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March 2020 Article of the Month
by John Ehman, Editor, ACPE Research Article-of-the-Month
and Manager for Pastoral Care, Penn Presbyterian Medical Center, Philadelphia PA


Case, A. D., Keyes, C. L. M., Huffman, K. F., Sittser, K., Wallace, A., Khatiwoda, P., Parnell, H. E. and Proeschold-Bell, R. J. "Attitudes and behaviors that differentiate clergy with positive mental health from those with burnout." Journal of Prevention and Intervention in the Community 48, no. 1 (January-March 2020): 94-112.

SUMMARY and COMMENT: Self-care and personal health are strong concerns in chaplaincy circles, including Clinical Pastoral Education programs, and have been explored in several previous Article-of-the-Month features [--see Related Items of Interest, §I, below]. The study this month, out of Duke University, uses a sample only of a group of Christian congregational clergy in North Carolina, but its findings may suggest themes generally useful to chaplains as well as to the many congregation-oriented students in CPE. Actually, the very demographic limits of its sample could prompt discussion among diverse chaplains and students about what may be commonalities and differences according to one's workplace setting and religious culture. Readers may also appreciate the authors' attempt to "offer practical suggestions for clergy to sustain positive mental health while performing meaningful but difficult work" [p. 6]. Of particular interest may be the concept of flourishing. NOTE: Given the current Covid-19 pandemic, the article may be valuable simply as a way to engage questions of positive mental health of burnout.

Motivated to prevent depression in the clergy, we sought to understand positive mental health in the clergy. ...In our study, we sought to identify differences between pastors with flourishing mental health versus those with languishing mental health and burnout. In so doing, we hoped to go beyond laboratory studies to identify the various factors related to why some clergy have flourishing mental health and others do not under real-world conditions.... [p. 6]
The sample was drawn from United Methodist Church clergy from the North Carolina or Western North Carolina Annual Conference and who had participated in a two-year holistic health and wellness intervention study called Spirited Life [--see Related Items of Interest, §IV, below]. That larger study had involved mental health assessments that paved the way for the current research to identify and recruit 52 participants who were characterized either by low mental health with burnout (18 people) or flourishing mental health (34 people). These clergy then completed a battery of measures that repeated those of the Spirited Life study and given a choice for an interview either in-person or via a web video process. The interviews were coded and analyzed according to grounded theory methodology. Among the qualitative methodological safeguards employed were an audit procedure by which "the lead analyst reviewed and provided written feedback on 25% of the coding and memo-ing completed by the other analysts," and a negative case analysis of the low mental health/burnout participants, "by which each transcript was analyzed by two analysts to reduce the likelihood of overlooking flourishing factors in this group." "In this way, we actively sought cases that ran contrary to our emerging findings" [p. 100]. In addition, "...we conducted follow-up interviews with a subset of 11 flourishing participants to get practical examples of how they promoted their mental health, which is consistent with the real-world focus of this study" [p. 100]. The sample was 38% female, 88% married, 90% White and 8% African-American.

Among the findings, five themes emerged from the data:
• Being intentional about health and well-being-promotion --
"FMH [flourishing mental health] participants more often recognized the importance of engaging in health and well-being-promoting practices and reported routinely engaging in these practices. In fact, many stated that they engaged in such practices daily. ...To enact these healthy behaviors, FMH participants reported having daily routines but indicated that their days often did not unfold as intended and that they had to be flexible within any given day to make sure they engaged in the activity at some point. Interestingly, FMH participants planned to be flexible; in advance, they thought of ways to accomplish their healthy behaviors even if disrupted." [p. 101]

• Participating in God's work and emphasizing process over outcome --
"FMH participants were more likely than those belonging to the LMH-B group to describe an orientation to ministry in which ministry was seen as 'God's work' and they were merely participants in that work. ...Perhaps as a consequence of this orientation to ministry, adherents often emphasized the process of ministry over its results. These participants believed working in concert with God was more important than achieving the desired result for ministry efforts. The de-emphasis on outcomes seemed to at least be partially based in the expectations that God's work does not always have an immediate and recognizable outcome and sometimes God's intended outcome may not be what we initially envision." [pp. 102-103]

