Mental health literacy in religious leaders: a ... - Wiley Online Library

Health and Social Care in the Community (2016)

doi: 10.1111/hsc.12316

Mental health literacy in religious leaders: a qualitative study of Korean American Clergy Yuri Jang PhD1, Nan Sook Park David A. Chiriboga PhD5

PhD

2

, Hyunwoo Yoon

MSW MPH

1

, Jung Eun Ko

PhD

3

, Hyejin Jung

PhD

4

and

1

School of Social Work, The University of Texas, Austin, Texas, USA, 2School of Social Work, University of South Florida, Tampa, Florida, USA, 3Department of Counseling, Kyung Hee Cyber University, Seoul, South Korea, 4 Department of Social Work, The University of Texas, El Paso, Texas, USA and 5Department of Child and Family Studies, University of South Florida, Tampa, Florida, USA Accepted for publication 2 November 2015

Correspondence Yuri Jang, PhD School of Social Work The University of Texas at Austin 1925 San Jacinto Blvd., D 3500 Austin, Texas 78712, USA E-mail: [email protected]

What is known about this topic

• •

Racial/ethnic minorities are known to underutilise mental health services. Religious leaders are known to play an important role in responding to community mental health needs.

What this paper adds

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The study explored the level of knowledge and perception of depression in religious leaders. Findings suggest the importance of mental health education and training for religious leaders in ethnic minority communities.

Abstract Although religious leaders in ethnic minority communities are often the first point of contact for mental health needs, little is known about their mental health literacy. The aim of the current study was to explore the knowledge and beliefs about depression held by Korean American clergy, using a qualitative approach. The Gateway Provider Model (GPM) and Jorm’s conceptualisation of mental health literacy served as a framework for the enquiry. Seventeen clergy members serving in Korean communities in two U.S. metropolitan cities participated in an individual in-depth interview during the spring of 2013. Using the constant comparison method, the research team coded the data independently, compared and modified codes, and derived major categories and themes in consensus approach. Eight themes emerged from the interviews, and they were grouped into five categories: (i) the ability to identify the problem; (ii) knowledge about causes and risk factors; (iii) knowledge and beliefs about treatment; (iv) knowledge about resources and services; and (v) contextual factors. Despite some variations, a majority of the participants acknowledged that depression is an important issue in the Korean American community and felt a sense of responsibility for the well-being of their community members. The findings highlight the need for mental health education and training for religious leaders in ethnic minority communities to help them properly respond to community mental health needs. Keywords: Korean Americans, mental health literacy, religious leaders

Introduction Leaders of religious organisations provide a wide array of services to their community and often serve as the first point of contact for the emotionally distressed (Taylor et al. 2000, Koenig et al. 2012, Yamada et al. 2012). It is estimated that more than 23% of the U.S. population seek help from the clergy for emotional concerns (Wang et al. 2003), and this reliance upon the clergy is particularly strong among racial/ethnic minorities (Zhang et al. 1998, Milstein et al. 2000, Koenig et al. 2012). For them, religious leaders may be © 2016 John Wiley & Sons Ltd

perceived as a less-stigmatising source for mental healthcare (Taylor et al. 2000, Yamada et al. 2012). The role of religious leaders in community mental health can be considered in terms of the Gateway Provider Model (GPM; Stiffman et al. 2004). The GPM emphasises the role of key community individuals who can facilitate the identification of mental health issues and provide a gateway to mental health services (Stiffman et al. 2006, Ellis et al. 2010). The clergy are an important example of ‘gateway providers’ because they have a salient influence over their institutions and shape the physical and social 1

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environments for community health (Bopp et al. 2013). The clergy’s knowledge and perceptions of mental health may determine the success of efforts to identify and address mental health needs in their congregation and the broader community (Taylor et al. 2000, Yamada et al. 2012). A number of studies explored mental health literacy among African American clergy (e.g. Payne 2009, Stansbury et al. 2012); however, little attention has been paid to religious leaders in other minority communities. Defined as ‘the knowledge and beliefs about mental disorders which aid their recognition, management or prevention’ (Jorm et al. 1997), mental health literacy has been acknowledged as a powerful enabler for mental health service use across diverse populations (Jorm 2012). The major components of mental health literacy can be broadly categorised into: (i) the ability to identify the problem; (ii) knowledge about causes and risk factors; (iii) knowledge and beliefs about treatment; and (iv) knowledge about resources and services (Jorm 2000). Literature suggests that the assessment of each component provides a better understanding of the knowledge and beliefs held by individuals and guides intervention strategies to promote mental health literacy (Phelan et al. 2000, Lauber et al. 2003). The present investigation focuses on Korean Americans, a recent but fast-growing immigrant group. The 2010 Census tallied about 1.7 million Korean residents nationally and ranked them as the fifth largest Asian American subgroup (Barnes et al. 2008, U.S. Census Bureau 2012). Korean Americans have consistently been found to have high levels of mental health problems but low rates of mental health service utilisation (Jang et al. 2007, NAMI 2011). With prevalence estimates in the middle to upper 30%, the rate of probable depression in Korean Americans is

