Title: Cognitive factors associated with depression in Presbyterian (USA) clergy
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Title: Cognitive factors associated with depression in Presbyterian (USA) clergy a comparison study with mental health counselors
Physical Description: xi, 217 leaves : ill. ; 29 cm.
Language: English
Creator: Griffin, Wayne David, 1946-
Publication Date: 1993
Copyright Date: 1993
 Subjects
Subject: Depression, Mental   ( lcsh )
Presbyterian Church -- Clergy   ( lcsh )
Mental health counselors   ( lcsh )
Counselor Education thesis Ph.D
Dissertations, Academic -- Counselor Education -- UF
Genre: bibliography   ( marcgt )
non-fiction   ( marcgt )
 Notes
Thesis: Thesis (Ph. D.)--University of Florida, 1993.
Bibliography: Includes bibliographical references (leaves 197-215).
General Note: Typescript.
General Note: Vita.
Statement of Responsibility: by Wayne David Griffin.
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Bibliographic ID: UF00099560
Volume ID: VID00001
Source Institution: University of Florida
Holding Location: University of Florida
Rights Management: All rights reserved by the source institution and holding location.
Resource Identifier: alephbibnum - 001962543
oclc - 31473017
notis - AKD9217

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COGNITIVE FACTORS ASSOCIATED WITH DEPRESSION
IN PRESBYTERIAN (USA) CLERGY:
A COMPARISON STUDY WITH MENTAL HEALTH COUNSELORS











By
WAYNE DAVID GRIFFIN
















A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF
THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF
THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY
UNIVERSITY OF FLORIDA
1993
























Copyright 1993

by
Wayne David Griffin













ACKNOWLEDGMENTS


When our beloved daughter, Heather, left home to go to college,

my last embrace was accompanied by a piece of wisdom that has

proven ever so meaningful over the course of this study: "Do not

forget where you've come from." From where I started and with

whom I have traveled have made the difference in where I am

today.
First, to my loving wife, Nancy, I give thanks for the countless

hours of patience, innumerable smiles and hugs, and willingness to

tolerate me in my moments of frustration. Her wisdom and love are

at the center of my success. And for Heather, my wonderful

daughter, besides allowing me to grow up with her, my fascination

with where on the horizon her intelligence and experience will take

her kept me invigorated and searching. I thank her for the honesty

and affection with which she shaped my education as father and

student.

My father, Hugh, and mother, Dorothy, have been the gentlest

of life's guides. Always gracious, they have promoted my search for

truth even when it led me beyond the scope of their experience. I

am thankful for my heritage, for a love of earth and mind, and for

the beauty to be found in respect for life and family. To Mom and

Dad McDowell, I give thanks for their generous spirit, which helped








make my continuing education possible. More importantly, I thank
them for their genuine love and hospitality, which has invited me to

be truly a member of the family.
I want also to acknowledge my indebtedness to the following
persons, who in a variety of ways have shaped and facilitated my
development as a successful student and person. Dr. Gerardo
Gonzalez, my committee chairperson, motivated, illustrated, and
shaped my critical thinking processes. He was timely, pertinent, and
always constructive in his counsel. I am delighted for his willingness
to be my mentor. Dr. David Miller not only reduced my anxiety
about quantitative research methodology but also helped me create a
working level of self-confidence. He was also wonderfully
supportive and a thorough reader. Dr. Jim Archer helped me
elaborate my thinking about the psychological processes associated
with the research topic, explore the domain of cognitive-behaviorism,
and examine the value of comparison group study. His sense of
humor helped me keep a perspective on my study, work and, family.
Dr. Sandra Seymour shared not only her wealth of knowledge about
the subject of my research but also her enthusiasm for life and the
pursuit of knowledge. She was ever accessible and ready with a
word of academic advice or personal support. She and her husband,
Larry, my good friend, have helped us to parent a daughter, grieved
with us the loss of friends, and been a source of hope and vision for a
better world.
Finally, I want to acknowledge the tireless and competent work
of my statistics consultant, Anne Seraphine, the contribution of







Barbara Smerage in editing this work, and Dr. Arlene Weissman for
allowing me the use of the Dysfunctional Attitudes Scale. Thanks go
to Celia Dillon, my staff assistant, for her loving and patient
encouragement and the students and Council of the Disciples and
Presbyterian Student Center for their confidence in me and
commitment to continuing education.
When all is done, I can look back with pride on this study for it
represents the best of my heritage and all those kind folk who have
helped fashion my path and traveled with me.












TABLE OF CONTENTS

Page

ACKNOW LEDGM ENTS............................... ................. ............... .................. iii

LIST OF TABLES............................ ... ..... ..... .................... ix

ABSTRACT...................... ............................ x

CHAPTERS

I INTRODUCTION.............................................................................. 1

A Perspective on Mental Health...................................... ......... 1
Statement of the Problem.................................................... 4
The Epidemiological and Social Significance of
Depression.............................. .... ............... ......................... 5
Depression as an Axis 1 Disorder............................................ 7
A Theoretical Framework............................ ................. 1 0
Components of the Cognitive Model................................... ..... 1 1
Mental Health and the Religious Professional................... 1 5
N eed for the Study................................ ................................... 2 1
Purpose of the Study............................................ ................. 2 3
Research Q uestions............................................. .. ................. 24
Definition of Terms.................................. ............................... 25
Limitations of the Study........................................ 2 8
Summ ary............................ ..... ... .................... 29

II RELATED LITERATURE................................................................ 32

Chapter Organization....................... .... .................... 32
Depression............... ........... ...................................................... 32
A Definition and Conceptualization of Depression........ 32
Epidemiology and Factors Associated with
Prevalence of Depression................................................... 35
A Conceptualization of Beck's Cognitive Theory
of Depression....... ....... 39
Developmental Models of the Cognitive Theory........... 40
Research in the Structural Model and Contributions
of Dysfunctional Attitudes in Depression................... 47







Mental Health and the Religious Professional................... 57
Conceptualization of the Profession.................................. 59
Occupational Roles ............................................................. 61
Lifecycle of the Profession............................................. 63
Factors Associated with Occupational Stress and
B urnout.................................................................................. 6 6
Clergy and Depression...................................................... 72
The Relationship of Mental Health and Religious
Beliefs....................................................... .......................... 7 5
Depression-Resistant or Countervalent Beliefs in
Presbyterian Clergy...................................................... 77
Mental Health Counselors as a Comparison Group....... 84
Chapter Summary...................................................... ...... 89

III METHODOLOGY........................................................................... 92

Chapter Organization............................................................. 92
Research Hypotheses............................................................ 93
Research Design.................................................. ........................... 94
Subjects...................................................................................... 9 6
Research Instrumentation................................................... 99
Rationale for Instrument Selection................................ ..... 99
Self-Report Strategy..................................... 100
Efficiency and Effectiveness of Measurement.............. 102
Purpose and Description of the Measures...................... 105
Usage of the CES-D and DAS in the Literature.............. 112
Evidence for the Validity and Reliability of the
M easures..................................................... ...................... 115
Additional Measurement Considerations........................ 126
Section Summary................................................................ 127
Data Collection and Analysis............................... ......... 128
Limitations of the Study.................................. ......... 129
Chapter Summary.................................................................. 1 3 1

IV DATA ANALYSIS AND RESULTS........................................... 133

Study and Chapter Overview............................................. 1 3 3
Data Collection and Associated Response Rates................. 134
Decision Rules................................................. ...................... 136
Demographic Description of the Research Sample........ 138
Reliability Estimates for the CES-D and DAS.................. 141
Analysis Procedures.............................................................. 142
Regression Results.............................................................. 144
Dependency of Possible Depression on Variables......... 152
H ypotheses Testing............................................................ 154
Chapter Sum m ary........................................................................... 15 7

V DISCUSSION AND RECOMMENDATIONS................................ 158

Overview of the Study.......................................................... 1 5 8
The Research Sample............................................................. 15 9







The Relationship of Dysfunctional Attitudes, Level of
Depression, and Demographic Variables......................... 160
Difference by Group on Level of Depression................. 160
The Relationship between the Level of Dysfunctional
Attitudes and Level of Depression................. 161
Differences by Group on the Level of Dysfunctional
Attitudes and Level of Depression.................................. 162
The Contribution of Demographic Variables on the
Level of Depression........................................ ................ 163
The Relationship of Level of Depression and
Demographic Variables by Group................................ 166
The Relationship of Dysfunctional Attitudes and the
Demographic Variables.............................. ........... ... 167
The Level of Dysfunctional Attitudes by Group............ 167
The Relationship of Level of Dysfunctional Attitudes
and Demographic Variables ....................................... 170
The Relationship between the Level of Dysfunctional
Attitudes and Demographic Variables by Group...... 175
Recommendations..................... ............. ................ 175
Improvements in Study Design.................................. 175
Implications for the Professions.................................. 177
Dysfunctional Attitudes and Cognitive Immunity...... 180
Chapter Summary...... ........................................ 183
APPENDICES

A DEMOGRAPHIC QUESTIONNAIRE FOR CLERGY.................... 185
B DEMOGRAPHIC QUESTIONNAIRE FOR COUNSELORS.......... 187
C CENTER FOR EPIDEMIOLOGICAL STUDIES'
DEPRESSION SCALE................................................................... 189
D THE DYSFUNCTIONAL ATTITUDE SCALE............................... 191
E ANNOUNCEMENT CARD................................................................. 194
F CO V ER LET IE R .................................................................................. 19 5

G FOLLOW -UP CARD.......................................................................... 196
REFEREN CES...................................................................................................... 19 7
BIOGRAPHICAL SKETCH................................ ........................................ 216












LIST OF TABLES


Table Page
1 Descriptive Data on Interval Variables........................... 138

2 Descriptive Data on Categorical Variables........................... 139

3 Variables Included in Regression Models 1 and 2.......... 143
4 Source Table for the Model to Test the Main
Effects with CES-D as the Dependent Variable.................. 145

5 Regression Coefficients and T-Values for the Model
to Test the Main Effects with CES-D as the
Dependent Variable.................................................................... 146
6 Source Table for the Model to Test the Main
Effects with DAS as the Dependent Variable................... 149

7 Regression Coefficients and T Values for the Model
to Test the Main Effects with DAS as the Dependent
V ariab le ............................................ .......................................... 15 0

8 Chi-Square Test on Marital Status by Possible
Depression Score.................................................. ................... 153












Abstract of Dissertation Presented to the Graduate School of the
University of Florida in Partial Fulfillment of the Requirements for
the Degree of Doctor of Philosophy
COGNITIVE FACTORS ASSOCIATED WITH DEPRESSION
IN PRESBYTERIAN (USA) CLERGY:
A COMPARISON STUDY WITH MENTAL HEALTH COUNSELORS

By
Wayne David Griffin

December 1993
Chairman: Gerardo Gonzalez
Major Department: Counselor Education

The purpose of this study was to apply Aaron Beck's cognitive

theory of depression in an investigation of levels of depression in

Presbyterian (USA) ministers. Specifically, this research was an

attempt to ascertain through use of the Dysfunctional Attitudes Scale

(DAS) the presence and level of attitudes Beck theorized to be

associated with the syndrome of depression. These attitudes were

evaluated as predictors of the current level of depression as

measured by the Center for Epidemiological Studies--Depression

Scale (CES-D). An additional purpose of this research was to

determine whether levels of depression and dysfunctional attitudes

in Presbyterian ministers occurred at rates similar to a cohort of

comparably trained help-giving professionals, namely, mental health
counselors.








The sample consisted of respondents to a nationwide random
sampling of Presbyterian (USA) clergy and members of the American
Mental Health Counselors Association. Five hundred fifteen (51.5%

clergy, 54.2% female) subjects composed the source for the data
analysis.
Multiple regression procedures were utilized for analysis of the

data. Level of dysfunctional attitudes, group membership, gender,
age, marital status, racial and ethnic background, tenure in
profession and type of service were evaluated as predictor variables.
Both CES-D and DAS scores were studied as outcome variables. No
statistically significant interactions were established in either model.
The level of dysfunctional attitudes was predictive of an

increase in the CES-D score. Additionally, married participants
demonstrated significantly lower scores on the CES-D while marital
status "other" participants scored higher. Finally, increased length of
service in one's profession was associated with a decreased level of
depression.

Increased age in respondents was associated with lower DAS

scores. The longer that one was in his or her profession, the higher

the DAS score. By group, Presbyterian ministers exhibited a

significantly higher mean score on the DAS. This was in contrast to

no statistical difference between groups on level of depression.
Using a cutoff score of 17 on the CES-D, 11.32% and 15.6% of
the clergy and counselors, respectively, were identified as possible
cases of depression. Recommendations for educational interventions
and further study of moderating variables are included.

xi













CHAPTER I
INTRODUCTION
A Perspective on Mental Health

The period in which we currently live is characterized by some
mental health specialists as one of heightened anxiety and
melancholia. The results of longitudinal studies conducted by the
National Institute of Mental Health appear to confirm an increasing

level of distress in our society. For example, the total number of
patient care episodes associated with mental health rose from 4.2
million in 1971 to 7.9 million in 1986, a change of 88%. Similarly,

during the same period, there was a 58% elevation in the number of
organizations providing mental health services (National Institute of
Mental Health, 1990). More recently, for the year 1988 an estimated
average of 227,900 persons were treated daily as inpatients for
problems associated with their mental health (U.S. Bureau of the

Census, Statistical Abstract, 1991).

Studies describing the rates of health-seeking behavior only
begin to depict the significant underlying costs of diminished
psychological health in our citizenry. According to Rice, Kelman, and
Miller (1991), losses associated with mental health problems resulted
in a $103.7 billion burden on American society in fiscal year 1985.
This statistic reflects expenses related to direct costs for services, loss
in production, mortality, and other related expenditures for mental









health. It is anticipated these losses in personal and economic

productivity will increase 24.6% to $129.3 billion by 1988. Further,
the United States Bureau of the Census (1991) estimates
expenditures of $95 per capital on mental-health-related concerns

during 1988.
The evidence of an increase in emotional distress in our society
is prompting a wide range of responses on the part of governmental
and educational agencies. The development of educational
interventions designed to raise sensitivity to mental health issues
reflects a concern to enhance the quality of citizens' lives. Programs
on topics such as stress, depression, suicide, and abuse of drugs,
children, and spouses, as well as the avenues by which to seek help,

are demonstrated at national and local levels. Even so, 39,707
persons are thought to have died from mental health complications
in 1985 (Rice et al., 1991). Additionally, results of the 1985 National
Nursing Home Survey indicate 66% of the resident population under
care suffered from at least one diagnosable mental disorder (National

Institute of Mental Health, 1990).
The helping professions are not immune from the factors that

diminish the general public's mental health. Anecdotal and empirical
evidence are beginning to shed light on the distress of the
professionals to whom others turn for help. Mismatches among
vocational expectations, level of control, work and role overload, and
degree of needed social support can potentiate personal dysfunction.
Levi (1990) notes that reactions to such disparities in the workplace
can result in emotional, cognitive, physical, and behavioral








symptoms, which under intensity can lead to disease. Thomas

Maeder (1989a) concludes that the helping professions, notably
psychotherapy and ministry, appear to attract persons who may be
vulnerable to emotional instability. Lured by images of power,
interpersonal influence, or altruism, these professionals may be
unable to resolve their own underlying problems and, as a
consequence, afflict their personal and professional lives.
In a survey of nonmedical psychotherapists working in a
variety of clinical settings (e.g., mental health centers, psychiatric
hospitals, university counseling centers, and private practice),
Deutsch (1985) found that 82% of the respondents reported having
experienced significant relationship problems. Further, 57% had

experienced depression, 27% of whom sought therapy. Eleven
percent of these professionals utilized medications with 3% being
hospitalized for treatment of depression on at least one occasion.
Deutsch also reported that 14% of the participants acknowledged
abuse of substances.
Emotional distress and problems with role and work overload
and burnout have been described in several professions including
social workers (Cournoyer, 1988; Oberlander, 1990; Ratliff, 1988)
and psychologists (Ross, Altmaier, & Russell, 1989; Thoreson, Budd, &
Krauskopf, 1986). Additionally, White and Franzoni (1990) reported
graduate counseling students in their study reflected higher levels of
psychological disturbance than did the general population norms on
six of the seven Minnesota Multiphasic Personality Inventory scales
under study, including depression. Although such a study does not









depict the state of students' mental health, it may give some

indication for adverse change under the duress of future professional

practice.
In summary, epidemiological studies that describe mental

health issues in our country illustrate the impact of diminished
emotional well-being at all levels. Anecdotal and empirical studies

appear to confirm that the helping professions, as well, suffer from

many of the same problems. Endeavors, therefore, which seek to

shed light on the complex factors associated with mental health are
important for their potential to enhance the quality of individual life

and mission of community.

