[Editor's note: The full text of this lecture, including an account of the author's own course of research and its role in his ministry and the development of his Four Worlds Model of Spiritual Assessment and Care, is available directly from the author at firstname.lastname@example.org.]
INTRODUCTION: TENSIONS AND DEFINITIONS
...In healthcare environments of excellence..., clinically trained chaplains are valued members of the medical treatment team because of the skills we bring and because of the values we hold in common with medicine and allied health disciplines: enhancing the health and well-being of the patient as a unity of body, mind and spirit within a unique family and cultural system. At the same time, it can be accurately said that we chaplains do our work on someone else's turf. We are persons of the spirit laboring among persons of science. The scientists, specifically the medical doctors, are in charge and rightfully so. With support and input from other members of the treatment team, patients and families, the medical scientists make the difficult life-and-death decisions and are held accountable for the outcomes of those decisions.
Thus eyebrows are raised when words representing spirit and science are placed together in a phrase like "Pastoral Research." This pairing of words may even be perceived by some as a contradiction-in-terms. Put metaphorically, this is tension between Head and Heart, a condition seen by my professor of psychology of religion and mentor, Samuel Southard, as the central problem of American religion. But the tension is centuries old.
Galileo Galilei (1564-1642) pointed his 20-power telescope to the sky and found sunspots, the four largest moons of Jupiter, and other things that did not mesh with accepted theological beliefs about perfectly round heavenly bodies, an Earth around which they all orbited, and so on. For his discoveries Galileo received a sentence of life imprisonment for heresy. To obtain a license to practice medicine in 1566 doctors were required to swear that they would stop seeing a patient on the third day unless (the patient) had confessed all sins and had a confessor's statement to prove it. Violations were punished by permanent removal from the practice of medicine. Little wonder that from then until now there have been scientists who would like to explain all the mysteries by empirical inquiry over against the faithful who fervently believe in spiritual forces immeasurable by any meter.
In the midst of this ongoing tension between Head and Heart, John L. Florell, a pastoral counselor, identifies two kinds of Pastoral Research: "empirical studies which examine actual events of care and counseling (and human problems to which they are addressed); and theoretical studies, which analyze or construct the concepts and images which define the problems and guide the practice of pastoral care and counseling." Florell goes on to identify the three most common methods of gathering information in pastoral care and counseling: case studies, correlation studies, and experimental studies.
Medical science is built exclusively upon experimental studies, but according to Florell experimental designs are not the only way pastoral care can legitimately expand its knowledge base (and I most certainly agree). In that more expansive sense, my own definition of Pastoral Research is the disciplined study of religious experience by pastoral practitioners toward increased effectiveness in ministry within the larger context of Religious Research (i.e., work conducted by persons representing many disciplines: theology, medicine, nursing, psychology, psychiatry, sociology, and so on).
The goal of this presentation is to examine the past, present, and future of Pastoral Research, including the chaplain's moral imperative to examine practice and to share what is found....
THE PAST: THE PIONEERS
The first pastoral practitioner to formulate and study the tension between Head and Heart in American religion is probably the last one you would have thought. It was none other than Jonathan Edwards (1703-1758), remembered as the fiery preacher of "Sinners in the Hands of an Angry God" and not for his ability to stand apart from what he was doing and view it with clinical insight. Almost everything that Edwards thought or observed was committed to his notebooks, which he then used as a basis for analysis in his ministry. He was troubled that many persons could name an idea but not be in contact with the feeling that the idea signified, and therefore were lost among meaningless signs in a state of disassociation. In Edwards' view the understanding of the Head must become the sense of the Heart. In other words, integration was in order. So he intentionally preached to stir feelings, and he was effective enough to help launch a revival, the First Great Awakening, in 1740s New England. His work with converts was reported in what Southard has called the primary clinical study of religious experience in America, "A Treatise Concerning Religious Affections."
Both the theory and the method of Pastoral Researcher Edwards were vigorously opposed by the Head-only people of the day, the learned clergy. To them, a correct understanding of confessions of faith was sufficient for church membership or ordination. Emotional expressions of religion were to be made in private. But there could be no argument that Edwards had provided the first model for the use of empiricism toward better understanding in matters of the spirit.