particularly high when compared to the 9%–16% found in Whites and African Americans (Jang et al. 2007, NAMI 2011). Throughout their immigration history, churches have served multiple functions in Korean American communities (Lee et al. 2008, 2014, Yamada et al. 2012), and one of their important services is related to mental health needs. For multiple reasons, including the stigma attached to mental health and a lack of culturally and linguistically competent mental health providers (NAMI 2011, Jang et al. 2014), Korean Americans often seek out religious leaders for their mental health concerns (Kim-Goh 1993, Lee et al. 2008). Given these religious leaders’ important function as ‘community mental health allies’ or ‘gateway providers’ (Yamada et al. 2012), the aim of the current investigation is to explore Korean American clergy’s mental health literacy, using a qualitative approach. In order to reduce the scope of the investigation, we focused on literacy related to depression, the most common mental disorder in the U.S. (National Institute of Mental Health 2011). Jorm’s (2000) conceptualisation of mental health literacy served as a framework for the enquiry. Furthermore, reflecting the characteristics of the target population, contextual factors in relation to immigration and culture and role as a religious leader were also considered. The overall framework inspired by the GPM (Stiffman et al. 2004) and Jorm’s (2000) conceptualisation of mental health literacy is depicted in Figure 1.

Methods Participants and procedures With approval from the University’s Institutional Review Board, the project was conducted in the

Gateway Providers' Mental Health Literacy 1. The ability to identify the problem 2. Knowledge about causes and risk factors 3. Knowledge and beliefs about treatment 4. Knowledge about resources and services 5. Contextual factors

Community mental health needs

Mental health service use

Figure 1 Conceptual framework inspired by the Gateway Provider Model and Jorm’s conceptualisation of mental health literacy.

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Mental health literacy in religious leaders

metropolitan areas of Austin, Texas and Tampa, Florida, during the spring of 2013. Prior to the interview, participants were asked to read and sign the consent forms. The forms included detailed information about the project (e.g. purpose of the study, risks/benefits, confidentiality and contact information of the research team). Participants were also informed that their participation would be entirely voluntary and they could withdraw at any time should they become uncomfortable with the study. The sampling goal was to recruit 8–10 participants in each location. Using a volunteer-based quota sampling method, we recruited clergy members serving in Korean American Christian churches. The focus on Christians was based on the report that more than 70% of Korean American populations identify themselves as Christians (Lee et al. 2008). A total of 17 clergy members (10 from Austin and 7 from Tampa) were included in the study. By using the theoretical sampling method, we intended to collect the pertinent data that elaborate the properties of the categories in the conceptual framework (Charmaz 2006, Glaser & Strauss 2007). After giving consent, participants were asked to fill out a self-administered short survey, followed by a face-to-face in-depth interview. The survey was in two parts: (i) a vignette of a non-psychotic depression and (ii) questions on socio-demographic and background information. The vignette used by Kim-Goh (1993) was modified to be culturally relevant (Box 1). The name and age of the character and the unit of weight (pound to kilogram) were modified, and the vignette presents the case of Yonghee Kim, a 75-yearold Korean immigrant woman, who has various symptoms of depression. Participants were asked to read the vignette and report what her problem was. The second part of the survey included questions on demographic information, their tenure as a leader, membership size of their church, prior mental health training, self-perceived knowledge on mental health, prior experience of referring parishioners to services for mental health concerns and willingness to take part in an educational programme on mental health. Box 1 A vignette of a non-psychotic depression Yonghee Kim is a 75-year-old Korean Woman who immigrated to the United States 5 years ago. Recently she started to have a difficulty falling asleep and has lost 7 kg during the last month. She has lost interest in her daily activities and has no motivation to get up in the morning. She is feeling hopeless and admits having thoughts of ending her own life. Note: The vignette was modified from the one used by Kim-Goh (1993), and copyright permission from the publisher was obtained.