Statement of the Problem
The focus of this research was to determine the existence of

relationships between attitudes theorized to be related to depression

and a measure of the current level of symptoms associated with the

syndrome of depression. Evidence of these relationships may help to

characterize the influence of these pathogenic attitudes and the

likelihood that persons ascribing to such attitudes may be susceptible

to depression.

The population focus of the research was a specific cohort of

helping professionals, Presbyterian Church (U.S.A.) ministers. A

comparative population of mental health counselors was studied to
further clarify attributes distinctive to the clergy. Presbyterian

ministers espouse a belief system that, if adhered to, may attenuate
the influence of attitudes that are, according to Weissman and Beck

(1978), associated with depression. The theology upon which









Presbyterian doctrine is based, namely the Reformed tradition of

church history, ideally moderates the content of these depressogenic

attitudes (e.g., the exaggerated needs for autonomy, acceptance, love,
entitlement, perfectionism, or omnipotence) that are believed to

exacerbate depression. These fundamental theological schemas

underpin the ministers' personal religious faith and professional

conduct. It is logical to think the clergy's commitment to these

beliefs may provide a type of cognitive resistance to depression.
Little empirical data exist to describe the prevalence of

depression in either the ministerial or mental health counselor

vocational groups. Nor is it known whether prevalence rates differ

between these two groups. Therefore, evidence related to

prevalence rates and the existence of relationships between cognitive

attitudes and depression may further validate the cognitive theory of

depression. The development of educational and therapeutic

interventions to prolong the personal and professional contributions

of these professionals can then follow.

The Epidemiological and Social Significance of Depression

Reus (1983) suggested the entire history of medical psychology

can be understood in terms of the evolution in the conceptualization,

diagnosis, and treatment of depression. The nomenclature used to

characterize depression reflects the breadth of this change. Initially

depicted as melancholia, and later as an affective disorder,
depression is currently classified as a disorder of mood (American
Psychiatric Association, 1987).









The World Health Organization has estimated some 100 million
persons worldwide suffer from a depressive disorder (Marsella,
Hirschfield, & Katz, 1987). In the United States, of the 28.9 million

persons who may have suffered from any mental disorder during a
1-month period in 1989, an estimated 5.2% were depressive in
nature (National Institute of Mental Health [NIMH], 1991). More

significant is the calculation that 8.3% of the adult population over
the age of 18 will suffer with symptoms of clinical depression at

some point in the course of their lifetime (NIMH, 1991; see also
Myers, Weissman, Tischler, Holzer, Leaf, Orvaschel, Anthony, Boyd,
Burke, Kramer, & Stoltzman, 1984). In a 1986 survey of specialty
mental health inpatient, outpatient, and partial care programs, the
primary diagnosis of mood disorder accounted for 22% of all persons

under care and 14% of all admissions (National Institute of Mental
Health, 1990).

The morbidity costs, the loss of production associated with

depression, are considered a significant drain on our economic
infrastructure. Results of studies undertaken by the Alcohol, Drug

Abuse, and Mental Health Administration (Rice, Kelman, & Miller,
1991) indicate depression results in more time in bed than any other
single illness including ailments such as ulcers, diabetes, high blood

pressure, and arthritis. Further, these findings characterize 1
employee out of every 20 as experiencing depression with overall
associated costs of lost time from work amounting to $17 billion in
1989.









Outcome studies on depression also suggest an alarmingly high
comorbidity with other physical ailments. Diagnosis with any

psychiatric disorder is related to a higher risk for some form of
medical illness (Hall, Gardner, Stickney, LeCann, & Popkin, 1980). In
a recent 1-year outcome study of persons diagnosed with major
depression, half of the subjects were also diagnosed with a
coexistent, nonaffective psychiatric or medical illness (Keitner, Ryan,
Miller, Kohn, & Epstein, 1991).

In summary, epidemiological studies in depression describe a
malady of relatively high lifetime prevalence involving significant

personal suffering and economic drain on the individual and
workplace. A goal of better understanding the various factors and
mechanisms associated with depression is merited. Resultant
development of more effective educational and therapeutic
interventions may reduce personal suffering and restore an
individual's contribution to home, work, and community.

Depression as an Axis 1 Disorder
Depression is categorized as a disorder of mood. Disorders of
mood can be understood in terms of their pattern and type, either
depressed or manic in nature. The mood syndrome represents a

clustering of symptoms that persist over a minimal period of time.
For clarity of diagnosis, any single episode associated with the
syndrome must not be attributable to a known organic factor such as
alcohol impairment or as a facet of a nonmood psychotic disorder

(e.g., delusional disorder). In addition, diagnosis of the depressive









syndrome must rule out the possibility of an organic mental disorder

(American Psychiatric Association, 1987).

For purposes of this study, the focus of assessment was the
cluster of symptoms associated with major depression. The
diagnostic criteria utilized are consistent with characteristics defined
in the Diagnostic and Statistical Manual of Mental Disorders (Third
Edition, Revised) (American Psychiatric Association, 1987).

Accordingly, five of the following symptoms must be present in the

same 2-week period and prevalent on a daily basis: (a) a depressed
mood, (b) markedly decreased interest in pleasurable activities, (c)
significant gain or loss in body weight not attributable to dieting (i.e.,
more than 5% of body weight in a month) or loss of appetite, (d)

either a lack of or overindulgence in sleep, (e) fatigue or noticeable

energy loss, (f) feelings of excessive or inappropriate guilt, (g)
diminished capacity to concentrate or make decisions, and (h)
repetitive thoughts about death that may include suicidal ideation,
an attempt, or development of a specific plan. Either depressed
mood or loss of interest in pleasurable activities must be present as
one of the five key symptoms. Further, diagnosis requires that an

organic factor be ruled out as the source or maintenance of the mood

disorder. No evidence must exist that delusions or hallucinations

have been present for as long as 2 weeks without the presence of
outstanding mood symptoms. Lastly, the depressed mood is not
overlaid on schizophrenia, schizophreniform disorder, delusional
disorder, or a psychotic disorder not otherwise specified (American
Psychiatric Association, 1987).









The range of symptoms associated with depression depict a

distress that affects the breadth of human experience. During an
episode of depression, one's physical, emotional, intellectual, and
behavioral domains are involved, and dysfunctions of varying
degrees can occur in any or all (Alcohol, Drug Abuse, & Mental Health
Administration, 1991). Criteria for the severity of an episode range

from mild to severe, with and without psychotic features that may or
may not be mood congruent. Partial and full remission of an episode
are distinguished by any history of dysthymia, a low-level but
chronic mood disturbance, and period of time free of symptoms
(American Psychiatric Association, 1987).
Diagnosis of chronic or melancholic types of depression is

distinguished by elevated or more intense symptoms related to mood
upon awakening, psychomotor agitation, eating and weight loss
patterns, previous history of personality disturbances and major
depressive episodes, and idiosyncratic response to antidepressant

drug therapy. Additionally, timing of onset, personal history of mood

episodes over 3 years, and duration of remission are considered
(American Psychiatric Association, 1987).
There is a significant presence of a depressed mood phase

within the second major classification of mood disorders, namely, the
bipolar disorder. The manic or elevated phase of mood is followed
by a characteristic swing to symptoms of depression. Essential
diagnosis of a depressive disorder is contingent on one or more
episodes of depression without the presence of manic or hypomanic









features (American Psychiatric Association, 1987; Goldstein, Baker, &
Jamison, 1986).
A Theoretical Framework
The idea that cognitions play a role in the formation and

maintenance of human behavior was elaborated by Bandura (1977)
in his principle of reciprocal, triadic determinism. According to
Bandura's social learning theory, behavioral, cognitive, genetic, and
environmental factors operate as the interacting determinants of one
another. Persons serve as reciprocal contributing influences on their
own motivation and behavior through a system of bidirectional

causation. Each facet of human perception, behavior, and
reinforcement influences one's future experiences with the same
stimuli (Bandura, 1977, 1986).
Aaron Beck (1976) elaborated Bandura's earlier thinking by

suggesting an affective response is determined in the way an
individual perceives and conceptualizes experience. He rejected the
idea a human is controlled by powerful unconscious forces outside
the realm of personal management. Rather, Beck located the basic
problem of emotional disturbance in a person's misconceptions about
self, irrational beliefs, and faulty assumptions about reality

(Weissman & Beck, 1978). Accordingly, it is possible for a person to

alter mood and behavior by changing dysfunctional thinking and
perceptual patterns. These changes are facilitated through planned
behavioral experimentation designed to reinforce more positive
attitudes acquired through new experience. This rational approach

to emotional disturbance consists in a person identifying









misconstrued notions about reality, putting to the test the validity of
their faulty assumptions, and subsequently developing and testing
more rewarding substitutions.
Components of the Cognitive Model
Beck's concept of maladaptive cognitions is elaborated in a

structural model. The model consists of immediate events,
information-processing styles, and underlying patterns of belief. At
the symptomatic level of experience are cognitive events. These are
best understood as the automatic thoughts associated with first
impressions in encountering a stimulus. While not often conscious to

the person in the moment, these thoughts may be retrieved through
focused inquiry and self-study (Marziller, 1986; Meichenbaum,
1977). For example, upon receiving a phone call late in the day and
confronted with fatigue, a minister may respond unconsciously to the
message, "I'm tired but I am supposed to be available to people."
The automatic thought may include recognition of personal fatigue
and the lateness of the call; however, a message of fundamental
obligation juxtaposes it. It is often the latter message that is
perceived as more compelling and, therefore, acted upon at the
expense of the individual's well-being.

Aaron Beck (1976) proposed the existence of a cluster of
automatic thoughts that compose the rational content of a cognitive
triad associated with depression. The triad consists of negative
perceptions in three major domains of experience: self, world, and
future. The depressed person's view of self is dominated by ideas of
unworthiness and incompetence. The world is viewed as threatening









and an often unrewarding place in which to live, work, and play.
Lastly, the future is envisioned as bleak and unresponsive to the
actions of one's willpower. These thought forms may combine to
encumber the will of a person and result in a further cycle in
deterioration of affect and adaptive behaviors.

The second major component in Beck's theory explains why an
individual maintains self-defeating thoughts despite evidence that
suggests the contrary is true. Because any experience consists of
multiple stimuli, an individual selectively chooses to attend to
specific facets of the event. This selectivity produces a pattern that

becomes meaningful when affiliated with the experience. Persons
then tend to bias future selectivity and meaningful decision based on
a history of prior encounters. In effect, a cognitive loop is developed
that explains phenomena and directs behavior. These systematic
patterns are termed schemas and constitute a person's underlying
cognitive structure (Beck, Rush, Shaw, & Emery, 1979). Utilizing the

earlier example of the phone call, the minister may subscribe to the
belief that failure to attend to the perceived need of another person

may result in a reduced level of respect or acceptance. A particular
environmental stimulus activates a specific schema that, in turn,

functions to screen, evaluate, and code the stimulus for its perceived
level of threat; differentiate response alternatives; and define the
pertinent reinforcement, motivation, and behavioral response.

The cognitive theory of depression states that under duress,
certain dysfunctional attitudes may be activated that skew an
individual's perception of reality. This distortion of experience









potentiates the cognitive triad and further reduces the effectiveness

of self-corrective coping skills. The more active the idiosyncratic

schemas are, the less control the person has with which to recall and

utilize more adaptive cognitive and emotional resources (Billings &

Moos, 1985). This closed feedback loop, once established, is thought

to produce heightened vulnerability to depression and the effects of
the cognitive triad.
The third facet of Beck's theory elucidates the contribution that

information processing makes towards a person's construction of

reality. A distortion in perception activated by maladaptive schemas

produces errors in thinking. These faulty thinking styles can sustain

erroneous viewpoints even when evidence to the contrary exists

(Meichenbaum, 1977). Beck (1967) described six faulty thinking or

processing styles:

(1) Arbitrary inference is the process wherein one draws

specific conclusions in the absence of evidence to support such

findings.

(2) Selective abstraction results from focusing on a single

aspect of an event taken out of context and often to the obviation of

more salient and related features.

(3) Overgeneralization is the tendency of an individual to draw
a rule or conclusion based on limited information.

(4) A magnification or minimization style reflects a propensity
for over- or underexaggerating experiences in relation to other life
events.









(5) Personalization is thinking wherein one perceives

everything as pertaining to the value of self, even when no basis for
such a conclusion is present.
(6) Absolutistic or dichotomous thinking consists of a response
set that characterizes reality in terms of extremes (e.g., good or bad,
all or none, for or against).
Fundamental change in a cognitive approach to the treatment

of depression consists of altering faulty thinking styles so a person
may more effectively process incoming information. This is
accomplished in challenging the credibility of one's perceptions by
behaviorally testing the logical outcomes of erroneous thought. This
therapeutic approach elaborates the lack of validity in a negative
construction pattern by providing contradictory evidence. An
individual may, therefore, be more capable of making informed
choices for coping. This process is thought to interrupt the cycle and
maintenance of the cognitive triad (Persons, 1989).
In summary, the cognitive theory of depression as put forward

by Aaron Beck (1967) is based on the idea that a person's early
experience in life creates predispositions or consistent attitudes

towards certain stimuli. These schemas form the cognitive structure
that facilitates the ways a person perceives and constructs a
response to environmental stimuli. A maladaptive schema or
dysfunctional attitude exists when premature negative or
exaggerated conclusions are drawn about an experience prior to
objective evaluation of the challenge and one's resources to manage
the stressor. The maladaptive schemas may precipitate a distortion









of experience through the activation of erroneous thinking styles.

This may result in the persistence of negative views of one's self-

worth, the world, and one's potential for a more creative future. The

maintenance of this negative cognitive triad reduces a person's

capacity to utilize self-affirming coping skills and will to alter one's
circumstances, and increases the likelihood of depressed affect and

isolation.

Mental Health and the Religious Professional
The relationship between religion and individual well-being

has undergone significant examination within the last three decades.