• Having a bounded approach to ministry --
"A higher percentage of participants with FMH evidenced an orientation to ministry in which they proactively created boundaries between their work life and home/family life." [p. 103] Suggestions [presented in a table on p. 105] include: arrange your schedule in a way that works for you, manage your phone and email and don't let them manage you, give yourself permission to take care of yourself, get clear on expectations, talk with congregant leaders about the need for clear and direct communication, and communicate your schedule to others. The researchers flag this as "[o]ne of the key distinctions between flourishing and low mental health with burnout participants" [p. 107]. They state: "[T]he current study provides some evidence for clergy that stricter work-life boundaries are beneficial to their positive mental health, although it is possible that the directional influence is, instead, that clergy with positive mental health are more likely to enact work-life boundaries." [p. 107].

• Having an unbounded approach to ministry --
"While more FMH participants approached ministry with boundaries, more LMH-B [low mental health/burnout] participants approached ministry with few or porous boundaries between work and other life domains. Participants who had this approach mentioned that a lack of boundaries resulted in their taking work home and experiencing difficulty 'disconnecting' from work and being present for other aspects of life." [p. 104] The researchers note that this approach may be the result of demand placed upon the person or discomfort requesting boundaries from others.

• Ongoing stressors --
"Our analyses revealed that nearly all [LMH-B participants] mentioned experiencing one or more ongoing stressors that they believed were currently undermining their mental health. One such stressor was a lack of self-acceptance, defined in this study as 'having a positive attitude toward yourself and your personality while being able to acknowledge and accept current or past negative aspects of yourself.'" [pp. 104 and 106] Other stressors included a history of psychiatric illness (e.g., depression), chronic physical illness (e.g., rheumatoid arthritis), financial strain, and having to engage with demanding congregants or in ministerial tasks that they disliked (e.g. administrative duties).

The authors acknowledge the limitations of the study and emphasize caution about generalizing the results. However, the themes of intentionality toward health promotion, of boundaries, and of ongoing stressors would seem to be broadly valuable, whether clergy are working in a congregational or health care institutional setting. Yet, one result was "unexpected": the authors state, "[W]e did not anticipate finding that flourishing participants align their work with God and emphasize process over short-term outcomes" [p. 106]. The authors comment that while clergy may be subject to job-based evaluations, "[a]t the most important level of their work, [they] answer to God, who does not give them a written annual review" [p. 108]. When participants were asked about the focus on process, "FMH participants indicated that they were always discerning" [p. 103].

For this reader, one contribution that the article makes to the literature is its emphasis on the concept of flourishing, which seems underrepresented in discussions among chaplains and other clergy about burnout. The authors do not explicate this key term beyond its characterization of positive mental health, but it may be a constructive conceptualization for emphasis within chaplaincy [--see of Related Interest, §III, below].

Suggestions for future research include replication with larger and more diverse populations, plus interventional studies in order to explore connections between certain themes and positive mental health. The most recent citations in the bibliography are from 2017.


Suggestions for Use of the Article for Student Discussion: 

Given the current Covid-19 situation, any discussion of mental health and burnout should probably begin with a question like, "How might the current stresses and challenges of living amid a pandemic relate to those of more normal times, as described in the article?" Might the themes discovered in the research still be quite pertinent, albeit perhaps in different ways than came up among participants at the time? Certainly, intentionality about health and well-being-promotion presently has enormous importance but in a particular way regarding the pandemic response, and issues of boundaries and a perspective on the process over outcome now have different twists. If the group never moves beyond this line of discussion, it could still be a worthwhile use of the article! However, to turn more to the article on its own terms, the group could check-in about students' experience with -- or plans for -- congregational leadership (if that's not already well known in the group) vs. institutional chaplaincy. Then, the four themes could be taken up individually. How do the students contend with disruptions of their plans for health promotion? What of the pair of boundary issues identified? The table reporting "Suggestions from flourishing participants on establishing and communicating boundaries" [p. 105], may warrant going over in detail. Does the "process" theme resonate? What ongoing stressors may be different between chaplains and congregational clergy? What do the students think about the idea of "flourishing"? The meaning of "flourishing" may be plain enough -- indeed, the authors of this month's article do not explicate it -- but it may be helpful to read aloud the following description from another source:

Flourishing refers to the experience of life going well. It is a combination of feeling good and functioning effectively. Flourishing is synonymous with a high level of mental well-being, and it epitomises [sic] mental health. [--From p. 838 of Huppert, F. A. and So, T. T., "Flourishing across Europe: application of a new conceptual framework for defining well-being," Social Indicators Research 110, no. 3 (2013): 837-861; and for more on flourishing, see Related Items of Interest, §II, below. ]
Finally, the group might muse about how the Christian context of the study limits its insight for non-Christian clergy/chaplains and/or offers some insights that may cut across religious traditions.


Related Items of Interest:

I.  For previous Article-of-the-Month features that have explored burnout see the features for July 2018, October 2013, and October 2011.


II.  Flourishing is identified in our featured article according to the 14-item Mental Health Continuum-Short Form (MHC-SF). That measure is available online from a number of sources, including the website of the Association of American Colleges & University of North Carolina at Chapel Hill. For more on the concept of flourishing, see:

Agenor, C., Conner, N. and Aroian, K. "Flourishing: an evolutionary concept analysis." Issues in Mental Health Nursing 38, no. 11 (November 2017): 915-923. [(From the abstract:) PURPOSE: Mental health is an important measure of public health...; however, nursing practice and research continues to prioritize mental illness, rather than well-being.... Flourishing is a recent concept in the field of well-being. The term has been used sparingly in nursing practice and research, and conceptual clarification is needed to promote comprehensive understanding of the phenomenon. The purpose of this study is to critically analyze flourishing, assess the maturity of the concept, and provide recommendations for future research, education, and practice. METHOD: The concept of flourishing was analyzed using the evolutionary approach to concept analysis.... A search for articles on flourishing within the context of well-being was conducted through CINAHL, MEDLINE, and PsycINFO. A sample of 32 articles and 1 book was reviewed. Data were reviewed for concept attributes, antecedents, consequences, surrogate terms and related concepts. FINDINGS: Four models of flourishing were identified with six overlapping attributes: meaning, positive relationships, engagement, competence, positive emotion, and self-esteem. Limited longitudinal and predictive studies have been conducted, but there is evidence for several antecedents and outcomes of flourishing. Research is ongoing primarily in psychology and sociology and is lacking in other disciplines. DISCUSSION: The concept of flourishing is immature; however, evidence is building for related concepts. A lack of consistent terminology regarding flourishing prevents knowledge development of flourishing as a distinct concept. Further multidisciplinary research is needed to establish standard operational and conceptual definitions and develop effective interventions.]

Catalino, L. I. and Fredrickson, B. L. "A Tuesday in the life of a flourisher: the role of positive emotional reactivity in optimal mental health." Emotion 11, no. 4 (August 2011): 938-950. [(Abstract:) Flourishing--a state of optimal mental health--has been linked to a host of benefits for the individual and society, including fewer workdays lost and the lowest incidence of chronic physical conditions. The aim of this paper was to investigate whether and how routine activities promote flourishing. The authors proposed that flourishers thrive because they capitalize on the processes featured in the broaden-and-build theory of positive emotions, specifically by experiencing greater positive emotional reactivity to pleasant events and building more resources over time. To test these hypotheses, the Day Reconstruction Method (DRM) was administered to a prescreened community sample of adults (n = 208), and they were recontacted two to three months later. Results showed that relative to those who did not flourish or were depressed, people who flourish generally responded with bigger "boosts" in positive emotions in response to everyday, pleasant events (helping, interacting, playing, learning, spiritual activity), and this greater positive emotional reactivity, over time, predicted higher levels of two facets of the cognitive resource of mindfulness. In turn, these higher levels of mindfulness were positively associated with higher levels of flourishing at the end of study, controlling for initial levels of flourishing. These results suggest that the promotion of well-being may be fueled by small, yet consequential differences in individuals' emotional experience of pleasant everyday events. Additionally, these results underscore the utility of the broaden-and-build theory in understanding the processes by which flourishing is promoted and provide support for a positive potentiation perspective.]

