Download Psychologist Bias in Implicit Responding to Religiously Divergent

Volume 2, Issue 1, 2008
Psychologist Bias in Implicit Responding to Religiously Divergent Nonpatient
Targets and Explicit Responding to Religiously Divergent Patients
Jennifer Ruff, PhD, Clinical Psychology, Fielding Graduate University, [email protected]
Abstract
This study examines how psychologists responded to a mainstream group believed to
be most religiously diverse from them, Evangelical Christians (ECs). Clinicians were
presented with two vignettes which described patients with comparable symptoms of
generalized anxiety disorder, who differed on either religiosity or career and volunteer
activity conditions. They rated each on measures of empathy and prognosis. Clinicians
completed a scale that measures attitudes about Christian beliefs that range from
orthodox to liberal positions. Clinicians’ automatic responding to EC targets was also
compared to automatic responding to Secular or No Religion targets on a timed implicit
measure, which reduces the opportunity to censor bias. Liberality of religious attitudes in
relation to Christian beliefs was associated with less cognitive and affective empathy and
a poorer prognosis for the EC patient. On the implicit measure, religiously liberal
clinicians’ attitudes toward Christian beliefs was associated with negative responding to
EC targets compared to Secular or No Religion targets. Last, given the opportunity to do
so, clinicians’ motivation to control prejudice reactions did not moderate the effects of
automatic negative responding to EC’s on self-reported expressions of empathy or
prognosis in relation to the EC vignette patient.
The results of this study have implications for Evangelical Christian patients who may
experience biased clinical judgment as a result of their religious background. Also,
results should be of interest to clinicians who seek to provide sensitive and competent
treatment to patients who belong to religious groups that diverge from their own, and for
whom it is important to honor ethics codes which guide clinicians to respect group
differences in psychotherapy. Lastly, it is suggested that clinical multicultural training
programs should include training for clinical work with patients whose religious beliefs
and values are different from those of the clinician.
A rationale for the study with an extensive literature review is presented in Part A,
followed by Part B which includes the current research.and a summary literature review.
KEY WORDS: bias, stereotype, religion, values, clinician variables, patient variables,
prejudice, empathy, prognosis, pathology clinical judgment, implicit processes, explicit
processes, Evangelical Christian, Implicit Association Test, conservatism, liberalism,
multicultural, cultural sensitivity, diversity
CLINICIAN RELIGIOSITY AND RESPONSE TO DIVERGENT PATIENT RELIGIOSITY:
AN INVESTIGATION INTO THE EFFECTS OF IMPLICIT AND EXPLICIT
STEREOTYPING ON EMPATHY AND PROGNOSIS IN INITIAL RESPONDING TO
PATIENTS WHO ARE RELIGIOUSLY DIVERSE FROM PSYCHOLOGISTS
A dissertation submitted
by
JENNIFER L. RUFF
to
FIELDING GRADUATE UNIVERSITY
in partial fulfillment of the
requirements for the degree of
DOCTOR OF PHILOSOPHY IN PSYCHOLOGY
With an Emphasis in
Clinical Psychology
~/i, f!iltlU)
--. Charles H. Elflo ,Ph.D
Chair
Kjell Erik Rudestam, Ph.D., Associate Dean
Debra Bendell Estroff, Ph.D., Faculty Reader
James Guinee, Ph.D., Extemal Examiner
Copyright by Jennifer L. Ruff
2008
TABLE OF CONTENTS
PARTS A & B
PART A: Comprehensive Review of the Literature
Page
Introduction ……………………………………………………………………... 1
Diversity and worldview match………………………………………………….. 2
Religiosity: Psychologists and the general U.S. population..……….……... 7
Multicultural training and application of ethical responsibilities………….. 11
The potential for compromised clinical efficacy with religious persons…………15
Stereotyping and prejudice………………………………………………… 15
Discordant values and efficacy of practice………………………………… 20
Other barriers to effective treatment……………………………………….. 25
Sociopolitical trends, religiosity, and affect……………………………….. 27
Empathy……………………………………………………………………. 30
Religion and Mental Health………………………………………………... 34
The current research………………………………………………………………. 39
Literature on bias with religious patients……………………………………39
Social desirability…………………………………………………………... 48
Implicit versus explicit cognitive processes in impression formation……… 50
Summary…………………………………………………………………………… 60
References – Part A …………………………………………………………………62
PART B …………………………………………………………………………….83
Introduction………………………………………………………………………… 84
Religiosity as a diversity variable in clinical psychology………………………….. 85
The “religiosity gap”……………………………………………………….. 86
Religion and multicultural competence……………………………………………. 87
Neglect of religious beliefs and values as a diversity variable……………...87
The potential for stereotyping and prejudice………………………………. 89
Outcomes and value convergence…………………………………………..93
Religion and mental health………………………………………………… 95
Sociopolitical influence……………………………………………………. 98
The impact of religious neglect or bias on treatment……………………………… 99
Selection of treatment goals……………………………………………….. 100
Empathy……………………………………………………………………. 101
Literature on clinical judgment of religious patients………………………………..101
Social desirability……………………………………………………………111
Automatic versus controlled cognitive processes………………………….. 113
Statement of the problem……………………………………………………………121
Variables…………………………………………………………………… 122
Hypotheses…………………………………………………………………. 125
Methods…………………………………………………………………………….. 126
Participants…………………………………………………………………. 127
Measures…………………………………………………………………… 131
Batson’s empathy adjectives………………………………………. 131
Interpersonal Reactivity Index’s Perspective Taking Scale……….. 132
Clinical Judgment Scale…………………………………………… 133
Religious Attitude Scale…………………………………………… 134
Implicit Association Test…………………………………………... 136
Motivation to Control Prejudiced Reactions Scale………………….138
Marlowe Crowne Social Desirability Scale-Short Form……………139
Religious Conservatism Scale………………………………………140
Procedure……………………………………………………………………....140
Results……………………………………………………………………………… 142
Descriptive statistics……………………………………………………………142
Preliminary analyses……………………………………………………………148
Hypotheses analyses……………………………………………………………153
Summary of results……………………………………………………………..163
Discussion………………………………………………………………………….. 164
References – Part B..………………………………………………………………..176
Appendix A: Materials provided to participants…………………………………... 195
Appendix B: Distribution of variable scores………………………………………..214
Appendix C: Examination of Regression Assumptions…………………………… 222
TABLES
Table 1: Sample Demographic and Background Characteristics ……..………........143
Table 2: Descriptive Statistics for Composite Measures……………………………148
Table 3: Normality Statistics for Variables Used in Hypothesis Tests……………...150
Table 4: Correlations among Variables Used in Hypothesis Tests………………….152
Table 5: Regression of Differences in Affective Empathy on Religiously Liberal
Attitudes in relation to Christian Beliefs: Hypothesis 1.........................…….154
Table 6: Regression of Differences in Cognitive Empathy on Religiously Liberal
Attitudes in relation to Christian Beliefs: Hypothesis 1……………………..155
Table 7: Regression of Differences in Prognosis on Liberal Attitudes in relation
To Christian Beliefs: Hypothesis 2………………………………………....156
Table 8: Regression of Differences in INA associated with Religiously Liberal
Attitudes in relation to Christian Beliefs: Hypothesis 3…..……………..….157
Table 9: Regression of Affective Empathy Differences with NMR-EC with
Motivation to Control Prejudiced Reactions as a Moderator on Liberality of
Attitudes in relation to Christian Beliefs: Hypothesis 4…………………….159
Table 10: Regression of Cognitive Empathy Differences with NMR-EC with
Motivation to Control Prejudiced Reactions as a Moderator on Liberality of
Attitudes in relation to Christian Beliefs: Hypothesis 4……………………161
Table 11: Regression of Prognosis Differences with NMR-EC with Motivation
to Control Prejudiced Responding as a Moderator on Liberality of Attitudes
in relation to Christian Beliefs: Hypothesis 5……………………..………..163
Part A Introduction
This paper discusses the potential for psychologist bias against religious
patients, particularly religiously conservative Christian patients, as a diversity
issue in need of further investigation. The dissimilarity between the religiosity of
the general American population and that of psychologists is explored through an
examination of studies on the religiosity gap. Trends toward psychologists’
secular and comparatively liberal worldviews and values, and the manifestation
of those trends, are examined. The status of inadequate clinician multicultural
training with religious groups and the consequences of the current deficit are also
discussed. The possibility of the culturally insensitive or biased treatment of the
group will also be explored. Factors that may contribute to differential treatment
may include differences in worldviews and values between clinicians and
religiously oriented patients, inadequate training in working with them as a
diversity group, affective responding or stereotypic or prejudiced assumptions
about religious patients, and other factors found in the theoretical and empirical
literature on stereotyping and prejudice between social groups in general. The
effects of bias or insensitivity on the initial impressions of patients, clinical
empathy, prognosis, pathology, disrespect of the patients’ religious beliefs or
values, patient concerns about entering “secular” psychotherapy, and value
convergence as a clinician-perceived variable in successful treatment outcomes,
are explored. An analysis of bias studies with religious patients follows, with
further examination of some problematic methodology that may contribute to
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mixed findings. Lastly, variables that may resolve some previous methodological
shortcomings in the literature and suggest directions for future research are
explored.
Diversity and Worldview Match
Weltanschauung is defined as “the overall perspective from which one
sees and interprets the world,” and “a collection of beliefs about life and the
universe held by an individual or a group” (American Heritage Dictionary of the
English Language, 2000). Culture is defined as the customary beliefs, social
forms, and material traits of a racial, religious, or social group (2000). Each
person’s Weltanschauung, or worldview, is often extensively informed by the
culture in which he or she is immersed. The individual’s worldview assists him or
her in making sense of the world, his or her place within it, and the nature of
interpersonal exchanges with others. Cultural groups may further inform the
individual about worldview perspectives such as which values are important and
which are not, and may guide one’s initiation of, and choice of responses to, his
or her experiences (Bilgrave & Deluty, 1998).
Cultural influence often has such an impact on one’s worldview that it
must be considered by clinicians attempting to have a comprehensive
understanding of their patients. The potential for clinician bias against patients of
various cultural domains is evident in the APA Code of Ethics (APA, 2002),
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Standards 2.01 and 3.01. Standard 3.01 bans discrimination against multicultural
groups, and 2.01 further explains multicultural competence (MCC) as
an understanding of factors associated with age, gender, gender identity,
race, ethnicity, culture, national origin, religion, sexual orientation,
disability, language, or socioeconomic status is essential for effective
implementation of their services or research, psychologists have or obtain
the training, experience, consultation, or supervision necessary to ensure
the competence of their services, or they make appropriate referrals (APA,
2002, pp. 1063-1064)
Not only does the APA mandate that psychologists become culturally
competent, but diversity has become so celebrated that it is considered a core
value, and even a fourth force in psychology by some (Cheatham, Ivey, Ivey, &
Simek-Morgan, 1980). While ethnicity and race have generated a plethora of
research and become the focus of a significant amount of multicultural education
and training, by comparison religiosity has been an often overlooked expression
of diversity in the literature and in diversity training programs (Yarhouse & Fisher,
2002). Nevertheless, religiosity must be considered from a sensitive and
informed multicultural perspective.
That there is a schism between the scientific worldview and one which
encompasses religious elements has been evident in psychology from the early
influence of Sigmund Freud. Freud described worldview as “an intellectual
construction which solves all the problems of our existence uniformly on the
basis of one overriding hypothesis” (Freud, 1933/1962, p. 158). He endorsed a
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scientific worldview, which he compared at length to a spiritual worldview, and
claimed that it precluded knowledge of the universe “other than the intellectual
working over of carefully scrutinized observations” (Freud, 1933/1962, p.159).
Indeed, psychology historians assert that naturalism, or the “doctrine that
scientific procedures and laws are applicable to all phenomena” which also
“assumes that all events in the world have a history that is understandable in
terms of identifiable forces” (Viney & King, 1998, p. 182), has defined the current
philosophy of scientific thinking since Freud’s time. Defined as such, Albert Ellis,
a notable theorist credited with the development of Rational Emotive Behavioral
Therapy, goes on to state that “In regard to scientific thinking, it practically goes
without saying that this kind of cerebration is quite antithetical to religiosity” (Ellis,
1980, p.9)
Since Freud’s time, others assert antireligious clinical perspectives and
theory. More recent antireligious views include comments made by Wendell
Watters, a respected professor of psychiatry and physician at McMaster
University in Ontario, Canada. In reference to Christian doctrine and teachings
he stated that they are “incompatible with the development and maintenance of
sound health, and not only ‘mental’ health,” and that “Simply put, Christian
indoctrination is a form of mental and emotional abuse” (Watters, 1992, p.10). In
reference to the majority of membership in the American Psychological
Association (APA), Emeritus professor of psychology at Yale University and
author of over 40 books, Seymour Sarason in his Centennial Address to the APA
stated that there are more than a few psychologists who regard ingredients of a
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religious worldview as a “reflection of irrationality, of superstition, of an
immaturity, of a neurosis,” and that “indeed if we learn someone is devoutly
religious, or even tends in that direction, we look upon that person with
puzzlement, often concluding that psychologist obviously had or has personal
problems” (Sarason, 1993). In the Diagnostic and Statistic Manual of Mental
Disorders (DSM-III-R), 12 references to religion in the Glossary of Technical
Terms were used to demonstrate psychopathology (American Psychiatric
Association, 1987).
