Chapter 2 – Literature review and theoretical framework

2.1 Overview of chapter

This chapter attempts to present the relevant literature and theoretical

framework needed to examine the aims of my study. The beginning sections will

first situate the study within the broader dimensions of the relationship between

the professional and traditional sector by examining professional competition in

general, and specifically between clergy and the mental health profession. This

literature will be an important backdrop to understand how clergy and mental

health professionals relate in the Singaporean case. After this though, I will turn to

review the literature more specific to referral behavior, an important dimension

that demonstrates the relationship between health sectors. I present the theoretical

model which I will use to understand the factors responsible for referrals between

clergy and mental health professionals and the criteria that ministers use to select

the specific professional they would make a referral to, should they agree that

such referrals are warranted.

2.2 Competition between professional groups

Professionals as defined by Andrew Abbott (1988: 8), are "exclusive

occupational groups applying somewhat abstract knowledge to particular cases”.

Historically professions grew out of recurring problems that beset groups of

people. Medicine, for instance, grew out of the needs posed by disease while legal

specialists developed to ensure that justice was properly administered and private

ownership safeguarded. As professions developed they offered claims of their

expertise to address particular issues with a specialised body of knowledge,

making particular areas their professional jurisdiction. In attempting to hold on to

36

their dominance in a set of tasks, they would develop an exclusive language and

esoteric practices, very evident, for example, in the case of medicine with its use

of latin nosology (Abbott, 1988).

However, the very basis of professional jurisdiction meant that competing

groups could organize themselves around another body of knowledge and

compete to break the dominance of a particular professional group. In fact, unlike

Freidson (1993) who attempted to understand the rise of professional groups

through their own struggles and attempts at professionalization, Abbott(1988)

argues that the success of any profession is intricately linked to the struggles of its

competitors. Besides this, the development of new technologies or ways of

conducting old procedures offer potential niches to be filled. In his own words a

profession “cannot occupy a jurisdiction without either finding it vacant or

fighting for it” (Abbott, 1988: 86).

The state, economic forces and public opinion have all been implicated as

forces that determine whether competing occupational groups successfully

undermine the professional dominance of an established group (Barnett, Barnett

and Keaves, 1998; Coburn, 1993, Stevens et. al., 2000). Sociological studies

especially those on the health profession, abound on how various competing

occupations have systematically removed the exclusive monopoly for health

provisions from physicians (Hartley, 2002). States often concerned with their

population’s continuous concerns over rising health costs have accepted the

claims of occupational groups such as optometrists, physician assistants and

podiatrists to allow these groups to provide services which at one time were the

exclusive privilege of physicians. Similarly, public opinion of the efficacy of

acupuncturist and other traditional forms of medicine have effectively made these

37

forms of therapy respectable sources of treatment covered by insurance plans

which formerly only made pay outs to allopatic medical practitioners (Saks,

1995).

In order to understand the mechanism involved in the fight by professional

groups for increased recognition, Kelner et al. (2004:916) utilizes stakeholder

theory, where she recognizes that key players who have interest within the system

will engage in “strategic fashion to influence the system”. She notes, for instance,

in the case of Ontario, how medical and allied professionals articulate a discourse

to disallow complementary medicine practitioners from professionalizing by

demanding that they show scientific evidence of their efficacy. Moreover these

medical professionals make it difficult for complementary practitioners to

integrate their practice with the allopathic practitioners and hinder governmental

support for research and education in alternative medical practice.

As professional groups struggle with one another, Abbott (1988) notes that

historically there have been various attempts to embark on some settlement

arrangement to ease this conflict. Five types of arrangements are proposed. Abbott

(1988, pp.69-79) notes that one profession can receive full right on a particular

area, or it can act in a superior position to the other profession though both occupy

the jurisdicational space. Alternatively, there can be a division of labor between

the professional groups where one profession has the jurisdiction but needs to

accept advice from the other, or both having their domain in structurally equal

parts, or with the type of client.

2.2.2 Historical background of soul care

In the fields of mental and emotional healthcare, the competition has been

stiff between psychiatrists, psychologists and professional counsellors, each

38

arguing that their particular tradition of helping is most effective for a range of

pathological conditions. While all the professional groups mentioned above utilise

psychological theories to explain mental and emotional problems, each profession

at its core has several distinctives, both in its training demands and its treatment

plans. Mental health professionals as a group, however, are in direct competition

with clergymen, a profession which has dominated the care of emotional and

mental concerns for centuries. To understand the complexities surrounding the

competition between clergymen and the mental health professionals, I look at the

historical development of this competition, played out most clearly in the Western

world.

The tradition of the care of emotional and mental concerns, often referred

to as the care of souls, is found as early as Jewish literature, particularly in the

writings of the Old Testament. In the Western world, it was Socrates who was

notable in arguing that his distinctive role as a philosopher was as a carer of the

soul (psyche) (McClure, 1991). Post Socratic philosophers continued to see

themselves as physicians of the soul who by employing the healing word offered

counsel to persons beset by problems in living. The endeavor of helping people

with issues of the soul (a term often synonymously used with “mind”) was argued

to be more important than the treatment of the body, and thus the study of

philosophy the sovereign remedy for sadness (McNeil, 1951: 28).

After the Christianization of the Western world, the priest as counsellor

and confessor replaced the philosopher, and for much of the next 2000 years, his

role remained virtually unchallenged (Reich, 1995). Oden (1984) in summarizing

the vast scholarship produced during the early and medieval church era, records

the many quasi-psychological prescriptions given for the care of the soul. It was

39

evident that the church provided most of the answers for the individual’s

emotional and mental concerns. In fact leading clergymen such as Gregory of

Nicea produced elaborate counseling manuals to educate parish priests on how to

deal with the problems of their members, some of which approximate modern

psychological remedies (McNeil, 1951). Other notable theologians continued to

hammer out aspects of the human nature through the centuries culminating in

probably the most profound work by Soren Kierkegaard in the 19th century who

sometimes in disturbing ways illuminated aspects of the human nature including

issues of the unconscious, anxiety and human development (Jones and Butman,

1991).

Beyond their role in providing counsel and aiding in the care of the soul,

clergymen were notably engaged in the introduction of humane treatment to those

who were considered mentally ill. Asylums and other institutions in monasteries

and churches attempted to provide the mentally ill an environment of care and the

possibility of recovery (Koenig and Larson, 2001).

2.2.3 Historical tension between psychotherapy and clergy

The advent of the modern discipline of psychiatry and psychology

however sounded the death knell for the privileged role that clergymen enjoyed in

the management and cure of the soul. Psychiatry which grew out as a medical

discipline worked hard to increase its grip in the jurisdiction of the care of the

mind, a position it held strongly from the 1930s till the 1970s when psychology,

which prior to this had acted as collaborator, became an ardent competitor

(Abbott, 1988). Psychiatry provided solutions to the problems in life through

psychotherapy, leaving what was considered organically caused to the hands of

neurologists.

40

While considered highly suspect by other medical disciplines,

psychotherapy which often dealt with issues no more profound that what

theologians handled, such as the meaning of life (existential issues), earned an

immense social role in American society (Rosenberg, 1975). Psychotherapy soon

assumed responsibility in both the diagnosis and cure of countless ills and

dysfunctions of the human soul. Among the major supporters of psychotherapy

were clergymen, particularly those from the liberal tradition (Reiff, 1987). In fact

psychotherapy and liberal Christianity at least in the earlier years enjoyed a

symbiotic relationship (Johnson and Jones, 2000).