The religious tension between Head and Heart was again critically examined at the turn of the 20th century by William James (1842-1910), described by Jacques Barzun as America's most original thinker since Edwards. From his studies, physiologist-psychologist-philosopher James, in his Gifford Lectures of 1901-02 (published as Varieties of Religious Experience), granted the Heart a deeper and more powerful role over the Head within the individual. "The unreasoned and immediate assurance is the deep thing in us; the reasoned argument is but a surface exhibition. Instinct leads, intelligence does but follow" (p. 73). But in the study of religious experience, as in any study, "To understand a thing rightly we need to see it both out of its environment [i.e., Head] and in it [i.e., Heart], and to have acquaintance with the whole range of its variations" (p. 35). Varieties examined the transformative experiences of encounters with the divine that were the privilege of great religious figures, and thereby established a two-category spiritual assessment schema of once-born and twice-born.
Along with William James at the turn of the 20th century, G. Stanley Hall, Edwin D. Starbuck, George A. Coe, Edward S. Ames, J. H. Leuba and others engaged in the empirical study of religious consciousness, with emphasis upon religious conversion. However, this new academic discipline, the psychology of religion, was quickly eclipsed by the rising popularity of psychoanalysis and later, behaviorism. Its concerns were for the most part incorporated into religious education, the philosophy of religion, pastoral psychology, and sociology, but there has been a steady stream of scholars writing on the subject to the present, including Orlo Strunk, Jr., G. Stephens Spinks, E. R. Goodenough, Paul W. Pruyser, William A. Sadler, Jr., Robert H. Thouless, Wayne E. Oates, Heije Faber, Geofrey E. W. Scobie, H. Newton Malony, Raymond F. Paloutzian, Andre Godin, and Kenneth I. Pargament.
Anton T. Boisen (1876-1965), a Presbyterian minister who was convinced that his own psychotic episodes had religious significance, dedicated his life to the study of "living human documents" (those suffering from mental illness) in the cause of understanding the meanings and messages (Head) of those experiences (Heart). In so doing, Boisen became a founder of the Clinical Pastoral Education (CPE) movement when as a chaplain he brought the first four seminarians to Worchester State Hospital for training in the summer of 1925.
A major contribution of Boisen to Pastoral Research was the adaptation to theological education of the medical case method that had just been developed by another founder of clinical pastoral education, Richard C. Cabot, MD. For Boisen, the desired effect was to get seminarians to pay careful attention to life experience (Heart) toward integration in their theological formation (Head). Boisen joined Cabot in his call for a clinical year for all seminarians so that they could address, case by case, the relationship between functional mental disorders and religious experience. Boisen also called for "some plan for encouraging high-grade research work on the part of pastors in the field, comparable to what medical [scientists] are doing."
...As the CPE movement matured toward its present form, the strong emphasis on the application of clinical findings to the day-to-day work of ministry using the verbatim record of pastoral care--instituted by Russell Dicks (1906-1965), a Methodist chaplain educator at Massachusetts General Hospital--at the expense of depth studies and theological perspectives, was a considerable disappointment to Boisen. Charles E. Hall (1919-2000), the first executive director of the Association for Clinical Pastoral Education, Inc. (ACPE), titled his book on the history of CPE, Head and Heart, and wrote in his introduction: "...I discovered an overarching theme of the CPE Movement: an attempt to integrate the messages of the head and the heart. CPE developed out of dissatisfaction with the intellectual assumptions of systematic theology separated from religious experience and dissatisfaction with ministry based on that separation." In that separation, the movement relied heavily on psychology, was strongly influenced by psychoanalysis, and as already noted, became focused nearly exclusively upon the day-to-day chaplain-to-patient action via the verbatim (Heart) to the near total exclusion of the depth studies, empirical research, and the theological reflection (Head) deemed so important by Boisen.
Robert B. Reeves, Jr. (1910-2002), a chaplain from 1954 to 1974 at The Presbyterian Hospital in the City of New York (now New York Presbyterian Hospital-Columbia Presbyterian Medical Center), brought Pastoral Research a giant step toward the present. In the mid-1960s he was asked by an eye surgeon colleague to see a patient who, six days after detached retina repair, had not begun to heal. Reeves discovered that nearly every close relationship the patient had ever known had become poisoned. On his second visit she "poured forth an almost incredible tale of bitterness, hatred, fear, and guilt." The morning following, the surgeon called Reeves to tell him that overnight the patient had caught up in her healing--her eye was as it should be at that time. Shortly thereafter Reeves and his colleagues obtained a grant and began researching the impact on healing of pastoral interventions with other ophthalmology patients. Reeves and his investigative team found that interventions by the chaplain positively correlated with high acceptance and rapid healing on the part of detached retina surgery patients.