While it is noted that the latest revision of the DSM, the DSM-IV TR
(American Psychiatric Association, 2000), now includes more culturally sensitive
language, that antireligious perspectives may have influenced the clinical
judgment of psychologists and psychiatrists alike, should not be easily dismissed.
Indeed, there is encouraging evidence that some psychologists’ worldviews have
evolved in conjunction with the demands for multiculturally appropriate
perspectives as can be seen in the morphing views of Albert Ellis. In one earlier
treatise on religiousness and psychotherapy Ellis states that, “If one of the
requisites for emotional health is acceptance of uncertainty, then religion is
obviously the unhealthiest state imaginable” (Ellis, 1980, p. 8), which also implies
by virtue of the religious person’s extreme pathology that he or she is likely the
hardest to treat. Indeed, he also stated that “the best the devout religionists can
do, if they want to change any of the rules that stem from their doctrines, is to
change the religion itself” (Ellis, 1980, p. 31). However, Ellis later recants some of
his earlier assertions and reports that his Rational Emotive Behavior Therapy is
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compatible with some religious views and can be effectively used with patients
who have devout beliefs about God without changing their religion (Ellis, 2000).
Nevertheless, it is difficult to imagine that such evolution in thinking about
religiosity and religious persons, as encouraging as it may be, necessarily
represents a sudden and ubiquitous absence of antireligious views in
psychology. Certainly, this type of antireligious thinking was common enough in
the not so distant past that it was acceptable for publication in peer-reviewed
journals, which one might assume have some commitment to publish culturally
appropriate materials.
Distance between scientific thought and religion or spirituality has likely
been deliberate on the part of psychologists who sought credibility for the
profession as an empirical and nonspeculative science. Strong scientific ideology
may be a cause of clinician failure to assess religion and religious functioning as
a part of patient experience to be regarded with seriousness and sensitivity. This
separation may be problematic for several reasons according to contemporary
psychologists interested in the interrelated themes between scientific and
religious thought. Three important themes have emerged in the literature
(Bilgrave & Deluty, 1998). The first is that the lines between religion and science
have begun to blur as the traditional view of science as strictly rational and
empirical has been challenged. Second, therapists use their values to guide their
choice of treatment goals and interventions, whether implicitly or explicitly. Last is
the theme that “religion and psychotherapy, at a deep level of analysis, are
functionally and even structurally equivalent” (1998, p. 2). Nevertheless, the
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nature of the “secular field” of psychology (Bergin & Jensen, 1990) as dissimilar
from that of the general population has been the focus of a fair amount of
attention in the literature.
Religiosity: Psychologists and the General U.S. Population
Definitions of the terms “spiritual” and “religious” vary in the literature,
although most authors are in agreement on core themes. For the purposes of the
current discussion, and in agreement with those themes, religious persons will
refer to those with affiliations with an organized religion. Religious beliefs are
considered “propositional statements (in agreement with some organized
religion) that a person holds to be true concerning religion or religious spirituality”
(Worthington, 1996, p.2). Values are superordinate statements about what a
person considers to be important in life. Worthington (1996) defines spiritual as
believing in or valuing some higher power other than what is seen to exist in the
material world. One may be spiritual and religious, religious but not spiritual,
spiritual but not religious, or neither religious nor spiritual. It is also understood
that the degree of religiosity and spirituality in endorsement of beliefs, adherence
to associated values, and participation in religious or spiritual behaviors, varies
between persons.
The U.S. population may be considered highly religious, with an estimated
94% of the population endorsing belief in “God or some universal spirit” (Gallup,
1996), 92% being affiliated with a religion, 84% reporting religion as either very or
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fairly important in their lives, and only 3% denying any beliefs in God. The
majority of the population endorses Judeo-Christian affiliations at 76%, with 72%
of those endorsing Protestant or Catholic categories (Gallup, 2006), and other
estimates as high as 84% when respondents were offered more choices of
religion including Orthodox Greek and Russian Christian affiliations (NewPort,
2004). The religious affiliation endorsed by the largest group of persons is the
Protestant denomination at 49%. Within the Protestant subgroup, 44% endorsed
the category described as either “born again” or “Evangelical.” Further, when
Evangelical activities and beliefs were measured and used to define
Evangelicalism, including believing the Bible is the actual word of God, being
born again or having a born again experience, and encouraging others to believe
in or accept Jesus Christ, approximately 53% of Protestants, or 1 in 5 Americans
(22%), can be considered Evangelical Christians (Gallup, 2005). Other research
estimates that 90% of Americans pray, 71% belong to a church or synagogue,
and 42% attend weekly religious services (Hill et al., 2000).
Psychologists have consistently been associated with lower rates of
religious affiliation compared to the U.S. public, and even to other clinicians and
academicians. One study (Ragan, Malony, & Beit-Hallahmi, 1980) found that
psychologists were much less orthodox in both religion and spirituality than had
been previously seen in the general academic population, with 34% of
psychologists denying the existence of God, compared to 23% of other
academicians, and 3% of the general U.S. population (Gallup, 2006). In another
study (Bergin & Jensen, 1990), religious preferences were rated in an
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interdisciplinary group of psychotherapists that included marriage and family
therapists, clinical social workers, psychiatrists, and clinical psychologists.
Differences were seen in atheist, agnostic, or no preference categories with a
cumulative sum of 30% of clinical psychologists, 24% of psychiatrists, 13% of
marriage and family therapists, 9% of clinical social workers, and 9% of the U.S.
public. Clinical psychologists expressed slightly more Judeo-Christian
preferences than psychiatrists at 67% and 65% respectively, but less than clinical
social workers at 82%, and marriage and family therapists at 76%. However,
more recently, Bilgrave and Deluty (1998) found that only 42% of counseling and
clinical psychologists endorsed Judeo-Christian affiliations.
While Ragan et al.’s (1980) findings that 34% of clinical psychologists
denied the existence of God led authors to conclude that the atheistic stereotype
of psychologists is supported, they also admit that one cannot predict that any
one psychologist will be an atheist. Others point to substantial endorsement of
the religious and spiritual beliefs of psychologists despite the lower frequency
with which they occur relative to other groups. For instance, in Ragan’s study,
43% of psychologists endorsed belief in some transcendent deity. In another
study (Bergin & Jensen, 1990), 33% of clinical psychologists positively endorsed
the item that “my whole approach to life is based on my religion,” and 65%
endorsed the statement, “I try hard to live my life according to my religious
beliefs.” Others challenge the atheistic stereotype (Shafranske & Gorsuch, 1984;
Shafranske & Malony, 1990; Smith & Orlinsky, 2004) and in particular when the
criteria for spirituality are broadened to include personally meaningful experience
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and focus on discipline, purpose, belonging, wholeness, and connectedness,
therapists may have substantial spiritual interests. It has also been hypothesized
that some spiritual and religious interests may be relatively unexpressed due to
the secular nature of psychologists’ education and practice (Bergin & Jensen,
1990).
Further, psychologists’ professional organizations concerned with religion
and psychology are often comprised of a significant portion of religious
psychologists interested in the interrelation of the two domains. APA’s Division
36, the division of the psychology of religion, “recognizes the significance of
religion both in the lives of people and the discipline of psychology” (APA, 2007),
and works toward “the re-establishment of the scientific psychology of religion”.
The Christian Association for Psychological Studies (CAPS) is an organization
largely made up of Evangelical Christian psychologists interested in the
integration of psychology and Evangelical Christianity. Specifically, integration
concerns how psychological theory and research is relevant to Christianity and
the generation of study and dialogue about concepts often associated with their
Evangelical faith such as forgiveness, and gratitude (see Ellens & Sanders,
2006; Lewis-Hall, Gorsuch, Malony, Narramore, & Stewart Van Leeuwam, 2006;
Yangarber-Hicks et al., 2006).
Nevertheless, that there are differences between the psychological
community and the general population on religion and spirituality is clear. As the
current Weltanschauung of the Western world includes both religious and
scientific-humanistic beliefs and values (Bilgrave & Deluty, 1998), we may
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assume that like the larger population, patients seeking psychological services
will also have worldviews which possess these elements. Considering the
potential differences in worldview between psychologists and patients, and in
particular associated values which guide what one considers important and what
one does not, it is worth examining how well prepared psychologists are to work
with persons who have religiously influenced worldviews which may be diverse
from their own.
Multicultural Training and Application of Ethical Responsibilities
Even though approximately 9 out of 10 persons in the US (Gallup, 2006),
and up to 65% of psychologists (Bergin & Jensen, 1990), report that religious
beliefs are important in their lives, only 29% of clinical psychologists (1990), and
50% of rehabilitation psychologists (Shafranske, 2000), believe that attention to
those cultural beliefs is important in their work with patients. Despite demands for
the ethical and sensitive treatment of diverse groups, and the focus on training to
effectively deliver multiculturally competent services, there is a noticeable gap in
the ethical application of those principles with religious patients (Meyer, 1988;
Yarhouse & VanOrman, 1999; Zeiger & Lewis, 1998).
It may be that as a result of divergent religious beliefs and values,
clinicians who do not consider religion important in their own lives may simply not
consider it important in the lives of their patients and subsequently to
psychotherapy. It may also be that clinicians deliberately avoid religiously
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thematic material for a number of reasons including fear of approaching what
may be considered a taboo topic. Fears may arise from awareness of a heavy
humanistic influence in the field and a history of disparagement of religion from
the early days of Freud to more recent theorists such as Albert Ellis.
Alternatively, clinicians may believe that religious issues are generally unrelated
to the clinical presentation or treatment of their patients. Another possibility is that
they may have personal bias against such belief systems or those who hold the
beliefs valuable. Additionally, therapists may feel inadequate in dealing with
religious material in a clinical setting. Any of these factors may result in either
deliberate avoidance of the topic, or the management of religiously thematic
material in ways which may not respect the patient’s beliefs or value systems.
Currently, levels of training in religious diversity in clinical practice are not
commensurate with the general religiosity of the U.S. public (Brawer, Handal,
Fabricatore, Roberts, & Wajda-Johnston, 2002; Yarhouse & Fisher, 2002). In
response to whether religion was covered in predoctoral internship training
programs, training directors reported that the topic was addressed in individual
supervision “if appropriate,” “it comes up periodically,” “highly variable,” and “only
a couple of supervisors address this issue.” Brawer et al. (2002) also found that
religion as a topic covered in APA-accredited graduate programs was largely
unsystematic or it was not covered at all. Another study found that only 5% of
clinical psychologists had professional religious training (Shafranske, 1990). An
informal study of cross-cultural and multicultural psychotherapy and counseling
textbooks revealed a significant lack of coverage of religious aspects of diversity
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(Richards & Bergin, 2000). Although multicultural writers emphasize the
importance of clients’ worldviews and values, religious worldviews and values are
usually not explored in multicultural texts at all, or they are given very little
attention.
Some studies found that as a group, counselors (Holcomb-McCoy &
Myers, 1999) and clinicians (Constantine & Ladany, 2000; Worthington, Mobley,
Franks, & Andreas Tan, 2000) rate themselves as multiculturally competent.
However, self- and other-ratings of competency in cultural case conceptualization
do not necessarily correlate significantly, and self-report measures of cultural
competency have even exhibited no correlation with cultural case
conceptualization ability when social desirability was controlled (Constantine &
Ladany, 2000; R. Worthington et al., 2000).
Research indicates that levels of multicultural training and rates of both
affective and cognitive empathy are positively related to the ability to
conceptualize patients’ mental health issues from a diversity perspective when
rated by others (Constantine, 2001) . Further, multicultural training should
increase awareness of the impact of personal values related to religious and
sociopolitical beliefs on the selection of treatment goals and the course of the
treatment process (Fuertes & Brobst, 2002; Holcomb-McCoy & Myers, 1999;
Sue, 1998).
Another study (Hansen et al., 2006) found that among the 91% of clinician
respondents who rated themselves as somewhat to very culturally competent,
there was a significant difference between what they believed to be important for
14
culturally competent practice and what they actually did in practice. Among
commonly recommended competency practices, several were not performed by
a significant percentage of the group. This included 42% who rarely or never
implemented a professional development plan to increase their cultural
competence, 39% who rarely or never utilized culturally specific consultation, and
27% who rarely or never referred cultural group members to a more qualified
practitioner.
The aforementioned studies examined clinician beliefs and practices
related to ethnic and racial groups, which have received significantly more
attention in the literature, psychology textbooks, and training programs than have
the beliefs and practices of religious groups (Richards & Bergin, 2000). Logic
would imply that even fewer steps were taken toward cultural competence in
relation to religion by practitioners who have largely reported a lack of concern
for religion in their clinical work.
Cultural competence as perceived by the patient can have an effect on the
patient’s overall satisfaction with treatment. In one study, researchers found a
strong correlation between cultural group members’ ratings of clinician cultural
competence and general competency and empathy (Fuertes & Brobst, 2002).
However, significant differences of the variance for minority groups’ satisfaction
beyond general competency and empathy were explained by multicultural
competence.