Notable liberal clergymen endorsed the values underpinning

psychotherapy which were congruent with their own analysis of human nature,

radically though opposed to more orthodox and historical views of Christianity

(Hollifield, 1983). This branch of Christianity, heavily influenced by modernism,

saw psychology as helping to reshape the Christian faith along lines of greater

individualism, less emphasis on morality and a greater dependence on reason and

science rather than biblical revelation (Powlinson, 1996). Besides this, liberal

Christianity had chartered its mission to provide salvation to humanity, not in

terms of an eschatological project but one experienced in this world through the

alleviation of present suffering. Thus the care of individual social and emotional

needs was prioritized above growing the Christian constituency or religious piety

(Aden and Ellens, 1990).

When Freudian theories were popularized, the world and the clergy were

shown that people with problems were “sick” and not sinful (Carter and

Narramore, 1979). The liberals were very favorable to this approach and moved to

41

help people understand how their Id, Ego and Superego helped maintain their

mental health. Theologians such as Harry Emerson Fosdick (1943) and Don

Browning (1987) began to endorse the psychoanalytic view that neuroses arose

from a strict conscience. Thus those who were dealing with emotional struggles

should stop worrying about sin and examine their environment, which was the

root of their problems. Even more influential than Freud was Rogers (1951) who

proposed his version of non-directive and client centered counseling. His rejection

of the sinfulness of humanity and the need for individual self actualization agreed

with the liberal theologies that were prevalent in his time, especially in Union

Theological Seminary, where he was at one time training to be a minister.

Thus liberal Christian denominations were incorporating new counseling

methods so as to stay on the cutting edge of psychological development. In fact

there was the attempt to rescue pastoral counseling from a legacy of over-

directedness where ministers had been too authoritarian and moralistic to

accomplish “effective” results (Clinebell, 1966; Oates, 1982). Despite the

supposed synergy between liberal Christian clergy and psychotherapy, it was the

latter that proved to be the stronger partner, because of its ability to show a clear

knowledge system which Abbott (1988) argues provides the needed professional

jurisdiction over a field.

By the end of the 1920s, clergy had lost all vestiges of jurisdiction over

the soul of American society. Abbott (1988: 309) aptly summarises this

There emerged in the period (1920s) a clinical pastoral training movement aiming to give young clergymen direct experience with the newly defined personal problems. Seminarians would learn the rudiments of human nature from psychiatrists, psychologists and social workers who “knew” those rudiments, that is, from professionals who controlled the definitions of them.

42

While clergymen continued to provide counseling, they increasingly

realized that they were at best second rate counsellors. At times they argued for a

role in providing care through the use of spiritual resources for those problems

which modern psychology had provided the diagnostic categories, a strategy

however that concedes too much to be effective (Abbott, 1988: 100).

While the liberals were attempting to salvage what they could of their

previously privileged jurisdiction over the concerns of the soul, conservative

evangelicals had completely stepped out of the battle much earlier. In fact

fundamentalist Christianity had adopted an anti intellectualist stance, a

preoccupation with millenarian hopes which ultimately led to a sub-cultural retreat

(Marsden, 1997). Where there was scholarship available this was concerned with

defending the fundamentals of the faith which had been swiftly challenged by

liberals and modernists.

2.2.4 Evangelical churches and psychotherapy

Evangelical churches then did little for most of the years preceeding the

1960s in terms of counseling care. Rather seminars and bible conferences,

spiritual devotion, and emotional experiences were emphasized. Problems in

living were often dealt with through the prescriptions handed by various bible

teachers and emotional change was expected to occur miraculously (Powlison,

1996). Those who were not able to successfully resolve their emotional and

mental problems either suffered in silence or slipped off unnoticed into the

burgeoning mental health sector.

However there was a growing movement among evangelicals which

brought psychotherapy into its midst, beginning in the 1930s with many

evangelical schools beginning to accept psychology into their curriculum

43

(Johnson and Jones, 2000) because of the desire to be recognized by accrediting

agencies. Even then, however, there was an interest in emphasizing the aspects of

psychology which were not in contradiction to biblical revelation. This can be

seen in one of the earliest evangelical textbooks on psychology where the author,

in her definition of psychology, clearly advances that psychology studies man in

his total environment, which includes the influence of spiritual forces (Cross,

1952).

The 1950s also saw an interest in a group of fundamentalist Christians who

saw their need to engage with the sciences and remove the anti-intellectual stance

that they had taken for some time (Powlison, 1996, Jones and Butman, 1991,

Johnson and Jones, 2000). Coupled with this were various psychotherapists who

were fundamentalist Christians beginning to set up conferences and even engaging

the broader world with their publications and radio programs (Maloney, 1977).

Interestingly, however the acceptance of psychotherapy was engaged from outside

the clergy ranks of evangelical Christianity. It was committed Christian

psychological professionals who engaged in this.

The years after the 1950s saw a major comeback by evangelicals in mental

health care (Whitfield and Johnson, 2003). Specialised graduate programs

churning out Christian professionals who were licensed by state bodies,

psychiatric clinics and hospitals with distinctively Christian elements to their

treatment and scientific journals which explored the relationship between

psychology and faith became commonplace. The evangelical church had finally

gotten onto the bandwagon and was furiously developing itself to reclaim the care

of the soul by entering into the field of psychology. The pace and extent of

evangelical involvement in mental health provision can clearly be seen in the

44

growth of two clinics, Rapha and Minirth-Meier, both providing a range of

psychological and psychiatric treatment for both outpatient and inpatients from a

distinctly Christian perspective. These had become the largest private

establishment of mental health institutions anywhere in the world by the 1990s

(Powlison, 1996).

Interestingly the driving force behind the entry of evangelicals into the

psychological field was committed Christian professionals and not clergymen.

Few seminary programs featured more than the two overview counseling modules

for their Masters of Divinity program, the standard requirement in most

evangelical churches for entry into the pastorate. On the other hand, most

seminaries had already run Masters programmes in counseling and even doctoral

programs in clinical psychology which continued to train committed lay persons.

The distinctive feature of these programs was the theological grounding that

would be expected of students. Unlike secular institutions where students would

have to complete 128 credits of psychology based courses for a doctoral program

in counseling or clinical psychology, students in these Christian seminary

programs had to attain an additional 30 to 60 credits in bible and theology. This

provided them between a third to a half of the training that a seminary student

preparing for the pastorate would undertake. Thus what had occurred was a

growing separation between clergy role in counseling. Now that they had a

minimum amount of training, they would be able to recognize their inadequacies

in providing counseling and instead refer their members to the many qualified

professionals in mental health agencies, who had a professional training in

psychology but also sufficient respect of Christian theology.

45

Part of the shift in a number of large evangelical churches in America was

also the staffing of a professional counselor or psychologist within the church

(McMinn et al., 1998). This person often had completed at least a Masters

program in a Christian based counseling programme which once again required

the student to attain a comparable number of counseling psychology modules as

their secular professional but with the additional theology courses. Pastors then

increasingly focused on other areas of Christian ministry, preaching, teaching and

growing their church which had become the preoccupation of much of

evangelistic Christianity.

In recent years, there has been some attempt of clergy to regain some

control in the care of the souls. Doctor in Ministry programs in North American

seminaries have begun introducing counseling or family therapy as an area of

specialization for their students. This degree track meant for ordained ministers

who had several years of experience, traditionally focused on specializations such

as preaching but now recognizing the interest of evangelical pastors to reclaim this

area, have prominently featured counselling related specializations.

2.3 Review of literature on referral behavior

Having examined the historical tensions between professions and more

specifically the clergy and mental health professionals, it is obvious that referral

practices are an important site where this tension is played out. Despite its

usefulness in studying issues of professional dominance, referral behavior within

the field of sociology has received very little empirical investigation. When

referral behavior has been examined, it has focused on issues within economic and

organizational sociology particularly through investigations of job referrals and

internal labor market mobility (Granovetter, 1995; Fernandez and Weiberg, 1997;

46

Neckerman and Kirschenman, 1991; Smith, 2003). Several sociological pieces

within the sociology of health have investigated lay referral patterns in which

laymen are sources of information and referrals for those with illnesses to obtain

professional care (Badgley, et al., 1977; Lee, 1969; Wellman, 1995). Very little

work has, however, examined referral behavior among professionals.