Fredrickson, B. L. and Losada, M. F. "Positive affect and complex dynamics of human flourishing." American Psychologist 60, no. 7 (2005): 678-686. [(Abstract:) AB Extending B. L. Fredrickson's (1998) broaden-and-build theory of positive emotions and M. Losada's (1999) nonlinear dynamics model of team performance, the authors predict that a ratio of positive to negative affect at or above 2.9 will characterize individuals in flourishing mental health. Participants (N=188) completed an initial survey to identify flourishing mental health and then provided daily reports of experienced positive and negative emotions over 28 days. Results showed that the mean ratio of positive to negative affect was above 2.9 for individuals classified as flourishing and below that threshold for those not flourishing. Together with other evidence, these findings suggest that a set of general mathematical principles may describe the relations between positive affect and human flourishing.] [See also various comments on the article in American Psychologist 69, no. 6 (September 2014): 626-635.]

Tuck, I. and Anderson, L. "Forgiveness, flourishing, and resilience: the influences of expressions of spirituality on mental health recovery." Issues in Mental Health Nursing 35, no. 4 (April 2014): 277-282. [(Abstract:) The relationships of spirituality, religion, and health have been the subject of research in a variety of disciplines over the past two decades. Findings have varied: Some findings appear to have strong evidence of relationships while other findings are deemed inconclusive. A few studies have distinguished between religion and spirituality, but most investigators have treated the two as one concept with no clear lines of distinction between them. This theoretical study, focusing on the topic of spirituality, explores several related concepts, including forgiveness, flourishing, and resilience, as a basis for developing approaches to facilitate recovery in mental health clients using spiritual interventions.]

VanderWeele, T. J. "On the promotion of human flourishing." Proceedings of the National Academy of Sciences of the United States of America 114, no. 31 (August 1, 2017): 8148-8156. [(Abstract:) Many empirical studies throughout the social and biomedical sciences focus only on very narrow outcomes such as income, or a single specific disease state, or a measure of positive affect. Human well-being or flourishing, however, consists in a much broader range of states and outcomes, certainly including mental and physical health, but also encompassing happiness and life satisfaction, meaning and purpose, character and virtue, and close social relationships. The empirical literature from longitudinal, experimental, and quasiexperimental studies is reviewed in attempt to identify major determinants of human flourishing, broadly conceived. Measures of human flourishing are proposed. Discussion is given to the implications of a broader conception of human flourishing, and of the research reviewed, for policy, and for future research in the biomedical and social sciences.] [This article available directly online from the National Academy of Sciences.]

VanderWeele, T. J., McNeely, E. and Koh, H. K. "Reimagining Health -- Flourishing." JAMA 321, no. 17 (April 1, 2019): 1667-1668. [This Viewpoint commentary argues that the concept of "flourishing"--a sense of well-being in domains of happiness, mental and physical health, meaning and purpose, character, social relationships, and financial stability--measures health more broadly than existing wellness metrics and should inform clinical and health policy trade-offs and decisions.]

NOTE: The Flourishing in Ministry study, out of the University of Notre Dame is a large project with a Christian focus, supported by the Templeton Religion Trust and the Lilly Endowment. See the project's (Workwell) website Among the products of this initiative is a book: Flourishing in Ministry: How to cultivate Clergy Well-Being, by Matt Bloom (2019), available from online retail.


