Incorporating evidence-based practices into faith-based organization service programs.

Terry, John D. ; Smith, Anna R. ; Warren, Peter R. 等

Faith-based organizations (FBOs) are increasingly involved in providing a range of services in communities and research indicates that such involvement will increase in the future. However, like other types of organizations, FBOs generally have been slow to embrace evidence-based practices (EBPs)--those that have scientific evidence of being beneficial. We contend that incorporating EBPs into both new and existing FBOs' service programs can enhance their effectiveness. In this paper, we discuss several relevant issues when implementing EBPs within FBO service. In this discussion we briefly explore FBO service provision, public policy to increase funding for FBO service, criteria for EBPs, and provide some considerations for future applications of EBPs within FBOs.

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There are significant benefits when faith-based organizations (FBOs) deliver social services, as acknowledged by ecological theory, federal policy initiatives, and recent conceptual papers (DeKraai, Bulling, Shank, & Tomkins, 2011; Kloos & Moore, 2000; Kramer, 2010). Some benefits of FBO service delivery include increased access to hard-to-reach populations, provision of services within naturally occurring settings, a more publically favorable and less stigmatizing view of emotional and behavioral health services, and the use of a culturally meaningful context to deliver services (Kloos & Moore, 2000; Kramer, 2010). Current work in this area aligns with the historical mission of the Church, modern-day congregations, and FBOs, to reduce suffering, increase wellness, and meet the needs of individuals. Alarmingly, in spite of good intentions, optimism, and hard work, community-based programs often fail to achieve results (Wandersman, 2009). FBOs have been and are ideally positioned to assist in providing services, but the services FBOs provide are not likely to be evidence-based practices (EBPs) informed by the latest science or rigorous systematic evaluation. Incorporating EBPs into both existing services and new programs can enhance effectiveness of FBO services.

Definitions

Faith-based organizations. Before proceeding, we briefly define FBOs and EBPs. FBO is a broadly applied term, often referring to a wide range of organizations (Bielefeld & Cleveland, 2013). This ambiguity makes it difficult to count FBOs, to measure both the amount and the type of services they provide, and to assess the effectiveness of their services (Kramer, 2010). It has been noted that anytime a complex phenomenon is turned into a categorical variable, information about variation is lost (Cohen, 1990). While we recognize that labels can lead to oversimplification and construct underrepresentation, we believe that researchers should explicitly describe how they operationalize and achieve construct validity for "faith-based organizations" in order to better explain the role of FBOs within systems and to better assess program effectiveness.

Here, we use the term FBO to describe organizations that formally provide services as part of their role as social service organizations. The term "service" is also highly variable; here, we use this term to include any social service or program, including mental health services, provided to those in need. It is also important to distinguish between religious congregations and faith-based social services (usually referring to FBOs). FBOs are professional or paraprofessional organizations; as a result, different standards may apply. Where FBOs have a primary social service mission, congregations may include social service as an important secondary mission. Sometimes these distinctions are blurred because religious congregations can be understood as both organizations and communities and may operate programs that provide professional services. The primary aim of this paper is to encourage FBOs (faith-based social service agencies) to incorporate EBPs into the services they deliver; however, in later sections we will also discuss how congregations would benefit from integrating EBPs into the services they provide.

Evidence-based practice. EBPs are services informed by the best existing scientific research (Sackett, Straus, Richardson, Rosenberg, & Haynes, 2000). Over the past two decades, professionals in the health and human services fields have argued for the necessity of EBPs in addressing needs of individuals and communities. This movement began in medicine and expanded to other disciplines, including psychology, public health, social work, and education (Sackett et al., 2000). In the early 1990s, the Institute of Medicine (IOM) championed this paradigm shift toward EBP, and it is now an element of professional training embraced across multiple professions (Collins, Leffingwell, & Belar, 2007). For example, in the field of psychology, the American Psychological Association (APA) developed the Task Force on Evidence-Based Practice in an effort to advance EBPs (APA, 2008); in nursing education, practitioners strive for more evidence-driven methods (Fineout-Overholt, Williamson, Kent, & Huchinson, 2010); and in social work, a variety of databases are recommended to promote EBP (Social Work Policy Institute [SWPI], 2010). Thus, the importance of EBP in service provision is well-supported and accepted across disciplines and, therefore, can be generalizable to FBOs.