The bulk of referral practices between professionals have been empirically

studied by health researchers. Their main focus has often been referral patterns of

physicians to various specialists or allied health professionals. On examining

referral patterns between General Practitioners and specialists, much of this work

has attempted to account for why referral rates of physicians drastically differ

(Franks et al., 2000). Non-medical factors have been recognized to be as

important as medical factors in determining such referrals (Langley et al, 1992).

These can be categorized as physician, patient and organizational and

environmental factors. Physician related factors which have been implicated for

differential referral rates include the gender of the physician, where females are

more likely to make referrals (Chan and Austin, 2003; Franks et al, 2000; Nutting

et al., 1992). Younger doctors seemingly make more referrals than older doctors

possibly because of differences in experience, reducing the need to refer for cases

which they have learned over the years could be managed adequately by

themselves (Bachman and Freeborn, 1999; Newton, Hayes and Hutchinson,

1991). The influence of residential training in a specialty, although implicated as

promoting referrals has been shown to inhibit referrals in other studies (Franks

and Clancy, 1997; Vehvilainen et al, 1996). Patient related factors included the

wishes of the patient for a referral which affected substantial decisions to refer and

at times the ability of the patient to manage higher costs for specialist consultation

47

(Langley et al, 1992). In the Hong Kong case referrals to reassure the patient

were exceptionally prominent (Munro et al.1991) Several factors which address

the organizational and environmental factors were also significantly related. The

lack of a ready supply of specialists in the proximity of the community

discouraged practitioners from making referrals, thus practitioners in rural

communities made significantly fewer referrals that those in urban settings

(Newton, Hayes and Hutchinson, 1991; Nutting et al., 1992). In a Finnish study

the distance was not significant although a ready supply of consultants was

important (Vehvilainen et al, 1996). Different types of health care systems were

another organizational level variable affecting referral practices. The Health

Management Organizations (HMOs) in the US produced higher rates of referrals

while a similar type of managed care under the National Health Service of Britain

reduced referrals. (Bachman and Freeborn, 1999; Forrest et al., 2003; Iverson,

2005).

In the studies on referrals to allied health professionals, scholars in health

have examined the various challenges involved in referral practices to the newly

developing health professionals. In Winefield’s (2003) account, referrals increase

among GPs once they are exposed to more psychologists especially when they

practice on-site at their clinic.

As in the case of physician referrals to specialists, the various factors can

be classified as patient, physician and organizational factors. Patient driven factors

involved their ability to pay for services, which often were not claimable through

insurance, and if subsidized the waiting lines were often long (Coyne &

Thompson, 2003). At other times when the possibility of a referral is to a

counsellor or psychologist, patient’s worries of being stigmatized or a negative

48

perception of such mental health professionals affects referral. Physician factors

most commonly cited include attitudes towards the allied profession. Doctors who

do not consider an allied field as providing useful help, beyond something that

could be easily acquired by the patient or which could be addressed by them, are

unlikely to make referrals. For instance, physicians who do not readily accept

psychotherapy as useful for psychological problems are unlikely to make a

referral to a counsellor or psychologists. Interestingly, those who become

interested in psychotherapy might, however, engage in providing such help

themselves and thus not make many referrals (Verhaak, 1993). However,

physicians themselves may at times not be able to detect some issues such as

mental health problems without specialist training, thus this could account for

some of the lack of referrals (Goldberg and Huxley, 1992).

Various organizational and environmental factors increase the possibility

of referrals. Physicians who have had contact with allied professionals and had

opportunities to interact or to see their work, are more likely to then make

referrals. Thus doctors who worked in multi disciplinary teams which engaged

physiotherapists and General Practitioners who had a psychologist practicing on-

site at their clinic were more likely to become familiar with these allied

professionals and subsequently make referrals to them (Winefield, 2003).

However often there is a clustering of on-site mental health practices alongside

larger GP practices which ultimately means that physicians in small practices are

often unlikely to make referrals (Kendrick et al., 1993; Thomas and Corney,

1992). In addition if the doctor perceives that the services provided by allied

professionals in a community are inadequate, referral is significantly reduced

(Hendryx et al., 1994)

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2.3.2 Referral practices between clergy and mental health professionals

I now turn to examine the literature which directly addresses the barriers

and promoters of referrals between clergymen and mental health professionals.

Once again I organize the review examining factors inherent to the client and his

distressing episode, the clergyman himself and the larger organization and

environment which includes mental health professionals.

Although clergymen receive presenting situations of mental and emotional

problems similar to mental health professionals, clergymen showed a willingness

to make referrals for situations which could be classified as severe mental illness

(Mannon and Crawford, 1996). Thus clients with difficult and complex counseling

situations often those with severe psychopathology would be referred to a mental

health professional. Clergymen, just as the other helping professionals were most

interested in working with clients who were motivated, verbal and where the

chance of success of the help was high. This resulted in those who were not too

motivated and where the chances of success was low being “pushed” to another

professional (Cummings and Harrington, 1963)

Beyond patient driven factors, several factors have been well studied

which relate to the clergymen. Several studies have examined the effect of

clergymen’s educational attainment, particularly his own background in

psychology or counseling, and its effect on referral practices. These studies have

however been inconclusive as to the role of education and referral practices.

Studies by Larson (1963) and later by Mannon and Crawford (1996) indicate no

significant differences in referral practices among clergy with different

educational attainment although other studies by Bentz (1970) and Rumberger and

Rogers (1982) noted a significant relationship with referral practices especially

50

among those who were highly educated. Other studies based on the US case, show

that more pertinent than educational attainment is their exposure to counseling and

psychological studies. Peters (1999) found that Virginian clergymen from 2

Protestant denominations who had more credits in either counseling or psychology

were significantly more likely to recommend referrals even though the level of

education did not affect referrals. Wright (1984), based on his Canadian sample,

noticed a similar trend that those who had been to seminars and workshops on

counseling recently were more likely to have positive attitudes towards

psychologists and suggest a referral. However, a very recent study using a New

York clergy population noticed that clergy’s completion of a Clinical Pastoral

Education program, a one year course which exposed clergymen to a hospital

setting as part of a team of mental health professionals, did not show very

different levels of referrals compared to those who had not completed such

programs (Moran et al., 2005).

There was much more agreement in the literature as to the relationship

between theological orientation and referral practices. In all of the studies

reviewed except Lamberton’s (1992), ministers who had stronger conservative

leanings, often referred to as Christian fundamentalists (Marsden, 1980) found it

hard to make referrals. This group had substantial difficulty in resolving the

propositions made by psychology which go counter to their theological views.

Conservative Christians view biblical literalism as an important marker of their

faith, asserting that Scripture should be taken literally as God’s word and the final

authority on all matters (Dixon, Jones & Lowery, 1992). This is unlike their

liberal counterparts who view Scriptural teaching as a product of various social

and historical predicaments (Ammerman, 1982; Hunter, 1987; Regnerus & Smith,

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1998). Pastors adhering to a liberal theology then were much more open to mental

health professional referrals (Larson, 1968; Mannon and Crawford, 1996; Virkler,

1979). Peters (1999) noticed that 44% of theological liberals and moderates felt

that referrals were positive compared to 14% of conservatives. This closely related

to their denominational affiliation, where he discovered that Baptists, who were

generally conservative, were less likely to refer compared to Methodists or

Lutherans.

Related to theological positions, Slanger (1994) in her examination of

Jewish rabbis noted that religious leaders’ attitudes towards the counseling

profession functioned to inhibit or promote referrals. Religious leaders may view

the counseling professional with suspicion because they perceive at least some of

their techniques as opposing religious tenets. Religious professionals may also

view mental health professionals as not being very more competent to themselves,

thus questioning the need for referrals. A similar observation was made by Lee

(1976) and Mannon and Crawford (1996) when they researched the case of

Christian clergy.