Results of research in the 1950s and 1960s by and large
characterized religion as a functional ideation utilized by individuals
who were described in the literature as more tense, anxious,
conforming, rigid, and symptomatic when compared to a nonreligious

cohort (Bergin, 1983). Even recently, Albert Ellis (1980), a noted

advocate of a strict rational approach to problem solving, equated

religious faith with emotional disturbance and portrayed the

relationship between believer and belief system as based on faulty
thinking. In a review of the literature, Bergin (1983) cited weak

research designs, limited samples, and a lack of clearly defined

constructs as factors contributing to negative findings in early

studies. Incorporation of more sophisticated research methodologies
utilized in recent years has failed to replicate the earlier and more
critical findings (Bergin, Masters, & Richards, 1987; Bergin,
Stinchfield, Gaskin, Masters & Sullivan, 1988; Masters, Bergin,

Reynolds, & Sullivan, 1991; Trent, Keller, & Piotrowski, 1984).









Results of recent inquiries suggest religion to have no significant
relationship with pathology (Bergin et al., 1988; Masters et al., 1991)

and some positive influence in highly religious groups of students on
morale and self-esteem (Trent et al., 1984). A cursory review of
professional journals indicates a renewed interest in understanding
the various aspects and functions of religious faith in the therapeutic
process (Keating & Fretz, 1990; Miller, 1992; Thorson & Powell, 1989;
Worthington, 1989).

Little is known, however, about the mental health of religion's
practicing professionals. Generally, information that might represent
their status either is not accounted for in denominational agencies or
is protected because of legal and ethical concerns regarding
confidentiality. Additionally, some religious organizations are

protective of the public's perception of the role.
To acquire background data for this research study, 16
denominations representing a diverse expression of the Christian
faith in the United States were surveyed by correspondence. Four
questions were asked of denominational bureaucrats identified as

key source persons in the area of pensions and major medical health
benefits for ministers in their respective organizations. The data
requested were to be aggregate and descriptive in nature. The
principal investigator requested information illustrating the
percentage of clergy utilizing mental health provisions in their
medical health care plans, the financial impact of such services on
the medical plan, and any differentiating patterns on usage (e.g.,
gender, ethnicity, age, or regionality).









Nine denominational representatives responded either by
phone or the enclosed self-addressed envelope. All but two of the

denominations cited the aforementioned reasons for not supplying
data. One indicated there were no comprehensive data but that
increases in outpatient mental health care costs resulted in
implementation of a recent limit of $2,000 annually per member.
The spokesperson from the other responding denomination described
a significant increase in cost to its insurance carrier. This resulted in
a change of inpatient treatment coverage to a maximum of $10,000

per year and $50,000 over a lifetime, down from the previous
$1,000,000 lifetime and no annual maximum provisions. In any one
year up to 1989, 2% of this denomination's clergy utilized
membership mental health service options. In the years 1990 and
1991, these figures rose to 5% and 11%, respectively (A. A. Hanna,
personal communication, March 26, 1992).

It is noteworthy that, though unable or unwilling to provide
the requested background information for this study, five of the

denominations indicated the value of such research and requested
abstracts of the completed research. This dearth of information on a
cohort of professionals traditionally viewed as important caregivers
suggests the need to explore further the effects of their work for
potentials of burnout, depression, and other forms of mental distress.

Writing on increased concerns regarding clergy health,
Whittemore (1991) cited a Southern Baptist Convention report that,
after maternity benefits, the largest portion of the $64.2 million paid









to pastors in medical claims during 1989 was for stress-related
illness.

Recently, a consortia of 10 Protestant denominations, including

the Presbyterian Church (U.S.A.), began pooling data on full-time

active religious professionals. This network is seeking to describe

the utilization and cost patterns associated with the denominations'

major medical insurance plans. In its preliminary report, the Church

Healthcare Network (CHN, 1991) found 75% of the 160,000 covered

insured participants made claims on their respective policies. Fifty-

six percent of all charges were incurred for outpatient treatment.

The top three major diagnostic categories by rank were

musculoskeletal system dysfunction, circulatory disorders, and

mental illness/ substance abuse. Further, when the various plans'
experiences are broken down into charges associated with inpatient

and outpatient services, the mental illness/substance abuse diagnosis

ranks second in both categories (CHN, 1991).

According to the CHN report (1991), admission rates and bed

days per 1,000 clients dropped from 1989 to 1990 by 10% and 14%,

respectively. Yet both remain higher than the national indemnity

plan norms by approximately 6% and 17%, respectively.

Additionally, the cost increase trend for the average amount of

charges for each employee for the years 1989 and 1990 was 17%.
Presbyterians realized an increase of approximately 8.5% in total
claimant charges to their health plan over the same years (CHN,
1991).









The CHN preliminary findings conclude that the mental health/
substance abuse diagnosis represents a problem area for the plans'

participants (CHN, 1991). This single diagnosis category accounted
for 12% of the total charges to all plans. Norms established by the
insurance industry set 5 admissions per 1,000 as a benchmark for
this diagnosis. In 1990 the CHN utilization statistics reflected an
admit rate of 13 per 1,000, an incidence 260% over what is expected
(CHN, 1991).
The financial impact of emotional distress is of interest to the

respective denominations as they seek to establish actuarial
directions for the future. The preliminary report (CHN, 1991)

established an average of $2,110 expended per claimant in the
mental illness/substance abuse diagnostic categories. Total inpatient
charges for this major diagnostic category were 12% of the total of all
inpatient expenditures in 1990. Insurance industry standards
suggest a problem exists when total charges in this diagnosis are
greater than 10% of all costs incurred (CHN, 1991).
In a cross-denominational survey of 300 ministers in

California, Blackmon (1988) found that 12% of the clergy sample
reported "often" feeling depressed. Forty-five percent responded to
feeling depressed "sometimes," while 43% indicated "rarely or never"
feeling depressed. Blackmon further suggested the statistics may
indicate ministers do not sufficiently comprehend depression to
know how to respond. Hart (1984) proposed clergy often suffer from
masked or hidden depression. He cited the likelihood ministers may
experience physiological symptoms of depression associated with








letdown after preparations and presentations in their roles as public
figures. Gaddy (1991), in an autobiographical portrait of his struggle
with clinical depression, pointed out the importance of the public role
and self-expectations of invulnerability to be significant barriers to
self-disclosure and help seeking.
Much of the literature available regarding clergy and mental
health is autobiographical and anecdotal in nature. The material may
be as focused on assisting ministers in understanding the needs of
parishoners or the idiosyncrasies of their employment as their own
needs and suffering (Gaddy, 1991; Hart, 1984; Holden, Watts, &
Brookshire, 1991; McCandless, 1991; Timmerman, 1988;
Worthington, 1989).

In summary, the existence of empirical evidence regarding the
mental health status, and more specifically depression, in clergy is
very limited. Data that do exist suggest clergy may be utilizing
mental health provisions in their pension and medical plans at an
increasing rate over past years. In one cross-denominational study,
the researcher concluded the incidence of diagnosis in mental health
and substance abuse represents a significant problem area. Further,
the limited incidence of depression reported is at least consistent
with lifetime prevalence rates for the general population. Indeed, an
inadequate understanding of depression or hesitance to self-disclose
may account for rates being lower than actually present.
The lack of empirical evidence regarding the mental health of
religious professionals, notably ministers, may also reflect an
underlying image of a role that is deleterious to the well-being of its









practitioners. Clergy suffering from depression or other emotional

disturbance may feel disinclined to utilize educational or therapeutic

resources for fear of disenfranchisement by peers or loss of role
credibility. Knowledge gained from this study may, therefore, be
beneficial in helping to better understand the mental health of
ministers and prolong the length and quality of their professional

contribution. In addition, the elaboration of cognitive factors related

to depression in clergy may encourage denominations to develop
entry-level training and continuing-education events as early
intervention strategies.

Need for the Study
Knowledge of the levels of cognitive schemas associated with

symptoms of depression in a sample of Presbyterian ministers can
provide additional evidence for validating Beck's cognitive theory of
depression. Presbyterian clergy represent a population of
professionals who by their ordination vows espouse a belief system
that might appear to attenuate the development of maladaptive

schemas. The denomination's theological emphasis on the worth of
each individual apart from one's station in life or particular labor and

the sovereignty of an ultimate creator is inconsistent with self-

defacing or perfectionistic attitudes (Calvin, 1967; Wallace, 1959).
Likewise, the Presbyterian focus on the sufficiency of God's grace and
resourcefulness of humans in community to help one another
appears to contradict attitudes that depreciate help seeking or
aggrandize any one aspect of human life at the expense of the whole

(Guthrie, 1968; Mead, 1990). The presence of dysfunctional attitudes









in any intensity may, therefore, reflect either an internal incongruity

of beliefs or the cyclic effects of depression upon one's core belief
system.
Information on the level and intensity of these cognitive

factors in depression in Presbyterian clergy will help to determine
the need to develop educational and therapeutic interventions
designed to modify the onset or course of depression in this
population. The absence of increased levels of dysfunctional
attitudes present with significant levels of depression may, however,
suggest additional directions for research in the cognitive theory of
depression. Such investigation may examine more closely the effects
of factors other than schemas (i.e., dysfunctional attitudes) in the

cognitive paradigm (e.g., automatic thoughts and information
processing levels).
Of additional value to the counseling profession is the
knowledge derived from a study based on a professional population
that shares many similarities in job function, level of education, and

personal characteristics as counselors. The Dictionary of Occupational

Titles (1991) classifies ministers as possessing similar levels of

specialized education for vocation and command of language and
mathematics as counselors, counseling psychologists, and social
workers. Ministers also share with the above professions humanistic
and artistic vocational descriptors. The findings of this comparative
study may, therefore, suggest the appropriateness of continued
research as a means of describing attitudes associated with

depression and professional burnout in the counseling profession.









Lastly, results of the study may be useful to the Presbyterian

denomination as it seeks to better understand the prevalence of

depression within its trained leadership. Any differences based on
moderating factors (e.g., race, gender, marital status, age, type of
service, tenure in the profession) may illustrate the need for targeted
interventions to assist specific populations. This information can also
clarify the value of developing curricula for students in the course of
their graduate, professional education and the provision of periodic

assessment and in-career educational opportunities for clergy
currently in service.
Purpose of the Study
The purpose of this study was to apply the cognitive theory of

depression proposed by Aaron Beck (1967) in an investigation of
depression in Presbyterian ministers. Specifically, this research was
designed to ascertain through the use of the Dysfunctional Attitude
Scale, a 40-item, self-report questionnaire developed by Weissman

and Beck (1978), the presence and level of dysfunctional attitudes

theorized to be associated with depression. Further, these attitudes
were evaluated as predictors of the current level of symptoms
associated with the syndrome of depression as measured by the
Center for Epidemiological Studies--Depression Scale (CES-D), a 20-
item, self-report assessment developed by the National Institute of
Mental Health (Radloff, 1977).
In addition, this research was conceived to determine whether
the levels of depression and dysfunctional attitudes in Presbyterian
ministers occur at a rate similar to a cohort of comparably trained









professionals in a help-giving vocation, namely, mental health

counselors.

Research Ouestions

Little empirical evidence is available to describe the levels of

emotional distress in ministers. In this study, the researcher sought

to contribute to this body of knowledge and explore the validity of a

cognitive theory utilized to explain the presence of syndromal

depression. To this end, the following research questions were

posed:

1. What is the level of current symptoms associated with the

syndrome of depression in Presbyterian clergy as measured by the

CES-D?

2. How does the rate of depressive symptoms in the clergy

sample compare to that of a sample of comparably trained help-

giving professionals, specifically mental health counselors?

3. To what degree are the dysfunctional attitudes proposed by

Beck's (1967) cognitive theory to be associated with depression

present in Presbyterian ministers?

4. How does the level of dysfunctional attitudes found in

Presbyterian ministers compare to that found in mental health

counselors?

5. To what degree does the relationship between the level of

dysfunctional attitudes elaborated by Weissman and Beck (1978)

and depression differ between Presbyterian ministers and mental

health counselors?









Definition of Terms
For the purpose of this study, key constructs and terms are
defined as follows:

An attitude is a tendency to evaluate an experience (concrete
or symbolic) in a specific way encompassing both an affective as well
as a predisposed behavioral response (Katz & Statland, 1959; Lott,

1973).
A cognitive theory of depression is a conceptual explanation of
depression based on the role cognition plays in the activation and
maintenance of a mood disturbance. The following constructs are

utilized to explicate the various dimensions of the theory.
1. Cognitive events are the automatic thoughts associated with

the encounter of an environmental stimulus. They comprise initial
impressions formed around concerns for the self-competency to cope,
the environment as a resource to problem solving, and the potential
of future well-being.

2. Faulty thinking styles are products of distortions in
screening and processing information. Utilization of these styles tend

to strengthen and reinforce erroneous viewpoints about a particular
stimulus though evidence to the contrary may exist.

3. Schemas represent fundamental values and biases that are
construed from past experiences. These schemas become patterns
for assessing one's experience with various stimuli and thereby
activate specific automatic thoughts and thinking styles in problem
solving.









4. A dysfunctional attitude is a negative distortion of seven

basic values hypothesized to be related to one's self-worth. These

negative schemas relate to the human needs for approval, love,
achievement, perfectionism, entitlement, omnipotence, and autonomy
(Weissman & Beck, 1978).
Depression is the presence of a mood disturbance associated
with the constellation of symptoms established by the Diagnostic
and Statistical Manual of Disorders (Third Edition, Revised)
(American Psychiatric Association, 1987) and, for the purposes of
this research, a total score of 17 or more on the Center for

Epidemiological Studies--Depression Scale.
A major depressive episode is a psychological disorder
characterized by feelings of sadness and loss of general interest.
These two symptoms must exist over a duration of at least 2 weeks
and include the addition of at least three of the following on a daily

basis: (a) significant and unexplained weight loss or gain, or decrease

in appetite, (b) either the inability to sleep, sleep disturbance, or
engaging in excessive sleep, (c) agitation or retardation of mental

and/or motor functions that can be observed by others, (d) a sense of
energy loss or fatigue, (e) a feeling of not being worthy or excessive

guilt, (f) a diminished capacity to concentrate and make decisions,
and (g) recurrent thoughts of death, suicidal ideation with or without
a plan, or an attempt. These symptoms must occur in the absence of
any organic explanation or nonmood congruent hallucinations or
diagnosis of thought or delusional disorder (based on the DSM IIIR
by the American Psychiatric Association, 1987).









Marital status is the concept used to designate a person's living
status by the following categories: (a) single--never married, (b)

married, (c) separated or divorced, (d) widow/er, or (e) other.

A mental health counselor, for purposes of this study, is
defined as a person holding membership (i.e., other than student
status) in the American Mental Health Counselors Association
(AMHCA), a division of the American Association of Counseling and
Development.

The Presbyterian Church (U.S.A.) is a member of the Reformed
theological tradition. The denomination is a product of the union of
the former Presbyterian Church in the United States and United
Presbyterian Church in the U.S.A. denominations in 1983.
Denominational offices are located in Louisville, Kentucky.

Racial and ethnic status is the determination of race or ethnic
status based on self-report in one of the following categories: (a)

Asian/Pacific Islander, (b) African-American, (c) Hispanic, (d) Native
American, (e) White (not of Latin origin), or (f) Other.

Spirituality describes the belief in a force or entity that is
perceived to be of greater stature and power than the individual.
Belief in this ideal compels the individual to search for a purpose and

meaning in life (Wittmer, 1989).

Tenure of service is the duration of service in the ministerial
profession since date of ordination into one's denomination of origin.
For mental health counselors, tenure is determined by length of
membership in the American Mental Health Counselors Association
(AMHCA).