In summary, there is a deficit in training and education in working with
religious groups. Further, there is often a difference between self- and other-
15
ratings of multicultural competency. These differences were evidenced in ratings
of competency in working with racially and ethnically diverse patients. As
education and training in working with racial and ethnic patients is more common
than those concerning clinical work with religious patients, it is reasonable to
assume that cultural competence with religious patients may be even more
compromised. Before examining if, and how, the delivery of effective services to
the group may be affected, it may be helpful to first explore the general
stereotyping and prejudice literature.
The Potential for Compromised Clinical Efficacy with Religious Persons
Stereotyping and Prejudice
Stereotyping can be defined as the use of expectations or beliefs
associated with a group or group member based on his or her group
membership. Prejudice can be defined as a valenced evaluation of that group or
group member (Sherman, Conrey, Stroessner, & Azam, 2005). For the purposes
of this paper, bias represents an instance of prejudice, and may manifest in
either a positive direction, such as bias toward a secular or liberal worldview, or a
negative direction as in a bias against a religious or conservative worldview.
When there is neglect in considering a group or group member’s cultural
16
differences or the impact of one’s personal beliefs and expectations of that group
or group member in a clinical setting, bias may occur.
Generally, the stereotyping and prejudice literature has focused on the
process between groups that are dissimilar on some variable. Byrne’s attraction
paradigm posits that those who are similar in some way will be attracted to each
other and those that are dissimilar will be repulsed by each other (Byrne, 1971).
Byrne further hypothesized that the similarity and dissimilarity of attitudes and
values is more significant in determining attraction or repulsion than are
demographic variables. Bryne showed study participants the attitude scale of a
stranger with either like or discordant attitudes on various topics including religion
and politics, and found that “the most negative response in the similar attitude
group was more positive than the most positive response in the dissimilar attitude
group,” and that the attitude variables were so significant that there was no
overlap between the two conditions.
Subsequent research on the attraction paradigm supports Byrne’s claims
for both the attraction and repulsion phenomenon (Chen & Kenrick, 2002;
Newcomb, 1961); however other research yielded data that supported the
repulsion hypothesis, but not the attraction hypothesis (Rosenbaum, 1986).
Relevant to our current concern with potential biased responding to religious
patients by religiously dissimilar clinicians, it is also noted that research that
examines stereotypes and prejudice for the decades following Bryne’s work,
generally focused on negative responding to out-groups. The phenomenon is so
well established that minimal group paradigms, or those groups that differ only in
17
irrelevant labeling such as assignment to group “A” or group “B,” also yielded
prejudiced responding (Crocker & Schwartz, 1985; Gaertner & Insko, 2000).
The stereotyping and prejudice literature is voluminous. It encompasses
several processes and many variables. The three categories of processes
involved in the development and maintenance of stereotyping and prejudice are
motivational, sociocultural, and cognitive (Hilton & Hippel, 1996). Many studies
overlap categories, such as those that examine the motivational aspects of
reducing cognitive load (Biernat & Korbrynowicz, 2003), or enhancing selfevaluation through social comparison (Brickman & Bulman, 1977; Festinger,
1954; Taylor & Lobel, 1989).
Sociocultural models include social comparison perspectives that examine
how the self is defined in relation to others (see Duckitt, Birum, Wagner, &
Plessis, 2002; Brewer & Gardner, 1996; Brickman & Bulman, 1977; Crocker,
McGraw, Thompson, & Ingerman, 1987; Festinger, 1954; Taylor & Lobel, 1989).
Examples of sociocultural explanations of prejudice include the effect of social
position and social dominance orientation on prejudice (Guimond, Dambrun,
Michinov, & Duarte, 2003), and the tendency to compare oneself favorably
against a less fortunate target when under threat (Taylor & Lobel, 1989). Other
sociocultural processes are found in the in- and out-group similarity and
dissimilarity effects literature (Byrne, 1971; Rosenbaum, 1986). Further, the
strength of social identity theory, or the theory that group membership creates
self-identification with an in-group that favors the in-group at the expense of the
18
out-group, has been explored in the minimal group paradigm (Crocker &
Schwartz, 1985; Gaertner & Insko, 2000; Tajfel & Turner, 1986).
Cognitive processes examine the relationship between variables such as
information-processing strategies and prejudice (Bodenhausen & Lichtenstein,
1987; Hamilton, Sherman, & Ruvolo, 1990; Hamilton & Trolier, 1986). It has long
been hypothesized that stereotyping can be viewed as a cognitive construct that
is utilized in order to generate and manage responses to an otherwise
overwhelming amount of information (Allport, 1954; Bodenhausen & Lichtenstein,
1987; Hamilton & Trolier, 1986; Korten, 1973). The use of stereotypes and
stereotype-based expectancies as a tool to reduce cognitive load has been
examined in research on cognitive resource preservation (Biernat &
Korbrynowicz, 2003; Crawford & Skowronski, 1998; Macrae & Milne, 1994;
Yzerbyt & Coull, 1999), as well as research on the relationship between
stereotyping and cognitive simplicity (Koenig & King, 1964).
Motivational processes are found in much of the stereotype and prejudice
literature, often overlapping with sociocultural and cognitive explanations. Those
processes include the motivation to increase self-esteem under threat (Crocker &
Luhtanen, 1990), to use stereotyping to reduce cognitive load (Biernat &
Korbrynowicz, 2003; Crawford & Skowronski, 1998; Macrae & Milne, 1994;
Yzerbyt & Coull, 1999), and to use stereotype information by those who have a
preference for cognition (Crawford & Skowronski, 1998). The motivation to
respond without prejudice to targets with which one might have knowledge of
stereotyped associations or expectancies has also been of interest (Devine,
19
Plant, Amodio, Harmon-Jones, & Vance, 2002; Plant & Devine, 1998).
Specifically, in efforts to explain differentials in how stereotype information may
be behaviorally expressed, Devine et al. (2002) and Plant and Devine (1998)
posit that motivation to either suppress stereotype tendencies or ignore
stereotype associations moderates the expression of prejudice.
The effects of both affect and cognition about targets has been examined
in the literature as well. Stereotype-related affect has been operationalized in the
literature in several ways including “liking” for targets or target groups (Jussim,
Manis, Nelson, & Soffin, 1995), and agreement with mood-affect adjectives about
targets (Jackson & Sullivan, 2001). Stereotype cognition refers to beliefs or
expectations about stereotype targets. Research indicates that both affect and
cognition play a role in the use of stereotyped and prejudiced responding.
In summary, it is clear that stereotyping and prejudice between groups is
common. A large focus of the literature is on understanding various mechanisms
that contribute to the development and maintenance of stereotypes and
prejudiced responding. The circumstances under which stereotyping or prejudice
may occur are many. To hypothesize that a clinician’s emphasis on empathy and
acceptance will necessarily preclude him or her from such a ubiquitous
phenomenon is probably not realistic, although it is hoped that clinicians’ general
training, clinical intention, and capacity for introspection at the least will moderate
some of those tendencies. Nonetheless, the possibility of prejudice against, and
stereotyping of, dissimilar groups exists, and clinicians who value empathy and
patient acceptance may also demonstrate biased patterns of responding. This
20
potential is further evident in APA policies that prohibit discrimination against
groups (see APA, 2002 Section 3.01). As Byrne hypothesized, those different in
values and attitudes may demonstrate even more bias against the out-group than
those who are demographically dissimilar. Such may be the case with clinicians
who have religiously diverse attitudes and values than their patients.
Discordant Values and Efficacy of Practice
Without religious training, insensitive, biased, or uninformed approaches
to religious patients may significantly impact treatment. For an understanding of
how religiously competent services can be affected by compromised approaches,
one must first look beyond religious affiliation and group membership to
differences in beliefs and values and their behavioral manifestation. Value
systems that arise from religious beliefs are distinct from the belief system itself.
Recall that religious beliefs can be defined as “propositional statements (in
agreement with some organized religion) that a person holds to be true
concerning religion or religious spirituality”, and religious values can be defined
as “superordinate organizing statements of what a person considers to be
important,” that arise from his or her religion (Worthington, 1996, p.2).
Religious values sometimes stand in contrast to humanistic values. For
instance, whether one’s particular religious beliefs are consistent with Jewish,
Muslim, or Christian doctrine, a value that arises from each is the importance
placed on some absolute and universal ethics, with less focus on the relative
21
values and situational ethics that are typically encompassed in secular
humanistic worldviews. Another religious value is that God is supreme, and
humility and acceptance of divine authority are desirable virtues, rather than
beliefs that either humans are supreme, or no one and nothing is supreme
(Bergin, 1980).
In the theoretical literature, other differences between clinical-humanistic
and theistic values have been proposed and discussed as valuable distinctions
by proponents of each value system (see Bergin, 1980; Walls, 1980) with a third
value system, that of a clinical-humanistic-atheistic one, added (Ellis, 1980a) .
These themes may appear overly simplistic; however, some contrasting themes
between theistic and clinical-humanistic values are evident. Some of the thematic
distinctions that can be made between religious values and humanistic ones are
personal identity that is eternal and derived from the divine and one’s relationship
with the divine, compared with personal identity that is ephemeral and mortal;
love, affection, and self-transcendence as primary, compared with personal
needs and self-actualization as primary; commitment to marriage, fidelity, and
loyalty with an emphasis on family life, compared with choice of no marriage,
conventional marriage, or open marriage with emphasis on self-gratification
which considers family life as optional; and personal responsibility for harmful
actions and changes in those actions with acceptance of guilt, suffering, and
contrition as key agents of change, compared with personal responsibility for
one’s own harmful actions with the minimization of guilt, and a focus on relief of
suffering.
22
In summary, the proposed clinical-humanistic values can be viewed as
more liberal than their theistic and conservative counterparts. The terms
“conservative” and “liberal” are as operationalized by William Stone, that “a
conservative person is one who is devoted to the status quo and who accepts
authority and the norms of society. A liberal is change-oriented and places great
emphasis on individual freedom, being opposed to the external imposition of
authority” (1994, p. 701). Stone also emphasizes that there are likely no pure
liberals as there are also not likely any pure conservatives, but “that they are all
mixtures, to some degree, of opposing tendencies” (p. 701).
Research indicates that therapists also emphasize values that are more
liberal than those of their clients. They generally endorse lifestyles that are freer,
particularly in the sexual area (Khan & Cross, 1983). Differences in, and
attitudes toward, sexual values vary in relation to religious involvement and
political affiliation as well as gender. In one study (Ford & Hendrick, 2003),
politically conservative and Protestant and Catholic therapists endorsed items of
“sex as an expression of love and commitment,” and beliefs about the desirability
of sex as expressed exclusively within marriage and committed relationships,
significantly more than did politically liberal therapists. Nonreligious and Jewish
therapists endorsed greater comfort with homosexuality as natural and same-sex
sexual practices. Politically liberal therapists endorsed items such as
homosexuality as natural, and that marriage provides too many restrictions on
sexual freedom, more frequently than conservative therapists. Overall, therapists
reported being comfortable working with a wide variety of sexual values in
23
therapy. However, although clinicians report comfortability working with a variety
of values, they may not be culturally competent in doing so with diverse groups.
The values of the clinician may be reflected in the treatment goals they endorse,
which may be discordant with the patients’ value system, or they may ignore the
spiritual or religious functioning issues of the patient. Particularly if the therapist is
unaware of the impact of his or her personal values on clinical work, or biases
against the values of others, compromised treatment may result.
The effects of reinforcement and nonreinforcement of patient values is
evident in the outcomes and value convergence literature. Value convergence is
often an indicator of counselor-perceived improved patient outcomes (Beutler &
Bergan, 1991; Worthington, 1988), however the effects for patient- and otherrated perceptions of improvement are less strong (Kelly, 1990). One implication
of these findings is that clinicians may perceive patients to be healthier when
their values more closely match their own. This effect may indicate that valueladen therapy may seek to alter patient values (Beutler, Crago, & Arizmendi,
1986; Beutler & Bergan, 1991; Kelly, 1990; Richards & Bergin, 2000;
Worthington, 1988). As evidenced in studies on Carl Rogers’s patterns of
reinforcement and nonreinforcement of patient verbalizations related to values
and differences in response style (Murray, 1956; Truax, 1966), even within a
therapy orientation that focuses on acceptance and positive regard, it is indicated
that the values of the therapist influence the course of therapy, and its perceived
outcomes. Indeed, following a discussion on the effects of therapist values on
therapy with religious patients (see Bergin, 1980) one author writes, “the fact
24
cited by Bergin that, in general, the values of psychotherapists differ from the
public’s is not alarming; it is encouraging”, and further that “we should both
expect and demand that the values of psychotherapists be more carefully
reasoned and, on the whole, more adequate than the values of the general
public” (Walls, 1980, p. 641). Further, Albert Ellis also encouraged therapists to
capitalize on their power to influence value change in their patients (Ellis, 1980).
However, both positions appear to be in direct conflict with APA’s Principle E
(2002) which discusses clinicians’ responsibility to respect group differences.
Also, when a clinician neglects to consider the nature of the patient’s
religious beliefs and values, therapeutic efficacy may be affected, and harm may
even result. In one case of religious neglect in therapy, a male therapist working
with a Latter-Day Saint (LDS) couple recommended that the couple abstain from
sexual relations for the coming week to relieve the wife’s feelings of being
sexually manipulated. The male therapist then advised the husband to
masturbate if he found it too difficult to refrain from being sexually active, not
realizing that masturbation was considered a sin in the LDS church. The therapist
further encouraged the wife to seek employment outside of the home when she
relayed feelings of stress around her homemaking role, again not realizing that
they both regarded her homemaking role as sacred and divinely appointed. The
couple was offended by the therapist’s lack of sensitivity to their religious beliefs
and terminated therapy (Richards & Bergin, 2000).