Evidence-based practice criteria. Thankfully, ample established criteria exist to determine whether a program has sufficient evidence to be considered evidence-based. The Society for Prevention Research (SPR) commissioned a task force to develop guidelines for identifying programs that are efficacious, effective, and ready for dissemination (Flay et al., 2005). The SPR task force identified a list of 47 criteria that need to be met before a program is ready to be disseminated. According to their guidelines, an intervention should be disseminated only when it meets the requirements for both efficacy and effectiveness. For example, SPR deems a program efficacious after it has

been tested in at least two rigorous trials that (1) involved defined samples from defined populations; (2) used psychometrically sound measures and data collection procedures; (3) analyzed their data with rigorous statistical approaches; (4) showed consistent positive effects (without serious iatrogenic effects); and (5) reported at least one significant long-term follow-up. (Flay et al., 2005, p. 151)

Notably, the task force defines treatments as effective if they

not only meet all standards for efficacious interventions, but also will have (1) manuals, appropriate training, and technical support available to allow third parties to adopt and implement the intervention; (2) been evaluated under real-world conditions in studies that included sound measurement of the level of implementation and engagement of the target audience (in both the intervention and control conditions); (3) indicated the practical importance of intervention outcome effects; and (4) clearly demonstrated to whom intervention findings can be generalized. (Flayet al., 2005, p. 151)

The criteria established by the SPR create a consistent set of standards by which FBOs can compare effective programs then choose from a menu of strategies that target the needs of their communities and fit their organization. (1)

Advantages and Necessity of EBPs in FBOs

Adopting EBPs is particularly salient for FBOs given the complex nature of the problems they aim to address and the often limited resources they have for doing so. Many religious traditions value providing services to the public that are intended to increase well-being and/or reduce suffering (e.g., helping those in poverty). FBOs implement programs that presumably aim to achieve these objectives by meeting the needs of an individual or community. While FBOs' services can be measured in terms of program outputs (e.g., number of individuals served), it is often unclear whether these outputs correspond to achieving the desired program outcomes.

One reason for this discrepancy is because latent variables, such as mental well-being, are more difficult to define without expertise in measuring outcomes that are not directly observable. For example, in providing food to the homeless, the outputs (e.g., food) directly meet the need of the community (e.g., hunger); whereas in the case of providing behavioral or educational services to children with mental disabilities, relationships between outputs and outcomes are not as clear because they are not directly observed or easily understood. Despite the best efforts of well-intentioned and hardworking community leaders, community-based programs often are not adequately evaluated, fail to reach intended outcomes, or in worst case scenarios, provide services that are iatrogenic or harmful (Dishion, McCord, & Poulin, 1999; Wandersman, 2009). FBOs that are incorporating strategies with demonstrated effectiveness into their existing programs or that are adopting a new EBP model could assist FBOs that are providing services of a psychological or mental health nature.

Prevalence and reach. It is important that EBPs are encouraged in FBO services because of the vast number of people served by FBO programs. The delivery of services via FBOs is longstanding and prominent, and FBOs are often the first source of help when people encounter stressful life situations (Veroff, Kulka, & Douvan, 1981). In fact, the federal government and other service organizations have recognized the vast impact of FBOs on individuals and communities. There is a venerable relationship between FBOs and the health and human service delivery system in the United States (U.S.), and this connection has increased over the past three decades (Asomugha, Derose, & Lurie, 2011). Because of the advantages of FBOs' service provision, federal legislation now emphasizes FBOs as an important partner in ecologically informed service delivery (DeKraai et al., 2011; Kramer, 2010). For instance, FBOs have long delivered a variety of social services and other forms of assistance, and recent public policy expands public funding to FBOs for service delivery

(Kramer, 2010). This is evidenced by articles spanning the last three decades that demonstrate there is an interest in increasing behavioral health services in connection to FBOs (see Bufford & Johnston, 1982; DeKraai et al., 2011; Kloos, Horneffer, & Moore, 1995; Kramer, 2010; Leavey, Dura-Vila, & King, 2012; Maton & Pargament, 1991; Maton, Pargament, & Hess, 1991; Pargament, Maton, & Hess, 1991; Sarason, 1993; Spriggs & Sloter, 2003; Uomoto, 1982).

Policy and legislation. Recognizing the potential benefits of increased collaboration with FBOs in social service delivery, Presidents Clinton, Bush, and Obama have all supported federal initiatives to increase services delivered by FBOs. During the past decade, a series of Presidential Executive Orders led to the establishment of the White House Office of Faith-based and Community Initiatives--now named the White House Office of Faith-based and Neighborhood Partnerships--which is charged with making decisions on policy for federal funding and programming delivered through faith-based organizations (Executive Order No. 13,199,2006; Executive Order No. 13,498, 2009; White House, 2001).