The type of service is the classification of a minister's
employment function by one of the following categories: (a) parish-
or congregational-based or (b) specialized/institutional. Type of

service for mental health counselors is determined by inclusion in
one of the following categories: (a) counselor (direct services) or (b)

administrator/supervisor.
Limitations of the Study
The limitations of this study are bounded in its focus on a
specific group of ministers, those serving in the Presbyterian Church
(U.S.A.) denomination, the acquisition of a comparative sample of

mental health counselors belonging to the American Mental Health
Counselors Association, selection of a particular theory to explicate
the mental disorder of depression, the instruments utilized to assess
the current levels of depression and dysfunctional attitudes, and the
procedures incorporated to interpret the underlying statistical
relationships.
The goal of this study was to acquire a nationwide random

sample of ministers in active service to the Presbyterian Church
(U.S.A.). Adequate representation of key moderating variables (e.g.,
gender, tenure and type of service, marital status, and racial/ethnic

identity) was sought. Efforts were made to secure subjects in as
unbiased a fashion as possible to avoid contamination of the sample.
Similar rigor was applied in acquiring an equivalent sample of
mental health counselors for comparative study.
The design of this study took into consideration the goal of
maintaining, as far as possible, the value of construct validity.









Therefore, instruments and questionnaires incorporated to assess the
presence and level of depression and dysfunctional attitudes were
selected for their psychometric properties. Interpretation of the
statistical relationships were based on procedures that address
concerns for the management of error in various formats.

Finally, a number of theories exist that seek to explain and
measure the causation and symptom history of depression from
differing perspectives (e.g., genetic, hormonal, neurological,
behavioral, psychological, cognitive, and psychobiological)
(Marsella et al., 1987). Each of these approaches is supported by

theoretical and research evidence. The focus of this study, however,
was a cognitive theory proposed by Aaron Beck (1967). The
constructs of this theory were used to conceptualize those factors

that may explain the presence of syndromal depression and
relationships existing between cognitive factors and current state of
depression as moderated by several demographic and vocational
variables.

Summary

This chapter presents a rationale for a study of depression in

Presbyterian ministers and mental health counselors. The need for
this research has been grounded in empirical data that give evidence

to rising rates of mental distress in our society. Depression is
reported as one of the leading major diagnostic categories producing
significant losses in personal and economic productivity.
The results of current research describe the vulnerability
of helping professionals to job-related burnout and emotional









distress. Along with psychologists, mental health counselors, social
workers, and psychotherapists, clergy are susceptible to similar
impairments. While ministers are, in general, acknowledged and

valued as caregivers by society, little empirical evidence exists to
describe the state and complexities of their mental health. Trend
analysis of major medical insurance plans employed by ministers in
1990 and 1991, however, indicate increased rates of help-seeking
behavior on the part of clergy. Interventions for mental health and

substance abuse problems for ministers have been reported at rates
higher than the general population. A next logical step, therefore,
was to undertake an empirical study of this professional cohort to
describe the current levels of symptoms associated with the
syndrome of depression. Comparison of these findings with a

sample of similarly trained helping professionals (i.e., mental
health counselors) assisted in determining the significance of the
findings.

Finally, Presbyterian ministers subscribe to a set of theological
tenets that may attenuate the influence of cognitive factors

affecting the onset and maintenance of depression. It was
hypothesized that the strain associated with fulfilling often
ambiguously defined professional demands may compromise these
palliative beliefs. If this is the case, according to Beck's cognitive
theory, increased rates of dysfunctional attitudes associated with
depression could be expected. The next logical step was to undertake
an examination of the prevalence of these cognitive factors in
Presbyterian clergy. The additional investigation of the






31

comparative prevalence of these attitudes in mental health
counselors can also contribute to the existing body of knowledge
associated with this helping profession.













CHAPTER I
RELATED LITERATURE
Chapter Organization

The purpose of this chapter is to review literature pertinent to

a study of cognitive factors related to depression in a comparative
sample of two groups of helping professionals, Presbyterian
ministers and mental health counselors. This component of the study
includes discussion of the following topics related to the research: (a)
a definition and epidemiological description of the disorder
depression, (b) the criteria for the diagnosis of syndromal, unipolar

depression, (c) a conceptualization of Beck's cognitive theory of
depression, (d) research in the structural model of the cognitive
theory, (e) empirical research in the cognitive theory of depression
with emphasis on dysfunctional attitudes, (f) knowledge about the
mental health of ministers, (g) idiosyncratic beliefs in Presbyterian

ministers which may attenuate the onset or maintenance of

depression, and (h) a rationale for the selection of mental health
counselors as a comparison study group.
Depression

A Definition and Conceptualization of Depression
Melancholia has long attracted the attention of those who study
the human condition. Such diverse fields as theology, philosophy,
psychology, literature, the fine arts, medicine, and the life sciences in









varied ways have studied or depicted the affects of depression on
the human. Reus (1988) went so far as to suggest the history of
medical psychology itself can be characterized in terms similar to the
evolution of the conceptualization, diagnosis, and treatment of
depression.
Adolph Meyer has been attributed the distinction of being one
of the earliest persons to use the term depression as a diagnostic
label, circa 1906 (Kline, 1976). Meyer's terminology was used to
describe an emotional condition typified by a dysphoric or
suppressed mood. Previously characterized as melancholia and later
as a disturbance in affect, depression is currently classified as a

disorder of mood with the degree of severity based on the specificity
and period of symptom experience (American Psychiatric
Association, 1987). More commonly, depression can be understood
as a mood (i.e., feelings associated with loss or disappointment), a
symptom of coexisting physical or psychological disturbance, or in its
more chronic form as a disorder (Klerman, 1987)

Depression is conceptualized in a variety of ways by a number
of disciplines which have explored its origins, effects, and relevant

therapeutic interventions. Included in these fields of inquiry are
genetics, neurological biology, neuroendocrinology, pharmacology,
virtually all schools of thought in psychology, and in cross-
generational and psychosocial paradigms (Marsella et al., 1987;
O'Neil, 1984; Reus, 1988; Tsuang & Faraone, 1990; Willner, 1985).
For purposes of this study, depression was determined through
a multiaxial approach which incorporates signs and symptoms









commonly related to depression. The symptoms comprising the

syndromal constellation include a pervasive affective distress,
physiologic disturbance, disruption of normal psychomotor function,

and psychological distress (Zung, 1984). An additional purpose of
this study was to determine the prevalence and contribution of
cognitive features in depression. For Aaron Beck (1974) the
development of a coherent cognitive theory explaining depression
was contingent upon identifying a sequence to the various aspects of
the syndrome. Beck's cognitive theory does not abrogate the
presence of cofactors in depression such as neuroendocrine levels,
life strain, and genetic predisposition. He did, however, advocate
cognitive features as primary among equals in the cycle of
depression. In other words, a comprehensive understanding of
depression and its effective resolution must include consideration of
cognitive processes in its origin and maintenance.
Criteria by which to determine the presence and level of
depression for this research has been established by subjective
reporting of the severity and duration of depressive symptoms.
Assessment was accomplished through a self-report instrument with
demonstrable reliability and validity in the measure of the
syndrome, unipolar depression. Diagnostic criteria, established by
the American Psychiatric Association (1987), include the presence of
five of the following symptoms in the same 2-week period and
prevalent on a daily basis: (a) depressed mood, (b) marked
decreased interest in pleasurable activities, (c) significant loss or gain
in weight not attributable to dieting that represents more than 5% of









body weight in a 1-month period, (d) a lack of or overindulgence in
sleep, (e) fatigue or persistent energy loss, (f) feelings of excessive or
inappropriate guilt, (g) decreased capacity for concentration and
decision making, or (h) repetitive thoughts about death which may
include suicidal ideation, an attempt, or development of a specific
plan to take one's life. Either depressed mood or loss of interest in
pleasurable activities is required as one of the five key symptoms.
While other facets of depression may be present in varying
degrees (e.g., neurological and endocrinological functions, genetic
predisposition, familial dynamics), it was the subjective impression
of experience which was utilized in this study. Specifically, this
research was conducted to determine the level and prevalence of
self-reported depression within the comparative samples and the
contribution dysfunctional attitudes makes to these levels.
Epidemiology and Factors Associated with Prevalence of Depression
Depression is considered a mental health problem worldwide in
scope. The World Health Organization estimates that globally some
100 million persons suffer from a depressive disorder (Marsella et
al., 1987). Although widely diagnosed and treated, it remains
difficult to establish exact assessments of prevalence and incidence

rates. Variances in epidemiological data are attributed to differences

in conceptualization of the disorder (i.e., mood, symptom, or
disorder), the criteria for diagnosis, and measurement and reporting
procedures. Additionally, many reports are based on evaluations of
individuals who do not seek therapy and whose conditions are not
scrutinized by professional standards (Reus, 1988).









Although exactness in prevalence and incidence data is
arguable, the evidence of depression in the United States is indicative
of its magnitude as a health concern. The National Institute of
Mental Health (1991) has estimated 5.2% of the 28.9 million persons
suffering from a mental disorder during a 1-month period were
depressive in nature. On average, 8.3% of the adult population over
the age of 18 are expected to experience symptoms of depression
during their lifetime (NIMH, 1991; see also Myers et al., 1984).
Utilizing more clinically stringent diagnostic criteria, Reus (1987)
estimated the prevalence rate for women from 4% to 9% and men at
3%.
In a study of persons under care in specialty mental health
inpatient, outpatient, and partial care programs, depression

represented 22% of all diagnosis and 14% of all admissions (National
Institute of Mental Health, 1990). Yet, the number of persons who
seek help for depression may reflect only 10% to 25% of those in
need (O'Neil, 1984). About 12% to 20% of the population
experiencing an episode of depression go on to develop chronic
depressive syndrome, with approximately 15% of those persons

suffering depression for more than a month committing suicide
(Reus, 1988).

Outcome studies on depression suggest a significant
comorbidity with other ailments. A diagnosis of any psychiatric
disorder was related to an increased risk for some type of medical
illness (Hall et al., 1980). In a 12-month outcome study of patients
with major depressive disorder, up to one-half of the inpatients also









presented with symptoms of a coexistent, nonaffective psychiatric or

medical illness (Keitner et al., 1991). This compound depression
appears to be a common occurrence in inpatient treatment settings

and complicates the course of illness. The recovery rates of persons
with compound depression were found to be lower over 12 months
(Keitner et al., 1991).
Lewinsohn, Zeiss, and Duncan (1989) studied the probability of
relapse after recovery from an episode of unipolar depression. Of

the 1,078 subjects under study, 45% experienced a second episode
with 33% reporting a third bout. The recurrence rates proved higher
for women. However, men reporting a second episode proved as
vulnerable to a third as did their female counterparts. From the

results of the study, researchers determined that for the majority the
onset of a first episode occurred on or right before the 40th year of
life with earlier onset proving to be more severe. Age at onset,
however, did not prove a predictor for relapse. The survival time
between episodes was found to decrease with the frequency of
occurrences.
The results of long-term studies involving follow up of 2 to 5

years are no more optimistic. Keller, Klerman, Lavori, Coryell,
Endicott, and Taylor (1984) reported 21% of the subjects

demonstrated minimal recovery after 2 years. Of those not
recovering, most experienced severe depression throughout the 2-
year follow up. Coryell's (1990) findings over a 5-year period were
similar. Seventy-five percent of the subjects reported recovery for
at least 8 months, but only 33% remained well for 6 months









thereafter. Twenty-five percent of the subjects experienced no

recovery over the 5-year study. Factors determined to influence a
no recovery status include the coexistence of severe illness, a history
of nonaffective, psychiatric illness, low family income, inpatient

status, and the presence of psychiatric features (Coryell, 1990; Keller
et al., 1984).
In summary, both anecdotal and empirical data describe
depression as a significant and growing mental disorder in the United
States. According to Reus (1988), it is possible to distinguish a

pattern of increasing rates of depression over successive generations
throughout this century. Furthermore, a progressively earlier age of

onset also contributes to increased severity in the disorder. Marsella
et al. (1987) predict the incidence of mood disorders may continue to
increase as life expectancy is prolonged and the expansion of chronic
illnesses associated with depression occurs. The utilization of
medications which have depression as a potential side effect can also

be expected to contribute to greater reporting of the disorder.
Finally, as society undergoes changes in its economic and socio/

political structures, excessive demands for coping and adaptivity
may result in more depression over the lifespan.
The diagnosis and treatment of depression poses a significant
challenge to help givers. If as some authors suggest (e.g., Marsella et
al., 1987; O'Neil, 1984; Reus, 1988) the majority of clinically
depressed persons fail to seek or receive needed help, a logical next
step is to seek more knowledge regarding these factors. This study
was conducted to describe attitudes that influence the onset and









maintenance of depression and contribute to the potential

therapeutic and educational gains from such knowledge.
A Conceptualization of Beck's Cognitive Theory of Depression

Since its introduction, Beck's (1963) cognitive theory of
depression has been studied extensively (e.g., Beck, 1964, Beck, Rush,
Shaw,& Emery, 1979; Meichenbaum, 1977; Persons, 1989). Beck's
theory incorporates cognitive appraisal and the contributions of
information processing into a comprehensive explanation of
individual adaptation and change. Subsequent developments in the
theory by Beck and others have expanded the application of
cognitive approaches to fields other than mood disorders. Although

not exhaustive, a survey from recently published handbooks on
cognitive therapy (Dobson, 1988; Freeman, Pretzer, Fleming, & Simon,

1990; Freeman, Simon, Beutler, & Arkowitz, 1989) included
treatments on the following topics: (a) cognitive assessment, (b)
combined cognitive therapy and pharmacotherapy strategies, (c)

restructuring cognitions in conjunction with stress reduction
approaches, (d) treatment of personality disorders, (e) the
assessment of suicidal ideation and lethality, (f) cognitive therapy for
anxiety and eating disorders, as well as (g) cognitive approaches for

the treatment of sexual dysfunction, control of chronic pain,
problems associated with the elderly, family systems, and women's
issues.

Such a wide array of applications suggests the popularity of
cognitive theory as a fundamental approach to conceptualizing the
origin of human problems and change processes. Proponents of the









theory cite its flexibility in considering the multiple factors which

impinge on an individual's capacity for problem solving and coping

(e.g., environmental, genetic, learning, social).
Developmental Models of the Cognitive Theory
Research in the cognitive theory of depression has stemmed

out across several emerging models. Beck (1987) described the six

major models as the cross-sectional, structural, stressor-
vulnerability, reciprocal-interaction, psychobiological, and
evolutionary paradigms. Each is considered distinctive yet shares
various aspects of conceptual framework and symbols with the
others. This research study utilizes one of the six approaches,

namely, the structural model. The following overview of the models

affords a basis for comparison and, more specifically, a rationale for
the selection of the structural model as the theoretical framework for
this research.
The cross-sectional model. The cross-sectional model asserts a

constellation of affective, cognitive, and behavioral experiences are
related in a way which constitutes a pattern of emotional response.

This model was initially proposed by Beck (1967) as a means of

explaining the presence of automatic negative thought constructs and

an emergent pessimistic view of self, experience, and future in
depressed persons. From his observations Beck constructed the idea
that a logical sequence of negatively biased thinking accounted for
the deepening intensity of cognitive and emotional despair.
This model also proposes that a person's processing of stimuli

becomes biased by faulty thinking styles which thereby result in the









preselection of negative events which reinforce depressogenic
interpretations (Beck et al., 1979). Dysfunctional information

processing is characterized by several styles. These styles are
described as follows, each with an accompanying example: (a) the
selective abstraction of content and experience (e.g., the minister
paid attention to everyone else), (b) a stereotypical interpretation of
the event (e.g., she must think they deserve more attention than me),
(c) one's thinking in polemic and judgmental terms (e.g., the minister
doesn't like me), (d) the overpersonalization of experience (e.g., she
must think I'm unattractive), (e) a gross generalization of the

consequences of an event (e.g., if I'm that unlikeable, no one likes

me), and (f) the creation of a negative prediction of the future based
on low self-worth and effectiveness (e.g., there's likely nothing I can

do to ever make me more attractive to others). The cross-sectional
model advocates that it is these errors in logic which consistently
shore up themes of loss and despair and result in the prevalence of

the cognitive triad in depressed persons.