25
Other Barriers to Effective Treatment
The theoretical and empirical literature also indicates that religious
patients may not receive services comparable to those provided to secular
patients based on several other factors. Those factors include patient
comfortability in receiving services from a secular profession whose values may
be markedly different from their own (Richards & Bergin, 2000). It appears there
is public awareness of the differences in religious beliefs and values between
clinicians and potential patients and community leaders. Even the most
religiously informed clinical treatment cannot benefit religious patients if they do
not attend treatment. Many patients express concern that psychologists will not
understand their worldview or may see it as inferior and seek to change it, and as
a result many are unlikely to seek psychological services (King, 1978).
Alternately, one analogue study that utilized a young cohort found that some
conservative Christians’ apprehension about therapy does not necessarily
indicate that they will avoid therapy or that their beliefs about therapy as effective
are necessarily compromised (Guinee & Tracey, 1997).
Reduced credibility and trust with religious patients, communities, and
leaders may occur and contribute to patient decisions not to avail themselves of
much needed services (Richards & Bergin, 2000; Worthington & Sandage,
2001). While one could argue that it is each person’s responsibility to seek
psychological help if he or she needs it, it is also appropriate that health
practitioners prepare themselves to provide services that are culturally empathic
26
and competent as they strive to serve a diverse public that may have awareness
of therapist’s worldviews and values that may conflict with their own. The
decision not to enter therapy can have tragic results. This is illustrated in the
case of a depressed religious man who refused to enter psychotherapy claiming
that “those immoral anti-God psychotherapists can’t be trusted” (Richards &
Bergin, 2000, p.11). His mistrust of psychotherapy unfortunately may have been
shared by his pastor who did not refer him to therapy. Six weeks following a job
loss, the man committed suicide.
Other clinical concerns may arise in relation to religiously oriented issues
in therapy. Worthington and Sandage (2001) cites five such examples. First,
highly religious patients may request religious therapy and may question their
therapist regarding their religious views. The therapist who is unfamiliar and
untrained in working with highly religious patients may view the questioning as
aggressive, defensive, or anxious. Also, patients may insist that religious
influence not be part of therapy. Next, if the therapist’s approach to religion is
implicit, disagreement on some fundamental beliefs may impair even the most
tolerant therapists’ ability to help. Level of acculturation plays a role in the
patient’s religious beliefs and identity, with generational and geographical
influences sometimes contributing to religious or spiritual confusion. Patients
should also be seen as part of a relational system, including as part of a couple,
family, church, or community with variations in religious commitment,
development, values, and functioning. Lastly, personal sociopolitical and religious
values and preferences may contribute to affective or cognitive bias against
27
conservative religious persons whose beliefs and values are markedly different
from those of the clinician, particularly as the impact of the clinician’s personal
beliefs on therapy goes unexamined.
Sociopolitical Trends, Religiosity, and Affect
Multicultural training programs sensitive to religious diversity, and
proponents of the representation of sociopolitical diversity in psychology, both
emphasize the importance of awareness of the impact of sociopolitical influences
on both research and clinical practice (Fuertes & Brobst, 2002; Redding, 2002;
Wester & Vogel, 2002). Awareness of sociopolitical influences is key in providing
culturally competent services to religiously diverse patients. The relationship
between sociopolitical views and religion is often assumed, and perhaps largely
exaggerated in the popular press. However, some evidence for a relationship
between the two has been observed. To examine the importance of this
relationship and its potential impact on patients, it is necessary to briefly discuss
the current sociopolitical trends.
The political literature explores the assumption that liberalism may be
thought of as the opposite of conservatism, and that each is to some extent
represented in politics by the Republican or Democratic parties (Kerlinger, 1984).
While this unipolar or “polarized” view of the cultural differences of American
sociopolitical groups has been viewed as overly simplistic and reductive, that a
28
political divide in America exists is generally agreed upon in the social
psychology (Seyle & Newman, 2006) and political (Wallis, 2005) literature.
Further, a trend for religiosity to fluctuate with sociopolitical selfidentification has empirical support. Older studies emphasized the correlation
between increased religiosity and political conservatism (Allport & Ross, 1967;
Batson, 1976; Gorsuch & Aleshire, 1974). More recently and more specifically,
research indicated that Evangelical or born-again Christians and Mormons were
most likely to identify with the Republican Party, while Buddhists, Jews, Muslims,
and those with no religion, had a greater preference for the Democratic Party
(The Graduate Center, 2001) . Another study (Winseman, 2005) indicated that
those who reported no religion were more affiliated with liberal ideologies, belong
to younger age groups, and were represented with a slight skew toward higher
education (where 12% of “nones” have some college education versus 9% that
have a high school education.) Further, liberal political ideology was associated
with a more secular worldview than a conservative one. Those who reported
having no political affiliation were also least likely to claim any religious affiliation.
The relationship is explored in data provided by the Gallup Organization (M.A.
Strausberg, personal communication, April 17, 2006) in which 73% of selfdeclared politically conservative persons reported that religion is very important
in their lives, compared to 45% of political liberals. Further, Evangelical
Christians, presumably a fairly conservative group, skew strongly Republican
(Newport & Carroll, 2005).
29
The divide may contribute to affectively charged feelings about whether
and how secular or religious worldviews influence American politics (Wallis,
2005). Sixty-two percent of Republican college students believe that the impact
of religion on daily American life is declining, and by a margin of 7 to 1 believe
this to be a “bad thing,” whereas 54% of college Democrats believe religion to be
increasing in influence, and by a 2 to 1 margin believe this to be a “bad thing”
(Shaheen et al., 2006). Differences between political parties in whether
politicians should talk openly about their religion, and whether religion should
influence policy, also reflect that divide.
Psychologists’ ideology has also been explored. Seventy percent of
psychologists identified themselves as Democrat and only 21% as Republican in
one study (McClintock, Spaulding, & Turner, 1965). In a series of four studies
between 1969 and 1989 (American Enterprise Institute, 1991), 68% of
psychology faculty members self-identified as liberal and only 15% self-identified
as conservative.
Other literature recognizes the lack of sociopolitical diversity in the field,
and in particular the absence of conservative influences, and advocates for more
diverse representations and less bias in research, policy advocacy, professional
education, and practice (e.g., Brand, 2002; Johnson, Nielson, & Ridley, 2000;
Redding, 2001; Richards & Davison, 1992; Wester & Vogel, 2002). Redding
(2001) asserts that due to an obvious trend toward sociopolitical homogeneity
within the profession of psychology, and an unspoken assumption that
psychologists must share the same liberal worldview, even psychologists with
30
more sociopolitical or religiously conservative views may be excluded or
marginalized, which in turn can have several negative consequences. These
include the impediment of services to conservative patients, biased research on
social policy issues, damage to psychology’s credibility with policymakers and
the public as a descriptive rather than a prescriptive science, and discrimination
against scholars and students (2001), particularly those who hold more
conservative worldviews and who are developing a growing sense of themselves
as therapists (Wester & Vogel, 2002).
In summary, as recent trends evidence some level of polarity between
political parties, whether exaggerated in the popular press or not, and the
relationship between religious conservatism or liberalism and political party
endorsement has been seen in the empirical literature, affect surrounding either
position may occur. It is possible that any negative affect or biased beliefs about
groups often seen as “polar” opposites in worldviews may generalize to the
clinical setting. Is it possible that empathy might be affected within the
relationship if such “polar” worldviews are present?
Empathy
The concept of empathy has generated a plethora of research following
Carl Rogers’ writings of its importance in psychotherapy. Empathy has been
thought to be a primary factor in discriminating effectiveness of therapy. Indeed,
Rogers (1957) made the case that empathy and related constructs are all that is
31
needed to produce positive change in a patient. Operationally, empathy has been
described several ways. These include cognitive dimensions such as vicarious
introspection (Kohut, 1977 p. 459), and affective dimensions or “vicariously
experienced emotion” (Strayer, 1990, p.225). Either of these may be achieved
“through the therapists sensitive ability and willingness to understand the client’s
thoughts, feelings, and struggles from the client’s point of view,” and “to adopt his
frame of reference” (Rogers, 1980, p. 85). It has also been described as seeing
the world through the eyes of another (Ivey, Ivey, & Simek-Morgan, 1993).
Various dimensional components of empathy have also been examined.
They include empathic resonance, expressed empathy and received empathy
(Barrett-Lennard, 1981), cognitive perspectives which seek to understand the
thoughts and feelings of others, affective empathy in which one seeks to
experience a sense of feeling and sharing in another’s emotions (Mehrabian &
Epstein, 1972), and approaches which combine cognitive and affective aspects
of empathy (Bilgrave & Deluty, 1998; Davis, 1983; Strayer, 1990). Much of
empathy-related theory and research is focused on empathy as a disposition or
personality trait (see Davis, 1994; Duan & Hill, 1996; Eisenberg et al., 1994;
Eisenberg & Lennon, 1983; Houston, 1990). One perspective often used in the
psychological literature is Davis’s (1994) multidimensional approach to empathy.
Davis’s Interpersonal Reactivity Index measures four dimensions of empathy.
The constructs are Personal Distress, or the tendency to experience discomfort
in response to the distress of others; Fantasy, which is the ability to transpose
oneself into imaginary situations; and particularly salient to the psychotherapist is
32
Perspective Taking or the tendency to adopt the psychological view of others;
and Empathic Concern or the tendency to experience warmth, concern, and
compassion for others.
Acceptance as a foundation to empathy has also been discussed (Ivey et
al., 1993; Rogers, 1957). Rogers’ theory of unconditional positive regard as
necessary for an effective therapeutic relationship, underscores the importance
of acceptance of the patient. He further describes specific actions and skills in
demonstrating an empathic attitude and in communicating empathy and
understanding of the client. These skills generally include reflective statements
that deliberately preclude the influence or communication of one’s own thoughts
or ideas. It is reasonable to assume that if the influence of one’s thoughts or
ideas goes unexamined, that this may be difficult or even impossible to do.
Culture also impacts the understanding of, and empathy for, others (Ivey
et al., 1993). Clinicians’ ability to empathize with their religiously diverse patients
may significantly affect whether or not they are able to provide culturally
competent services. In multicultural psychotherapy, Ivey et al. (1993) posit that
“the concept of respectfully entering the other person’s world has profound
implications” which echoes APA mandates that “multicultural empathy requires
that we respect worldviews different from our own” (1993, p.25). Further, Ridley
and Lingle (1996) defined cultural empathy as the therapist’s tendency to
understand the experience of culturally diverse patients based on the therapists’
interpretations of “cultural data.” Ivey et al. (1993) stipulated that positive regard
as a precursor to empathy requires that we find positives in that data, and
33
positives within the worldviews and attitudes of culturally diverse patients.
Finding positives in a worldview with which one may strongly disagree, or that
one has strong negative affect about, may be difficult for the most empathic
psychotherapist.
Subtle messages of approval or disapproval of worldviews with which one
disagrees, has negative affect about, or which is judged inferior or unhealthy,
may be communicated to the patient, perhaps without the awareness of the
therapist. Patterns of responding may manifest in duration and frequency of eye
contact, affirming or disconfirming facial expressions, verbalizations, or gestures.
Even Carl Rogers evidenced repeated patterns of reinforcement or
nonreinforcement of value-laden patient communications (Truax, 1966) and
similarity of patient style of expression (Murray, 1956). His patterns of responding
were noted to lead to altered patient behavior, despite presumed attempts to
respond in an accepting and empathic manner without influence of his own
thoughts, ideas, or feelings.
When working with religiously diverse patients, particularly those whose
religious worldviews and values may elicit affective charge or negative cognitive
appraisals, it may be more difficult to have empathy for the dissimilar patient,
than the religiously similar patient. One study of dimensional empathy indicated
that therapists high in affective and cognitive empathy demonstrated increased
cultural conceptualization skills, and those high in affective empathy were more
aware of cultural factors in conceptualization that those with low empathy
(Constantine, 2001). In another study (Burkard & Knox, 2004), psychologists who
34
were willing to acknowledge the impact of race in patients’ lives, demonstrated
more empathy than those rated as “color blind” or racist.
In conclusion, empathy is viewed as a cornerstone of psychotherapy that
seeks to understand and respect the patient’s experience. However, even
clinicians who most value an empathic stance toward their patients may be
unaware of responding that alters the patient’s behavior. Implicit or explicit
patterns of responding may be value-laden enough to change the course of
therapy and treatment outcomes. Explicit recommendations to encourage value
change are in contradiction to APA’s guidance (see APA, 2002, Principle E)
about respecting group differences. For obvious reasons, responding to patients’
cultural values in a way that explicitly encourages change, clearly impacts one’s
ability to communicate empathy and positive regard for the worldview that is
perceived to be in need of change. If indeed it is true that empathy is key in
forming a therapeutic relationship and effecting treatment outcomes, impaired
empathy with diverse groups can impact the course and efficacy of treatment.