III.  Our authors mention the "Broaden and Build" theory of positive emotions. This theory suggests that positive emotions and positive interpersonal experiences reinforce one another and potentiate an increase in both. Most of the work on this theory is by Barbara L. Frederickson, PhD, University of North Carolina, Chapel Hill, where she directs the PEP Lab (Positive Emotions and Psychophysiology Lab). For more on the theory, see:

Garland, E. L., Fredrickson, B., Kring, A. M., Johnson, D. P., Meyer, P. S. and Penn, D. L. "Upward spirals of positive emotions counter downward spirals of negativity: insights from the broaden-and-build theory and affective neuroscience on the treatment of emotion dysfunctions and deficits in psychopathology." Clinical Psychology Review 30, no. 7 (November 2010): 849-864. [(Abstract:) This review integrates Fredrickson's broaden-and-build theory of positive emotions with advances in affective neuroscience regarding plasticity in the neural circuitry of emotions to inform the treatment of emotion deficits within psychopathology. We first present a body of research showing that positive emotions broaden cognition and behavioral repertoires, and in so doing, build durable biopsychosocial resources that support coping and flourishing mental health. Next, by explicating the processes through which momentary experiences of emotions may accrue into self-perpetuating emotional systems, the current review proposes an underlying architecture of state-trait interactions that engenders lasting affective dispositions. This theoretical framework is then used to elucidate the cognitive-emotional mechanisms underpinning three disorders of affect regulation: depression, anxiety, and schizophrenia. In turn, two mind training interventions, mindfulness and loving-kindness meditation, are highlighted as means of generating positive emotions that may counter the negative affective processes implicated in these disorders. We conclude with the proposition that positive emotions may exert a countervailing force on the dysphoric, fearful, or anhedonic states characteristic of psychopathologies typified by emotional dysfunctions.]

Fredrickson, B. L. "The broaden-and-build theory of positive emotions." Philosophical Transactions of the Royal Society of London - Series B: Biological Sciences 359, no. 1449 (September 29, 2004): 1367-1378. [(Abstract:) The broaden-and-build theory describes the form and function of a subset of positive emotions, including joy, interest, contentment and love. A key proposition is that these positive emotions broaden an individual's momentary thought-action repertoire: joy sparks the urge to play, interest sparks the urge to explore, contentment sparks the urge to savour and integrate, and love sparks a recurring cycle of each of these urges within safe, close relationships. The broadened mindsets arising from these positive emotions are contrasted to the narrowed mindsets sparked by many negative emotions (i.e. specific action tendencies, such as attack or flee). A second key proposition concerns the consequences of these broadened mindsets: by broadening an individual's momentary thought-action repertoire--whether through play, exploration or similar activities--positive emotions promote discovery of novel and creative actions, ideas and social bonds, which in turn build that individual's personal resources; ranging from physical and intellectual resources, to social and psychological resources. Importantly, these resources function as reserves that can be drawn on later to improve the odds of successful coping and survival. This chapter reviews the latest empirical evidence supporting the broaden-and-build theory and draws out implications the theory holds for optimizing health and well-being.]

Fredrickson, B. L. "The role of positive emotions in positive psychology: the broaden-and-build theory of positive emotions." American Psychologist 56, no. 3 (March 2001): 218-226. [(Abstract:) In this article, the author describes a new theoretical perspective on positive emotions and situates this new perspective within the emerging field of positive psychology. The broaden-and-build theory posits that experiences of positive emotions broaden people's momentary thought-action repertoires, which in turn serves to build their enduring personal resources, ranging from physical and intellectual resources to social and psychological resources. Preliminary empirical evidence supporting the broaden-and-build theory is reviewed, and open empirical questions that remain to be tested are identified. The theory and findings suggest that the capacity to experience positive emotions may be a fundamental human strength central to the study of human flourishing.]