These policy initiatives emerged in part to elucidate misunderstood aspects of the constitutional separation between church and state. Legislation enacts protection for individuals receiving services and protection for faith-based agencies providing services with public funding (Kramer, 2010). Most notably, the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) contains the "Charitable Choice" clause, allowing organizations to provide services with public funding while protecting their religious character. Still, concern exists that providing services within FBOs may lead to services only being beneficial to recipients who are themselves religious (e.g., members of faith communities) and result in discrimination against those who are not likely to attend FBOs. However, the federal policies we have described above aim to enhance service provision while simultaneously protecting the rights of both the providers and recipients of services. These policies and legislation show federal investment to support FBOs' service, making it more imperative for FBOs to use best practices and to know how to evaluate their programs.

Necessity of Evaluating Existing FBO Programs

Unknown or harmful effects. Regardless of whether a FBO has adopted an evidence-based approach, once a service program has been established, evaluation should be a routine practice. One cannot assume that the provision of psychological or educational services is always beneficial. In fact, a number of psychological and/or educational services are ineffective and even some plausibly helpful interventions delivered with good intentions have been shown to be harmful. Social scientists describe this phenomenon as "iatrogenic effects," and they caution against ignoring this possibility (Moos, 2012).

Unfortunately, the effects of a variety of widespread interventions are unknown despite being highly popular in community settings (e.g., the D.A.R.E. program [Rosenbaum, 2007], peer groups for conduct problems [Mager, Milich, Harris, & Howard, 2005], and some peer-mentoring interventions [Dishion et al., 1999]). Even more regrettably, unintended negative effects from interventions can and do occur outside the awareness of those implementing them. Without careful evaluation, it is difficult to determine either the positive or the negative effects of psychological/ educational interventions (see Wright & Cummings, 2005).

Potentially harmful treatments. There are several notable examples of mental health interventions and community-based programs that demonstrate harmful effects (see Lilienfeld, 2007; Tan, 2008). Lilienfeld (2007) reviews interventions that are potentially harmful for some individuals by examining the various levels of research support for their negative effects. A provisional list of programs that are potentially harmful are identified as: critical incident stress debriefing that can lead to a heightened risk for PTSD symptoms, Scared Straight programs that can exacerbate conduct problems in youth, facilitated communication interventions that can lead to false accusations of child abuse against family members, attachment therapies (rebirthing) that have the possibility of death and serious injury to children, recovered-memory techniques that may have the effect of producing false memories of traumas, dissociative identity disorder-oriented therapy that is suggested to induce "alternative personalities," grief counseling for individuals with normal bereavement reactions that can increase depressive symptoms, expressive-experiential therapies (e.g., Gestalt) that can potentially exacerbate painful emotions, bootcamp programs for youth conduct disorder that can exacerbate conduct problems, and D.A.R.E. programs that may increase alcohol and substance use (Lilienfeld, 2007). Tan (2008) extends the discussion of potentially harmful interventions into the context of Christian counseling services by reviewing data that indicates incorporating religious interventions into counseling services can be helpful for some individuals and potentially harmful to other individuals. Tan argues for the creation of a provisional list of potentially harmful interventions in faith-based settings akin to Lilienfeld's list of potentially harmful treatments occurring in other settings.

Faith-based organization example. The youth mentoring literature is an example in which the intentions of service providers have been found to be inconsistent with the outcomes of certain programs. Youth mentoring is a popular intervention designed to promote positive behavior in youth, with over two million youth receiving mentoring every year (Dubois & Karcher, 2006). FBOs often recruit and organize volunteers to participate in youth mentoring programs, and several models of FBO-specific mentoring programs exist (Bauldry & Hartmann, 2004). However, only recently has research empirically investigated the impact of youth mentoring programs in certain contexts (Wheeler, Keller, & Dubois, 2010). While some research has been encouraging (Karcher, Kuperminc, Portwood, Sipe, & Taylor, 2006), other research has found that mentoring may not work in certain circumstances and may actually be harmful in others. For example, McQuillin, Smith, and Strait (2011) describe a "cautionary result" (p. 844) after conducting a randomized evaluation of a school-based mentoring program which found that the mentoring program's services had significant negative effects on students' reading grades while offering no significant positives effects. Studies such as these reveal how evaluating programs' results is beneficial not only in determining effectiveness but also in protecting against iatrogenic effects.