Religion and Mental Health
In addition to the possibility of transferring negative affect associated with
the clinician’s personal religious and/or sociopolitical beliefs and experiences to
the therapeutic setting, therapists may have cognitive appraisals of religious
patients as more mentally ill than their nonreligious counterparts. If clinicians
believe there is an association between religiosity and poor mental health, initial
35
impressions of the patient may be affected. Initial impressions of patients which
include personal liking for the patient, therapist assessment of patient’s potential
for change, and ease of patient expression, may have an effect on treatment
outcomes in several ways. These include therapist satisfaction with patient
progress, therapist perception of patient satisfaction, and type of termination
(Brown, 1970). Also, the patient’s religiosity or associated values may be
targeted for change if it is evaluated as a contributor to poor mental health.
Lastly, the patient who is viewed to have poorer mental health may also be seen
to have a poorer prognosis. Expectations that are based on stereotyped
information have been associated with effects on information processing and
judgments, information seeking and hypothesis testing, and interpersonal
behavior via self-fulfilling prophecies (Hamilton et al., 1990). It is reasonable to
assume that therapists may also be affected by expectations of patient prognosis
or outcomes based on stereotyped appraisals of their religiosity and
subsequently adjust their clinical approach accordingly.
As we have seen, historically there has been some disparagement of
religion within the field of psychology for various reasons. Sigmund Freud
offered that God is “nothing but an exalted father” (Freud, 1913/2000, p. 256),
and that all faith was at least neurotically determined (Freud, 1913/2000, pp. 174281). Freud either ignored healthy and nonpathological faith or simply did not
believe that it existed. His aggrandizement of the scientific worldview and
sweeping disparagement of those who endorse religious and spiritual beliefs is
echoed 67 years later by Albert Ellis. Prior to recanting some of his views
36
recently (Ellis, 2000), Ellis was clear in articulating his beliefs that religious
persons are quite emotionally disturbed, and even suffer from the most severe of
disturbances (Ellis, 1980, p. 8).
Ideological influences are evident in psychological scales purported to
assess mental health or development. These do not consider an understanding
of the religious persons’ worldview and may characterize religious persons as
Ellis describes, irrational and dogmatic, and even morally less well developed
(see Altemeyer & Hunsberger, 1992; Richards & Davison, 1992) . C.S. Lewis
cautions against holding up a view of Christianity that a small child might take
and presenting it in its concretized and overly simplistic form as an expression of
the whole breadth and depth of Christian religious thought (Lewis, 2001). For
instance, the assessment of narrow-minded authoritarian fundamentalism can be
attributed to antireligious, and overly reductive ideological statements in the
Religious Fundamentalism Scale (Altemeyer & Hunsberger, 1992). This scale
forces religious persons to choose between severely concrete “unsympathetic
normative assumptions” (Watson et al., 2003) or denying their religious beliefs.
An example of such splitting is the statement “whenever science and sacred
scripture conflict, science must be wrong,” rather than a more culturally
appropriate alternative such as “God’s hand is in all creation and in all truth; so
conflicts between faith and science should not frighten us, but rather inspire us to
seek God’s truth” (2003).
Unfortunately, claims made by figures such as Freud (1913/2000), Ellis
(1980), and (Watters, 1992), that religious persons are irrational, neurotic, and
37
generally emotionally unhealthy, and that religious psychologists may be
assumed to have or have had personal problems (Sarason, 1993) cannot be
easily dismissed. They have been made over time by influential psychologists,
and they may represent the views of other psychologists or may further influence
the therapist’s conceptualization of religious persons. On the heels of those
claims, whether there is a relationship between religion and mental health is a
question worth investigating.
Contrary to broad assertions about the relationship between poor mental
health and religiosity, two meta-analytic studies (Bergin, 1983; Gartner, Larson, &
Allen, 1991) yielded no evidence and inconsistent evidence respectively. A
careful review of the literature (Gartner et al., 1991) revealed that differences in
variables and measures may contribute to former mixed findings. For example,
trends toward negative religious coping (religious discontent, punishing God
reappraisals) are associated with poorer mental health, while positive religious
coping (seeking spiritual support, religious forgiveness, and benevolent religious
reappraisal) is expressed more frequently and associated with better mental
health (Pargament, Smith, Koenig, & Perez, 1998). The differences in findings in
the two styles of religious coping emphasize that when drawing conclusions
about religiosity and mental health, it is as important to operationalize and
distinguish between types of religiosity, as it is to distinguish between good and
bad therapy.
Also, extrinsic religiosity (religiosity used as a means to another end such
as increased social status) moderated an overall mild association between
38
religiousness and fewer depressive symptoms, while positive religious coping
and an intrinsic orientation (one in which religion is an end in itself) were
associated with lower levels of depression (Smith, McCullough, & Poll, 2003) as
well as lower levels of manifest anxiety (Bergin, Masters, & Richards, 1987).
Moreover, increased associations between general psychological well-being and
religion were demonstrated in a Christian sample (Francis & Peter, 2002), and
positive religious coping has been consistently associated with improved mental
health in patients experiencing chronic pain (see Rippentrop, 2005 for review)
and rehabilitation (Kilpatrick & McCullough, 1999). Lastly, a review of religiosity
and mental health was summarized by the conclusion that “devout religiousness
and frequent involvement in both private and public religious activities are
associated with better mental health” (Koenig, 1997 p. 101).
In summary, in this section we have briefly explored the frequent use of
stereotyping and prejudice of out-groups under various conditions and for various
reasons. Further, we have explored whether or not the effect of psychologists’
emphasis on empathy and acceptance precludes them from responding to their
religious patients in ways that are culturally compromised or with less positive
regard than their nonreligious counterparts. We have discussed the potential for
affect to be associated with clinicians’ responses to religious, and in particular
religiously conservative, patients. Several factors were explored that can
contribute to the uninformed, neglectful, or biased responding to religiously
diverse patients. These include the lack of multicultural training with an emphasis
on the need for the personal evaluation of the impact of one’s sociopolitical
39
ideology, personal beliefs and prejudices, and training specific to assessing,
understanding, and working with persons with religious worldviews. Liberal
trends in academic, clinical, and research psychology have been discussed, and
have been recognized and discussed by those interested in sociopolitical
pluralism which includes a more adequate representation of sociopolitical
diversity in psychology. Cognitive evaluations of religious persons as neurotic,
irrational, illogical, emotionally unhealthy, and dogmatic have been demonstrated
by primary theorists and implicitly validated through the publication of these
antireligious views. Given these considerations, what does the literature to date
on clinical bias with religious patients yield?
The Current Research
Literature on Bias with Religious Patients
Studies on bias against religious patients have been inconsistent to date.
Methodological concerns indicate that conclusions and generalizability of results
should be considered carefully. Negative findings were reported in several
studies with problematic methodology.
Reed (1992) investigated clinician assessment of pathology and prognosis
of religious or nonreligious couples who were referred for adoption evaluations.
No bias was found in this study. Another study with negative results often cited in
the literature is Wadsworth and Checketts’ study (1980) of potential clinical bias
40
in clinician/patient dyads with dissimilar religious values. Houts and Graham
(1986) also found no clinical bias in prognosis, pathology, and internal versus
external attributions of patient difficulties with religious patients. However, other
studies uncovered bias (Gartner, 1990; O'Connor & Vandenberg, 2005.). A
closer look at each study is warranted to understand findings more clearly and in
determining directions for future research that seeks to resolve inconsistent
results and methodological shortcomings.
Two studies (Houts & Graham, 1986; Lewis & Lewis, 1985) failed to find
significant bias in the assessment of pathology with religious persons. Both of
these studies were conducted using populations in geographical regions which
may be presumed to be conservative (the South and the Midwest). It is not
known what impact ongoing exposure to a culture dissimilar to one’s own may
have on stereotype or prejudice formation and maintenance of the group. In other
words, it is possible that the dissimilar group’s status as an outgroup has less
impact on stereotyping when there is significantly more familiarization with the
group, than with groups that are in the minority and may thereby be more easily
perceived as deviating from the norm.
Work on the attitudinal effects of exposure to a target indicate that mere
exposure facilitates liking, relative to attitudes toward targets to which one has no
exposure (Zajonc, 1968). This exposure effect, or the phenomenon that
“familiarity breeds liking,” is demonstrated in interpersonal attractiveness
research in which a target is perceived as more intelligent and attractive when
exposure occurs more frequently. It is possible that this effect may moderate
41
biased responding in areas in which religious groups are the norm, and thereby
more familiar to clinicians. Research indicates that clinician first impressions of
patients which include “liking” for them, has a significant effect on outcomes
including evaluation of patient progress, eventual number of sessions,
assessment of patient progress, clinician satisfaction with patient progress, and
type of termination (Brown, 1970). If ongoing exposure to a cultural group or
group member may increase one’s perception of a group member’s intelligence
or attractiveness, and first impressions of patients including “liking” have
significant effects on treatment outcomes, there is potential that in a geographical
location where a religiously conservative person is a distinct minority and may be
quite dissimilar in beliefs and values to a clinician, initial impressions of the
patient based on any affect or cognitive evaluations about his or her religiosity
unmoderated by familiarity, may significantly impact treatment outcomes.
Further, Houts and Graham’s study (1986) reported no bias in prognosis,
pathology, and internal versus external attributions of patient difficulties, as
evaluated by either religious or nonreligious clinicians. In this study, groups of
patients were assigned categories of either no mention of religion, moderately
religious, or very religious. No bias was found against those designated to the
very religious category relative to the other two groups, but bias was found
against the moderately religious category. Closer examination of the moderately
religious group reveals that persons in that group expressed doubt about their
religious beliefs. It is difficult to reconcile doubt about religious beliefs with a
“moderate” religious belief system. This group was rated as having more
42
psychopathology and a poorer prognosis than the other two groups.
Interpretation of results in this study should be made with caution as the category
designations are not representative of the descriptive narrative in the vignette.
The group assignment of clinicians as either religious or nonreligious may also
be problematic. Recalling Byrne’s theory that attitudes and values have more of
an impact on attraction and repulsion than do demographics, dichotomous
labeling of one’s religiosity appears reductive. Interpretations made based on
data yielded between groups assigned in such a manner should be undertaken
with caution.
Similarly, Lewis and Lewis (1985) measured pathology, prognosis, and
patient attractiveness rated by religious and nonreligious clinicians, as
determined by clinician self-report about whether he or she was religiously
affiliated. No significance was found on pathology and liking of the patient;
however, the patient’s religiosity had a significant effect on clinician perception of
her difficulties. Both religious and nonreligious clinicians predicted fewer sessions
would be needed for progress with the religious patient than with the nonreligious
patient. Of particular interest is that nonreligious clinicians rated nonreligious
patients as needing almost twice as many sessions as the religious patient.
Authors speculate that this finding may reflect clinicians’ belief that treatment
progress may be enhanced by the religious patient’s religious background.
In another study often cited for finding no bias in the clinical evaluation of
religious patients (Wadsworth & Checketts, 1980), only Latter-Day Saints and
“other” subjects were evaluated, and they were evaluated by psychologists in
43
Utah. Clearly, generalizing these results to clinicians from other geographic
regions or to patients of other religious backgrounds is problematic. Also in this
study, Wadsworth used no control vignettes and each of the four vignettes used
described religiously affiliated persons, whether they were currently active or
inactive participants in religious beliefs or behaviors.
Another study that did not find bias (Reed, 1992) used a between-subjects
design to measure psychologists’ reactions on a pathology measure to one of
four patient vignettes. The patient vignettes characterized either a deeply
religious or strongly atheist position, or a newly religious or newly atheistic
position. This study is interesting in its approach to expand on other research
(i.e., Houts & Graham, 1986) that indicated that stability of religious position may
be a factor in clinicians’ determination of pathology. However, clinician religiosity
was not considered in the analysis and using a homogenous group to evaluate
vignettes in a between-subjects design may have mitigated negative bias such
that it was undetectable.
There are limitations in each of the studies discussed. One limitation is the
relatively undefined dichotomization of religious versus nonreligious clinicians
and/or patients represented in vignettes. The use of more descriptive
categorizations of religiousness that discloses more information about religious
beliefs and values, or the extent to which religious beliefs or behaviors are made
manifest in one’s life, might yield more helpful information. Dimensional and
descriptive narratives would be more appropriate than categorical assignment if
research seeks to detect clinical bias with individuals who differ from them in
44
religious beliefs and behaviors rather than labels. Negative findings could be the
result of poor clinician group assignment. In other words, religious affiliation does
not a religious person make, and many levels and dimensions of religiosity may
be represented in those categorical assignments.
Another limitation is the inability to generalize results from research
conducted in areas that may be presumed to have a fairly substantial religious
population. It may be that bias would have been found in similar studies
conducted in more religiously liberal areas or on a national sample. We have
seen that research on the exposure effect indicates that exposure to religiously
diverse groups may contribute to an increase in clinicians’ perception of patients’
intelligence and attractiveness, and therefore potentially affect clinicians’
judgment of pathology, prognosis, or empathy. Perhaps their out-group status is
less pronounced as they become more familiar. Generalizability of findings to
areas in which one has limited exposure to religiously diverse groups, or to a
national population of clinicians, may be unwarranted.
Also, each of the studies above utilized a between-subjects design with no
attempts to detect favorable bias in the direction of the religious patient
compared to the nonreligious patient. Therefore, negative bias may have been
mitigated so that it was undetectable, compromising results. Lastly, social
desirability was not controlled in any of the studies above. With the emphasis on
clinical empathy and patient acceptance, and fairly ubiquitous social disapproval
of prejudice, it is reasonable to assume that social desirability could have
affected clinician responding in each of the studies.