The structural model. The structural model of cognitive theory
describes a continuum or axis of depression on which particularly

powerful, underlying beliefs or enduring rules of behavior influence

the processing and interpretation of environmental stimuli. Beck
(1963) identified these constructs as depressive schemas. He
suggested these idiosyncratic schemas influence the activation of
thought-content bias and illogical information processing. Karasu
(1990) depicted these schemas as structures which are comprised of
"silent assumptions rigidly held, nonverbal, covert and axiomatic."









Krantz's (1985) definition of schema shifted emphasis to the
resistance of schemas to change even when life circumstances dictate
otherwise. He viewed schemas as predisposing attitudes or basic

rules which are relatively independent of life's circumstances.
According to the structural model, dysfunctional or

predisposing attitudes are conditional in nature, activated only in the
presence of relative circumstances. Zuroff and Mongrain (1987)
described this relationship between attitude and stimulus as a
principle of specificity. For example, the absence of collegial support
in a conflict situation may activate the basic rule, "If unlike, I am
unworthy." As the continuum of depression is described, it is this
schema which when prompted by circumstances influences the
dysfunctional processing of further information. Even information
which might counter the initial perspective is selectively screened,

thereby shading reality in more foreboding tones. Dysfunctional
attitudes are viewed as dormant, therefore, until such time as
stressors perceived as loss or failure precipitate their articulation.
Beck (1983) suggested differences in personality may account
for the types of stressors that potentiate relevant schemas. A

sociotropic person, one who places value in the quality of
interpersonal relationships and measures self-worth based on the

acceptance, praise and affection of others, is likely to be affected by
events whose themes include interpersonal conflict, loss of
attractiveness, and distrust. In comparison, the autonomous
individual places a high premium on independence, self-

determination, task oriented-success, and status. Stressors









associated with loss of freedom in decision making, change in reward

systems, threat to physical mobility, or status may prime

depressogenic schemas.
Whether sociotropy or autonomy are best conceptualized as
discriminant types or as a continuum of preferences is arguable.
Results of several studies indicate substantial percentages of persons
diagnosed as depressed do not fall into the differentiated types but
are classified as mixed in their personality profiles (Goldberg, Segal,
Vella & Shaw, 1989; Hammen, Ellicott, & Gitlin, 1989).
In summary, the structural model elaborates the primary
continuum of depression with idiosyncratic schemas, or dysfunctional

attitudes, serving as the foundation. When these enduring beliefs
are negative in content, they predispose an individual to stressors
which reinforce their negative belief system. Further, these schemas
result in a negatively biased processing of incoming stimuli from the
environment resulting in more critical views of self, experience, and
future. The model also postulates a continuum in personality types

between sociotropic and autonomous persons which may account for
the types of stressors which activate dysfunctional schemas.

The stressor-vulnerability model. The stressor-vulnerability
model focuses on the specific experiences which potentiate a person's
vulnerabilities. The identification of which stimuli precipitate
depressive responses must take into account the distinctive social
and psychological conditions which shape a person's underlying
belief systems. For example, understanding a threat to a person's
sense of fulfillment requires some knowledge of the history of









pertinent support and reward systems. The schema, "If I fail, I am
unworthy," becomes salient only in the presence of stressors which

are historically relevant to the individual. According to Beck (1987),
some individuals appear more vulnerable to depression because
underlying depressogenic attitudes are the product of longstanding
and intense exposure to relevant stressors. This may explain the
chronic dysthymia, persistent self-negation, and destructive
behaviors attributed to adults victimized by physical, sexual, and
emotional abuse (Beck et al., 1979).
The stressor-vulnerabiliity model also advocates for the
importance of identifying distinctions between persons depressed
with identifiable stressor content (i.e., exogenous or reactive type)

and those persons lacking any definitive sources of stress. Beck
(1987) noted the possibility existed that biochemical deficiencies
may be a causative factor in what is traditionally viewed as
indigenous depression. However, the stressor-vulnerability model

does not rule out a possible explanation that persons psychologically
predisposed to depression may, as a result of cognitive deficiencies
and faulty thinking styles, become more vulnerable to various

biological variables.
The reciprocal-interaction model. The reciprocal-interaction
model, addresses the effects which significant others play in the way
a person maintains a negative loop of perception and depression
behaviors. This is a systemic approach to conceptualizing how the
overt and covert behaviors of others is requisitioned into the
cognitive triad (i.e., a pessimistic view of self, past and present









experience, and control of future) which is symptomatic of the

depressed person. In describing the application of cognitive therapy
within the group system context, Wessler and Hanklin-Wessler

(1989) liken the client's construction of reality to the mind of the
artist. The artist perceives the objective and creates a unique
construction of what is assumed real in his or her mind. This model
seeks to clarify the interpretation of messages (i.e., the artists sense
of reality) and examine the effects of feedback from other persons in
the social system on altering or sustaining conditions which support
one's construct of reality.
Epstein and Baucom (1989) characterized the importance of
idiosyncratic interpretations and attributions in a marital system as
one of the two basic reasons cognitive theory is becoming popular in
couple's therapy. Spousal interpretations based on either distorted
or invalid perceptions are considered amongst the chief causes of
dysfunctional behavioral in marital systems. The restructuring of
these cognitions and their reciprocal responses on the part of each
member in the system is fundamental in balancing and maintaining a

regulated, therapeutic change.
The psychobiological model. The psychobiological model of the
cognitive theory of depression represents an effort to synthesize the
study of the cognitive and biological dimensions in depression.
Approaches to understanding depression as either solely a product of
cognitive distortions or biochemical imbalances have increasingly
given way to more collaborative models.









Beck (1987) characterized these multidimensional inquiries
into the etiology of depression as merely viewing the same problem

from different sides. Wright and Schrodt (1989), however,
attributed the increase of cooperative theoretical and therapeutic
efforts to understand depression to scientific, economic, and market-
driven factors. They also noted that findings of research suggest
depression and other disorders are likely best understood as a
collection of psychological and biological functioning which interact to
create symptomatic patterns. Wright and Schrodt (1989) cited the
works of several authors which support a combined therapeutic

approach based on this model (see Akiskal & McKinney, 1975; Beck,
1985; Wright, 1987).
The evolutionary model. The last of the models may best be

understood as a species evolutionary approach to conceptualizing
depression. Accordingly, symptoms of depression are viewed as a
contradiction of drives in the human species, the impulses to acquire
pleasure, procreate, derive nourishment, and thrive. Beck (1987)

suggested depression may be a systematic slowdown related to a
biological conservation of resources during unusually stressful
periods.
Experiences related to the human need for bonding and status

affect perceptions along pathways which may be either supportive or
disruptive. In disruptive circumstances, an individual may feel
threatened by rejection or loss of importance to others and,
therefore, alter cognitive appraisal and risk-taking behaviors. It is

possible that this temporary withdrawal is necessary to protect the









person from the potential of further harm. If withdrawal persists,
that is the individual begins to fail in fulfilling the social contract,
then the reciprocity of getting needed resources from the social
milieu is threatened and the cycle of depression becomes chronic.
Beck (1987) further suggested the symptoms of futility, anhedonia,
and fatigue in depressed persons may be grounded in exaggerated or
distorted expectations of anticipated rewards and social support.
In summary, this discussion outlined six models utilized to
operationalize research in Beck's cognitive theory of depression.
They represent separate but overlapping descriptions of the onset
and maintenance of the disorder. The contribution of maladaptive
schemas as an aspect of the structural model is of particular

relevance to this research. While not singularly causitive of
depression, these underlying beliefs are associated with depression.
An important question to this study is, therefore, the effect of these
attitudes on persons who by virtue of their profession ascribe to a
systematic belief system whose beliefs are counterposed to the
maladaptive schemas described by Beck and other researchers.

Research in the Structural Model and Contributions of Dysfunctional
Attitudes in Depression

The purpose of this research is to apply Beck's cognitive theory
of depression in an investigation of depression in Presbyterian
clergy. An aspect of this inquiry is the contribution dysfunctional
attitudes make in a concurrent measure of depression. The
structural model of Beck's theory asserts that these strong
underlying beliefs or rules for behavior influence the processing of









information and are rigid and resilient to changing life circumstances
(Krantz, 1985). Further, they have been shown to be associated with

negative information processing and depression (Weissman & Beck,

1978).
The structural model also proposes that depressogenic attitudes
are activated when their conditional attributes are met. For example,
the schema, "I need to be loved," is confounded when persons who
are subjects of mutual affection engage in conflict. Faced with a
prospect of being found unacceptable, the person holding such a
schema may produce distorted cognitions confirming the

depressogenic attitude. Beck et al. (1979) asserted this triggering

event resulted in the deterioration of logic and information
processing and biased the individual toward unfavorable

interpretation of their circumstances.
Haaga, Dyck, and Ernst (1991) in a meta-analysis of research in
the cognitive theory of depression created a distinction between the
descriptive and causal features of depression. Descriptive features

include the cognitive aspects of depression commonly found across
research populations of depressed persons. These features are

characterized by automatic thoughts which are manifested in a
pattern of negative construction in one's perception of self, past and

present experience, and control of the future. Beck (1963) termed
this constellation the cognitive triad of depression. Hypotheses
tested in studies of descriptive features of cognitive theory include,
among others, the presence and levels of negative thinking,
components and contributions of the cognitive triad, biased thinking









processes (e.g., encoding, recognition, and recall), and hopelessness

and suicidality (Haaga et al., 1991).
Cognitive schemas are conceptualized by Haaga et al. (1991) as

causal features of depression. The use of the term causal in this
study is restricted to explicating the linkage between schemas and
the logical sequence of processes resulting in depression.
Depressogenic attitudes are viewed, therefore, as a precipitative

factor in the cognitive symptoms associated with depression.
Perris (1989) emphasized the importance of schemas as
cognitive organizations which are grounded in prior experience.
These perceptual patterns serve to frame a person's future encounter
in similar situations. The schemas may facilitate efficient approaches
to repeated or novel stressors. These beliefs, however, have the
negative effect of exaggerating the severity and threat of a current
stimulus based on recall which has become unfavorably biased over

time. Dysfunctional schemas, then, when activated by content

consistent circumstances, fuel the sequence of cognitive processes
which are associated with depression.
Much of the current trend of research in the structural model is

to establish dysfunctional attitudes as a causitive agent or linkage
agent in the developmental sequence of depression. The nature of

depressogenic attitudes as covert beliefs, however, presents
problems in measuring the presence and level of the attitudes prior
to the onset of depression. In their review Haaga et al. (1991) found
little evidence to support the notion that schemas are causitive

agents in depression. Nevertheless, they indicated such a hypothesis









cannot be ruled out until more sophisticated design methodologies

are employed which utilize prodomal priming of attitudes,
longitudinal study with interval measures, and consideration of
personality factors and stress variables.
It was not the purpose of this study to test the causality thesis.
The focus of this research was to assess the contribution which

schemas make to a concurrent measure of depression in comparative
populations. Further, this study is designed to acquire knowledge
about a professional cohort heretofore little studied from the
perspective of cognitive theory. Little is known about the interaction
of ideational-based belief systems and depressive attitudes.
Presbyterian ministers represent a population of persons who
espouse an overt belief system which may mitigate the influence of
dysfunctional beliefs identified by Weissman and Beck (1978). The
results of this study may clarify whether their belief system is a
benefit in moderating the association of dysfunctional attitudes and

depression.
Dysfuntional attitudes and depression. Dysfunctional attitudes
have been related to current measures of depression in a number of
studies (Bowers, 1990; Eaves et al., 1984; Levine & Wetzel, 1986;
Peselow, Robins, Block, Barouche, & Fieve, 1990; Power, 1988;
Weissman & Beck, 1978; Wierzbicki & Rexford, 1989). Simons,
Murphy, Levine, and Wetzel (1986) in a 12-week study comparing
cognitive therapy and pharmacotherapy for depression established
high dysfunctional attitude scores were related to depression.
Weissman and Beck (1978) also determined a relationship existed









between depression and dysfunctional attitudes in their study of

college students. In a study of symptomatic and remitted unipolar
major depression subtypes, Eaves and Rush (1984) found higher

scores on the Dysfunctional Attitude Scale (DAS) among symptomatic
depressed persons than the nondepressed group. Similar results
were found in a study comparing symptomatically depressed,
clinically remitted, and normal controls (Dohr & Rush, 1989).
Results of a study of dysfunctional attitudes in depressed

patients before and following clinical treatment compared to normal
controls established depressed subjects as having higher initial DAS

scores than the normal control group (Peselow et al., 1990). Findings
in the study also established the tendency of measures of
dysfunctional attitudes to diminish over the course of treatment.
Posttreatment scores on the DAS of symptomatic subjects compared
favorably with the controls. Miller, Norman, and Keitner (1991),

assessing the effectiveness of cognitive therapy with depressed
inpatients, also described a decrease in DAS scores over the course of
treatment.
In a 4-month longitudinal study, Power (1988) determined the

measure of dysfunctional attitudes correlated with depression

symptoms at both the pre- and postmeasures. The DAS scores,
however, were not significantly related to depression at the
postmeasure when symptoms at the first measure were controlled
for. Power concluded that while dysfunctional attitudes may be a
marker for a possible episode of depression or anxiety, they could

not be construed as primary causes.









Stability of dysfunctional attitudes. The results of several
studies have asserted the stability of measured levels of maladaptive
schemas, that is, the consistency of mean individual mean scores,
when compared to self-reported symptoms of depression (Dobson &
Shaw, 1986; Oliver & Baumgart, 1985; Weissman, 1980; Weissman &
Beck, 1978). Dobson and Shaw (1986) found the scores of the DAS
stable for 60 days, and Keller (1983) observed subjects high in DAS
scores at outset remained relatively so at follow-up. Hamilton and
Abramson (1983) recommended that future studies which consider
the significance of attitudes as causal agents must develop variables
to account for the stability of the DAS scores (e.g., mood state,
therapeutic interventions, environment in which study is
undertaken, and intervals of measures).
The sensitivity of the DAS to changes in dysfunctional schemas
has been observed in a number of studies (Bowers, 1990; Eaves et al.,
1984; Power, 1988; Reda, Carpiniello, Sechiaroli, & Blanco, 1985).
Longitudinal studies of 12 weeks and 4 months by Simon et al.
(1984) and Power (1988), respectively, established a decreasing
trend in DAS scores. In the Simon et al. study (1984), the DAS
outcomes and other measures decreased in both cognitive and
pharmacotherapy groups. This trend in DAS scores was also found in
a study utilizing pharmacotherapy by Reda et al. (1985). In a
comparison study of subjects receiving cognitive therapy with
medication, relaxation with medication, and medication only
treatment modalities, Bowers (1990) observed scores on the DAS
decreased over the course of the interventions.