Age and level of experience were related to referral decisions in a few

studies. Kane (2001) in his study of Catholic clergymen observed that younger

priests were more likely than older priests to believe in the usefulness of referrals

to mental health professionals. Another demographic variable that had some

relation to referrals was race. African American clergymen were seemingly more

likely to make referrals to a mental health professional than their White

counterparts, although there was a preference for therapist who were of the same

racial group (Young, Griffith and Williams, 2003).

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Beyond examining patient and clergymen factors, environmental factors

also made some impact on referral decisions. Mental health professionals’

attitudes towards clergymen in themselves provided a reason for the lack of

referrals. Piedmont (1967) recognized that when mental health professionals failed

to correspond with the clergymen who had referred a client to them, there would

be subsequently less referral from the clergymen who suspected that the lack of

reciprocity was a product of mental health professional’s low regard for the

professional status of the clergymen.

Referrals were also sometimes a product of the size of the congregation

and the workload of the pastor (Shabazz, 2003). Clergy who ministered in larger

churches naturally had higher counseling workloads since staffing was not always

proportional to the number of members in the church. These were more willing to

make referrals to a mental health professional. Referral patterns could also be

related to the level of linkage that mental health professionals had with the church.

Thus when mental health providers promoted their services to churches, there was

increased referrals to the agency (Perlmutter, Yudin and Heinemnann, 1974).

Thirdly it has been shown that clergy were more willing to refer clients to a

mental health professional if they were part of a church based counseling center

where there was an explicit regard for faith (Mannon & Crawford, 1996).

2.4 Analysis of literature on clergy referral practices

An examination of the literature addressing the referral patterns of

clergymen and mental health professionals revealed that much of this study placed

emphasis on documenting the level of referral intention of clergymen. This has

partly been propelled by an interest to examine the role of clergy in community

mental health and for policy initiatives to involve clergy in mental health delivery.

53

When factors have been examined they have often addressed demographic factors

such as psychological or counseling education, theological orientation and church

composition in terms of race and size. Little attempt has been made to address

other factors which may be very significant in the referral process especially

various social psychological processes.

2.5 Theoretical Approaches to Understanding Referral Behavior

The sociological perspective can provide important lenses through which

referral behavior can be understood. Functionalist approaches understand referral

practices as necessary behavior to ensure the cohesion of the total mental health

system. Here the religious sector and mental health sector function in different

roles. Clergymen provide for the spiritual needs of religiously inclined individuals

while mental health professionals take care of mental and emotional concerns.

This division of labor is natural since mental health professionals are trained to

have expertise in the mental and emotional health domain while the training and

socialization of clergymen equip them to serve spiritual needs.

A functional analysis however does little to understand the current practice

of referrals. It merely serves as justification by mental health professionals that

clergymen should rightfully refer their parishioners readily to them. The generally

low levels of referrals that the literature suggests are indicative that clergymen do

not understand the supposedly “proper” division of labor. A critical perspective on

the other hand, offers more in terms of an explanation for the current state. Here

referral behavior is essentially an avenue to observe the competition of two sectors

that claim legitimate control over the mental and emotional concerns of society.

The professional sector is seen as systematically subordinating clergy help and

relegating it as inferior compared to its superior, scientific approach to care.

54

While the critical perspective is helpful in understanding the competition

between the two sectors and the attempt of the professional sector to dominate, the

interactionalist perspective provides insight into the micro processes of referrals.

Fundamental here is that clergymen through their encounters with those of the

mental health profession begin to embrace a new understanding of their role and a

new perspective on mental health issues. These encounters may shape their beliefs

of the appropriateness of referrals to the professional sector.

Through considering the broad sociological perspectives on referrals, I

note two important dimensions which can affect the willingness of clergymen to

make referrals to mental health professionals. These are (1) different cultural

constructions of mental and emotional problems and (2) aspects of professional

behavior.

1) Clergymen’s construction of mental problems may derive from two contrasting

worldviews, a secular, scientifically-oriented model which stresses organic and

psychologically-based theories for the causation and treatment of mental concerns,

and a religious model which sees the role of sin and the all-sufficiency of

Christian teaching and pastoral practice in the treatment of such concerns.

Clergymen who lean to a psychologized worldview then may be more likely to

make referrals to mental health professionals. A psychologized worldview itself

may be a product of the secularization of the minister and, in turn, may be related

to his academic background and the demographic characteristics of his

congregation. Clergymen who adopt a conservative theological position may be

adverse to secular interventions.

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2) Inter-sectoral collaboration may be stifled by several aspects of professional

behavior on the part of the minister which include professional role identity,

professional ideology, professional networks and professional competence.

Clergymen have traditionally performed much of the emotional and mental care in

many societies and thus maintained their dominance and power within their

congregations. Referring their parishioners to other professionals may then act to

undermine their role identity. However, at the same time, it is possible that

clergymen have redefined their role in providing care to their parishioners to

particular domains such as being an authority with regards to marital and family

issues but not in issues to do with obsessive behaviors. Thus they might have

different views of the levels of professional competence of clergymen for different

types of presenting issues. On the other hand, some clergymen may be concerned

with the increased encroachment of the mental health profession on domains

which clergymen have been responsible for centuries. These clergymen might, in

turn, develop a professional ideology which denies the usefulness of psychology

or the mental health professional. Buffering these processes are social

relationships, particularly professional relationships between clergymen and

mental health professionals. Social linkages, seen in organizational affiliations

and informal networks with mental health professionals, may increase inter-

sectoral referrals.

In addition to these variables, I will also examine the classical elements

which have often been studied as highlighted in the above literature review, but

never in an Asian context. I will consider the role of various demographic features

such as the age of the minister, his years of experience, his level of seniority

within the church, the congregation’s size, the pastor’s level of training in

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psychology / counseling and his secular and theological educational attainment.

In addition to these demographic variables, an attitudinal variable, religious

conservatism might have bearing to referral practice. These variables function

both as variables that might affect referral behavior, but also variables that affect

the cultural construction of mental illness and professional behavior.

Having laid out the various aspects of my model, I now examine the

literature which deals with these theoretical issues. I first examine literature on the

cultural construction of illness and etiology models of psychological distress as

this area of research deals with the different worldviews of illness causation. I

then discuss the literature on professional behavior particularly those which deal

with the concepts of professional role identity, professional network, professional

ideology and professional competence. In each of these discussions I show the

theoretical implications of these concepts to referral behavior.

2.6 Literature on the etiology of emotional and mental problems

The literature on the cultural construction of mental illness highlights that

despite the appreciation of the symptoms of psychological distress, documented as

early as ancient Egyptian manuscripts, there has been a divergence between the

interpretation of these symptoms across cultures (Kovacs and Beck, 1978). In Sri

Lanka an individual who is feeling sad, lacking energy and socially withdrawn is

seldom considered as needing treatment while a similar individual in Western

society, would be diagnosed as suffering from depression (Waxler, 1977).

Similarly among the American Indians, dementia does not receive the same kind

of diagnosis and concern as it would receive in the West. Dementia here is

considered “supernormal” in the sense that it is normal because its an outcome of

aging but special because it allows the individual to be in contact with the

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supernatural world (Henderson and Henderson, 2002). These examples then point

to a certain cultural construction of illness where individuals within a society

interpret psychological symptoms within various cultural frames of references

(Garro, 1994).

The case for the cultural construction of illness is even more evident when

we consider culture bound syndromes such as amok and latah (Guarnaccia and

Rogler, 1999). These afflictions do not correspond with a disorder recognized by

Western illness classification systems but receive recognition in their particular

cultures as being a form of illness (American Psychiatric Association, 1994).