45
In a within-subjects study that did reveal biased results, vignettes of
patients belonging to extreme ideological groups were rated (Gartner, Hohmann,
Harmatz, & Larson, 1990). Groups that were represented were right wing
religious, left wing religious, right wing political, or left wing political groups.
Fictitious patients were represented equally in each of either the four ideological
categories or a nonideological group. This within-subjects design measured
reactions of psychologists to both nonideological categories and one of the four
ideological categories. Subjects rated the patient on measures of empathy,
pathology, and perceived maturity of the patient. Using a national sample of
clinicians, significant bias was found on every variable. As this study explored
clinician reaction to liberal and conservative ideological poles, the vignettes were
more informative about the patients than if they had been identified by religious
affiliation alone. It is also important to note that this study utilized a withinsubjects design in a national sample of psychologists, which may be considered
more religiously liberal than the general public.
Another study found bias against religious patients who were rated as
more mentally ill and in need of more sessions to make progress compared to
their nonreligious counterparts by a group of homogenous therapists (Hillowe,
1986). In this study, therapists’ traditional and nondoctrinal religiosity was
measured. Interestingly, as therapists’ nondoctrinal religious attitudes increased,
the prognosis of religious patients increased relative to nonreligous patients’
prognostic ratings. Hillowe speculated that his study may have found results
where others did not because of dichotomous categorization of therapists in
46
previous work, whereas the religiosity of the vignette patients and clinicians in his
study were descriptive in terms of expressed beliefs and behaviors, and
measured on the dimensions of traditional or nontraditional religiosity. He also
believes that the interaction found between nondoctrinally religious clinicians and
more positive prognostic ratings of religious patients may be due to the clinicians’
beliefs that religious patients may share a base of faith and hope that will assist
them in the therapy process toward more optimistic outcomes.
Bias was found in another study (O'Connor & Vandenberg, 2005) that
used a between-subjects design and investigated clinicians’ evaluation of
religious beliefs as more or less pathological in terms of psychosis, depending on
religious beliefs that are most mainstream (Catholic), less mainstream (Mormon),
and least mainstream (Nation of Islam.) The doctrine of each religion was
represented by corresponding beliefs articulated by patients in vignettes. Beliefs
included that one patient “came to believe quite passionately in the Mormon
religion, whose tenets state that he will be transformed into a god after he dies,”
that the Catholic patient believed “the Holy Spirit has given him a special strength
to defend the faith,” and that the patient who was a member of the Nation of
Islam “believes in the revelation that a spaceship, the Mother Wheel, has been
hovering over the United States since 1929.” Four sets of vignettes depicted the
various beliefs described in either religiously specific language, or in language
that does not identify a specific religion, or with changes as a result of these
beliefs representing either a no-harm situation (these beliefs deepened his
relationship with his girlfriend), or a harm situation (the change affected a
47
relationship that had previously been a positive one to the point that the patient
considered killing his girlfriend following a betrayal). Three other distracting
vignettes were also used. Each participant received and rated 6 vignettes total,
consisting of 3 distracter vignettes, the religious, the nonreligious, and either no
harm, or harm vignettes.
Less mainstream religions were considered more pathological, with
Catholic beliefs being rated less pathological than Mormon beliefs, and Mormon
beliefs rated less pathological than Nation of Islam beliefs. When Catholic and
Mormon beliefs were associated with their religions in the vignettes, they were
rated as less pathological than when they were not. However, there was no
difference in the pathology rating for Nation of Islam patients in either case, with
Nation of Islam beliefs rated highly and equally pathological, and significantly
more pathological than Mormon or Catholic beliefs, whether identified as related
to religion or not. Authors speculated that general familiarity with Catholic and
Mormon beliefs may have contributed to the finding that they were less
pathological, and that high pathology ratings of Nation of Islam beliefs may be
related to the subject’s general unfamiliarity with them or something about their
content. It should be noted that the religious beliefs in this study were rated as
symptoms of the most severe mental illnesses, potentially having serious
consequences for the patient.
Lastly, in another study, bias was found against conservative Evangelical
Christian school applicants by a national sample of professors of clinical
psychology in APA -accredited doctoral programs (Gartner, 1986). This between-
48
subjects study revealed that professors were less likely to admit applicants who
were either identified as born-again, or who hoped to integrate their faith and
their practice of psychology, compared to similar applicants who did not mention
religion. Although the Evangelical applicant was rated higher than the
integrationist applicant, the differences were not significant. Bias against
psychology graduate student applicants by psychology professors cannot be
generalized to bias against patients by clinicians; however, the findings of bias by
psychologists against a conservative Christian group in a between-subjects study
are notable as bias presumably occurring between religiously dissimilar groups.
Authors also note that artificially limiting the number of religious psychologists
into doctoral programs, continues to perpetuate the underrepresentation of
conservative religious persons in the field. As we have seen, this has implications
for those who may be unlikely to seek psychological services from secular
psychologists (King, 1978).
Social Desirability
Another factor that may complicate the results of the religious bias
research that is worth investigating in more depth is social desirability. Social
norms discourage prejudice against cultural groups and group members. It is
logical that since all of the studies discussed used self-report measures in
evaluating groups of various religious orientations, there is a possibility that
clinicians may have responded to those measures in a socially desirable manner.
49
In fact, the MODE model of biased responding suggests that the more sensitive a
domain is, such as social group evaluation over evaluation of food preferences
for example, the more likely responses will be influenced by social desirability
effects (Fazio & Olson, 2003). The MODE model emphasizes motivation and
opportunity as determinants in responding with bias. Motivation may be either
internally driven, such as that which may occur when one has a set of internal
standards that do not approve of stereotyping or prejudiced responding. Also,
motivation may be externally driven, so that one may refrain from responding in a
biased manner to avoid the disapproval of others. According to the MODE model
of biased responding, if one has the motivation and the opportunity to respond
without prejudice, one will likely attempt to do so.
Multicultural diversity and the desirability of cultural awareness and
competence are emphasized in psychological research and current academic
curricula (Constantine & Ladany, 2000). Psychologists are often aware of the
need for awareness, knowledge, and skills in working with culturally diverse
patients. They may have knowledge of stereotype information about social
groups but work to control prejudiced responding for either internal or external
reasons. However, when social desirability was controlled using the Marlow
Crowne Social Desirability Scale (MCSDS), one study on cultural competencies
yielded little correlation between competencies measured by explicit self-report
versus objective other-rated measures (Worthington et al., 2000), and no
correlation was found in another study (Constantine & Ladany, 2000).
50
In addition to the focus on cultural competence in clinical work, the
emphasis on empathy and patient acceptance may also contribute to socially
desirable responding. The motivation to respond without empathic bias on selfreport measures may not be a reflection of responding to similar patients in a
natural setting. Also, self-reported empathy may not correlate with a patient’s felt
sense of empathy or empathy as perceived by others. The literature indicates
that there are often significant differences in self-reported empathic responding
and empathy as experienced or perceived by others (Davis & Kraus, 1997;
Graham & Ickes, 1997; Ickes, Marangoni, & Garcia, 1997). As a result of these
findings, one must consider the results of the religious bias literature as
potentially being mitigated by social desirability.
Implicit versus Explicit Cognitive Processes in Impression Formation
Given the nature of the clinician’s responsibility to evaluate patients
thoughtfully when forming clinical judgments, cognitive processes should
naturally be engaged in efforts to form a clinical impression. The use of
stereotypes in impression formation has been explained as a method of
simplifying and reducing information for the purposes of efficiently managing
what otherwise may be an overwhelming amount of information, which may
subsequently overload cognitive processes (Allport, 1954; Erlich, 1973; Hamilton
& Trolier, 1986). Some theorists believe the use of stereotypes to assist in social
categorization is inevitable (Erlich, 1973; Hamilton & Trolier, 1986). Simply put, in
51
order to simplify information-processing tasks, reduce and organize the
information to be evaluated in a manner that makes it manageable, and to make
sense of a complex world of social information, we categorize persons into
groups. When one encounters a group member or group label such as African
American or Evangelical Christian, if other information is lacking, stereotypes
may be utilized to assist in effectively categorizing the individual. Some theorists
posit that stereotypes are still common in today’s society, despite that they are
openly discouraged (Devine et al., 2002). Particularly when information may be
ambiguous in the early stages of treatment, stereotype applications may be more
frequently utilized and may have more of an impact on first impressions, and
subsequently on treatment outcomes.
Impression formation utilizes both explicit and implicit cognitive processes.
In particular, stereotype formation, maintenance, and behavior resulting from
stereotype attitudes and beliefs, is often the result of a complex combination of
motivational, cognitive, and sociocultural processes. The research on bias with
religious patients has made use of self-report measures to investigate bias in
empathy, pathology, prognosis, and patient maturity among other variables. The
explicit self-report measures used offer research respondents the opportunity to
reflect and react to questions, potentially allowing censorship of those responses
for a variety of reasons. These include externally motivated social desirability
effects, or those based on a set of internal standards that rejects stereotyped or
biased responding. It may be assumed to some degree that if a clinician utilizes a
personal set of internal standards that discourage biased responding to research
52
queries, those same standards will tend to discourage biased responding in a
natural setting. However, if social desirability is one’s primary motivation to
respond in an unbiased manner, that motivation is not likely to motivate unbiased
responding in natural settings where one’s responses will not be judged by
others.
Other measures have been helpful in capturing attitudes and beliefs about
social groups or group members, without allowing the subject the opportunity to
censor responses. Implicit measures purport to capture attitudes outside of one’s
awareness, or in a manner that does not require, or indeed may prohibit,
introspection that may have censoring or reacting elements. Whether or not the
subject has an awareness of having the relevant attitude, the detection of
automatic attitudes compared to those endorsed in an explicit manner, has
shown promise in alleviating methodological difficulties in capturing biased
responding without social desirability confounds.
Explicit self-report measures and implicit measures of attitude activation
often exhibit low correlations in the stereotyping and prejudice literature (Devine
et al., 2002; Greenwald & Banaji, 1995; Rudman, Greenwald, Mellott, &
Schwartz, 1999), although not always (see Fazio & Olson, 2003 for review).
Implicit processes have been explored in several domains including religion
(Rudman et al., 1999), aggression (Berkowitz & LePage, 1967), sexism
(McKenzie-Mohr & Zanna, 1990), and race (Dovidio, Kawakami, Johnson,
Johnson, & Howard, 1997; Greenwald, McGhee, & Schwartz, 1998; Sinclair &
Kunda, 1999).
53
Automatic activation of attitudes has been seen in priming experiments in
which attitudes have been detected following priming with some attitude object or
word (Banaji & Greenwald, 1995; Banaji, Hardin, & Rothman, 1993; Berkowitz &
LePage, 1967; Dovidio et al., 1997). For instance, developmental psychologist
Leonard Berkowitz found that the presentation of an aggression-provoking cue
such as a rifle, elicited aggressive responses (Berkowitz & LePage, 1967).
In another study, females were rated by respondents as more dependent than
males for the same behaviors following dependence but not neutral primes, and
males were rated more aggressive than females following aggression primes but
not neutral primes (Banaji et al., 1993).
Activation of automatic attitudes has also been seen in word fragment
completion tests (Dovidio et al., 1997; Gilbert & Hixon, 1991; Hense, Penner, &
Nelson, 1995). In one study utilizing word fragment completion tasks, Gilbert and
Hixon (1991) demonstrated the utilization of stereotypes as a cognitive resource
tool. In this study, in experiment 1, an Asian research confederate elicited
stereotypic completions of word fragments when subjects were cognitively
occupied, but not when they were not busy. In experiment 2, when stereotype
activation occurred, busy subjects were more likely than not busy subjects to
apply the activated stereotypes. Other research examines the tendency to
explain stereotype incongruent information more often than stereotype consistent
information (Sekaquaptewa, Espinoza, Thompson, Vargas, & von Hippel, 2003),
,and tendencies to attribute responsibility to a stereotype target’s internal process
54
rather than to his or her external situation (Sekaquaptewa et al., 2003; Sherman
et al., 2005).
Automatic attitudes have also been demonstrated to have predictive
validity on behavior. In one experiment (Dovidio et al., 1997), Caucasians high in
implicit prejudice had greater indications of anxiety when interacting with an
African American partner than with another Caucasian partner. In other research,
(Sherman, Mackie, & Driscoll, 1990), subjects’ evaluations and preferences for
targets were predicted by passively activated categories of prime-relevant versus
prime-irrelevant dimensions. Exposure to pornography in another study predicted
ability to recall physical characteristics and sexual motivation toward a female
experimenter (McKenzie-Mohr & Zanna, 1990). In other research, higher levels
of prejudice predicted more attention to processing stereotype inconsistent,
compared to stereotype consistent information (J. W. Sherman et al., 2005).
A well known measure of implicit stereotyping that has received attention
in the literature is the Implicit Association Test (IAT; Greenwald et al., 1998). The
IAT measures the strength of associations between target groups or members of
target groups and stereotype congruent or incongruent words or concepts. The
strength of the association is measured in response time. The theory behind the
IAT is that it is easier to select words or concepts that are highly associated with
a target, rather than selecting words or concepts that are not associated with a
target. Therefore reaction times will be faster when categories are matched with
associated words or concepts.