In summary, the services that FBOs provide are prevalent, offer numerous advantages, and are likely to increase due to research interest and federal policy initiatives. As FBOs increase both the number and type of services provided, incorporating EBPs can increase the effectiveness of these services. In addition to employing EBPs in service provision, formal evaluation will help FBOs determine if these services are meeting their intended goals. Issues such as null or iatrogenic effects highlight the importance of implementing valid and proven methods of evaluation for faith-based programs (Smith & Teasley, 2009). Given the recent increase of faith-based programs, it is becoming increasingly important to have valid models for evaluating their effectiveness across a variety of domains (Bielefeld & Cleveland, 2013; Hula, Jackson-Elmoore, & Reese, 2007; Janzen & Wiebe, 2010).

Challenges to EBP Implementation with FBOs

Philosophical tensions. Both compatibilities and tensions exist in emphasizing EBPs within FBOs, and discussion about their relationship is ongoing. A principle of evidence-based practice is to provide services with rigorously established scientific support for effectiveness (Flay et al., 2005). Given this principle, it may be more difficult to gain support for EBPs from FBOs than from secular organizations because of the oft-perceived incompatibility of faith and science (McGrath, 2005) or of psychology and Christianity (Johnson, 2007). Making the matter more complicated, considerable heterogeneity exists both between FBOs and within FBOs in the degree to which their service providers value the use of research, and there are differing opinions both within psychology and within the church concerning the best way to provide services--especially mental health services. Unfortunately, on issues such as these, extreme views are often the focus of debate and discourse (Johnson, 2010). Fortunately, a collection of writing exists on the relationship between psychology and theology and on the application of psychological practice within faith settings (Johnson, 2011; Miller & Jackson, 2010). Most scholars agree that a relationship between psychology--the scientific study of human behavior--and religious beliefs does exist (Johnson, 2007; Miller & Jackson, 2010). Whether or not this acceptance has gained momentum in FBOs and communities is yet to be determined.

Tensions between faith and science are often due to conflicting philosophical ideas. For instance, some individuals within FBOs may tend to value teleology, spiritual guidance, and God's will, whereas EBPs are often based on the philosophical assumptions of determinism, human agency, empiricism, and objectivism. It may be the case that individuals providing service in a faith-based context feel that an increase in empirical methods overemphasizes human agency or determinism and underemphasizes the role of faith in alleviating the suffering of others. However, it is possible for these values to be in tension without being incompatible. The tension between God's will and human agency plays out in organizations like Alcoholics Anonymous, which though technically secular, popularized the Serenity Prayer: "God, give me grace to accept with serenity the things that cannot be changed, Courage to change the things which should be changed, and the Wisdom to distinguish the one from the other" (Niebhur, 1986, p. 251).

Faithfulness and effectiveness. The idea of EBPs emphasizing effectiveness in providing service versus FBOs emphasizing faithfulness in providing service also creates tension between EBP and FBOs. This idea reflects the fact that EBP and FBOs both have desired outcomes or mission statements (e.g., betterment of the community and alleviation of suffering). Contrary to EBPs, however, FBOs are not focused solely on finding significant effects of their service. FBOs may agree that knowledge and wisdom should be applied to FBOs' practice; however, they may also emphasize that accomplishing service outcomes is not the entire point of FBO service. In some circumstances, positive outcomes (e.g., a cure or abatement of symptoms) may not be possible or likely (e.g., chronic mental illness, hospice care). Nevertheless, some FBOs provide care regardless of whether this results in a positive outcome. In such situations, the lack of a positive outcome does not necessarily reflect failure of the FBO service.

Limited evidence. An additional challenge is that the evidence base for a specific problem is often limited. When there is no established EBP to address a particular individual or community need, proponents of EBP suggest that promising practices should be researched and evaluated before any service is provided. Ideally, only programs with the support of research should be implemented. Here, balancing the importance of being evidence-based with the urgency to aid others may be difficult, particularly for FBOs. In a research setting, if no effective program is available, all stakeholders should be informed that the program is experimental and the probability of positive results is unclear; stakeholder consent would be obtained thereafter. However, in some instances, these ideas can be antithetical to FBOs with a mission of providing immediate services to those in desperate need.