Some scholars then have argued that psychological distress is really culturally

determined with cultures shaping both the illness experience and the very

conception of it (Kleinman. 1977:4) Others have argued that cultural bound

syndromes are most likely “culturally determined variants of universal forms of

psychopathology”(Carr and Vitaliano, 1985:244).

While it is arguable whether cultural bound syndromes are universal or

particular, there is little contention now that psychological distress is recognizable

across cultures. Foster and Anderson (1978) argue that no culture allows for

bizarre and erratic behavior disregarding contexts. Studies among African tribes

have frequently shown that bizarre behaviors such as violence, incomprehensible

speech, and walking around naked have been associated with madness (Edgerton,

1966). Kiev (1972) further argues that while the content of delusions may differ

across cultures, the existence of such delusions is universal.

As has been argued, the cultural construction of psychological distress

does not indicate that psychological distress is a mythical construct popularized by

Western psychiatry as some like Szasz (1971) have argued, though it does assert

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that cultures view psychological distress in different ways. This is particularly

seen in how cultures make varied attribution to the causation of psychological

distress and how the crisis should be treated (Fenton and Sangster, 1996)

The importance of understanding the causation models and treatment

preferences of a variety of cultures has staged prominently in both psychiatric and

psychological circles (Bhui and Bhugra, 2002; Guindon and Sobhany, 2001; Joel

et al. 2003; Kleinman, 1980). The helping professions have recognized that how

individuals and cultures appraise psychological distress is crucial in how they

approach treatment from mental health professionals and their willingness to

comply with instructions (Foulks, Persons and Merkel, 1986; Littlewood, 1990;

Solomon, 1994). Studies have even shown that doctor-patient interaction which is

normally lower for minorities, is greatly enhanced with patients reporting higher

satisfaction levels when their doctor attempted to understand their explanatory

models of distress (Callan and Littlewood, 1998; Parkman, Davies and Leese,

1997)

Murdock et al (1978) provided the most comprehensive early attempt to

classify cross cultural theories of illness causation. Although this attempt

examined both physical and mental disorders, the categorization has been

influential in subsequent categorization of illness causation models for mental

distress (Eisenburg, 1990). Using the World Ethnographic Atlas the researchers

coded the data from 1300 distinct cultures to produce 13 categories subordinated

under the broad categories of natural and supernatural causes. Supernatural causes

included animistic, mystical and magical categories. Animistic theory ascribed

“the impairment of health to the behavior of some personalized supernatural

agent, a soul, ghost or god” (Murdock, 1978: 454), while a mystical cause was

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understood as “the impairment of health as an automatic consequence of some act

or experience of the victim mediated by some putative impersonal causal

relationship rather than by the intervention of a human or supernatural being”

(Murdock, 1978:453). A magical causation model implicated sorcery where

individuals would use magical means to injure their victims. On the other hand

natural causations were divided into stress which dealt with different stressful

events such as pace of modern life and western and non-western physiology, the

former involving causation theories common in Western biomedicine such as

chemical imbalance or disruption in a vital organ while the latter dealt with

theories which do not have western equivalents such as hot and cold, movements

of air and eating foods which are not proper for the particular person.

While Murdock’s classification has generated substantial criticism with

anthropologists critiquing it for imposing western causation models on non-

western societies, and not properly representing the true case of the local context,

the categorization bears usefulness at least broadly (Eisenbruch, 1990; Samuelsen,

2004).The many subsequent attempts to elicit explanatory models of illness

causations have shown the prominence of both supernatural and natural causation

theories (Bhui and Bhugra, 2002; Patel, 1995).

Several studies have shown that among some Asian cultures mental and

emotional distress was also understood as physically based. These were

sometimes described as the imbalance of “qi” or the disharmony of the vital

organs as in the East Asian case, wind passing through the body in the case of

Southeast Asians or the ayurvedic notions of hot and cold in the case of South

Asians (Bhui, 1999; Eisenbrunch, 2000; Kleinman, 1980; Pang, 1998). The

causation theories that individuals from these cultures hold about their mental

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illness also result in presenting their problems in somatic terms such as “feeling

my heart sink”, feeling hot, and, body aches and pains (Bhugra et al. 1997; Pang,

1998; Sulaiman et al, 2001).

Beyond natural physiological causes to psychological distress,

supernatural causations were the preferred explanatory model for mental distress

in many traditional non-western societies. In a study reviewing the research done

on explanatory models in the Sub-saharan African countries of Nigeria, Senegal,

Uganda, Zimbabwe, Botsvana, Etiopia, Ghana, Swaziland, South Africa, Guinea-

Bissau and Kenya, Patel (1995) notes the prevalence of causations attributed to

traditional religious beliefs among lay people and traditional healers. These beliefs

implicated the work of deities and spirits. Ancestor spirits were believed to bring

good health except when social taboos were broken, in which case illnesses

resulted. Malicious spirits, on the other hand, caused illness in a random manner.

Studies on East Asian, South Asian and Southeast Asian populations similarly

have shown that laymen attribute significant amount of mental distress to deities

and spirits (Allen, Naza, Ishizu, 2004; Eisenbruch, 1991; Gaw, 1993; Kim, 1993;

Weiss et al., 1986).

Besides the belief in the ability of spirits to cause mental distress, there

was the common belief in witchcraft and sorcery among Asian and African

societies. Sorcerers were alleged to place curses on individuals who were their

enemies, resulting in various misfortunes including serious madness (Al-Krenawi,

Graham, Kandah, 2000; Kulhara, Avasti and Sharma, 2000; van de Put &

Eisenbruch, 2002)

There was however a disjuncture in causality beliefs of mental distress

between medical practitioners in non-Western societies and lay persons (Bhui and

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Bhugra, 2002; Kleinman, 1980; Pearson, 1993). Medical professionals,

particularly physicians adopted a biomedical view of mental illness, one that they

were well socialized in during their allopathic medical training (Pearson, 1993).

This however does not suggest that the biomedical view is pervasive throughout

the medical profession. Lower level community health workers in South India for

instance, were more likely to hold indigenous beliefs markedly differing from the

biomedical model (Joel et al. 2003). Even when physicians held a biomedical

view of illness causation they may be ambivalent about the role of spiritual forces.

This is evident as Coker (2004) suggests in the case of Egyptian psychiatrists

where their case notes prominently describe the religious underpinnings of the

mental illness as presented by the patients. Psychiatrists interestingly gave voice

to the religious elements, in no way diminishing the reality of such beliefs though

neither providing a final diagnosis which was religious in orientation.

When studies were done comparing western and non western respondents

in western societies, supernatural etiologies were still prominent. McCabe and

Priebe (2004) in comparing four ethnic groups in UK found that non-whites were

more likely to endorse supernatural causation models for schizophrenia than their

white counterparts who cited biological causes. Other studies have shown that

non-Western ethnic groups living in Western societies although attributing

psychological disorders to supernatural causes do not do this to the same extent as

their counterparts in their countries of origin and do not necessarily view

supernatural causes as the primary etiology of mental illness (Landrine & Klonoff,

1994; Sheikh and Furnham, 2000). Studies on White populations show that they

embraced a natural or patient centered explanation of distress, but preferred

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biological causations, depending on the severity of the mental illness

(Angermeyer & Matschinger 1994; Lauber et al. 2003).

Interestingly, a study of families of schizophrenic patients in urban China

suggests that there was very little endorsement for a supernatural causation model

to explain serious mental illness (Phillips et al. 2000), although in the rural parts

of China such beliefs were still dominant (Li & Philips, 1990). Instead most of the

attributions were made to psychosocial factors sometimes implicating various

personality factors of the patient. The lack of a supernatural causation model then

lends support to the fact that societies utilize constructs which are prominent to

shape their conception of illness etiology. Since the Cultural Revolution and

purging of supernatural elements especially in urban centers in China, the masses

have lost much of their traditional worldview which was steeped in the Chinese

religious traditions of ancestor worship and shamanism. Rather a new cultural

worldview has become dominant, shaped by the Communist state’s efforts to

dilute the role of the supernatural and glorify individual responsibility for failure.