Florell's replication studies with 150 orthopedic surgery patients and Mills' work with 100 open-heart surgery patients also showed a high correlation between acceptance and healing. Unfortunately, there were no further studies based on the work of Reeves, Mason, Florell, and Mills after 1975. The next nine years (1976-1984) produced only a few Religious Research studies directly addressing pastoral care and healthcare per se. One, Yates, et al., reported in 1981 that significant benefits were found in pain reduction and sense of well-being among advanced cancer patients with religious commitment and associated religious activities. This was the calm before the surge of attention to culture-wide matters of spirituality and holism in health care.
THE PRESENT: BURGEONING INTEREST, EXPANDING LITERATURE, AND SOME HAZARDS
Pastoral Research in the present is a picture of burgeoning interest, expanding literature, and hazards for the practitioners of pastoral care. One trigger for this explosion of interest was the publication in 1972 of Archie L. Cochrane's book, Effectiveness and Efficiency, in which he addressed the inattention of the medical profession to the specific effects of their practices. As a result, careful attention to outcomes became the byword as a matter of professional responsibility, first for medicine and inevitably for all allied health disciplines. Today the Cochrane Collaboration is a worldwide voluntary project of health care professionals in forty groups that review what physicians report about their practice of medicine.
A second stimulus to the new interest in religion and health was the dawning of the Age of Aquarius: the sexual revolution, the culture's discovery of holistic health, and the increasing popularity of individual spirituality vis-a-vis organized religion. The stage was being set for a dramatic paradigm shift that would soon see the rise of patients' rights, the new psychiatric perception of religion as a part of health (not pathology), the inclusion of spirituality in medical school curriculums and research in seminary curriculums, and careful attention to clinical spiritual assessment. Yet another factor (and perhaps the most powerful of all) was economics: the rapid acceleration of U.S. health care costs and an accompanying urgency in employing cost containment measures.
Amidst this roiling sea of change, a new round of studies directly addressing pastoral care, spirituality and healing began to appear, primarily undertaken by Religious Researchers from many disciplines, not clinical clergy Pastoral Researchers.
In 1985, Chu and Klein found that encouragement of inpatient schizophrenics in prayer and worship contributed to lower readmission rates among 128 African American patients. In 1988, ...[Randolph Byrd] found therapeutic effects among coronary care unit patients who were the beneficiaries of intercessory prayer offered from outside the hospital, ...and Richard B Osmann found that hospital staff benefited significantly in stress reduction from pastoral care, with accompanying savings to the institution. Elisabeth McSherry and her associates in the VA system published findings in 1989 indicating that the special spiritual needs of spinal cord injury patients resulted in slower care without an adequately staffed hospital-based chaplain team, and in 1990, Pressman, et al., found that religion as a source of strength and comfort was significantly related to post-operative ambulation status and inversely correlated with level of depression in elderly women with hip fractures....
Two 1992 studies are noteworthy. In one, outcomes for 200 men readmitted for depression an average of six months after initial evaluation indicated only one of 17 variables predicted lower rates of depression: the variable of religious coping. In the other, seven study modules take the reader through research studies from the scientific literature that focus on religious commitment and its impact on health and mental health. Findings strongly suggested that religious commitment was negatively correlated with suicide rates, alcohol and drug abuse, juvenile delinquency, divorce rates, depression, and general psychological distress. Regular church attendance was positively correlated with lower mortality rates and with fewer incidences of heart disease and emphysema. Certain other religious commitment measures were positively correlated with reduced hypertension.
In 1993, Benor reported that of 155 published works on spiritual healing, more than half showed significant results, and several such results were statistically significant. In that same year the co-author of the seven study modules just noted, David B. Larson, MD, noted that "a growing number of studies demonstrate that spiritual commitment is associated with clinical benefit for both mental and physical health status. Results are so consistently positive and so contrary to prevailing academic ideas that we believe that the mental and physical health professions may be on the verge of a transformation in perspective in the next few years." John W. Ehman has noted that Larson's words proved to be accurate and timely. In 1993 there was "a significant jump in the number of Medline-indexed articles on spirituality..., a jump that has been well-sustained ever since."
By 1996, I had personally accumulated 90 listings in my own unpublished annotated bibliography, "Spiritual Care and Health," and could readily access over 300 studies that directly correlated spiritual involvement and interventions with wellness and with disease prevention and suicide prevention. The next year clinical psychologist and professor Kenneth I. Pargament classified some 250 studies in five categories of religious coping in his comprehensive book, The Psychology of Religion and Coping. With respect to the ratio of Religious Researchers to Pastoral Researchers, I could recognize the name of only one Pastoral Researcher in those 250 Religious Research reports: that of Larry VandeCreek.