For the in-depth interviews, a semi-structured interview guide was used. Major questions included: ‘What do you think depression is?’, ‘Could you tell how it occurs?’, ‘Have you ever encountered anyone with signs of depression in your church? If so, what did you do?’, ‘What do you think about seeking professional help for depression?’, and ‘Do you know whom or where to contact if someone needs professional mental health services?’ The interviewers asked questions and prompted follow-up explanations. Although the language option of English and Korean was offered, all participants preferred to be surveyed and interviewed in Korean. Interviews were conducted at a quiet place convenient to each participant, such as a meeting room at the church or public library, and each interview lasted about an hour. The sessions were audio-recorded with consent, and participants were paid $50 at the end of the interview. Analytic strategy The audio-recorded interviews were transcribed verbatim in Korean. Using the constant comparison method (Glaser & Strauss 2007), the coders independently coded each transcript, compared and discussed each code and meaning, and developed and modified the codes. The coding procedure began with open coding, which was then refined, with comments eventually clustered and re-clustered into larger categories in order to yield emerging themes (Creswell 2012). In data analysis and interpretation, several strategies were used to ensure the trustworthiness/rigour of this study such as intensive engagement, triangulation and record keeping (Miles & Huberman 1994, Shibusawa & Lukens 2004, Maxwell 2012). In terms of intensive engagement, the researchers involved in interviewing and coding have expertise in mental health and experiences working with Korean populations and clergy. Such knowledge and skills facilitated rapport and engagement of participants. With respect to triangulation, we collected the information from clergy with diverse backgrounds in two geographic settings. For several interviews, two interviewers were present and asked questions. This process provided combined perspectives on the interviewing process, coding and interpreting results. Lastly, researchers kept their memos such as process recordings and reactions to coding and discrepancies. Researchers paid a particular attention to discrepant cases. Such trails of records have been discussed and reflected in coding and interpreting themes. The first four authors participated in the interviewing, read parts or all of the transcripts, and immersed themselves in the data. Then they 3

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independently developed a list of codes and compiled a preliminary code list. Being bilingual, these researchers read the transcripts in Korean and developed preliminary codes in English. Using the preliminary code list, three authors (YJ, NP and HY) independently coded the initial two interviews line-by-line; they were free to add codes to the preliminary list. Then they compared the coded transcriptions, discussed discrepancies and recoded the interviews using the consensus codes. The three coders independently coded an additional two transcripts and compared their codes. Through this iterative process, the coders agreed that the transcripts could be reliably coded, based on the main codes and definitions. Then two coders (YJ and HY) coded the transcripts through the consensus approach (coding separately followed by discussions of all areas of disagreement), and the third coder (NP) reviewed all coded transcriptions and discussed any discrepancies. For an additional reliability check, two co-authors (JK and HJ) independently reviewed the codes and checked the accuracy of the codes. A qualitative data analysis programme, Atlas.ti (Scientific Software Development, Berlin), was used for organising the codes and categories. Translation of the selected quotes into English was conducted as a final step in order to minimise the loss of content and meaning in the original language (Suh et al. 2009).

Findings Sample description Ten participants were recruited from Austin and seven from Tampa. Their mean age was 52.4 (SD = 14.3), with a range from 35 to 87. A majority of participants were males (94.1%) and had a graduate degree (94.1%). All participants were born in Korea and used Korean as their primary language. The number of years lived in the U.S. ranged from 5 to 43 years, with a mean of 15.6 years (SD = 10.7). More than half of the sample (52.9%) reported that they had received education or training on mental health issues, and about 64% rated their level of knowledge on mental health to be ‘quite high’. Despite the high level of their perceived knowledge on mental health, only 35% of the sample correctly labelled the problem in the vignette as depression. Other terms used to describe the problem included culture shock, stress, frustration and lack of faith. While over 41% of the sample had never referred a parishioner for mental health concerns, a majority (92%) indicated their willingness to take part in an educational programme on mental health. 4

Findings of qualitative interviews Towards the end of the interview phase (n = 17), the research team agreed that the categories have been saturated with adequate variations in conceptual categories. Through immersion with the data and consensus coding by multiple researchers, eight themes emerged from the interviews, and they were grouped into the five categories presented in the conceptual framework. The identified themes and categories are presented in Table 1 and discussed along with the exemplary quotes from the participants. Category 1. The ability to identify the problem Definition/detection. Participants presented different levels of knowledge and diverse perspectives on depression. One participant demonstrated confidence in his ability to identify depression by stating: I have been in religious service for more than 30 years and dealt with many different people. I just can tell if one is depressed at a glance. I can sense darkness in their faces and minds.