In societies where etiological explanations for mental illness took on

supernatural dimensions, invariably the treatment form that was preferred

followed the lines of the traditional sector. In these instances the etiological belief

models that the healers in the traditional sector hold to invariably correspond to

those of their clients (Alegria, Guerra & Martinez., 1977; Kleinman, 1980).

In comparison to the large amount of literature dealing with the

attributions of mental distress provided by traditional healers there has been

substantially less research on the views of clergymen from the major world

religions. These clergymen too have belief models stemming from their respective

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faith positions (Haque, 2001). However the anthropologiocal interests in exotica

possibly marginalizes investigation of mainstream religion and healing.

The only study which looked at clergymen and their conceptualization of

mental illness was Kim-Goh’s (1993) exploration of 50 Korean pastors in the US.

In this study Kim-Goh (1993) used vignettes of three kinds of psychotic scenarios

to elicit the belief models used by the pastors. Although there was some

bifurcation of views when a scenario had a religious element in it, in the vignettes

portraying depression or hallucination, the pastors overwhelmingly understood the

problem as psychological. None of the respondents attributed the malady to a

physical cause although Asians in general are well known to conceptualize mental

illness in physical terms.

2.6.2 Analysis of literature on different cultural constructions of psychological

problems

As has been demonstrated in the literature review, the different

constructions that individuals and healers have about the etiology of mental and

emotional problems affect how they deal with these problems. Furthermore an

analysis of the literature reveals a paucity of studies which deal with the etiology

models and treatment beliefs held by clergymen. This then certainly merits greater

investigation.

For my purposes I hypothesise that the different belief models held by

clergymen have an effect on the relationship between the clergy and professional

mental health sector and ultimately on referral behavior. If ministers conceptualize

symptoms of mental illness as spiritual maladies, and differ with mental health

professionals as to the etiology of these problems, this in itself becomes a site of

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tension. Referrals to a mental health professional would also be unlikely, rather a

spiritual solution would be encouraged.

Moreover I hypothesize that the dominant etiological and treatment model

a clergymen endorses, is related to several demographic dimensions. Clergymen

who have attained higher levels of secular, and psychological education, would

tend to endorse psychological and organic models, consistent with a more

secularized outlook to many aspects of life including issues of health. On the other

hand, those with greater levels of theological education, I posit will endorse a

spiritual explanation and its concomitant treatment models since these clergymen

are more embedded within a discourse of the supernatural.

2.7 Literature on Professional Behavior

Having dealt with the first major dimension in my theoretical model, I now

review the literature dealing with aspects of professional behavior, which I argue

is another central feature in understanding the relationship between the two

sectors and referral behavior in particular. I examine the literature discussing four

aspects of professional behavior, namely professional role identity, professional

ideology, professional competence and professional networks.

2.7.1 Professional role identity

By the concept of professional role identity I deal with what the

professional includes as being an integral part of his duty as a member of a

particular profession (Swisher, Beckstead and Bebeau, 2004). Much of the

literature on professional identity has situated around the health professions,

particularly nursing and other health fields which have arisen in competition with

the allopathic medical profession. Research has examined how members of

various helping professions define their core identities and its concomitant values.

65

Caring is integrally linked in the professional identity of nurses while providing

counsel is part of the professional role of ministers (Watson, 1995; Benner &

Wrubel, 1988; Ventimiglia, 1978). Professional identity is also known to change

over time and in reaction to competition. Osteopathic medicine which set itself

apart from the allopathic medical profession in its contempt for using

pharmaceuticals, systematically changed its professional identity to one which is

concerned with the holistic treatment of the mind and body (Miller, 1998). Little

examination has however been made of how professional identity may shape other

social processes. Quinney (1963) is among the few who have noticed that

pharmacists who define themselves more as health experts rather than

businessman are less prone to prescription violations.

In my current study I argue that there are theoretical reasons to believe that

professional identity can be related to referral practices. Allen and Hawkins

(1998) in their study of mothers and their gate-keeping behaviors which limit the

role of their husbands’ in child care provision, argue that role identity is a salient

concept. They argue that women who understand their role as being caretakers of

the family tend to keep their husbands from participating in housework through a

variety of measures. In the same way, in this study, I argue that clergymen who

define themselves in terms of their counseling ministry, i.e. they are good

shepherds of their congregation and provide the appropriate counseling care, are

more likely to engage in gate-keeping and limit referrals to mental health

professions.

2.7.2 Professional Networks

A second concept I explore pertains to professional networks. This idea is

further embedded in the vast research on social networks. The existence of social

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and economic benefits to those who participate in various networks of family and

friends have been undeniable (Campbell and Barrett, 1992; Kasarda and Janovitz,

1974). Beyond its benefits, social networks have been known to significantly

affect the social behavior of those who are linked together (Brass, Butterfield &

Skaggs, 1998; Burt, 1982). A central premise of network analysis is that

The structure of relations among actors and the location of individual actors in the network have important behavioural, perceptual and attitudinal consequences both for the individual units and for the entire system (Knoke and Kuklinski, 1982:13)

A number of research attempts have been made on the social networks of

professional groups. This analysis has shown that the networks are important in

obtaining prestigious positions, crucial information and has allowed for the

diffusion of knowledge and techniques (Burt, 1987; Galaskiewicz and Burt,

1991). Social influence theorists have recognized that social networks can

strategically influence and shape professional behavior. The earliest studies

examining this among medical professionals showed that besides the doctor’s

professional training and his reading of medical journals, doctors who were more

integrated into professional networks were more likely to prescribe new

generation drugs compared to those who were socially isolated (Coleman, Katz &

Menzel, 1966).

Burt (1992) however contends that it is not the number of ties that actually

result in influencing professional decision making. Rather it is the structure of the

network that determines how much it actually affects the individual. Dense ties

arguably result in redundant information, as over time, the homogeneous group

tends to think in the same way. On the other hand, scarce networks are able to

provide information from a variety of places and not have become stale. This fits

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in well with Granovetter’s (1973) seminal study of the strength of weak ties where

he showed that the network ties that who helped individuals find jobs were seldom

their strongest ties but those which were on the level of acquaintances.

Although Burt’s (1992) theory of structural holes offers more promise of

understanding how individuals incorporate new information, Marsden and

Friedkin (1994) argue using the social psychological literature and Hechter’s

(1987) theories on group solidarity that cohesive networks, analyzed through

network density, are much more efficient in setting group norms and influencing

the behavior of individual members. This is partly because networks can act as

important reference groups which become salient in providing guidance as to the

appropriate behavior, especially when situations are ambiguous (Erikson, 1988).

These reference groups also provide important group norms which lead those

within them to persuade others to adopt similar values and norms (Marsden and

Friedkin, 1994).

In this current study I focused on network density, which has been defined

as the proportion of all those links that could possibly exist among persons that

do, in fact, exist, and which tells how tightly knit a network is and describes the

overall level of cohesion. Professional networks theoretically affect referral

practice since professionals who are socially linked with another professional are

more likely to have values which are similar, and beliefs in the usefulness of the

other profession. This has been noticed in Grimm & Chumbler’s (1995) work on

podiatrists whom he notes are more willing to make referrals to physicians when

they had residency trainings in hospitals and thus had contact with such

professionals. In a similar vein it is possible to argue that clergymen who have

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more contact with mental health professionals are more likely to make referrals to

them.