...However, within this rising tide of Religious Research-generated data, a narrow stream of dedicated, low-visibility Pastoral Researchers--Board Certified Chaplains, professors of pastoral care, pastoral counselors and CPE educators--has been steadfastly encouraging and engaging the Head in Pastoral Research in the midst of the Heart-only resistance of their colleagues: Samuel Southard, H. Newton Malony, Orlo Strunk, Jr., Merle R. Jordan, James L. Travis, III, Margot Hover, Larry VandeCreek, W. Noel Brown, John W. Ehman, William E. Johnson, Paul Derrickson, and George Fitchett, to name a few. In so doing, these Pastoral Researchers carefully and skillfully maneuver among very real hazards. Those hazards include pop spirituality, the co-opting of the care of souls by other disciplines, the temptation to allow other disciplines' definitions of research to drive their work, and other disciplines' agendas to dominate....
In her 1994 Foreword to Research in Pastoral Care and Counseling, Chaplain Margot Hover acknowledged that this small but determined corps of Pastoral Researchers is gaining momentum. Increasing numbers of chaplains and pastoral counselors are turning to quantitative and qualitative research methodologies to pinpoint such cost-effective relationships as the correlation between pastoral visits and length of hospital stay or the frequency of use of pain medication. More chaplains are submitting proposals to institutional review boards. Chaplain residents are increasingly required to undertake research projects. And a widening array of Doctor of Ministry programs emphasizes careful research toward practical applications. Yet much work remains to be done.
THE FUTURE: THE CHAPLAIN'S MORAL IMPERATIVE
For more than 75 years now, despite the work of the dedicated few Pastoral Researchers, most clinical clergy, rabbis, imams, lay caregivers, and others who work in correctional, mental health and general health care settings continue to minister in an essentially idiosyncratic way. We apply Head and Heart to the healing relationship as we see fit. We approach the client with our own unique styles. We resist any pressure toward critique or consensus about our daily practice.
Like it or not, ready or not, all clinical chaplains have a four-fold moral imperative: to stay abreast of Religious and Pastoral Research findings, to test those findings in the cause of improving our own quality of care, to further examine our practice, and to share what we find. Our professional colleagues from other disciplines have proclaimed that message to us. As plenary speaker at the College of Chaplains' annual conference in 1987, the VA physician cited above, Elisabeth McSherry, MD, made an impassioned and urgent plea for clinical chaplains to engage their Heads in research-based spiritual assessment and more precise pastoral responses, lest they be overrun and outdated by the increasing demands of cost containment and measures of cost-effectiveness throughout the U.S. health care delivery system.
In so doing, McSherry was echoing another strong voice, also from a non-chaplaincy discipline (clinical psychology) in the person of Paul W. Pruyser, who had in 1976 appealed to all pastors to reflect on their special heritage and use its theoretical foundations and practical applications to the fullest extent. He included clergy as professionals when he wrote, "The first duty of any professional is to achieve clarity about the problems brought for the sake of guiding the interventions (to be contemplated). If (the professional) does not fulfill this duty, he (or she) is a charlatan, albeit perhaps a very 'nice' one-whatever his (or her) shield proclaims him (or her) to be." Pruyser went on to liken such to the old-fashioned patent medicine vendor selling one vial of liquid as the remedy for "seventy-eight known diseases."
That call has continued to come from within by our clergy colleagues as well. Edwards and Boisen have been joined by their professional progeny in urging full engagement of the Head in the work of the Heart through Pastoral Research. Six years before Pruyser published The Minister as Diagnostician, Boston University School of Theology professor of psychology of religion Orlo Strunk, Jr. said in his address to the joint conference of the ACPE and the American Association of Pastoral Counselors in 1970, "Just as clinical pastoral education provides raw data for the psychologist of religion and consciously reminds (one) of these data, so too must the psychologist of religion confront the clinician with the necessity of sharing insights in styles acceptable to others besides himself (or herself) and (other) clinicians. And the clinically oriented must learn to do this in terms of the other's criteria as well as (one's) own. If this does not take place, a great deal of clinical knowledge becomes private or at least fraternalistically secret, driving deep wedges between endeavors which ought to be in creative dialogue."