However, most participants noted a difficulty with defining and identifying depression. One exemplary quote was: Since I am not a medical expert, my approach to depression is limited to the religious and spiritual side. I don’t think there is one easy and simple way to say what depression is. I am personally not quite sure if I can correctly detect someone who has depression.

Religious view. Not surprisingly, the overall concept of depression was consistently viewed from a religious perspective. One participant said: God gave us healthy and normal emotions such as happiness, excitement, sadness, anger and many others. If you

Table 1 Categories and themes of Mental Health Literacy in Korean American Clergy Categories

Themes

1. The ability to identify the problem 2. Knowledge about causes and risk factors 3. Knowledge and beliefs about treatment 4. Knowledge about resources and services 5. Contextual factors

(1) Definition/detection (2) Religious view (3) Causes and risk factors (4) Beliefs about treatment (5) (6) (7) (8)

Lack of information Training needs Immigration and culture Role as a religious leader



cannot control these emotions and make a balance, that’s depression.

Another participant stated: It is the belief in God that prevents people from feeling lonely and depressed. Along the same line, one participant made a quite strong statement: I don’t know much about depression, but I do know that religious people do not get depressed. You know that a famous Korean actress committed suicide a few years ago because of her depression. I heard she was Christian. But I don’t believe so. People deeply rooted in religion would never get depressed.

However, some participants demonstrated a rather careful approach: You should not attribute [depression] to lack of faith. People are all different – they have their own situations and paths. Depression can hit you even if you are fully filled with the holy spirit. Even clergymen can get depression. It is totally rude to say ‘your faith is not strong enough and you need to pray more’ to someone who is depressed.

Category 2. Knowledge about causes and risk factors Causes and risk factors. Participants noted possible causes and risk factors of depression related to psychological, social and biological issues. The most frequently mentioned causes were feelings of isolation and lack of social support. One participant stated: I believe depression starts with such thoughts as ‘there is no one to help me’, ‘all are enemies’, ‘there is no one to trust’ and ‘I am all alone’.

Participants also indicated that stressful life events or changes with ageing can lead to mental health issues: When people can’t endure the intensity of stress, they feel helpless, frustrated and disappointed. Furthermore, as people get older, many negative changes happen . . . illness, sickness, disappointment to children, and loneliness flood them and they would feel depressed.

Many participants noted a particular vulnerability of older immigrants to depression. An exemplary quote was: Adjusting to American life and culture is not an easy task. Older immigrants’ psychological issues mostly stem from cultural differences. Many of them talk about discordance and conflicts with their adult children. In many families, parents have traditional Korean ways of thinking but their children are Americanised. Cultural differences and miscommunication between generations make older people psychologically stressed and depressed.


Difficulties in interpersonal relationships were also identified as a key contributing factor. One participant stated: I have seen a case that a female church member got depressed because of the conflict with her mother-in-law. That sister was not psychologically strong enough to bear the stress.

In addition to family issues, social relationships within a church community were recognised as a contributor: People could get depressed due to relationships with church members. Sometimes the relationship issue hit them very hard. Relationships in a church are very important, probably more so than religion itself. I have seen many people get hurt by those gossips and even stop coming to church. It is shameful.

Although few, some participants biological causes of depression:

mentioned

The cause may be something like abnormality in hormones. When I attended a lecture at a psychiatric hospital, I learned that depression is associated with changes in your brain chemicals, like dopamine.

Category 3. Knowledge and beliefs about treatment Beliefs about treatment. Participants identified various treatment options for depression, including religious practice, counselling, psychotherapy, hospitalisation and medication. Of those options, the most discussed among participants was religious practice – praying, attending church services, counselling with clergy or reading bibles. One exemplary quote was: In the outside world, they talk about medication and doctors. But in the world of religion, prayer comes first. Everything will be okay when you hold the hand of the Mighty God. If you have strong faith in God, you will get cured and blessed. That blessing doesn’t mean that nothing bad would happen to you but you will rather have strength to overcome challenges – whether it is depression, financial problem, disease or whatever. God will help us overcome the mountains of trouble. That is God’s promise.

However, there were differences in the extent to which participants believed in the effectiveness of religious practice for treating depression. For example, some participants considered the use of religious practice adequate in treating depression: If a person has a physical illness, he/she needs to see a doctor to get treatment, medication and maybe surgery. However, depression, something we don’t know the cause of, [is] a problem [that] needs to be resolved through religious practice. He/she can recover by praying and consulting

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with clergy. I would wrap their wound with words in the Bible and pray for them. It will cure them 100%.