Kearney, D. J., McManus, C., Malte, C. A., Martinez, M. E., Felleman, B. and Simpsonm T. L. "Loving-kindness meditation and the broaden-and-build theory of positive emotions among veterans with posttraumatic stress disorder." Medical Care 52, no. 12, suppl. 5 (December 2014): S32-38. [(Abstract:) BACKGROUND: Loving-kindness meditation (LKM) is a practice intended to enhance feelings of kindness and compassion for self and others. OBJECTIVES: To assess whether participation in a 12-week course of LKM for veterans with posttraumatic stress disorder (PTSD) is associated with improved positive emotions, decentering, and personal resources. RESEARCH DESIGN: In an open-pilot trial, veterans were assessed at baseline, after the course, and 3 months later. Effect sizes were calculated from baseline to each follow-up point for each construct of interest. Measures were chosen as an initial investigation of the broaden-and-build theory of positive emotions. SUBJECTS: A total of 42 veterans with active PTSD (40% female) participated. MEASURES: Emotions, decentering, psychological wellbeing including autonomy, environmental mastery, personal growth, positive relations, purpose in life, self-acceptance, and sense of social support were measured at each time point. RESULTS: Significant increases in unactivated pleasant (d=0.73), but not activated pleasant, emotions were found over time. Activated and unactivated unpleasant emotions decreased over time (d=-0.69 and -0.53, respectively). There were also increases in environmental mastery (d=0.61), personal growth (d=0.54), purpose in life (d=0.71), self-acceptance (d=0.68), and decentering (d=0.96) at 3-month follow-up. CONCLUSIONS: Overall, positive emotions increased, and enhancement of personal resources occurred over time. Further investigation of LKM for PTSD is warranted.]


IV.  The Spirited Health study, the sample of which was used to recruit the sample for this month's featured study, is reported in:

Proeschold-Bell, R. J., Turner, E. L., Bennett, G. G., Yao, J., Li, X. F., Eagle, D. E., Meyer, R. A., Williams, R. B., Swift, R. Y., Moore, H. E., Kolkin, M. A., Weisner, C. C., Rugani, K. M., Hough, H. J., Williams, V. P. and Toole, D. C. "A 2-year holistic health and stress intervention: results of an RCT in clergy." American Journal of Preventive Medicine 53, no. 3 (September 2017): 290-299. [(Abstract:) INTRODUCTION: This study sought to determine the effect of a 2-year, multicomponent health intervention (Spirited Life) targeting metabolic syndrome and stress simultaneously. DESIGN: An RCT using a three-cohort multiple baseline design was conducted in 2010-2014. SETTING/PARTICIPANTS: Participants were United Methodist clergy in North Carolina, U.S., in 2010, invited based on occupational status. Of invited 1,745 clergy, 1,114 consented, provided baseline data, and were randomly assigned to immediate intervention (n=395), 1-year waitlist (n=283), or 2-year waitlist (n=436) cohorts for a 48-month trial duration. INTERVENTION: The 2-year intervention consisted of personal goal setting and encouragement to engage in monthly health coaching, an online weight loss intervention, a small grant, and three workshops delivering stress management and theological content supporting healthy behaviors. Participants were not blinded to intervention. MAIN OUTCOME MEASURES: Trial outcomes were metabolic syndrome (primary) and self-reported stress and depressive symptoms (secondary). Intervention effects were estimated in 2016 in an intention-to-treat framework using generalized estimating equations with adjustment for baseline level of the outcome and follow-up time points. Log-link Poisson generalized estimating equations with robust SEs was used to estimate prevalence ratios (PRs) for binary outcomes; mean differences were used for continuous/score outcomes. RESULTS: Baseline prevalence of metabolic syndrome was 50.9% and depression was 11.4%. The 12-month intervention effect showed a benefit for metabolic syndrome (PR=0.86, 95% CI=0.79, 0.94, p<0.001). This benefit was sustained at 24 months of intervention (PR=0.88; 95% CI=0.78, 1.00, p=0.04). There was no significant effect on depression or stress scores. CONCLUSIONS: The Spirited Life intervention improved metabolic syndrome prevalence in a population of U.S. Christian clergy and sustained improvements during 24 months of intervention. These findings offer support for long-duration behavior change interventions and population-level interventions that allow participants to set their own health goals.]



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