Samuel Southard's 1976 book Religious Inquiry was addressed to all clergy, not just pastoral specialists. The first chapter was entitled "Research Is Your Business" and therein he set forth his thesis, which is also mine. "Research in religion is a natural and required part of religious experience and life in the church." In that same paragraph Southard promised "to provide guidelines and examples for research that will be appropriate in the church and manageable by professionals who have no advanced training in statistics or other quantitative methods." He went on to suggest and describe the practicality of reviews of documents, sample surveys, field observation, area analyses, and focused interviews.
The most recent and perhaps the sharpest wake-up call has been sounded by Larry VandeCreek, who views the lack of empirical research as a sign that we pastoral clinicians are not "pulling our weight as a profession in this scientific age." He says, "We have been unable to put the capstone in place. That is, we have not built an empirical research tradition which tests our observations and theories. That, I believe, makes us morally culpable. As members of our respective organizations we have been too ready to make a living on existing, borrowed insights and practice patterns, and not ready enough to test our own insights. Consequently, we can legitimately be seen in the scientific world as a 'do nothing' profession which has failed to make a contribution to knowledge in a scientific age."
Regarding the moral imperative to further examine our own practice, I propose these steps toward greater professional responsibility and accountability.
First, become familiar with the literature. To begin that daunting task I would point you toward the master compiler of materials of importance to clinical ministry and Pastoral Research, W. Noel Brown. In every quarterly issue of The Journal of Pastoral Care and Counseling since the Spring of 1999, Brown has included a current list of Pastoral Abstracts excerpted from his own data base, The Orere Source. (You may even subscribe to bi-monthly newsletters from The Orere Source by writing to Box 362, Harbert, MI 49115-0362.) Brown also has published a list of suggested readings, "Current Contents in the Literature of Interest to Pastoral Care," grouped under the following headings: The Cochrane Collaboration, Chaplains (and Others) Urging the Development of Outcomes-Based Chaplaincy, Articles Reporting Outcome-Oriented Results of Care, Intervention Methods Being Used, and Papers about Research that Have Implications for Pastoral Care.
Second, review suggested how-to formulas for the conduct of Pastoral Research. The best plain-talking source for ministry in general, including the local church, synagogue and mosque that I have ever seen is Samuel Southard's book, Religious Inquiry: An Introduction to Why and How (Nashville: Abingdon, 1976). The best discussion of quantitative vis-a-vis qualitative Pastoral Research can be found in Research in Pastoral Care and Counseling, by Larry VandeCreek, Hilary Bender and Merle R. Jordan (Journal of Pastoral Care Publications, 1994).
Third, pay attention to your own need to go deeper into some aspect of ministry. This need could be created by the necessity for demonstrating the efficacy of pastoral care in your own clinical setting. Or it could be a matter of simple curiosity. Why does this or that seem to happen in my ministry? Is there a pattern? If it's a good thing, how can I help make it happen more often? If it's not a good thing, how can I minimize the chances of it happening? And so on.
Fourth, partner with your ministry colleagues and your Pastoral Research colleagues via existing networks. Most major professional pastoral care associations have a research committee or network that meets during the annual conference. My primary professional organization, the Association for Clinical Pastoral Education, Inc., has the ACPE Research Network.... Also partner at your institution with your allied health colleagues who have technical research knowledge. Talk about your ideas and invite feedback with all of these people, but don't yield too easily to the ideas of others that may move you away from your original agenda just because you deem them to be more expert or more powerful in some way.
Fifth, and critically importantly, be sure to get the proper support and authority from within your own system to proceed in pursuit of answering your research curiosity or otherwise meeting your research agenda. Learn the workings of your internal research on human subjects' board as a part of your networking efforts, as well as the leanings and biases of other decision-makers in your organization.
Finally, develop a carefully thought out project design including realistic outcomes sought, timelines, and so on. An excellent step-by-step resource for this process is the VandeCreek, et al. title already mentioned, Research in Pastoral Care and Counseling....
NOTES [re-numbered from the original manuscript to follow sequentially in this edited version]
 Morton T. Kelsey, Healing and Christianity. N.Y.: Harper & Row, 1973. p. 212.
 For more detail on the historic interactions of science (Head) and religion (Heart), see Chapter 2 of Research in Pastoral Care and Counseling, VandeCreek, et al., JPC Publications, 1994.
 John L. Florell, "Empirical Research in Pastoral Care and Counseling," Dictionary of Pastoral Care and Counseling. p. 354.
 Samuel Southard, Religious Inquiry: An Introduction to the Why and How. Nashville: Abingdon Press, 1975. pp. 36-37.