For FBOs, it may be impossible, inappropriate, or even unethical to delay offering an intervention until researchers have established its evidence base. Indeed, FBOs have often played a role in identifying and addressing new social problems before professional helping technology was available. At the time of this writing FBOs are involved in the treatment and prevention of Ebola virus in West Africa where immediate service is desperately needed. At the same time, the World Health Organization is providing guidance on the ethics of the immediate use of experimental medical treatments while emphasizing rigorous evaluation during difficult treatment circumstances (World Health Organization, 2014). These important issues should be explored, discussed, and debated more in the future.

Difficulty in implementing EBPs. It may be difficult to increase the use of EBPs by FBOs for many reasons. First, FBOs often lack the time and resources necessary for adopting an EBP to their mission or particular population. For instance, FBOs may need experts' help in identifying which ongoing practices to evaluate, in selecting appropriate EBPs, and in training their staff in EBPs. Second, some FBOs may not be using EBPs due in part to having limited experience with consuming, evaluating, and translating scientific research into practical applications. EBP jargon, or the failure to translate research findings into plain language, may intimidate practitioners from engaging in EBP.

Difficultly in evaluating FBO service. Engaging in lengthy evaluations of FBO services may be equally challenging for FBOs with limited resources. In general, assessing the validity of evaluation methodologies (e.g., ambiguous temporal precedence, selection, history, maturation, regression, attrition, testing, instrumentation, interaction of these threats) can be difficult. FBOs may have difficulties with some of these threats to validity more specifically. While some interventions are associated with significant positive change (Hodge, 2006; Hook et al., 2006; Marker, Weeks, & Kraegel, 2007), evaluating the outcomes of faith-based interventions can be complicated because those interventions often lack the scientific rigor necessary to draw strong inferences. In one meta-analysis of faith-based organizations, less than one third of the studies of FBO outcomes used a comparison group (Wuthnow, Hackett, & Hsu, 2004). Often, studies of faith-based services' effectiveness have not evaluated long-term or community outcomes (Wuthnow et al., 2004); thus, a full picture of the status of services is lacking. For studies that have been conducted on FBO service programs, there is a trend in which it is more difficult for studies without significant effects to be published both in psychology (Ferguson & Heene, 2012) and in other areas (Rothstein, Sutton, & Borenstein, 2006); thus, faith-based services through which the client improved only slightly or even worsened slightly may be unrecorded, giving us an incomplete view of the services. In summary, while some FBOs may be effecting meaningful change within their populations of interest, the relative deficiencies and lack of validity in their evaluation techniques makes it difficult both to disseminate their findings and to have those findings viewed as scientifically valid.

It is apparent that harmonies and tensions exist when emphasizing EBPs within FBOs, most notably around the concepts of being effective in service versus being faithful in service. There may also be problems when there is limited evidence on effective treatments for a specific issue, as it may be inappropriate, impractical, and even unethical to delay offering an unsubstantiated intervention. Often times, a deficiency of resources or capacity can be a challenge for FBOs in implementing and evaluating EBPs. In the next section, we discuss ways to work more towards overcoming philosophical differences as well as some promising directions for EBPs with FBOs, including examples of larger congregations who have adopted EBPs into the services they provide in the community.

Overcoming Challenges and Future Directions

Harmony of FBO service and EBP. Contrary to commonly held misconceptions that faith and science are antithetical, incompatible, and competing, there is room for an integrated perspective. FBOs aim to help those in need; they may primarily be motivated to provide service faithfully but possess a simultaneous desire to provide service effectively. For example, FBOs may desire to be faithful in their service regardless of outcomes and, at the same time, desire to manage time and resources well. Therefore, FBOs should consider research-based programs and practices to achieve desired outcomes of service. This article champions the notion that FBOs can increase their ability to serve others in meaningful ways by selecting practices with research support.

Christian psychology. While it is not the main focus here, biblical cases can be made for the utilization of the best available, empirically supported practices (see Craddock, 2001; Graham, Walton, & Ward, 2005). Several leading scholars are attempting to understand the relationship and differences between psychology and theology and are working to define a separate "Christian Psychology" (Barnett, 2008; Johnson, 2007; Johnson, 2010; Miller & Delany, 2005; Miller & Jackson, 2010). According to Sisemore (2011), a key aspect of the Christian Psychology movement is that "a Christian Psychology approach to relating Christianity and psychology will not eschew research, but rather embrace it" (p. 272). This movement posits a framework for a doxological understanding of human behavior, while also suggesting that human behavior can be understood through empirical methodology. In this context, moving from "research to practice" in FBO settings is a logical next step as EBPs become more pervasive in other applied fields and other settings that provide services. As Christian Psychology develops and research accumulates, discussion about the specific role of EBPs and their application within FBOs is needed.

