that are frequently used and valued in situations of high uncertainty and distress (Chatters, 2000). Our findings clearly show that one way that individuals manage DA, AG and GAD, disorders that are extremely stressful and debilitating, is through religious coping. Ellison and Levin (1998) propose that individuals may use religious and devotional practices such as prayer to develop a personal relationship with God that is characterized by unconditional positive regard (i.e., love) and the experience of solace and divine guidance. Interactions with a ‘divine other’ may also be useful in confirming a sense of vicarious control or self-efficacy over problematic circumstances and as a means to cultivate positive emotions.

African American and Black Caribbean adults who had at least one 12-month psychiatric disorder were less likely to believe that God is a source of strength than those who did not have any disorders. By way of context, it is important to note that, overall, 83.66% of African Americans and Black Caribbeans did not have a 12-month psychiatric disorder. Also, the finding for number of disorders was only significant for the God is a source of strength variable. This finding may be an indicator of negative religious coping. Pargament (2011) describes positive religious coping as a benevolent religious appraisal and religious forgiveness that reflects a secure attachment with God and that generally improves mental health. On the other hand, negative religious coping is a reappraisal of God’s power and feelings of abandonment or punishment by God that is associated with poor mental health. One out of 10 respondents in our sample disagree with the statement that they look to God for strength, support and guidance. Although the NSAL does not have direct indicators of negative religious coping, disavowing the notion that God is a source of strength may be an indicator of negative religious coping for persons experiencing psychiatric disorders.

Overall, research on the role of religious practices in relation to mental health and psychiatric disorders indicates that prayer and related practices may be helpful in several ways (Bonelli & Koenig, 2013; Hefti, 2011; Lewis et al., 2008), including recovery from depression (Johnson, 2018) and managing anxiety symptoms (Ellison et al., 2014). Hefti’s (2011) review of research on integrating spirituality into mental health care indicates that several studies document a beneficial association between religious coping (including prayer) and psychiatric disorders. Tepper et al., (2001) found that more than 80% of persons with persistent mental health problems reported using religious coping, with prayer being the most frequently mentioned activity. Specifically, relationships between religious coping and symptom severity indicated that persons who experienced more severe symptoms and had lower levels of overall functioning were more likely to have used specific (e.g., prayer) strategies (Tepper et al., 2001:662). This pattern is consistent with a support mobilization perspective (Taylor et al., 2004) suggesting that persons with greater mental health disability and more impaired functioning are more likely to mobilize coping strategies. Nonetheless, Tepper et al., (2001) found that after accounting for the number of years that religious coping had been used and the overall time devoted to this practice, religious coping was associated with less severe symptoms and better overall functioning. One of the challenges of cross-sectional studies of prayer and psychiatric disorders is the lack of information about prayer use as part of an ongoing religious coping process. Further, research frequently assesses several types of religious coping activities (e.g., use of religious readings and television programming) in conjunction with prayer, making it difficult to determine the specific and independent impacts of different practices.

Limitations

There are several important limitations to this study that should be recognized. Like the vast majority of national probability-based samples, homeless and institutionalized (e.g., prison) adults and non-English speakers were not included in the study. Second, there is a flawed skip pattern for the WHO-CIDI questions assessing alcohol and drug dependence that resulted in underreporting of prevalence rates of substance dependence, which influences our findings related to substance disorders. Third, even though we have a large sample of African Americans and Black Caribbeans, the number of cases of individuals who have a particular 12-month psychiatric disorder can be small. As a consequence, this substantially reduced the ability to detect significant differences. Fourth, the analyses were conducted on data collected in 2001–2003, which may limit the generalizability of the findings. Lastly, the NSAL is cross-sectional and as such we cannot make causal inferences. Despite these limitations, this study has several significant strengths. It uses data from a national probability sample, it is one of only a few studies of religion and psychiatric disorders that uses clinical criteria for psychiatric disorders (as opposed to depressive or anxiety symptoms), and it has a specific focus on African Americans and Black Caribbeans, who are understudied population groups.

Future Directions

Future research focusing on prayer, religious coping and psychiatric disorders could take several directions. One consideration would be adopting measurement and analysis strategies that allow for assessing the distinct contributions of prayer as one form of religious coping, as well as specifying how individuals use prayer to address mental health problems. Further research is needed to understand differences in types of prayer used for coping (e.g., meditative, colloquial, petitionary, and ritual), as well as the quality and conditions that facilitate positive coping through prayer (Jeppsen et al, 2015; Ladd & Silka, 2013). The nature of prayer as a form of positive vs. negative religious coping is another important line of inquiry (Pargament, 2011; Wachholtz & Sambamthoori, 2012). Future studies should be extended to highlight other forms of within-group differences to understand the complex social and cultural contexts that shape how Black Americans pursue coping strategies and seek help (Lincoln et al., 2007). Extensive qualitative interviews could also complement the quantitative findings distilled here and focus on other religious activities that are used in coping with psychiatric disorders.

Practice Implications

In clinical settings, mental health practitioners refer clients to clergy, chaplains, or another mental health professional with competency in addressing religious and spiritual issues that is consistent with ethical and evidence-based practice (Cummings & Pargament, 2010). Practitioners trained in psycho-spiritual interventions can identify and understand the ways religion and spirituality provide a coping and consoling role to address mental health symptoms. For example, a client experiencing depressive symptoms after the loss of a parent might require mental health treatment. However, the shame and embarrassment about this diagnosis and treatment might prevent the client from attending church or being consoled by prayer and the social support of church members (see cases in Boyd-Franklin, 2010).

A culturally responsive mental health practitioner would identify and assist the client to resolve the religious conflict or spiritual struggle that is likely worsening the mental health condition and distancing the client from positive religious supports (Cummings & Pargament, 2010). One approach would be supporting the client to reconnect with their positive religious practices and their “church family” (Boyd-Franklin, 2010, p. 985). Often prayer also “reveals the need to add earthly actions to our heavenly appeals” (Ulmer, 2020). Another approach would be to address negative religious coping and improve mental health outcomes through psycho-education and religious reframing (Francis et al., 2019). These interventions are particularly important for Black Americans that endorse an approach to life in which religion is closely linked to identity (Chapman & Steger, 2010) or culture (Boyd-Franklin, 2010; Park, Holt, Le, Christie, & Williams, 2018).

The social work labor force and practice orientations (e.g., working across multiple systems and levels of care) are important in ongoing efforts to provide behavioral health care in a variety of settings, including integrated health primary care practices. Woodward and Taylor’s (2018) analysis of data from the Collaborative Psychiatric Epidemiology Surveys found that clients seeking behavior health services reported contact with social workers in social service agencies, psychiatric and substance abuse outpatient settings, emergency departments, drop-in centers, and churches. This work indicates that a subset of clients interact with social workers while seeking assistance for issues that are not related to mental health. The availability of social workers in diverse practice settings holds promise for improved delivery of mental health treatment in settings, as well as the recognition and appreciation of prayer as an important resource for coping.

Finally, findings from this research confirming prayer as a religious coping mechanism for psychiatric disorders have important practice implications for social work interventions with Black Americans. The findings suggesting that Black Americans overall report high rates of prayer use as a coping strategy provide useful information that can help social workers and other mental health practitioners to understand and adapt interventions that mobilize a client’s religious coping strategies to facilitate treatment. Mental health practitioners may also engage Black congregations as collaborators to encourage early and consistent treatment, as well as to inform their beliefs about mental health problems. By recognizing prayer as one of many coping strategies, mental health practitioners will be better equipped to treat a diverse Black American population that continues to be largely underserved within the specialty mental health services sector.