 Samuel Southard, "The Head and the Heart in Clinical Training," Address, William S. Hall Psychiatric Institute, Columbia, SC, April 29, 1971.
 William James, The Varieties of Religious Experience. N.Y.: Mentor, 1958.
 Anton T. Boisen, "The Challenge to Our Seminaries," Christian Work, January 23, 1926, cited in Glenn H. Asquith, Jr., ed., Vision from a Little Known Country. Journal of Pastoral Care Publications, Inc., 1992. pp. 19-23.
 Boisen, "The Present Status of William Jamesís Psychology of Religion," Journal of Pastoral Care, Fall 1953, cited in Asquith, op cit., p. 112.
 Charles E. Hall, Head and Heart: The Story of the CPE Movement. Journal of Pastoral Care Publications, Inc., 1992.
 Robert B. Reeves, Jr., Carol Gardner Lecture, October 16, 1968.
 Randall C. Mason, Jr., et al., "Acceptance and Healing," Journal of Religion and Health, 8(2), 1969. pp. 123-142.
 Florell, "Crisis Intervention in Orthopedic Surgery--Empirical Evidence of the Effectiveness of a Chaplain Working with Surgery Patients," Bulletin, American Protestant Hospital Association, 37(2), 1973. pp. 29-36.
 Mitchell Mills, et al., "Prediction of Results in Open Heart Surgery," Journal of Religion and Health, 14(3), 1975. pp. 159-164.
 J. W. Yates, et al., "Religion in Patients with Advanced Cancer," Medical and Pediatric Oncology, 9, 1981. pp. 121-128.
 W. Noel Brown, "Introduction," The Discipline for Pastoral Care Giving. Larry VandeCreek and Arthur M. Lucas, eds. Binghamton N.Y.: Haworth Pastoral Press, 2001. p. xiii.
 C. C. Chu and H. E. Klein, "Psychosocial and Environmental Variables in Outcome of Black Schizophrenics," Journal of the National Medical Association, 77(10), 1985. pp. 793-796.
 R. C. Byrd, "Positive Therapeutic Effects of Intercessory Prayer in a Coronary Care Unit Population," Southern Medical Journal, 81(7), 1988. pp. 826-829.
 Richard B. Osmann, "Ministry to Hospital Staff and Its Effect on Hospital Operating Costs," The Tie, College of Chaplains, September/October, 1988. pp. 8-9.
 Steven R. Salisbury, et al., "Clinical Management Reporting and Objective Diagnostic Instruments for Spiritual Assessment in Spinal Cord Injury Patients," Journal of Health Care Chaplaincy, 2(2), 1989. pp. 35-55.
 P. Pressman, et al., "Religious Belief, Depression, and Ambulation Status in Elderly Women with Broken Hips," American Journal of Psychiatry, 147, 1990. pp. 758-760.
 Harold G. Koenig, et al., "Religious Coping and Depression in Elderly Hospitalized Medically Ill Men" American Journal of Psychiatry, 149, 1992. pp. 1693-1700.
 David B. Larson and Susan S. Larson, The Forgotten Factor in Physical and Mental Health: What Does the Research Show? An Independent Study Seminar funded by The John Templeton Foundation, 1992.
 Daniel J. Benor, "Healing Research: Holistic Energy, Medicine and Spirituality." Research in Healing, Vol. 1. Munich: Helix Velag GmbH, 1993.
 David B. Larsen, et al., "A Paradigm Shift in Medicine Toward Spirituality?" Advances, 9(4), 1993. pp. 39-49.
 John W. Ehman, e-mail message, February 10, 2003.
 Kenneth I. Pargament, The Psychology of Religious Coping. N.Y.: Guilford Press, 1997. pp. 407-464.
 Margot Hover in Larry VandeCreek, et al., Research in Pastoral Care and Counseling. Journal of Pastoral Care Publications, Inc., 1994. p. x.
 Joan E. Hemenway, Inside the Circle. Journal of Pastoral Care Publications, Inc., 1996. p. 119.
 Paul W. Pruyser, The Minister As Diagnostician. Philadelphia: Westminster, 1976. pp. 10, 58.
 Orlo Strunk, Jr., quoted in John J. Gleason, Jr., Growing Up To God. Nashville: Abingdon Press, 1975. p. 9.
 Samuel Southard, Religious Inquiry, op. cit., pp. 17, 29-30.
 Hemenway, op cit., p. 120.
 W. Noel Brown, Ibid. pp. xv-xx.