Several studies have also determined the DAS to be sensitive to

decreases in the level of dysfunctional schemas following the
remission of symptoms (Dohr & Rush, 1989; Eaves et al., 1984;
Silverman, Silverman, & Eardley, 1984). This propensity for DAS

scores to diminish over the course of treatment has led some
researchers to challenge Beck's original idea that schemas are
enduring trait like structures (Hamilton & Abramson, 1983; Miranda
& Persons, 1988). Miranda, Persons, and Byers (1990) concluded
from a study on the endorsement of dysfunctional beliefs that while
these attitudes were markers for vulnerability to depression, they
exhibited a dependency on mood state. Yet, other researchers
described the change in scores over time as evidence that
dysfunctional attitudes are activated and measured only during the

period of florid symptoms (MacDonald, Kuiper, & Olinger, 1985; Reda
et al., 1985).
Dysfunctional attitudes, negative life experience and stress.

The study of an interactive relationship between dysfunctional
attitudes and negative life experiences with depression is relatively
new. Wise and Barnes (1986) determined a significant interaction

between dysfunctional attitudes, negative life experience, and

depression existed in a sample of normal college students. A clinical
sample in the same study reflected both the scores on the DAS and
negative life stress exerted independent effect on mood. In a similar
study of undergraduate students, Barnett and Gotlib (1988a) found
dysfunctional attitudes moderated the relationship between stress
and mild symptoms of depression. Results of a study by Robins and









Block (1989) also determined a relationship existed between scores

on the DAS, perceived stress of events, and depression.
Kuiper, Olinger, and Swallow (1987) hypothesized that an
increase in anxiety would result from increased levels of stress
associated with public self-consciousness and lead to the increased
potentiation of dysfunctional attitudes. Subsequent research
confirmed increased scores on the DAS were correlated in vulnerable
individuals with relevant life events (Olinger, Kuiper, & Shaw, 1987).
In a study of clinical and nonclinical populations, Wierzbicki and
Rexford (1989) established a correlation between depressogenic
attitudes, frequency of pleasant activities, and level of depression.
Barnett and Gotlib (1990) described a combination of high levels of

dysfunctional attitudes and concurrent low social support in a sample
of women to be related to depressed mood.
Suicidality. Dysfunctional attitudes have also been studied as a
factor in suicidal ideation. Ellis and Ratliff (1986) studied the
cognitive characteristics of suicidal and nonsuicidal persons in a

psychiatric inpatient placement setting. Scores on the DAS were
found to be one of the highest contributions discriminating between

the two populations. The level of dysfunctional attitudes were
higher on suicidal patients with attitudes embracing perfectionism,
approval, achievement, and entitlement.
A comparable study of psychiatric patients was undertaken by
Ranieri, Steer, Lawrence, Rissmiller, and Piper (1987). Levels of
dysfunctional attitudes contributed, along with degree of depression,
unique discriminant variance. Six attitudes representing









perfectionism and sensitivity to social criticism on the DAS explained
77% of the variance considered in assessing suicidal risk. The results
of the study were similar for both inpatient a;n outpatient samples.
Dysfunctional attitudes and eating disorders. Cognitive theory

has also been applied to conceptualizing factors associated with
eating disorders, a disorder often associated with varying degrees of
depression. Results of research by Goebel, Spalthoff, Schulze, and
Florin (1989) established dysfunctional schemas to be one of the
predominant factors in bulimic females in their study. The level of

DAS scores were not, however, found to be predictive of the severity
of the disorder. Mean scores on the Eating Disorder Inventory
developed by Garner, Olmsteat, and Polivy (1983), a measure of
attitudes associated with eating, were also found to be higher in
anorexics when compared to other psychiatric outpatients (Cooper,
Cooper, & Fairburn, 1985). Additional studies have addressed the
role of residual attitudes in therapy effectiveness in the remission of
eating disorders (Freeman et al., 1989).
Dysfunctional attitudes as a predictor variable. Some

researchers suggest caution when utilizing levels of dysfunctional

attitudes as a predictor of vulnerability and psychological state. In
studying dysfunctional schemas and attribution style in healthy
controls and persons diagnosed with a thought disorder, depression
with psychiatric features, and nonpsychotic depression, Garner,

Coryell, Corenthal, and Wilson (1986) established no difference
between the depressed populations. They determined future studies
need to specify whether the vulnerability status accorded








dysfunctional attitudes are symptoms of depression or a coexistent
depressive illness.
Outcomes of other studies point to more direct findings about a
relationship between dysfunctional attitudes and depression. O'hara,
Rehm, and Campbell (1982) found scores on the DAS to be a
predictor variable of postpartum depression in mothers 3 months
after date of delivery. Parker, Bradshaw, and Bignault (1984)
established the presence of higher scores in a measure of
dysfunctional attitudes were related to increased severity of
depression. Rush, Weissenburger, and Eaves (1986) concluded that
dysfunctional attitudes may predict subsequent vulnerability to
depressive symptoms or be more sensitive to subsequent
psychopathology than the classical signs.
In a comparison study of cognitive therapy and
pharmacotherapy, Simons, Murphy, Levine, and Wetzel (1986)
identified high scores on dysfunctional attitudes as one of the
independent variables associated with relapse following 12 weeks of
therapy. Norman, Miller, and Keitner (1987) found high DAS scores
to be related to greater severity of depression, more days in the
hospital, and increased likelihood of readmission. Peselow et al.
(1990) also confirmed prior findings that higher initial DAS scores
were associated with poorer response to treatment. In a study
discriminating between cognitive vulnerability and depression,
Swallow and Kuiper (1987) determined only subjects scoring higher
on the DAS saw themselves as less similar to others as their
symptoms of depression increased.









In summary, this portion of the chapter provided evidence in
the literature that depression is a significant mental health concern.

Epidemiological data describe the disorder as a growing problem
with associated personal, economic, and social costs. Several models

of Beck's cognitive theory of depression are described as efforts to

conceptualize the onset and maintenance of depression. Further, a
rationale has been provided for the selection of the structural model
of Beck's theory as the theoretical framework for research questions
posed by this study. A review of the research literature associated
with the structural model and dysfunctional attitudes was provided.

Although debate exists regarding the status of dysfunctional
attitudes as a primary cause of depression, there is more than

adequate research evidence to demonstrate a relationship between
the presence of these attitudes and depression. Further, results of

studies have established some capacity for dysfunctional attitudes to
serve as a marker for the onset of depression and an indicator of
changes toward remission.

This study had, as one of its goals, an inquiry into the capacity
of belief systems to serve as attenuating influences on the

development of depression. This was an important logical next step

toward better understanding the interrelationship between both
negative and positive dimensions of cognitive processes and their
effects on emotional health.
Mental Health and the Religious Professional

By some estimates there are between 350,00 and 537,00 clergy
in the United States (Jacquet, 1991; National Council of Churches cited









in Whittemore, 1991). These men and women are modern-day
representatives of a profession which spans thousands of years and
diverse cultures and belief systems. Some are the products of
rigorous selection processes, advanced graduate educations, and
detailed initiation procedures. Yet, others gain admission to the
profession by virtue of their personal charisma or less formal
recognition by a local religious organization.
As old and diverse as the ministry is, little is known about the
mental health of its professional membership. Much of the literature
associated with the profession is anecdotal or autobiographical in
nature. Often the goal of such material is to assist clergy in
addressing the needs of others or to clarify the vicissitudes of their
vocation. It is less frequently aimed at empirically assisting the
practitioners in understanding their particular vulnerabilities (e.g.,
Gaddy, 1991; Hart, 1984; Holden et al., 1991; McCandless, 1991;
Timmerman, 1988).
In the decade of the 1950s, however, concerns were raised
about the rates and factors associated with clergy leaving their

profession. In initial studies, Blizzard (1956, 1958) began to isolate
stress associated with role confusion and overload as components in
decisions to withdraw from the ministry. Blizzard's work was
subsequently followed by similar efforts to establish benchmarks for
better understanding the various aspects of the clergy's work and
models of ministry (e.g., Strommen & Schuller, 1980; Webb, 1967).
Bergin (1983) and Blackmon (1988) identified several factors
which tended to limit the generalizability of outcomes in the earlier









studies. Among the limitations were a lack of sophisticated research
designs and data analysis, limited pools of subjects, poor response

rates, restrictions imposed by denominations, and a lack of clearly
defined constructs. Further, the modernist debate between the
traditional structural and emerging behavioral schools of psychology
tended to deemphasize the purview of religion and spirituality as
important aspects of personality.
There is, however, recent increased interest in the roles which
religion and spirituality play in human development and

adaptability. The articles in several professional journals (e.g.,
Gilchrist, 1992; Keating & Fretz, 1990; Miller, 1992; Thorson &
Powell, 1989; Worthington, 1989) have suggested the importance of
religious conviction in the consideration of assessment, diagnosis, and
development of treatment strategies. A logical extension to this field
of inquiry is to acquire more knowledge about the professional
cohort which most influences the transmission of religious and

spiritual values, namely, the clergy.
Conceptualization of the Profession
Malony and Hunt (1991) described an evolution in the public
stereotypes utilized to describe ministers. These images were
described as the following: (a) the common man of the westward

expansion movement who embodied the values of a democratic
society, (b) the refined and learned gentleman of the late 1800s,
(c) the great achiever of the revivalist period in American history,
(d) the social change agent of the reform period in the decades of the
1960s and 1970s, and (e) the current view of minister as









organizational manager. Each of the images in their own way

captures the various aspects of the profession. It was this diversity

of images and confusion of self-understanding that Blizzard (1956,
1958) found to be problematic for many clergy. Jacquet (1991) cited
Donald Smith's (1973) appraisal of the ministry as one of the few
professions which requires such a broad range of skills and styles of
activities.

The Dictionary of Occupational Titles (1991) identifies the
following functions associated with ministry: (a) provision of
spiritual and moral guidance, (b) preparation and delivery of public

addresses, (c) interpretation of doctrine, (d) instruction of children,
youth and adult populations, (e) administration of religious and
secular rites and rituals (e.g., sacraments, weddings, funerals), (f)
visitation of the sick, (g) counseling of the distressed and bereaved,

(h) service to the poor, (i) administrative oversight of an
organization and personnel, and (j) work in community
development.

Gaddy (1991) and Hart (1984) pointed to these multiple
functions and the clergy's self-expectations about personal
performance as key components in their distress. Similarly, Blizzard

(1958) found the inability of clergy to establish a master role around
which to identify as a professional to be a significant factor in their
decision to withdraw from the vocation. Historically, it has been the
questions regarding the effects of these occupational responsibilities
on the well-being of the minister which have spawned the most
research on the profession.








Occupational Roles
Results of Blizzard's research (1956, 1958) clarified what many
clergy had long acknowledged regarding the multiple roles of the
profession. A lack of boundaries and clear expectations were
inherent sources of identity confusion. The outcome of Webb's
(1967) efforts to describe more specific role functions yielded 10
aspects to the work of the minister. These roles included (a)
counselor, (b) administrator, (c) teacher, (d) scholar, (e) evangelist,

(f) spiritual guide, (g) preacher, (h) reformer, (i) priest, and (j)
musician. A comparison of Webb's roles to those elaborated by the
Dictionary of Occupational Titles (1991) demonstrates considerable
overlap in description of functions.
In a study of how clergy use their time, Merrill and McNally
(1980) utilized similar roles as those defined by Webb (1967) and
established a rank order by which clergy perceived importance in
their work. The estimated percentage of time expended on a weekly
basis is noted in parentheses. In order of most to least influence the
results of the study were (a) preacher (20), (b) pastor (18), (c)

theologian (14), (d) marketer (4), (e) administrator (34), and (f)
traveler (11). Administrative functions were determined to extract
more of the ministers' time than any of the roles perceived as more
important. An obvious conflict between roles considered by the
clergy to be important and the demands of the work existed. A
study by Gauster, Fusilier, and Mayes (1986) determined that role
conflict of this nature and ambiguity in the definition of roles when
combined with the under utilization of skills and interests were









associated with higher indices of distress in mental and physical
health.

As part of a nationwide study of clergy entitled the Readiness
for Ministry Project (see Schuller, Strommen, & Brekke, 1980),
Aleshire (1980) described 11 areas of ministry, 9 of which were

determined to be positive indicators of successful practice. Two
aspects were described as impediments to effective practice. Ranked
in order of importance, the positive dimensions were (a) an open and
affirming style, (b) caring for people in distress, (c) provision of
congregational leadership, (d) being a theologian in life and thought,
(e) exemplifying a personal commitment of faith, (f) developing faith
and worship, (h) possessing an awareness of denominational or
sectarian tradition and government, (i) engaging in ministry to the
community, and (j) practicing the priestly and sacramental roles.
Embodying a privatistic and legalistic leadership style (i.e., isolated
and domineering) and possessing disqualifying personal and
behavioral characteristics (e.g., an undisciplined and irresponsible
lifestyle, pursuit of personal advantage) were found to be negative
markers for competent practice.

Hart (1984) included in his description of the occupational risks
associated with ministry the notion that there existed few clear
boundaries between roles associated with work and the minister's
personal life. Addtionally, Shuller et al. (1980) concluded from their
findings that the primary cause of role conflict was the reality that
clergy face the same limitations as those with whom they work and
serve. Yet, the pastoral roles demand an absence of such limitations.









This inability of ministers to clarify these boundaries and

moderate stress related to the work lead some clergy to withdraw

from the profession. Results of recent studies suggest dropout rates
to range upwards to 30% in some denominations (Williams, 1988).
This figure may not include the number of ministers relieved from
their duties for varying periods for incapacitation. In the article
entitled "Ministers Under Stress" published in Parade Magazine
(April, 14, 1991), Hank Whittemore reported a 31% increase of clergy
terminations in an 18-month period ending in 1989 in one
denomination, the Southern Baptist Convention.
According to Whittemore (1991), each member in a church

appears to possess a different set of perceptions and expectations as
to what the role of the minister should be. Although the differences
at individual levels may be small, the combined effect is viewed as
overwhelming by some clergy. It is the minister's inability to meet

the expectations of their congregation combined with little objective
standards for performance evaluation which exacerbates professional

and comcomitant personal stress.
Lifecycle of the Profession
Early study in the diversification of roles and its effects on

professional well-being led to inquiry regarding the developmental
phases of the vocation. As there are pivotal moments of change in
the course of human development, it was thought that periods in the
ministers lives may exist when they were more vulnerable to the
stress associated with their profession. In a study of the reasons
pastors left their profession, Jud, Mills, and Burch (1970) developed a









four-stage model for professional development with two key

stressful triggering events. Each of the stages was determined to
incorporate specific risks to the minister. Thus, graduation from
seminary through the first 2 years in the field required adjustment
from the theoretical to applied contexts where individual

competency and flexibility were prone to be tested. Three to 5 years
after graduation ministers typically evaluated their degree of

progress in light of promotions and increased responsibilities. This
often resulted in a refinement of career goals based on factors
including finances, family situation, degree and type of feedback
received on performance, and marketability as a professional. At
approximately the age of 40, ministers tended to assess their career
goals with an eye toward peak earning capacity. This period was
especially sensitive to expanding family needs as children began to

exit the family for higher education. Little distinction was made
between the anticipation for retirement and the actual event as
clergy tended to continue laboring during their retirement years,
albeit at somewhat reduced levels. This period was found to be
representative of a heightened insecurity about personal health, and

loss of vocational identity and collegial support system.