EBP resources. As FBOs plan programs, several resources exist to facilitate the selection of programs with demonstrated effectiveness and efficacy in addressing community and individual needs. For instance, the Substance Abuse and Mental Health Services Administration (SAMHSA, 2013) publishes the National Registry of Evidence-based Programs and Practices (NREPP). Additionally, the U.S. Department of Education, Institute of Educational Sciences (IES; U.S. Department of Education, 2013) makes public the What Works Clearinghouse (WWC,). The Center for the Study and Prevention of Violence (CSPV, n.d.) also publishes the Blueprints for Violence Prevention initiative to identify violence, delinquency, and drug prevention programs that meet the strict criteria for effectiveness. Furthermore, the Social Work Policy Institute (SWPI, 2010) is a web-based resource that supports evidence-based mental health treatments in social work practice. FBOs can use these and other registries of EBP to identify practices that could meet an identified need. Psychologists or researchers could also act as key resources in helping FBOs gain access to these blueprints.

Collaboration. FBOs are ideally suited to provide services in partnership with psychologists or other behavioral health providers (DeKraai et al., 2011). DeKraai and colleagues (2011) developed a multimodal model emphasizing the value of FBO partnerships in behavioral systems of care. The model emphasizes three tiers of service provision: the lowest level refers to informational services (e.g., referrals and prevention); the central level includes support services (e.g., housing, independent living skills, financial support, employment assistance, education, transportation, social and recreational opportunities, mentoring, care management, and education/support groups); and the highest tier refers to treatment and clinical care services (e.g., outpatient and inpatient treatment, residential treatment, crisis intervention).

While the specific treatments and interventions within the highest tier may be the most challenging for FBOs to implement, DeKraai and colleagues describe organizations such as Lutheran Family Services of America, Samaritan Counseling Centers, and Catholic Social Services as examples of licensed and accredited FBOs that deliver outpatient mental health and substance abuse services. More FBOs are able to carry out the support services described in the central tier as such services may flow naturally from existing services and are not exclusive to the needs of those with mental or behavioral health problems, though they may be particularly salient for such individuals. Most FBOs will be able to intervene at the lowest level of this three-tier model with the provision of information or preventative services (through workshops, development of positive relationships, etc.) and referrals to evidence-based programming. Again, the federal government's interest in FBOs offers access to this lowest tier of intervention.

Congregation service. Even though most of the discussion so far has focused on faith-based social service organizations, the individual congregation also has its role. Because of the prevalence of emotional and behavioral problems, which impact approximately 1 in 4 individuals within the general population, religious congregations will inevitably interact with individuals and their family members facing difficulties with a mental illness (Miller & Jackson, 2010). The 2007 National Congregations Study (NCS) surveyed churches within the U.S. and found that 45% of religious congregations were involved in formal delivery of social services and an additional 27% were involved informally (Chaves & Anderson, 2008).

Congregations offer several highly practical and logistical advantages to providing services. First, congregations can reach large numbers of people in need since they often provide services in individuals' natural environments (Iscoe, 1974). In the U. S., 43% of Americans attend a religious institution weekly or almost weekly across all major faith traditions (Gallup, 2010), with 78% of adults identifying themselves as members of the Christian faith (Pew Forum on Religion & Public Life, 2008). Second, congregations use more volunteers in the workforce and rely less on government funding, which can promote continuity in programming. Conversely, it can also make congregations more vulnerable (e.g., susceptible to economic downturns, reliant on charismatic leadership). Third, the relationship and alliance between staff and client may be closer in congregations in comparison to secular programs (Fischer & Stelter, 2006), allowing congregational relationships and support to persist long after the helping episode has ended. In particular, children and families tend to benefit greatly from these relationships and to more persistently engage in both service activities and in their religious community (Johnson, Tompkins, & Webb, 2002). Lastly, most Americans (69%) support providing government funding to congregations to assist those congregations in expanding their services to include options such as counseling (Pew Forum on Religion & Public Life, 2009). Hence, there are many benefits to services being provided by workers in congregational settings.