On the other hand, some others endorsed the collective use of religious practice and medical treatment. The following quote reflected the view: There are people who need medical treatment. When a person needs medication, you can’t say ‘don’t take medication’ or ‘you only need spiritual help’. You’ve got to do what you’ve got to do. If a doctor tells you that you need treatment, you should follow the instruction. However, I mean, that is not enough. The bottom line is that all human beings have spirit. Without dealing with spirit, [treatment] is limited.

Another participant also endorsed the similar viewpoint: There are different specialties which can treat our spirit, mind and body. They all have their own specialties. The problem occurs when the clergy consider spirit and mind as the same problem and approach it only from a religious perspective. Also, psychopathology or medication itself is limited in treating depression. I think all should work together to provide help.

Training needs. Many of the participants reported some educational experience in counselling or psychology during their pastoral training. Yet they all emphasised that their degrees were not specific to mental health. Their perceived need for mental health education or training is indicated in the following quotes: Yes, we do need training. Indeed, we don’t have a degree in mental health. What we can do is limited because we are not trained to provide mental health counselling. I’d like to learn counselling skills so that I can use them in my service.

Another participant noted the need for continuing education: I only took two counselling courses when I was at school. It was more than 20 years ago. Category 5. Contextual factors Immigration and culture. This theme was particularly indicative of the participants’ understanding of mental health issues within the context of Korean immigrant communities. Many mentioned cultural resistance to the self-disclosure of emotional concerns. One participant noted:

The majority of participants did not reject the idea of seeking help from professional mental health service providers, especially among those who mentioned non-religious causes of depression. The participant who mentioned biological aspects of depression, for example, strongly endorsed professional mental health treatment:

Korean immigrants usually don’t open their personal issues. As a marginalised population, they tend to have a selfdefence mechanism and try to solve the problem on their own. It clearly serves as a barrier in sharing their personal concern with others.

How would you fix a hormonal problem with prayer? It is impossible. You need to see a mental health specialist and get medical treatment.

Usually people don’t seek outside help. Mental health problems are perceived as a shame and something that should not be disclosed to other than family members.

Category 4. Knowledge about resources and services

One participant shed light on tendency from a different perspective:

Lack of information. Participants noted a lack of mental health-related information and services available in their community. One participant said: Not much [resources and services] here in this area. It is not like Los Angeles and New York. We have a few Korean primary doctors here but no mental health providers. When I need information, I always search the Internet.

Many spoke of an urgent need for services for those with limited English proficiency. One participant noted: Our church is associated with one of the American Baptist churches. This church has its counselling centre. When I encounter a person with a mental health problem, as long as he/she can speak English, I can refer him/her to that centre. However, for those who do not speak English, I don’t have any place to refer them.

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Shame is quite frequently mentioned as an underlying reason for their reluctance to self-disclose:

the

cultural

People don’t want to impose a burden on others. That Korean way of thinking may be one of the reasons why people don’t want to talk about personal issues. Even people who are quite acculturated to America still show this tendency when it comes to expressing their emotions.

Noting the characteristics of parishioners, many participants urged a culturally sensitive approach to mental health issues. One participant said that the typical reaction he would get for his recommendation of mental health treatment would be ‘are you treating me as a crazy person?’ Another participant called attention to the importance of family: I sensed something was going on with him. He definitely needed help, but I couldn’t say anything. In this immigrant community, you should be careful when approaching to others. You have to have acceptance from all family



members. If there is even a single person in the family who doesn’t want to have me around, I cannot do my job.

Role as a religious leader. Many participants noted the demands made on them to fulfil multiple functions in so-called immigrant communities. An exemplary quote was: We are not only clergy members but also social service providers. From their arrival to settlement, we provide all kinds of help and information to new comers. When immigrant families arrive, we are there at the airport and help them settle. We provide rides and interpretation and help them get a driver’s license and enrol their kids to schools. Often school teachers call me because the family cannot speak English . . . Without churches, Korean communities cannot function. Churches play a central role in moving Korean community forward.

These multiple demands seem to pose a burden on the clergy, and many noted the heavy responsibility they feel for the community. One participant said: Life as an immigrant is tough. Many people suffer with various problems – big or small. I feel a huge responsibility to take care of people in this community.