Jud et al. (1970) described three specific triggering events
which tended to exacerbate stress during these stages of professional
development. First, moving to a new placement, though possibly
symbolizing promotion or the removal of existing interpersonal
conflicts, also meant uprooting and leaving stable support systems
for the minister and members of the family. Second, conflicts









between the clergy and congregation often resulted in ministers
questioning their self-esteem, character, and integrity. During these

periods of conflict, unresolved personal issues also often surfaced.
Lastly, changes in denominational structures which determined
movement, promotions, status, and support often shifted the familiar

basis of power and decision making. The experience of any or a
combination of these triggering events tended to potentiate the risks
associated with the existing developmental phase of the minister.
Malony, Newton, and Hunt (1991) refined a five-stage model of
ministry which included periods for academic or mentor preparation
in college or seminary, entry level experience of 3 to 5 years,
advancement symbolized by moves to larger churches during the
minister's 30s and 40s, a maintenance of status during late midlife
through the early 60s, and a period of decline in responsibilities from
the late 50s into the 70s.
In a discussion on the relationship of commitment to longevity
in the profession, Malony et al. (1991) cited an unpublished study by

Dean Hoge, John Dybel, and David Polk in which researchers
questioned clergy on their consideration of leaving their existing
parish or the vocation. Results of the survey indicated that within

the last year, 26% of the respondents thought they would like to
leave, 13% were considering a move, and 10% were actively pursuing
a move from their current location. In the same survey, 9% of the
clergy were uncertain they would enter the ministry again while 4%
indicated they probably or definitely would not do so. Nineteen

percent of the clergy thought somewhat seriously over the past year









about leaving the ministry with 6% currently reconsidering their
commitment and 1% actively engaged in trying to leave the vocation.

That some percentage of ministers consider a vocational change
makes them little different than other professional groups. Of
interest in this study, however, is the degree to which maladaptive
attitudes when combined with personal and occupational stress
become associated with depression. The onset and course of
depression can exacerbate existing problems and, if severe enough,
paralyze the minister's capacity to fulfill professional and personal
responsibilities (see Gaddy, 1991). It is the contention of this

research that depression may in the long run be a major factor in
clergy withdrawing from the profession.
Factors Associated with Occupational Stress and Burnout
The sources and reactions to stress encountered in the
workplace and day-to-day activity can be varied. Levi (1990)
concluded, however, that when a mismatch existed between

perceptions the worker holds about the job and the realities of the

work, the potential for maladaptive behaviors is increased.
Moreover, if the employee lacks certitude and some measure of
control over the work environment, adequate coping mechanisms,
and social support, more severe pathogenic and chronic reactions

may occur.
Hatcher and Underwood (1990) examined the relationship of
self-concept and stress in a group of Southern Baptist ministers.
Their findings suggested trait anxiety has a negative relationship

with self-criticism and several life changes. Clergy under stress who









scored higher on trait anxiety tended to have a lower self-concept

and respect for their efficiency as a minister. Concomitantly, the
minister tended to engage in self-criticism which further impeded
constructive coping. The researchers suggested these factors when
associated with life changes could potentially disrupt levels of
personal and professional function.
Results of Blackmon's survey research (1988) also described

clergy concerns around issues associated with self-esteem. Fifteen
percent of the 300 respondents indicated a neutral evaluation of
their self-esteem while 12% viewed themselves negatively. Only
27% of the clergy in his study evaluated themselves as having a
healthy level of self-esteem. There was no differentiation across
denominations in this regard.
As in other studies (Mills et al., 1971, 1972; Whittemore, 1991),

personal finances were seen as problematic. While 85% of the
respondents thought their salaries adequate, 75% described
insufficient savings, and 50% were distressed about their pension
plans. This was viewed as an area of concern which impacted the
ministers sense of self-worth.

In a study of the relationship between continuing education

and stress in clergy, Mills and Hesser (1972) determined time
pressure and deadlines along with inadequate funding were barriers
to participating in educational interventions. Of significance in the
findings was that increased career stress (e.g., status inconsistency,
relative deprivation of personal needs) was associated with a greater
desire for study. High stress was viewed as a marker of inadequacy









in intellectual resources and coping. Failure to acquire ameliorative
skills, therefore, added to the perceived job stress. Blackmon's study
(1988) determined that 42% of his sample did not feel adequately
trained to lead a church creatively. Additionally, 41% did not see
themselves as properly prepared to provide counsel to persons in
crisis though virtually all viewed this as an important job function.
It is logical that ministers, confronted with increasing job
demands and occupational stress and lacking in adequate skills, may
succumb to more critical views of themselves. This self-critical view
may result in potentiating negative attitudes which act as tinder for
depression. Levi (1990) noted that such reactions entail emotional,
cognitive, behavioral, and physiological dimensions. Under the right
conditions, they may lead to physical and mental disease. In a
profession acknowledged by some authors (see Congo, 1983; Daniel &
Rogers, 1982) to be vulnerable to burnout, knowledge about
cognitive factors contributing to diminished personal health can be
utilized to enhance coping mechanisms and skills to avoid stress
related illness and depression.
Women and the ministry. A more detailed examination of
stress in women serving in religious leadership roles was undertaken
by Rayburn (1991). Levels of stress, strain, depression, and coping
measures were assessed in nuns, ministers, and rabbis. Nuns were
found to experience lower levels on all measures than clergywomen.
Female rabbis experienced the greatest stress, strain, and possible
depression and possessed the fewest coping resources.









Results of studies on the experience of women in the ministry,

a traditionally male-dominated profession, have, by and large, found

some of the stress and strain explained as a function of their
difficulty in breaking into the profession and gaining the respect of
their male counterparts and congregations. Carroll, Hargrove, and

Lummis (1981) determined that women demonstrated a greater
need to excel in seminary and were more aware of the sexist nature
of the church in its treatment of clergy. This intellectual astuteness
and political awareness has been both a blessing and a curse for
clergywomen. Although the church has benefitted from these
competent practitioners, the female practitioners have not enjoyed
equal recruitment and hiring opportunities.
Some researchers have found evidence to support women's
contention that they experience more rejection and suspicion and are
blamed for going against social conventions because they function in

a male-dominated field (Rayburn et al., 1986). Clark and Anderson

(1990) determined that 55.7% of their female sample of
clergywomen had significant frustration in working relationships
with their male counterparts. Additionally, 40% believed restrictions
on their work roles (e.g., worship leader, teaching, visitation) were

the result of gender bias.
Evidence exists to support the view of the ministry as a
stressful profession (Congo, 1983; Daniel & Rogers, 1982). Results of
one study including both women and men clerics, however,
suggested clergy (i.e., priests, brothers, nuns, ministers, seminarians)
may experience no more work stress than other professions.









Rayburn, Richmond, and Rogers (1986) utilized a survey

questionnaire and measure of occupational environment to study
stress within religious leadership roles. Of the five factors examined,
role overload, role insufficiency, role ambiguity, role boundary, and
physical environment, men and women differed only on ambiguity
and overload with males being higher on both. Both men and women
thought the latter responded more constructively to unclear
definitions of job expectations and situations where job demands
might exceed personal resources.
In a similar study Richmond, Rayburn, and Rogers (1985)

determined single clergypersons of either gender to experience less
stress. Clergy couples were found to be the best combination for
overall decreased scores on occupational stress as partner-shared

experience and support favored the moderation of severity levels.
At highest risk was the nonclergy spouse of a female pastor. He
experienced increased levels of role insufficiency and psychological
and vocational strain. Perhaps this was also congruent with the
female nonclergy spouse's experience prior to the acceptance of dual-

career marriages.
Studies by the same authors assessed the influence of marriage

and family on the clergy's perception and experience of job-related

stress. In a similar study of single, married, and clergy couples,
Rayburn (1988) indicated both single male and female clergy
differed on their perception of stress. Women viewed their female
cohorts capable of responding to stress more constructively. In the
group of married clergy, men demonstrated significantly higher









levels of role insufficiency, ambiguity, and boundary confusion.

Additionally, it was determined men experienced higher role strain
and possessed fewer recreational and personal coping resources.
In summary, evidence in the literature suggests that when
considering the association of maladaptive schemas and depression
in women clergy, some thought has to be given to their minority
status as reformers within a historically male profession.
Additionally, findings in the literature point to marriage status as a
potential moderating variable affecting professional esteem and
emotional health.
Sexuality and professional behavior. Blackmon's survey of
clergy (1988) described self-reported sexual behaviors to be a source

of personal and professional concern amongst the respondents.
While 15% of the 300 ministers indicated they felt sexual attraction
on a daily basis, 37% believed they had engaged in sexual behaviors
inappropriate for their profession. Further, 12.7% stated they had
engaged in sexual intercourse with a church member other than their

spouse. A survey by the Professional Ethics Group at the Graduate
Theological Union-Berkeley determined one in four clergy has had

sexual contact with a parishoner (Crooks & Baur, 1990). Comparably,
Pope, Keith-Spiegel, and Tabachnick (1986) found 87% of the 575
psychotherapists surveyed in their study reported sexual attraction
to their clients on one occasion. However, only 9.4% of the males and
2.5% of the females had acted on such feelings.
In a profession which values the implied covenant of fidelity in

marriage and the trust relationship between clergy and congregant,








the breech of such moral and ethical conventions in sexual behavior
may be an indication of severe personal distress including depression

on the part of the minister. Concern over this issue in the
Presbyterian denomination has resulted in the development of a
comprehensive paper on the ethics of sexual misconduct. Acquistion
of knowledge about the cognitive and emotional factors which
contribute to behaviors which may injure those persons ministers
are called to serve as well as the clergy themselves is a worthy
undertaking.
Clergv and Depression
It is difficult to know how much stress-related illness and

professional dysfunction in clergy is in some part related to
depression. A lack of assessment designs, operationalized constructs

(e.g., burnout), and the sheer dearth of studies precludes any
significant conclusions. For instance, a consultant cited by
Whittemore (1991) concluded that approximately 17% of the parish

clergy with which he has worked were suffering from long term
stress or burnout (see p. 4). While no definition for burnout is given,
it is reasonable to think that some symptoms of burnout may be
confused with or coexistent with those of depression.
It can be deduced, however, from the evidence cited in studies
described in this review of the literature on stress, vocational
dropout, and related professional concerns (e.g., inadequacy in
salaries, insufficient preparatory education, sex discrimination,
limited personal coping skills, and breeches in ethical behavior
codes) that depression is a factor. Blackmon (1988) found 10% of the









ministers in his sample admitted to feeling depressed. This is a rate
higher than the estimated normative at large population (see NIMH,

1991). Further, 57% of the respondents in his study indicated they
sometimes or often felt depressed.
While there are limited empirical data concerning depression in

clergy, several recent popular works make a case for depression
being viewed as a serious concern for clergy. Hart (1984) suggested
that ministers' failure to take care of their bodies, the ambiguous
nature of the work, the loneliness endemic to the leadership role, and
demands on time and personal life combine to make the profession

highly vulnerable to depression. In the autobiographical narrative of
his descent into and subsequent recovery from chronic depression,
Gaddy (1991) depicted a lack of meaningful personal support and

clearly defined occupational roles within the church as significant
factors in his illness. So compelling was his story, Norris's (1992)
review of the book was selected as the cover theme in the
Presbyterian Outlook, a weekly professional journal for ministers.
Some evidence also exists to suggest persons choosing the

ministry as a profession may be vulnerable to its hazards based on
their personalities. According to Maeder (1989), the choice by some

to become a helping professional (e.g., ministers, psychiatrists,
psychotherapists) was unknowingly based on the attraction to power,
dependence of others, an image of benevolence, and the possibilities
of adulation. Maeder (1989) also described two kinds of clergy, one
aligned with the common folk in a search for salvation founded on a
self-awareness of one's limits and the other a rigid and judgmental









figure carrying out the profession's duties from a position of

authority.

In validating a vocational preference inventory on clergy,
Fabry (1975) found clergy tended to rate their attraction to social
interaction at rates twice that of other aspects in the inventory.
Utilizing the Holland Personality Profile Types, clergy as a group
ranked themselves highest to lowest as social, artistic, investigative,

enterprising, realistic, and conventional. Heightened attention to the
social aspects of the profession may be confounding in that
interpersonal conflicts, failure to meet perceived expectations, and

disaffection of membership may potentiate associated dysfunctional
attitudes (e.g., need for perfection, avoidance of differences,
diminished self-worth).

Similarly, Hart (1984) described the following five personal
characteristics of clergy as prepotent for depression: (a) a lack of
internal control or self-discipline by which to moderate occupational

stress, (b) a low sense of responsibility, (c) unrealistic and self
imposed expectations, (d) a sense of perfectionism in their
exemplification of faith, and (e) an idealistic view of the ministry as

free from the vicissitudes of conflict and disappointment associated
with other secular vocations.

In summary, a review of the literature on ministers described
a profession which by virtue of its varied roles, ambiguous standards
for evaluation, and organizational resources is vulnerable to stress-
related illness and burnout. Both of these conditions are also related
to vulnerability toward depression. Much of the literature on









ministers is centered on clarifying various paradigms utilized by

them for professional practice. Little study of their mental health or
the cognitive factors which may contribute to their well-being is in
evidence.
The Relationship of Mental Health and Religious Beliefs

Results from recent studies examining the relationship of

religion and personal well-being have described no inherent
significant negative associations. Among their research sample,

McClure and Loden (1982) found time spent on religious activities
was positively related with perceived happiness and negatively
associated with stress. In a study of an intrinsically and extrinsically
religious sample, Bergin et al. (1987) detected no relationship

between scores on the Religious Orientation Scale in either group
with irrational beliefs or depression. In a follow-up study assessing
the relationship between religious lifestyles and psychopathology,
Masters et al. (1991) also observed no linkage between religiosity

and psychopathology. Results of research conducted by Trent et al.
(1984) established some evidence to support the argument that
morale and self-esteem were boosted on measures of the Minnesota

Multiphasic Personality Inventory in a highly religious student

sample.
In a study of depression and religion, Cadwallader (1991) has
described two modes of religion which can be viewed as a continuum
of lifestyle. One pole of the continuum was conceptualized as life
celebrating and self-affirming and appeared to deter depression.

The other was viewed as life constricting, self-derogating and









potentiated depression. Similarly, Bergin et al. (1988) discovered
that persons with a continuous religious development and ongoing
experience of faith appeared healthier than those with discontinuous,
episodic, and intense belief structures and styles.
While results from the aforementioned studies confirm a more

positive role for religious belief in health, overemphasis or distortion
of certain aspects of religious faith may be detrimental to resolving
distress. Holden et al. (1991) found counselors and clergy agreed on
the need to challenge religious convictions which were
misinterpretations or distorted applications of faith tradition.
McCandless (1991) identified perfectionism, exaggerated self-denial,
surrender, the repression of feelings of anger and grief as examples
of religious attitudes which may hinder personal and relational
development. The need to teach principles emerging from religious
faith which encourage self-esteem, problem solving skills, and
enrichment of personal spirituality was emphasized.

In his article titled, "Shedding light on the darkness of
depression," Timmerman (1988) described several characteristics of

belief systems which could exacerbate recovery from depression. A
sense of unworthiness and forsakeness lead to inappropriate self-
blame and guilt in persons. Some formulaic notions of Christianity
resulted in a posture of failure and shame (e.g., Let go, Let God, All is
well with the world when one is right with God, The power of
positive thinking will help things be better). These slogans
represented quasi-religious beliefs and tended to encourage
reductionistic and simplistic explanations of complex life experiences.