Individual congregations have the opportunity to provide services to individuals in a number of ways. It is important to note that the services congregations provide to the community are not always explicitly religious nor do they always take place in a typical religious setting. The use of public funding for proselytizing is prohibited by federal policy, encouraging congregations funded partially by federal resources to provide services outside of religious contexts. Rather, individual congregations have the opportunity to reach individuals through many different means. Some services can be extended by using paraprofessional staff with various levels of training as has been done in medical setting with some nurse practitioners now providing services that were previously more common for physicians to provide (APA, 2008). In congregations, this may include having paraprofessionals provide services that would usually be provided by specially trained mental health staff persons, such as psychologists, social workers, or counselors. For example, the Stephen Ministry program trains individuals in a paraprofessional role to offer support to individuals within the church undergoing difficult life circumstances. Currently, many churches have adopted group-based curricula to offer additional support to individuals that have experienced symptoms associated with anxiety, depression, trauma, or substance abuse (Wilkerson, 2011). By having lay church staff and volunteers provide particular mental health interventions, congregations can expand the reach of mental health services beyond formal providers.

Partnerships with FBO and EBP strategies. The selection, implementation, and evaluation of EBPs may be a difficult endeavor for most FBOs and may be particularly difficult for a congregation with limited resources and professional staff. Just as in community-based and governmental organizations, successfully implementing EBPs in FBOs or congregations may require content experts such as psychologists, researchers, or others to train and guide implementation. Health promotion literature, which has modeled such collaboration, has relatedly described a difference between faith-based and faith-placed interventions. In the former, programs are emic and are generated and conducted by preexisting groups or parties within the congregation, and in the latter, the programs are etic and come from outside the congregation or FBO. However, the ideal program is collaborative and grows from a partnership between churches and outside groups (Campbell et al., 2007). Kloos, Horneffer, and Moore (1995) interviewed leaders of religious communities in order to examine their perceptions of collaboration with psychologists and universities. This study noted that 15 out of 18 religious leaders who were interviewed indicated that partnership with psychologists could benefit their community. Based on this qualitative study, seven recommendations were offered to improve relationships between psychologists and FBOs:

1. Do not psychologize religious phenomena.

2. Learn and use the language of religious communities as well as psychologically oriented language.

3. Acknowledge contributions of church consultants and the psychological training leaders might have.

4. Do not assume membership in a religious community is beneficial to all individuals, or is beneficial in the same ways.

5. Distinguish consultation from collaboration and the community's interest in either or both (i.e., Is the community interested in the psychologist being there as a consultant or in the role of a collaborator?).

6. Consider and examine inreach/outreach emphasis (i.e., whether services are going to focus on individuals inside the congregation or in the community).

7. Consider familiarity with a university community, being sensitive to possible distrust of academic researchers.

These recommendations will help guide community psychologists interested in collaborating with FBOs.

Past experiences and FBO/congregation characteristics may impact whether members of the FBO or congregation are initially trusting or accepting of psychologists or researchers and their work. An important consideration of one such characteristic involves churches that are predominantly composed of a population that often distrusts formal institutions or external resources due to previous negative experiences with helping professions. These populations often live in economically disadvantaged or rural areas where values such as religion and distrust of outsiders may present challenges to their engagement in mental health resources (Harowski, Turner, LeVine, Schank, & Leichter, 2006). An example includes churches in black communities (Taylor, Ellison, Chatters, Levin, & Lincoln, 2000), which often include members who are underserved but who view a community of faith as an essential part of their identity (McMinn, Meek, Canning, & Pozzi, 2001). In these scenarios, faith-based organizations are excellent resources for intervention but only when psychologists are careful to "respect and learn from these communities of faith, to enter these communities with humility, and to recognize that the psychological skills we offer must be viewed in the context of religious, cultural, and historical factors" (McMinn et al., 2001, p. 326), and thus build successful collaborative partnerships.

Congregations' attitudes toward any mental health intervention or science-based intervention may also vary based on the congregation's location on a continuum of religiosity. For instance, Kunst (1993) noted that higher levels of conservative religiosity were related to more positive attitudes toward church interventions or interventions that mixed religiosity and psychology but not toward non-church interventions. Thus, as partnerships may be needed to increase the use of EBPs, the values and concerns of FBOs and congregations must be acknowledged and respected, and the interests of all partners should align and be mutually beneficial. Though FBOs and congregations may seek partnerships (with individuals such as university researchers, consultants, or psychologists) in order to increase the effectiveness of their services, these partnerships may be limited or unfavorable because of differences in values, the presence of distrust, and other characteristics of either the FBO or potential collaborators(Kloos et al., 1995).