2.7.3 Professional ideology

I follow Saks’ (1995) use of Plamenatz’(1971:5) definition of ideology as

a “set of closely related beliefs or ideas, even attitudes, characteristic of a group or

community”, and his subsequent application of this definition to the medical

profession. In his commentary of professional ideology held by medical doctors,

he describes in detail their attitudes towards the complementary therapy of

acupuncture through the decades. Acupuncture as expressed by these doctors

through the years has been seen as “crass stupidity of persons who, when anything

is the matter with them, place themselves in the hands of men who rob their

victims of both money and life” (Lancet 1871:598 as cited by Saks, 1995:232) and

in more recent eras “snakes blood and crocodiles teeth as a remedy for illness”

(BMJ, 1968 as cited by Saks, 1995:235)

Collins and Pinch(1979) in providing a framework of how established

scientists reject the knowledge claims of paranormal psychology, list several

items including making a blank refusal to believe, accusations of triviality; attacks

on the methodological precepts underpinning competing sets of ideas, and the

sensationalizing of anecdotal evidence. These attempts they argue were important

parts of the professional ideology of scientists.

In my current study of clergymen, I use the concept of professional

ideology by relating it to claims that clergymen make to discount the role of

psychology and the mental health professions. As shown in the earlier part of this

chapter, there has been significant conflict in terms of the usefulness of

psychology and the mental health professional advanced by the more conservative

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camp of Christianity, partly in the attempt to advance the continued jurisdiction of

religion over mental health issues.

I argue that professional ideology has implications for referral practices.

When clergymen hold professional ideologies that undermine mental health

professionals by claiming that their knowledge fields are not efficacious and

possibly detrimental to the client, they are unlikely to want to make referrals to

such professions. This is because they do not see them as offering any useful help

for the individual.

2.7.4 Professional Competency

As Cheetham & Chiver’s (2005) argue, the very basis of professionalism

lies in the professions ability to argue that they are competent in some particular

task not mastered by lay persons. They argue that professional competence is best

seen as a multidimensional attribute which includes the technical dimension of

how well a profession can manage a particular task, a behavioral component in

terms of its ability to behave appropriately and an ethical dimension in terms of

possessing the appropriate professional and personal values and applying them in

various setting. The professional competence, seen in the professionals ability to

provide the necessary services through the application of the relevant knowledge,

skills and behavior (McNamara, 1975) is exceptionally important since failing

this, the profession loses trust from consumers and may pose risks to its

beneficiaries (Jensen, 1979) . Much of the research on professional competence

has examined various health professionals, particularly nurses, who articulate

what they are most proficient in, sometimes using a phenomenological approach

(Girot, 1993; Meretoja, Isoaho & Leino-Kilpi, 2004, Watson et al, 2002). Other

studies have attempted to gauge professional competence by examining the views

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of other professionals or the lay public (Cescutti-Butler & Galvin, 2003;

Fosbinder, 1994; Stevens et al, 2000). In the study of professional competition, it

becomes apparent that claims of professional competence form the basis of one

profession’s demands for more control and autonomy in their provision of health

services (Warnock, 2005). This has been examined in the fields of vision care

where optometry has asked for greater autonomy to help correct vision disorder,

and professional psychologists who have claimed the rights to prescribing anti-

psychotic medication (Heiby, 2002; Stevens et al., 2000; Warnock, 2005).

Professional competence forms the basis for referrals among most

professional groups since no single professional is deemed as competent in all

domains (Koocher, 1979). Physicians and psychologists have maintained this

principle by asserting that it is a matter of ethics to recognize the expertise one has

and refer all other patients to those who are more proficient in the field (Pearson,

1999; Overholser and Fine, 1990). The reverse then arguably is true, that when

professionals such as clergymen deem that as a group they are competent in

providing for certain mental and emotional needs, they are less likely to make a

referral.

2.8 Summary of hypotheses in theoretical model of referral intentions

To summarise, the main hypotheses I use to understand the factors that

promote or inhibit clergymen’s referral to mental health professionals are

H1 = Ministers who strongly endorse a spiritual model to understand the

etiology of mental and emotional problems are less likely to make referrals to a

mental health professional while those who strongly endorse a psychological or

organic model are more likely to be willing to make such referrals.

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H2a = Ministers who have stronger beliefs that counseling is part of their

professional role identity are less likely to be willing to make referrals.

H2b = Ministers who have stronger professional networks with mental

health professionals are more likely to be willing to make referrals.

H2c = Ministers who have stronger professional ideologies undermining

psychology and its professions are less likely to be willing to make referrals.

H2d = Ministers who hold to stronger views of their professional

competency in counseling are less likely to be willing to make referrals.

H3a = Ministers who hold stronger religious conservative (fundamentalist)

views, are less likely to be willing to make referrals.

H3b = Ministers who have lower secular and psychological education, are

less likely to be willing to make referrals.

H3c= Ministers who have greater theological educational attainment are

more likely to be willing to make referrals.

H3d= Ministers who pastor in smaller congregations are less likely to be

willing to make referrals.

As is clear from the arrangement of these hypotheses, Hypothesis 1 refers

to the issues of the different cultural constructions, Hypothesis 2 with variables

deriving from professional theory and Hypothesis 3 those dealing with

background variables commonly discussed in the literature.

2.9 Theoretical literature on criteria for specific referral partner

Having presented a theoretical model which attempts to explain the factors

responsible for explaining clergymen’s willingness to make referrals to mental

health professionals, I now move to present the literature which I use to account

for the criteria that clergymen use in determining who they will make a referral to

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once they have established such a need. This investigation is important for a

complete understanding of referral behavior which as shown in Veroff, Kulka &

Duovan’s (1981) stage model, includes not only the stage of deciding to make a

referral but also includes the selection of a treatment professional.

The now popular social scientific literature on trust emphasizes that trust is

the “very fabric upon which social relations are founded” (Proctor, 2006:189).

This concept is useful in this study to understand the criteria used to select the

specific professional that clergy engage as referral partners. The sociological

treatment of trust best defined by Barber (1983: 165) includes two elements

namely the expectation “of technically competent performance…(and) of

fiduciary obligation and responsibility”. Both of these elements are crucially

important to reduce the complexity and uncertainties intrinsic in social life and

manage expectations that parties within society have of each other (Luhmann,

1979). While there is little literature examining inter-professional relationships

using the concept of trust, substantial literature in the health fields implicate trust

as an essential feature of the relationship between health care practitioners and

patients and implicate patient trust to the health system as imperative for quality

care (see Hupcey et al; 2001 for review). Thorne & Robinson (1988) further posit

that trust is vital for interprofessional relationships within the health field. Referral

practices, although not specifically mentioned, should then be seen as essentially

transactions between professional groups girded by trust. Applying the definition

of trust provided by Barber (1983) to the case of referral relationships, it is

apparent that referrals require the referring party to expect certain levels of

competence by the other professional and deem that the referred professional will

perform his duties responsibly. Building these trust relationships are especially

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crucial when there is uncertainty and risk involved in the environment (Luhmann,

1979; Gluckler & Armbrustler, 2003), which certainly is involved in referrals as I

will show in a subsequent chapter.

The sociological literature identifies two kinds of trust, interpersonal trust

which implicates specific relationships of trust and general or system trust where

trust is focused on a larger social organization (Luhmann, 1979). The bases of

trust for both these sets of trust relationships are possibly different. Lewis &

Weigert (1985: 970-971) commenting on Luhmann’s (1979) work identify three

bases of trust, a cognitive, emotional and behavioral dimension. Cognitive

processes are used to discern between persons or institutions which are deemed as

trustworthy and those which do not elicit trust. Often these are guided by various

markers of trustworthiness, such as cognitive familiarity with the services

provided by a particular individual or group. On the other hand the emotional

bases of trust are reliant on the emotional investments that individuals’ place on

certain relationships. Breaching such trust entails severe emotional reaction and

sometimes emotional outrage. A behavioral component essentially relates to the

cognitive bases of trust. This is since as Lewis and Weigert point out,

When we see others acting in ways that imply that they trust us, we become more disposed to reciprocate by trusting in them more. Conversely we come to distrust those whose actions appear to violate our trust or to distrust us. (1985:971)

While trust is often a combination of both emotions and cognitive

processes, Lewis & Weigert (1985) argue that certain situations entail greater use

of cognitive or emotional bases of trust. They argue that in industrial society with

its limits of face to face interactions, there is a move away from interpersonal

relations of trust to more system based trust. In the latter case cognitive bases of

trust are more common since ultimately individuals even when relating to other

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individuals (as would be seen in interpersonal trust) actually put their trust in the

integrity of the larger system which brings the two persons in contact. For instance

when two individuals engage in a sales relationship, they put their trust in the

legal system to ensure the needed protection should either party break the terms of

the contract.