Discussion Given the paucity of information about the mental health literacy of religious leaders in the Korean American community (Kim-Goh 1993, Lee et al. 2008, Yamada et al. 2012), the present study used qualitative methodology to explore the leaders’ knowledge and beliefs about depression. Focusing on the role of the clergy in community mental health, the premise of the current investigation was based on the notion of the GPM (Stiffman et al. 2004). In the analytic process, Jorm’s (2000) conceptualisation of mental health literacy provided an organising framework. The first four categories derived from the interviews were in line with Jorm’s (2000) framework, and we found another salient category pertaining to the context of culture and immigration. The overall findings suggest that there were some variations in beliefs and knowledge about causes, risk factors and treatment for depression among the Korean American clergy interviewed. It was notable that some comments from participants reflect lack of knowledge of depression and stigma. However, a majority of the participants acknowledged that depression is an important issue in the Korean American community and felt a sense of responsibility for the well-being of their community members. Yet most felt unprepared to deal with the mental health needs and welcomed opportunities for mental health education and training. © 2016 John Wiley & Sons Ltd

It is worth noting that there was a discrepancy between self-rated familiarity with mental health and their ability to recognise depression in the vignette. Although about 64% rated their perceived mental health literacy as ‘quite high’, the percentage of individuals who were able to correctly label the problem in the vignette was only 35%. This rate is about half of the 67%–70% observed in general lay adult samples in the U.S. (Link et al. 1999), Canada (Wang et al. 2007) and Australia (Jorm et al. 2006). Considering that the ability to identify the problem shapes the pathway for depression treatment (Jorm 2012), this observed low rate is of concern. It was notable that more than 41% of the participants had never referred a parishioner because of mental health concerns. This rate is higher than the 25% reported in a sample of Asian American clergy members in California (Yamada et al. 2012), but the difference could be partially attributed to geographic variations in service availability. Among participants, there was general consensus regarding the lack of information about mental health information and referral sources. Indeed, many participants emphasised the need for a better mental healthcare system for immigrants, such as culturally and linguistically sensitive mental health services. Participants indicated that a lack of mental health services adequate to serve Korean American immigrants poses a critical barrier to referring someone to mental health services, even after they identify mental health needs. Conceptualisation of depression in terms of its causes, risk factors and treatment was quite often made from a religious perspective. As suggested in other studies (e.g. Kim-Goh 1993, Lee et al. 2014), there is an urgent need for outreach programmes or educational interventions for the clergy on the medical aspects of depression. Such efforts may enhance clergy members’ sensitivity to mental health issues and increase referral rates to mental health services. One of the unique findings from the study concerned cultural beliefs regarding mental health and the perceived role of the clergy in the immigrant community. Cultural issues concerning self-awareness, disclosure, shame and family involvement were identified by the participants, and such information should be incorporated into intervention efforts. Participants also noted the multiple roles of the clergy and their responsibility for the health and well-being of their community members. Along with participants who voiced their lack of readiness to help Korean Americans with mental health problems, the findings substantiate the need for mental health education and training targeted for religious leaders in ethnic minority communities to equip them to be better prepared 7

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to deal with mental health concerns. It is promising that a majority of the participants indicated their willingness to participate in mental health education and training. In this regard, it is encouraging that empirical studies have demonstrated positive outcomes of educational interventions designed to improve mental health literacy (Christensen et al. 2004, Jorm 2012). By promoting clergy members’ mental health literacy, community mental health can be protected by early detection of mental health-related problems and proper referrals. Furthermore, mental health literacy can be efficiently diffused throughout the community when clergy members play a central role as knowledge disseminators. Some limitations of the present study should be noted. All analytic decisions were made by the members of the research team, and their biases and perceptions may have, to some extent, influenced the interpretation of data (Denzin & Lincoln 2005, Creswell 2012). Also, given the geographic restrictions and voluntary nature of the sample, the current participants may not be representative of the entire body of Korean American clergy members. It is plausible to assume that those who participated in the study might be more open to mental health issues. Finally, given the limited scope of the target population, future studies should include diverse groups representing different ethnicities, religions and regions. Despite these limitations, the present study has important implications. Given the clergy’s understanding of Korean immigrant culture and their role in the community, collaborations between the Korean American clergy and mental health providers appear to be pivotal. Future efforts need to be focused on how to provide clergy training and effectively utilise churches and clergy members in community outreach and empowerment for mental health promotion.

Acknowledgements This work was supported, in part, by the University of Texas at Austin Special Research Grant (#RO 207604-9651; PI−Yuri Jang, PhD).

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