Conclusion

Faith-based organizations (FBOs) encompass many different types of organizations that provide a variety of services. In this paper, we primarily focused on social service organizations with some mention of large-scale, congregation-based community service programs. These FBOs have a long tradition of serving individuals and communities and are currently a prevalent means of providing services for hard-to-reach populations in naturally occurring settings. As such, FBOs are already in a position to help facilitate mental and behavioral health services and have begun responding to the call placed by scholarly articles and policy initiatives for increased provision of mental health services (Kloos & Moore, 2000; Kramer, 2010).

As with any intervention aimed at a specific community, the conversation about needs, goals, and outcomes must begin in the context of that organization or community. Interventionists wishing to implement an EBP in a faith community must be prepared to interface with individual congregations and meet them on their own ground, paying special attention to the unique social and organizational qualities of those groups as well as any potential differences between the faith traditions of the FBO and of the faith-based community they wish to work with (e.g., a Methodist FBO wishing to work with a Catholic diocese). To that end, faith leaders and members of faith communities who are already in unofficial positions (e.g., deacons, lay ministers) can serve as liaisons to their congregations in order to better identify both the specific needs of their congregations and the best ways to improve community buy-in for FBO interventions.

As services increase, the use of EBPs and of ongoing evaluation of these practices will be important for ensuring the effectiveness of programs. Without incorporating these practices, FBOs may be offering services that are unhelpful or even harmful, and the staff members who serve tirelessly might be working with ineffective tools. Despite concerns FBOs may have, using empirical approaches to choose programs and evaluate their success is not antithetical to faith practices; rather, it may be viewed as consistent with the religious values of applying knowledge and wisdom and carefully managing resources. Though differing focuses on effectiveness versus faithfulness may introduce conflict--particularly when the evidence base for an intervention or service is limited, solely relying on intuition when choosing programs may result in negligible, stunted, or harmful outcomes. Programs that are implemented should be continuously evaluated to help determine if that program is performing effectively.

Given this framework, there are considerations for applying EBPs in the future. As Christian Psychology is further developed and the relationship between science, psychology, and Christianity is further deliberated, discourse on the application of EBPs within FBOs should be included. Currently, FBOs have several resources for finding EBPs in order to address their specific organizational mission. In the future, further emphasis on multi-tiered frameworks describing and enhancing the fit of FBOs within the intervention systems is needed. Individual congregations have the ability to provide services at varying levels depending on their goals and number of service personnel available. The use of EBP in FBOs for the purpose of alleviating suffering and promoting well-being should be emphasized.

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Author Information

TERRY, JOHN D. MA. Address: Department of Psychology, University of South Carolina, 1512 Pendleton Street, Columbia, SC 29208. Title: Pre-doctoral Clinical Psychology Intern. Degrees: BS (Experimental Psychology) University of South Carolina; MA (Clinical-Community Psychology) University of South Carolina. Specializations: Motivational interviewing, evidence-based practice, program evaluation.

SMITH, ANNA R. MA. Address: University of Hawaii at Manoa, 2530 Dole Street, Sakamaki C 400, Honolulu, HI 96822. Title: Master's candidate in Psychology. Degrees: BA (Psychology) University of South Carolina; MA (English) University of South Carolina. Specializations: Community and cultural psychology, community- and faith-based organizations, program evaluation.

WARREN, PETER R. PhD. Address: 29 Kolob Street, Columbia, SC 29205. Title: Clinical psychologist. Degrees: PhD (Psychology) University of South Carolina. Specializations: Intimate partner violence, psychology of religion, community psychology.

MILLER, MARISSA E. MA. Address: Department of Psychology, University of South Carolina, 1512 Pendleton Street, Columbia, SC 29208. Degrees: MA (School Psychology) University of South Carolina.

McQUILLIN, SAM D. PhD. Address: Psychological Health and Learning Services, University of Houston, 472 Farish Hall, Houston, TX 77004. Title: Assistant Professor of School Psychology. Degrees: PhD (School Psychology) University of South Carolina. Specializations: Youth mentoring programs for adolescents.

WOLFER, TERRY A. PhD. Address: University of South Carolina, 1512 Pendleton Street, Columbia, SC 2920. Title: Professor and PhD Program Coordinator. Degrees: MSW (Ohio State University); PhD (University of Chicago). Specializations: Congregational social work.

WEIST, MARK D. PhD. Address: Department of Psychology, University of South Carolina, 1512 Pendleton Street, Columbia, SC 29208. Title: Director of Clinical Community Training; Professor of Clinical-Community and School Psychology. Degrees: BA (West Chester University); MA (Psychology) West Virginia University; PhD (Psychology) Virginia Polytechnic Institute and State University. Specializations: Clinical child and adolescent psychology.