The choice of the specific mental health professional that clergy make

referrals to is ultimately a decision based on trust. Since the predominant modes of

trust especially between professional groups are system based rather than purely

interpersonal I consider the cognitive and behavioral dimension which seems to be

most relevant to this kind of system trust. The emotional dimension of trust

relations is not suitable in the attempt to understand the criteria that clergy use to

select a suitable referral partner based on notions of trustworthiness. Rather the

emotional bases of trust seems to describe the strong emotional attachment that

those engaged in trust relations have, which can only be measured by the extent of

their emotional outburst should their trust be betrayed.

In this study the cognitive dimension of trust is examined through the

criteria of social linkages and homophily. It is apparent that cognitive familiarity

between individuals is reinforced through their knowledge or personal connection

with the particular professional, which then fosters trust (Giddens, 1990;

Luhmann, 1979). Homophily as seen in greater demographic and attitudinal

similarity is also expected to cultivate a sense of psychological familiarity and

thus trustworthiness (Kanter, 1977; McPherson, Smith-Lovin & Cook,. 2001). For

the behavioral dimension I consider the criteria of interprofessionality which

essentially entails behaviors which show that the professional is willing to

acknowledge the referring party as a colleague and is committed to collaborative

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efforts. These collegial exchanges as Loxley (1997) demonstrates are important

because displays of trust that one professional shows to the other is often

reciprocated.

In the following section, I further clarify each of these three criteria by

discussing the literature associated with them.

2.9.1 Social Linkages

Social networks are important in structuring various decision making

processes (Faria, Barrett and Goodman, 1985; Cross et al., 2001). Besides their

utility in decision making processes, social networks provide individuals access to

countless other individuals from whom they may require help and expertise (Lin,

2002). A good number of studies have shown the use of social networks to obtain

useful contacts in the pursuit of labour market advancement and employment

(Granovetter, 1985). Studies in medical referrals have similarly shown that in the

absence of any regulatory framework, general practitioners are most likely to

make specialist referrals to those in their professional network (Joyce, Veitch,

Crossland, 2003).

While one’s social linkages include those one is directly acquainted with, the field

of social networks shows that networks also include the contacts of individuals

one is acquainted with, thus the common adage that the world is only six persons

separated from each individual! Kadushin’s (1969) study on New Yorkers

searching for psychotherapy showed that, very often, the choice of practitioner

was determined by one’s membership in a social circle. These were not

necessarily the individual’s close friends but were individuals one had

acquaintance with who would often provide information of their own friend’s

activity. Thus it was not unlikely that an acquaintance would remark that he knew

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someone who was analyzed by a particular psychoanalyst. This recommendation

would then become the choice for an individual in his search for a

psychotherapist.

Social linkages then, both those formed directly between two actors and

those which are mediated by third party relationships are important in maintaining

trust relationships (Giddens, 1990; Luhmann, 1979). In fact research on social

capital reiterates how important network ties are in determining many business

and financial arrangements. Due to the unpredictability of markets and the

environment, organizations are apt to do business with other organizations within

their network, rather than even those who may offer better value (Biggart, 2000).

Birley (1985) studying entrepreneurs setting up their business in Indiana between

1977 to 1982 showed that they depended to a great extent on their network ties

with family, friends and colleagues to source out raw material, space and the other

building blocks of their business. Essential to the reason why networks were

frequently deployed was based on the reduction of risk that was characterized in

dealing with those in one’s social networks (Grannoveter, 1985). This was since

the web of social relations ensures that heavy sanctions are imposed if individuals

within the social network default on their obligations. Grannoveter illustrates this

sanction well when he says,

My mortification at cheating a friend of long standing may be substantial even when undiscovered. It may increase when the friend becomes aware of it. But it may become even more unbearable when out mutual friends uncover the deceit and tell one another (1992:44).

2.9.2 Homophily

One way of examining the criteria used for referrals is based on the

principles of homophily, the idea that those who are similar tend to develop

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relations to those like themselves. Research has shown that homophily is a

powerful force in structuring the relations that people have in a variety of settings,

including voluntary organizations (McPherson and Smith-Lovin, 1987), social

support networks (Wellman and Wortley, 1990) and workplace colleagues (Feld,

1984). Network studies according to McPherson, Smith-Lovin & Cook (2001)

showed substantial homophily based on demographic characteristics such as age,

sex, race/ethnicity, and education and by psychological characteristics like

intelligence, attitudes, and aspirations. At the core of these homophilic

relationships is the assumption that similarity indicates shared knowledge which

enhances association since communication is eased with a shared cultural taste

(Carley, 1991; Mayhew et al, 1995). Moreover similarity seemingly reduced

uncertainty and allowed homophilous partners to trust each other more because of

the inherent belief that there were less uncertainties between them (Bird, 1989).

This was clearly seen in a study of Carnegie Mellon University students who

chose group partners for projects based on homophilous characteristics trusting

that these would allow them to succeed (Hinds et al. 2000: 227). While homophily

has been known to shape behavior processes, it has hardly been used to

understand referral practices. The few which have considered features such as

preference for similar gender or age, aspects of homophily in referrals have been

inconclusive (Gonzalez, Emmon and Rizzo, 1991; Grimm and Chumbler, 1995).

2.9.3 Interprofessionality

The third criterion that I examined was based on the concept of

interprofessionality. This concept, very much current in the academic literature

deals with the willingness and actual practice of different professionals to

collaborate (D’Amour and Oandason, 2005). Underlying this concept is the trust

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which different professional groups show, (or do not show) during their regular

interaction with each other (Loxley, 1997; Ivey et al, 1998) The idea of

interprofessional collaboration has become particularly important in recent years

with the recognition that many problems are best handled by a team of specialists

from different disciplines who have varied expertise, all of which important for

the resolution of the problem (Cooper, Spenser and McLean, 2005; Hudson,

2002). Much of this discussion of interprofessionality has been centered on the

health care field where this is a distinct reality since different professionals may in

fact offer better recovery prospects for patients (Wildridge et al., 2004).

Underlying the concept of interprofessionality is the well documented

difficulties that many allied health professionals face when collaborating with

physicians because of the perceived lack of collegial relationships (Norman and

Peck, 1999). Physicians have traditionally adopted a superior and commanding

relationship and have treated allied health professionals as subordinates, which

has often resulted in unhappiness among health workers working in medical teams

(Adamson, Kenny, Wilson-Barnett, 1995). Inter-professional relationships are

further affected when specialists do not acknowledge referrals from general

physicians or non-medical professionals (Piedmont, 1968). Based on Blau’s

(1964) exchange theory, where the norm of reciprocity is not functional, a system

is likely to disintegrate. This then suggests that the failure of one professional to

adequately acknowledge the contributions of another professional and show a

reciprocal relationship will be susceptible to disintegration.

2.9.4 Summary of theoretical model on specific referral criteria

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I argue that based on a sociological understanding of trust, each of these

three criteria, homophily, social linkage and interprofessionality are important

considerations that clergymen use as to their choice of a referral partner.

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