55
For example, associations are made between a target group such as
African Americans and clearly valenced words (e.g., poison, flower) and
stereotype congruent or incongruent characterizations (e.g., wealth, welfare).
Categorizations are designated by one key stroke for one group assignment and
another key stroke for another group assignment. The latency in responding to
instructions to categorize valenced words or concepts with either target groups or
other groups using computer key strokes represents the strength of the implicit
associations held by the subject. For instance, the categorization of Black
stereotype congruent names such as “Latoya” and White stereotype congruent
names such as “Cathy” is practiced. Then the categorization of words with a
clear pleasant or unpleasant valence such as “flower” or “poison” is practiced.
Following these practice categorizations, combination of the valenced words and
race related concepts (or names in this case) are assigned to target categories.
Individually presented Black names and pleasant words are assigned to the
“Black/pleasant” category, and White names and unpleasant words are put into
the “White/unpleasant” category. Then the category combinations are switched
so that Black names and unpleasant words are assigned to the
“Black/unpleasant” group, and White names and pleasant words are assigned to
the “White/pleasant” group. Latency of responding to each categorization for
each grouping combination is measured in milleseconds. In a race study utilizing
these methods, (Greenwald et al., 1998), when Black names were paired with
unpleasant words, response time was significantly faster than when they were
56
paired with pleasant words, indicating a negative implicit association with Black
names.
The IAT as a measure of implicit associations has been criticized by some
(Brendl, Markman, & Messner, 2001; Karpinski & Hilton, 2001). There is some
speculation that shifts in response patterns may indicate that learned response
patterns are facilitated in difficult trial blocks. Also, critics claim that the tendency
to categorize familiar words faster than nonwords suggests that other factors
may contribute to previous findings interpreted as implicit prejudice. Conclusions
drawn by authors from experiments on nonsocial group responding as predictive
of behavior caused them to question the validity of the IAT as a measure of
implicit responding to social groups (Karpinski & Hilton, 2001). In Karpinski and
Hilton’s study (2001), candy bar and apple associations using the IAT did not
correlate with participant behavior when given the choice of selecting either a
candy bar or an apple to eat. Authors assert that previous results about social
group associations that were interpreted as prejudiced or stereotyped responding
may have been premature. They posit that the associations demonstrated may
have been a reflection of environmental exposure rather than prejudices against
a target group. However, Karpinkis’ own results may be inconsistent with other
IAT research due to the nature of his groups. Apples and candy bars may have
varying valences depending on whether health or taste is more salient to the
participant, and which dimension is more salient at the time the participant is
confronted with a choice of the food rather than the category designation.
Research results with groups such as words versus nonwords and apples versus
57
candy bars are not consistent with research that examines responses to social
groups. The results and causal inferences of one cannot be extrapolated to the
other. The IAT consistently demonstrated in- and out-group biases of social
groups (Greenwald et al., 1998; Nosek, Banaji, & Greenwald, 2002; Rudman et
al., 1999), and social group bias has even been found in minimal paradigm
research (Ashburn-Nardo, Voils, & Monteith, 2001), when group assignment is
random and participants have no previous environmental association with the
target group.
However, the possibility that the automatic activation of attitudes about
social groups may be environmentally learned is one that cannot be lightly
dismissed. General research on social groups suggests that stereotypic
associations of social groups are indeed often well learned, as is evident in the
ability to effectively use stereotype “congruent” or “incongruent” concepts.
However, even though there is evidence for predictive validity of implicit
measures, not all associations result in prejudiced responding. Further
explanation may lie within motivational processes as moderators of automatic
associations.
The MODE model of prejudice (Fazio, 1990) specifically posits that both
explicit and implicit processes of responding contribute to attitudes, judgments,
and behaviors. Those processes include the automatic activation of attitudes and
the motivation and opportunity to respond to those attitudes with deliberation.
Similarly, Devine (1989) asserts that both automatic activation of attitudes and
conscious decision making about whether to judge a target and act on those
58
attitudes, contribute to response patterns to social groups. These two-stage
models of prejudice are a less deterministic perspective of the meaning and
impact of implicit attitudes, although they acknowledge the socialization effects of
stereotype information. Devine posits that what may be activated and captured
by measures such as the IAT are knowledge structures or schema of common
stereotype data, rather than internalized attitudes about a group. She explains
that in addition to one’s knowledge of stereotype information, one has the ability
to choose to act on that knowledge or not. Devine’s two-stage model suggests
that attitudes captured by the IAT may not have predictive validity because they
do not represent internalized prejudices, but only stereotype knowledge and that
one has the motivation to respond without prejudice to that knowledge. Plant and
Devine (1998, p. 1) address “the presence of the rather pervasive external social
pressure to respond without prejudice [that] has created enduring dilemmas for
both social perceivers and social scientists as they try to discern the
motivation(s) underlying (generally socially acceptable) nonprejudiced
responses” by exploring the importance of motivations to respond without
prejudice.
Similarly, Dunton and Fazio’s Motivation to Control Prejudiced Reactions
Scale (MCPRS; 1997) is concerned with one’s motivation to control prejudiced
responding. As Plant and Devine point out, social perceivers may experience a
dilemma in choosing between stereotype knowledge and motivations to respond
without prejudice. Social perceivers will likely be differentially motivated to
respond to prejudice or stereotype data. The MCPRS measures the amount of
59
motivation to control prejudiced reactions using a two-factor solution. Factor 1
consists of concern with acting prejudiced due to an internal set of standards in
which prejudice is found distasteful or unacceptable, and concern about how one
may be perceived by others for acting in a prejudiced manner. Factor 2
measures tendencies to restrain oneself from expressing prejudice due to the
possibility of confrontation with or about targets of prejudice. Motivation to control
prejudiced reactions can be differentiated from social desirability measures such
as the MCDS (Crowne & Marlowe, 1960). The MCDS measures attempts to
respond to self-report measures in a socially acceptable manner, whereas
motivation to control prejudice measures assess origins of motivations to
respond to situations without prejudice (Plant & Devine, 1998) or the amount of
that motivation (Dunton & Fazio, 1997).
The socialization effects of religious stereotype congruent associations
may or may not be ubiquitous in the United States, although common knowledge
of their nature dictates that they are indeed common. The activation of such
attitudes may be the result of environmentally learned associations and/or
internalized prejudices. An interesting note when considering whether IAT results
reflect stereotype schema or internalized prejudices is that one would expect that
group members would also demonstrate those associations with their own
groups, if the associations only represented environmentally learned data, since
socialization probably exposes them to stereotypes about their own group.
However, implicit measures consistently demonstrate bias, or knowledge of
stereotype data, based on in- and out- group membership. If one has automatic
60
associations about a group, it is assumed that one may seek to control the effect
of those associations. Future research that purports to examine the predictive
validity of automatic associations on behavior may also benefit from examining
the role of motivation to control prejudice in moderating those attitudes. As
applied to research on clinician bias with religious patients, motivational
processes may moderate any automatic negative associations with religious
persons, so that associations do not dictate the evaluators’ clinical judgment.
Summary
There is a schism in the scientific worldview and the religious one.
Psychologists differ statistically from the general U.S. public on measures of
religiosity, religious affiliation, and the importance of religion in their lives. There
are clear sociopolitical trends toward liberal worldviews in the psychological
community. Psychological publications have published disparaging comments
about religious persons and their mental health. Similar commentary about racial
or ethnic minorities is not likely to be given the same consideration, giving
validation to the hypothesis that the antireligious views held by some researchers
and prominent theorists, may be shared by others in the psychological
community. Assertions have been made and published that psychologist value
judgments are, and should be, more carefully considered and more adequate
than those of the general public.
61
The religiosity gap and the general focus on multiculturalism and cultural
competency has been the impetus for some research on potential bias with
religious persons. Unfortunately, that research is scant relative to work in other
cultural domains, and has often had methodological difficulties that did not
adequately address transparency or social desirability confounds. Research that
yielded positive results of bias often utilized a national population and a withinsubjects design, which is likely to be more impervious to those concerns. That
positive results of bias were found in any studies that utilized self-report
measures in a society in which bias is discouraged, should be viewed as
significant. Also, when social desirability is controlled, results are more likely to
be an accurate reflection of the bias that exists in a sample than when it is not
controlled. Social desirability has been effectively controlled in research using
psychologist samples, a group likely to be savvy to the purposes of such
measures. Nevertheless, religious bias studies may benefit from the use of
implicit measures of stereotype activation. The stereotyping literature
emphasizes implicit measures in which response patterns are not likely to be
affected by censoring or reactive elements. Given that some attitudes
automatically activated may be environmentally learned but not acted upon,
predictions about clinical judgments should not be inferred from such results
alone. It is hoped that in a psychologist population, motivation to control
prejudiced reactions may moderate the effect of any automatically activated
attitudes about religious persons that do exist.
62
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CLINICIAN RELIGIOSITY AND RESPONSE TO DIVERGENT PATIENT RELIGIOSITY:
AN INVESTIGATION INTO THE EFFECTS OF IMPLICIT AND EXPLICIT
STEREOTYPING ON EMPATHY AND PROGNOSIS IN INITIAL RESPONDING TO
PATIENTS WHO ARE RELIGIOUSLY DIVERSE FROM PSYCHOLOGISTS
PART B
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Introduction
Multiculturalism has been called the fourth force in psychology by some
(Cheatham, Ivey, Ivey, & Simek-Morgan, 1980) and has been treated with
commensurate significance in the APA’s Code of Ethics (APA, 2002). Further,
the Code of Ethics bans discrimination against multicultural groups in Standard
3.01 and addresses competence in Standard 2.01 which stipulates that
an understanding of factors associated with age, gender, gender identity,
race, ethnicity, culture, national origin, religion, sexual orientation,
disability, language, or socioeconomic status is essential for effective
implementation of their services or research, psychologists have or obtain
the training, experience, consultation, or supervision necessary to ensure
the competence of their services, or they make appropriate referrals
(APA, 2002, pp. 1063-1064)
An investigation into clinician approaches to religious patients is warranted for
several reasons. These include that the addition of religion as a group addressed
by APA multicultural mandates is fairly recent, that there is a history of
controversial relationship between science and religion, and that there is
evidence of divergent religious values between patients and clinicians. Further,
the current but scant research in this area yields confusing and sometimes
seemingly contradictory results.
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Religiosity as a Diversity Variable in Clinical Psychology
Psychology has its roots in philosophy and may therefore be considered a
close relative to theology when considered from an epistemological perspective.
However, psychology has had to elbow its way into respectable standing among
the hard sciences which may have caused a deliberate and excessive distance
from this realm of human experience. For example, early psychologists struggled
with issues concerning the selection of methodologies and methodological purity
as psychology continued to develop as a discipline within the sciences, even
such that “the very scientific status of psychology hinges, from some points of
view, on methodological purity” (Viney & King, 1998, p. 24), a paradigm which
has been inconsistent with that which frames much of religious thought. The
schism between the two is often evident in the scientific literature. For instance,
the National Academy of Sciences (1984, p. 6) claims that science and religion
are “separate and mutually exclusive realms of human thought”, while other
positions (Jones, 1994) emphasize that there are similarities, specifically with
ways of knowing and attempts to structure understanding of a complex
existence. At the least, it is safe to assume that within the practice of clinical
psychology, patients bring subjective worldviews, beliefs, and values into the
therapeutic environment, many of which are informed by their religious
orientations.
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The “Religiosity Gap”
Inasmuch as there are invigorating arguments on either side about the
essence or compatibility of the scientific and religious realms, the fact remains
that a large portion of the population holds, and is influenced by, religious views.
In fact, in the United States an estimated 94% of the population believes in “God
or some universal spirit” (Gallup, 1996). The general population has also
consistently endorsed religion as either “very important” or “fairly important” in
their lives, with 85% endorsement of these items in 1996 (Gallup) and 84% in
2006 (Gallup). Seventy-six percent of the population endorsed Judeo-Christian
religious affiliations in the categories Protestant, Catholic, Jewish, Orthodox (1%
of total including both Jews and Christians) and Mormon, with 49% of those
endorsing Protestant and 23% endorsing Catholic affiliations. In addition to the
forced Judeo-Christian categories, 11% percent endorsed “other” (which may or
may not consist of other Judeo-Christian affiliations), 11% selected the category
“none”, and 1% were “undesignated” (Gallup, 2006). Other research (Hill et al.,
2000) indicates that 90% of Americans pray, 71% belong to a church or
synagogue, and 42% attend religious services weekly.
Psychologists have typically had lower rates of traditional religious
affiliation than the general population (Shafranske, 2000), lower rates than other
mental health professionals including social workers, psychiatrists, and marriage
and family therapists (Bergin & Jensen, 1990), and lower rates than other
professionals in the natural sciences in general (Long, 1971). In one study
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(Ragan, Malony, & Beit-Hallahmi, 1980) of 522 psychologists (a 2% random
sample of the APA with a 67% response rate of usable questionnaires), 43% of
members endorsed belief in some deity, and 34% denied the existence of God.