Lastly, persons sought and sometimes did not find immediate and
sufficient answers to explain the occurrence of tragedy or illness
which had befallen them or their loved ones. A failure to arrive at

meaningful answers resulted in a heightened sense of unworthiness
or blame taking. The sufferer in such cases could be twice victimized
for fear of questioning the religious presuppositions upon which
some of these approaches were based.
Timmerman (1988) stressed the importance of religion helping
persons conceptualize a curative alliance between the mind, body,
and spirit. Additionally, he viewed the religious community as a
source of social support to assist in one's recovery. As example,
Timmerman suggested an emphasis on the humanity of Jesus of
Nazareth in the Christian tradition could serve to normalize
experience and create an empathetic relationship between one's
personal suffering and the Creator.
More knowledge is needed about maladaptive schemas which

may diminish the effectiveness of religious faith as a curative factor.
Maladaptive attitudes based on distorted religious convictions can

serve to exacerbate depressive illness. The inquiry of this research
into the influence of maladaptive attitudes in depression in an
acknowledged highly religious sample can contribute to a better
understanding of these relationships.
Depression-Resistant or Countervalent Beliefs in Presbyterian Clergy
Weissman and Beck (1978) identified seven dysfunctional
attitudes or schemas which have been found to be associated with
depression. These attitudes consist of content, which when









exaggerated, can predispose a person to negatively interpreting life

experience. The schemas relate to the personal desires for approval,
love, achievement, perfectionism, entitlement, omnipotence, and

autonomy. Beck et al. (1979) suggested the presence of these
activated schemas primed the individual for the cycle of depression.
The presence of one or more of these attitudes has been related to
depression or depression-related symptoms in a number of studies

(e.g., Barnett & Gotlib, 1988a; Eaves et al., 1984; Ellis et al., 1986;
Giles, 1982; Peselow et al., 1990; Rush et al., 1986).
Of particular interest to this study is the association of these
attitudes with a concurrent measure of depression in an expressly
religious cohort of ministers. Presbyterian ministers espouse a
theological belief system which is, at least in the abstract,

countervalent to the depressogenic attitudes hypothesized by Beck's
cognitive theory. It is logical to think this belief system, if adhered
to, would provide a type of cognitive resistance to depression.
There are, however, social, economic, and occupational factors
which appear to test this cognitive resilience. Maeder (1989)
described a prevailing and unrealistic social stereotype and

expectations of clergy. Ministers are not only to be good in a moral
sense but as persons called by God, devoted to serving others. They

are to reflect attributes of humility, piety, generosity, and exemplify
the highest standards of their faith in the eyes of the public.
Ministers are expected to view their professions as a commitment to
a full-time lifestyle.









Hart (1984) described the minister's trap as the temptation to

subjugate one's personal and social well-being to the good of the
church. The professional, therefore, succumbed to a loss-prone
perspective on life and work. Though conflict, death, and
disappointment are to be expected in a people-oriented profession,
they were experienced by clergy as personal failures. Boundaries
between the personal and family life and the need of the church or
clear criteria for measuring success tend to result in self-criticism

and blame. Hart (1984) also found the minister more sensitive to
being placed on a pedestal and expected to perform at unrealistic
levels. Inevitably, the clergy viewed their profession as a conflict

between one's humanity and the demands of the church.
Ministers are also presented with a diverse array of models
from which to conceptualize their professional practice. As if

multiple paradigms can be utilized, each to fit a particular problem
area, ministers can understand themselves as professional
practitioners (Glasse, 1968), wounded healers (Nouwen, 1972),
contemporary apostolics (Smart, 1960), sacramental persons (Holmes,

1971), or pastoral shepherds (Hiltner, 1969), to name but a few

identities. Beyond the traditional roles of prophet, priest, and
counselor, clergy have been increasingly engaged as social change
agents and community development specialists. This plethora of
vocational identities and the attendant role confusion lead Malony
and Hunt (1991) to suggest that a warning be stamped on each
ordination certificate which would read: Warning! Ministry may be
dangerous to your health!









Clearly, the stress and ambiguities associated with ministry

may strain the efficacy of ministers' underlying belief system. Yet, it
is this set of fundamental schemas which shapes the minister's

intrapersonal perspectives and the collective network of colleagues.
The ordination questions which are propounded to candidates in the

Presbyterian Church (USA) emphasize the role of these beliefs at the
personal and corporate levels. A candidate for ordination is asked
the following: "Will you be governed by our Church's polity (i.e.,
government), and will you abide by its discipline? Will you be a
friend among your colleagues in ministry, working with them subject

to the ordering of God's Word and Spirit?" (Book of Order, 1991).

Response to these and other questions regarding faith and practice
undergird the minister's public confession and assent to the
denomination's theology.
The theology of the reformed tradition from which
Presbyterianism has evolved is based on several fundamental

principles. In content these seminal beliefs contradict the negative
content of attitudes Weissman and Beck (1978) described as

depressogenic. Mead (1990) described the denomination's theology
to be centered on the idea of God's sovereignty over the world and

people's lives. Humans are ultimately dependent upon God as
creator and sustainer. Individual autonomy is viewed as a gift and
not a goal to be achieved at the expense of dependence upon God or
interdependence on one's fellow humans (Calvin, 1967). Aspiring to
exaggerated individualism is viewed as idolatrous and self-
aggrandizing.









Another aspect of Presbyterian theology which may mitigate
against exaggerated autonomy is a doctrine called the priesthood of

all believers (Wallace, 1959). This belief suggests each person is

called upon to serve others and be open to such ministrations by
fellow believers. Ideally Presbyterian ministers see themselves,
therefore, as members of a community in which a reciprocity of care
and learning is possible. Openness to care offered by others is
consistent with the idea of being a member in a responsible and
caring community.

Attitudes which embellish human perfection and omnipotence
also contradict the Presbyterian theological tenet of God's
sovereignty. Only the Creator is viewed as perfect or complete.
Guthrie (1968) characterizes humankind as totally dependent upon
God, yet, created to enjoy freedom and the associated limitations
which accompany human responsibility. Human endeavors to
achieve perfection are considered veiled efforts at becoming like God,

a form of idolatry. These superhuman efforts are characterized by

greed and insecurity and lead to diminished appreciation for one's
role in and the welfare of the community. The recognition of one's

limitations and acceptance of boundaries to personal and social action
is understood to enhance the development of self and strengthens

the relationship between God and the human community.
Mead (1990) also described the centrality of Jesus Christ for
Presbyterians as the source of salvation. This theological assertion
views the human need for salvation and forgiveness to be a
universal experience. Some degree of failure in all arenas of human









life is expected. For Presbyterians dependency on God's forgiveness

is the key to creative personal and community life. Professional or
personal behaviors which represent aspirations to perfectionism
abrogate this key belief.
The need of humans to be loved and enter into relationships
with others has long been acknowledged in psychological and

religious traditions. Presbyterians believe that human beings are
created in God's image. This act of creation implies that being human
means to live in relationship with God and one's fellow humans
(Guthrie, 1968). To deny the fundamental need of community is to
deny one's humanity. While the need for participation in community is

of seminal importance, Presbyterians also assert the Creator's love as
the only truly sustainable and reliable source of love. To expect
other humans to meet all one's needs for affection and love is

considered unrealistic and prideful.
Likewise, expectations that other persons must be in

agreement with what we say and do is a distortion of how
Presbyterians perceive the nature of community. Conflict is the
inevitable product of persons being created differently.
Reconciliation and atonement are the products of mutual sacrifice
and forgiveness. Any effort to idealize or diminish one's personal
contribution and responsibility in conflict becomes self-serving and,
therefore, injurious to self-esteem and community. Exaggerated self-
debasement or denial are viewed, therefore, as idolatrous and self-
centered. Conflicts which occur in a church setting can be viewed as
expressions of individuality and grist for creative reconciliation as









opposed to attacks on the personal or professional attributes of
clergy.
Gaddy (1991) and Hart (1984) described the inner motivation
of ministers to achieve, to take on more responsibilities as a way of

gaining control over ambiguity through activity. Presbyterian

theology sees the motivation for achievement primarily rooted in the

response to being loved by God and others. Question 4 in the
constitutional questions for the ordination of Presbyterian ministers
invokes the candidate to love others and work for the reconciliation

of the world (Book of Order, 1991). Work is understood to be the
response to God's love of creation and self. The minister's labors are
ideally shaped by personal commitment and a grand perspective on

life of the church. Achievement for the sake of self-glorification or
meeting one's deficiency needs contradicts the spirit of human
enterprise as conceptualized in Presbyterian theology. Humans work
to live, therefore, not live to work. Obsession with work detracts
from the balance of a creative relationship with God, creation, and
others.

Presbyterian theology also recognizes a dependency of humans

on a God that creates and loves. Human freedom is seen as a gift
which is bounded by temporal and physical limitations. Individuals
both seek autonomy in self-determination, yet are dependent upon
others for the love and support necessary to be creative within
community. Exaggerated claims or activities which promote self over
others or attempt to resolve personal insecurities at the expense of









others is viewed as idolatrous and counterproductive to being fully
human.

It is reasonable to think that, if adhered to, these theological
beliefs may attenuate the formation of depressogenic attitudes based
on distorted ideas of perfectionism, approval, entitlement, and
omnipotence. Obtaining knowledge about the levels of maladaptive
attitudes in Presbyterian ministers can contribute to better
understanding the influence of a countervalent belief systems on
their development and potentiation.
Mental Health Counselors as a Comparison Group

One goal of this study was to determine the presence and
influence of dysfunctional attitudes as a concurrent measurement of
depression in a sample of Presbyterian ministers. This knowledge
may contribute to existing ideas about the role of those attitudes in
cognitive theories of depression. Additionally, the data from this
study may add to information about the status of mental health in
the clergy. Assessment of a comparable professional group also may
aid in differentiating the results of the study and clarify which
attributes may be distinctive to the Presbyterian clergy. Further,

data acquired about the comparison group of mental health
counselors contribute to the existing body of knowledge about this

profession as well.
Mental health professionals are not immune from the
exigencies of stress which cause distress in the populations they
serve. Mismatches in their vocational expectations, levels of control
and work overload of therapists can result in similar emotional,









physical, and behavioral symptoms. Maeder (1989) concluded

psychotherapists and ministers were particularly vulnerable to
distress because of the values which motivated entry into their
respective professions and the realities of the demands, ambiguous
roles, and uncertain standards for evaluating progress. Levi (1990)
argued that such an unresolved conflict over time resulted in
diminished physical and mental health. Ganster, Fusilier, and Mayes

(1986) found a positive relationship existed between work strain,
dissatisfaction, and depression. Social support, that is the network of
family, friends, and coworkers, was found to have only modest effect
on lowering perceived strain. It was not a significant buffer of work-
related stress.
Although underlying belief structures based on theological,
philosophical, or scientific belief preferences may differ, the ministry

and mental health counseling professions share certain occupational

functions. The Dictionary of Occupational Titles (1991) has

characterized both vocations as people-oriented fields requiring
advanced higher education. In the case of Presbyterian clergy this is
a minimum of a master's degree, 3 years beyond college. For

purposes of certification and licensure, depending on the specific
state's law, mental health counselors also require 2 years of graduate
education and additional clinical experience. Both professions,
according to the D.O.T. (1991), require effective skills in reading and
writing with a facility for critical thinking and analysis. Each

occupation provides counsel and guidance to persons in crisis as well








as education of life skills for living. Some skills in administration and

organizational leadership are also utilized.
Like ministers, mental health counselors and other helping
professionals have also been found to suffer from role overload and
burnout in their work contexts. Oberlander (1990) described
community mental health counselors working with the seriously

mentally ill to have relatively higher levels of stress and job
dissatisfaction. In a study by Cournoyer (1988), 64% of the social
caseworkers suffered from stress-related health problems. Stress
was perceived as a byproduct of the increased breadth of challenges
relative to personal and vocational demands. Included in factors
related to the stress was the lack of improvement seen on the part of
clients relative to the amount of energy invested on the part of the
therapists. Similarly, Ross et al. (1989) established that perceived
higher stress was related to burnout in a counseling center staff.
Ratliff (1988) reported that 44% of the therapists surveyed in

his survey indicated a lack of tangible therapeutic success accounted
for the greatest stress at work. Other factors identified as significant
stressors included functioning in an emotionally demanding job for
which there is little reciprocation of energy expended, personality

characteristics of the therapist, and the other centered nature of the
work. These occupational characteristics are similar to those
described as inherent in the ministerial profession.
Evidence suggests experience with stress begins in the
formative years of professional development for both professions.
Smith (1985) found both graduate psychology and divinity students








in one university scored higher on negative mood measures than did
their peers in schools of medicine, religion, and business
administration. The results of an analysis of the mental health of

graduate counseling students in training described the sample as
having higher psychological disturbance than did the general
population on six of the seven MMPI scales, including depression
(White et al., 1990). Global stress including work, studies, and strain
on relationships were suggested as factors in the outcomes.
An additional factor supporting the comparison of the two
groups in this study is their mutual concerns for human growth and
development. Though sharing different paradigms (see Bergin,

1980), both clergy and counselors seek to enhance the quality of life
for persons and the systems in which they live and work (e.g.,
family, work, and community). This mutual interest is symbolized in
recent journal articles which call for consultation and understanding
between the groups in the interest of better serving clientele (Holden
et al., 1991; Keating et al., 1990; Miller, 1992). Bergin (1980) has

also encouraged a rapprochement between the disciplines of
psychology and religion and a greater understanding of the theistic
concepts utilized by a majority of the American population served by
the psychological professions. A review of professional journals in
the mental health and counseling fields indicates consideration of the
merits of religion and spirituality as key concepts in human
development is underway (e.g., Gilchrist, 1992; Keating & Fretz, 1990;
Miller, 1992; Thorson & Powell, 1989; Worthington, 1989).









There exist some distinctive attributes which distinguish

mental health counselors and Presbyterian ministers. Bergin (1980)
elaborated the differences in change paradigms between the groups.
For example, there are substantive philosophical differences between

the humanitarian and sectarian approaches to understanding the
nature and destiny of life. The role of rituals and the subordination
of personal will to a monotheistic and transcendental life source
remains foreign to counseling practitioners who emphasize
individualism and self-actualization. Additionally, for Presbyterian
ministers the teleological concerns from which persons draw
meaning for their lives include concerns for duty and responsibility

for the well-being of others. Moral and ethical conduct toward
others, even at the cost of one's own interests, is viewed as a seminal
component in a faithful religious lifestyle. While such behavior is
applauded by counselors, it is not necessarily or systematically
taught as an aspect of emotional well-being.
The organizational context within which the two groups carry

out their vocations also differs significantly. Mental health
counselors do not regularly function in voluntary associations.

Generally, their services are provided on a cost basis with a goal
toward turning at least a modest profit. The minister's services are
often provided at no specific cost above and beyond that which is
ordinarily a part of the parishoners contribution to the church. The
exception to this practice is the work of the trained pastoral
counselor who may work in a for-fee service and structure not
unlike mental health counselors.









The role and power associated with occupational hierarchy may
also differ with regard to oversight, administration, and job mobility.
The two groups do not likely share the same performance
expectations on the part of their clientele, who in the case of the
clergy are comprised of the employer, the congregation. Further,
female professionals in mental health counseling may experience
some discrimination based on client reactivity. Their inherent right
to practice their chosen vocation, however, is not called into question
on the basis of their gender as is the case with many women
ministers.

In summary, Presbyterian ministers and mental health
counselors share a number of similarities in job functions,
requirements in preparation for professional practice, occupational
stressors, and related interests in the development of human well-
being. The distinctions between the two groups provide enough
differences to distinguish the populations without disqualifying them
as similar helping professionals. It is logical, therefore, to utilize
mental health counselors and Presbyterian ministers as reasonable
comparison groups for the purpose of this study.

Chapter Summary
The review of literature pertinent to this research provided
supporting evidence for a study of cognitive factors related to
depression in Presbyterian ministers. The epidemiological data
reviewed herein suggests depression is a major mental health care
concern in the general population. Additionally, results from




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