Bilgrave and Deluty (1998) examined the beliefs of a sample of 237
psychologists (a 51% return rate of usable questionnaires) that included 56%
clinical- and 44% counseling- psychologists drawn from selected divisions of the
APA. They found that 66% of participants in this sample endorsed beliefs which
included “God or a Universal Spirit” compared with 94% of the general population
(Gallup, 1996), and 43% endorsed Judeo-Christian affiliations compared to the
aforementioned estimate of 76% of the general population (Gallup, 2006). Other
affiliations endorsed in the study were 15% “other,” 12% agnostic, 8% Eastern,
and 6% atheist (Bilgrave & Deluty, 1998). The divergence between psychologists
and the public in endorsement of religious affiliation and religious beliefs has
been referred to in the literature as the “religiosity gap” (Richards & Bergin,
2000).
Religion and Multicultural Competence
Neglect of Religious Beliefs and Values as a Diversity Variable
Religious values are distinct from the beliefs from which they arise.
Consistent with definitions found elsewhere in the literature, Worthington (1996)
defines religious beliefs as “propositional statements (in agreement with some
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organized religion) that a person holds to be true concerning religion or religious
spirituality”, and religious values as “superordinate organizing statements of what
a person considers important” that arise from his or her preferred religious
beliefs. Religion is considered a cultural group (Richards & Bergin, 2000;
Shafranske, 1996; Merriam-Webster, 2003) whose members’ beliefs and values
can influence their worldview sufficiently to prompt the APA to mandate
competencies in working with them, as with ethnic, racial, and other multicultural
groups (APA, 2002). Also consistent with directives in working with other
multicultural groups, there is a need for a culturally sensitive approach to their
treatment.
However, current levels of training in religious diversity in clinical practice
are not commensurate with what one would expect based on the religiosity of the
U.S. public (Brawer, Handal, Fabricatore, Roberts, & Wajda-Johnston, 2002;
Yarhouse & Fisher, 2002). One study reported that only 5% of clinical
psychologists had religious professional training (Shafranske, 1990). In another
study (Brawer et al., 2002), when training directors in predoctoral internship
training programs responded to whether the topic of religion was covered in their
training program, they reported that the topic was addressed sporadically. Also in
Brawer’s study, it was found that if the topic of religion was covered in APAaccredited training programs it was largely unsystematic, or it was not covered at
all.
Given the findings that the majority of Americans report that religious and
spiritual beliefs are important in their lives and the APA policy about
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competencies in clinical work with religious persons, it is interesting to note that
not only is there such little participation in religious diversity training programs,
but also in a study that investigated values considered relevant to therapy, only
29% of clinicians consider those beliefs important in their work with patients
(Bergin, 1991). The relative disinterest compared to the interest of the general
population could be the result of several factors. These include deliberate
avoidance of religion resulting from fear of exploring the topic in clinical work,
personal bias against it, the judgment that religious beliefs are simply unrelated
to the clinical needs of patients, or general neglect of the topic as a result of its
relative unimportance to the psychologist’s own life. However, given the
importance of religion to the general public, clinicians may indeed undervalue the
impact that a religiously influenced worldview may have on a comprehensive and
respectful understanding of the patient’s experience and clinical presentation.
The Potential for Stereotyping and Prejudice
Stereotyping, defined as the use of beliefs or expectations associated with
a group or group member based on group membership, and prejudice, defined
as a valenced evaluation of that group or group member (Sherman, Conrey,
Stroessner, & Azam, 2005) against religious belief systems or the values
consistent with a religious worldview can contribute to bias in clinical work. Bias
for the purposes of this paper is operationalized as an instance of prejudice.
Neglect in considering religious worldviews for any reason may result in the
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exhibition of positive bias in the direction of secular worldviews and/or negative
bias against religious worldviews in treatment. Particularly without religious
multicultural training, clinicians may be unaware of how their beliefs and value
systems can affect the therapeutic process, selection of treatment goals, and
subtle reinforcements of shifts in the patients’ own value system. Further, if
clinicians do consider religious themes important in their work with patients, it is
important to know how those beliefs and values are interpreted by clinicians who
may have very different worldviews.
Before examining the impact of religious stereotyping or prejudice in more
depth, it is helpful to have some basic knowledge of the variety of processes and
variables that contribute to either. The literature on stereotyping and prejudice
development and maintenance is voluminous and encompasses several
processes and examines many variables (Hilton & Hippel, 1996). Primarily there
are three categories of processes: sociocultural, motivational, and cognitive.
Sociocultural models of stereotyping and prejudice include social comparison
models (Brewer & Gardner, 1996; Brickman & Bulman, 1977; Crocker, McGraw,
Thompson, & Ingerman, 1987; Festinger, 1954; Taylor & Lobel, 1989), social
identity theory (Tajfel & Turner, 1979), social position effects on prejudice
(Guimond, Dambrun, Michinov, & Duarte, 2003), and in- and out-group similarity
and dissimilarity effects (Byrne, 1971; Rosenbaum, 1986). Motivational
processes examine the use of stereotype information by those who have a
preference for cognition (Crawford & Skowronski, 1998), a need for increased
self-esteem under threat (Crocker & Luhtanen, 1990), and use of stereotyping to
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reduce cognitive load (Biernat & Korbrynowicz, 2003; Crawford & Skowronski,
1998; Macrae & Milne, 1994; Yzerbyt & Coull, 1999). Cognitive processes focus
on information-processing strategies (Bodenhausen & Lichtenstein, 1987;
Hamilton, Sherman, & Ruvolo, 1990; Hamilton & Trolier, 1986), stereotyping as a
cognitive construct (Korten, 1973), and the relationship between stereotyping and
cognitive simplicity (Koenig & King, 1964).
The effects of both affect and cognition have been examined together in
the literature. Affect has been operationalized several ways including agreement
with mood-affect adjectives following evaluations of stereotype targets (Jackson
& Sullivan, 2001), and “liking” for target groups (Jussim, Manis, Nelson, & Soffin,
1995). Cognition is often defined by beliefs about stereotyped targets (Jackson &
Sullivan, 2001; Jussim et al., 1995). Also, the effect of induced happiness on
stereotypic judgments has been explored (Bodenhausen, Kramer, & Susser,
1994).
The categories in many of these studies overlap as the literature continues
to more narrowly define the mechanisms by which bias occurs. Still other
literature looks to motivational processes that moderate prejudice, with some
emphasis on the value that many place on responding without prejudice for the
purposes of maintaining interpersonal harmony and/or due to an intrapersonal
value system that disapproves of prejudiced behavior (Devine, Plant, Amodio,
Harmon-Jones, & Vance, 2002; Dunton & Fazio, 1997). Yet other work examines
the phenomenon of rebound effects of stereotype suppression, or the tendency
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for stronger stereotyping behaviors to follow attempts at suppressing stereotypes
(Macrae, Bodenhausen, Milne, & Jetten, 1994).
The possibility of prejudice and stereotyping of culturally diverse groups in
clinical work is evident in that there are policies prohibiting discrimination against
those groups (see APA, 2002 Section 3.01). The social psychology literature
consistently shows negative stereotyping of members of dissimilar groups
(Ashburn-Nardo, Voils, & Monteith, 2001; Devine et al., 2002; Jussim et al.,
1995; Sears & Rowe, 2003; Sherman et al., 2005). Byrne (1971) offers the
hypothesis that the average person is less attracted to, and maybe even dislikes,
people whose values, attitudes, beliefs, and opinions are different from his or her
own. Research on Byrne’s repulsion paradigm (Rosenbaum, 1986) examined
participants’ responses to persons with similar and dissimilar attitudes on a
number of dimensions, and contrasting with controls, the study yielded significant
differences in repulsion ratings for those with dissimilar attitudes. In another
study (Chen & Kenrick, 2002), the repulsion hypothesis was demonstrated in
three experiments after participants learned of dissimilar controversial attitude
positions of others. Further, the effects of in- and out-group bias are
demonstrated in minimal group paradigms, which refer to bias effects when
groups differ only in label assignment (Tajfel & Turner, 1979; Gaertner & Insko,
2000).
In summary, it is evident that the circumstances under which stereotyping
or prejudice may occur are many. Much of the theoretical and research literature
focuses on similarity and dissimilarity of groups as a precursor to stereotyping
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and prejudice under those varied conditions, even when that difference is only
implied or completely ambiguous as is the case in the minimal group paradigm.
Even with clinical training that emphasizes the impact of empathy and patient
acceptance as a significant part of successful clinical treatment, practitioners who
value these approaches may also demonstrate biased patterns of responding.
Clinicians’ biased responding to dissimilar patients can take many forms in a
clinical setting. Areas in which bias effects might manifest range from trends in
value convergence to decreased empathy and the selection of treatment goals
which conflict with the patients’ preferred values and worldview. An examination
of the forms that clinical bias may take will begin with a brief discussion of the
implications of the value convergence literature.
Outcomes and Value Convergence
Initial similarity of clinician and patient demographic variables including
SES, ethnicity, gender, and age has been shown to have an effect on
relationship enhancement and even treatment outcomes (Beutler, Crago, &
Arizmendi, 1986; Kim, Gladys, & Ahn, 2005). Consistent with Byrne’s theory,
Beutler and Bergan (1991) posit that the role of values may have an even greater
impact on treatment bias than the roles of age, ethnicity, and gender, which often
do not accurately represent group members’ attitudes and values. Further, value
convergence is often an indicator of counselor-perceived improved patient
outcomes (Beutler & Bergan, 1991; Worthington, 1988). However, these results
94
are inconsistent (Beutler, Machado, & Neufeldt, 1994; Beutler et al., 2004), and
the effect is less strong for other- and client-rated perceptions of improvement
than for counselor-perceived improvements (Kelly, 1990). Nonetheless, the
phenomenon that clinicians consider patients healthier when their values more
closely match their own may be evidence that judgments are being made about
preferable value systems.
Also, the process by which value shifts occur may indicate subtle
reinforcement of movement in the direction of or away from particular values.
Even clinicians who intend to be nondirective may be unaware of subtle
messages of approval or disapproval communicated to the patient, such as
frequency and duration of eye contact and affirming or disconfirming facial
expressions, gestures, and verbalizations. Repeated occurrences of
discriminatory reinforcement and nonreinforcement were seen in two
independent studies of Carl Rogers demonstrating Rogerian therapy, in which
patterns of responding based on value preferences (Truax, 1966), and similarity
of patient style of expression and other response classes (Murray, 1956), altered
patient behavior. Since Rogerian therapy is well known for its emphasis on
unconditional positive regard and patient-led processes, it should be recognized
that even the most nondirective, accepting therapeutic stances may have
embedded within, value preferences that influence treatment. Some (Ellis, 1980)
have even encouraged clinicians to emphasize value stances to capitalize on
value convergence research, despite guidance of the APA Code of Ethics to
respect group differences (APA, 2002, Principle E). The effect of value
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convergence is a concern for clinicians and researchers who recognize the
power of the therapist as an agent of change whose influence may be better
described as one of “persuasion and conversion rather than one of healing”
(Beutler et al., 2004).
Religion and Mental Health
More overtly, clinicians may direct conscious challenges to the patient’s
religious belief system or the values that arise from it, if clinicians believe it to be
less desirable than their own or pathological in some way. Sigmund Freud
repeatedly professed opinions that God is “nothing but an exalted father” (Freud
1913/2000, p. 256), and that all faith was at least neurotically determined (Freud,
1913/2000, pp. 174-281), ignoring healthy and nonpathological faith. More
recently, Albert Ellis stated that religion is illogical and questioned what changes
religious persons could make without giving up their religious beliefs, which he
claimed were characterized by inflexibility and devout “shoulds, oughts, and
musts,” and even saw religion as evidence of the most severe emotional
disturbance (Ellis, 1980, p. 31), although he later recants some of his earlier
positions (see Ellis, 2000).
Other and recent antireligious views include comments made by Wendell
Watters, a respected professor of psychiatry and physician at McMaster
University in Ontario, Canada. In reference to Christian doctrine and teachings
he stated that they are “incompatible with the development and maintenance of
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sound health, and not only ‘mental’ health,” and that “Simply put, Christian
indoctrination is a form of mental and emotional abuse” (Watters, 1992, p.10). In
reference to the majority of membership in the American Psychological
Association (APA), Emeritus professor of psychology at Yale University and
author of over 40 books, Seymour Sarason, in his Centennial Address to the
APA stated that there are more than a few psychologists who regard ingredients
of a religious worldview as a “reflection of irrationality, of superstition, of an
immaturity, of a neurosis,” and that “indeed if we learn someone is devoutly
religious, or even tends in that direction, we look upon that person with
puzzlement, often concluding that psychologist obviously had or has personal
problems” (Sarason, 1993, p. 187). In the Diagnostic and Statistic Manual of
Mental Disorders (DSM-III-R), 12 references to religion in the Glossary of
Technical Terms were used to demonstrate psychopathology (American
Psychiatric Association, 1987).
While it is noted that the latest revision of the DSM, the DSM-IV TR
(American Psychiatric Association, 2000), now includes more culturally sensitive
language, that antireligious perspectives may have influenced the clinical
judgment of psychologists and psychiatrists alike, should not be easily dismissed.
Indeed, there is encouraging evidence that some psychologists’ worldviews have
evolved in conjunction with the demands for multiculturally appropriate
perspectives as can be seen in the morphing views of Albert Ellis. In one earlier
treatise on religiousness and psychotherapy Ellis states that, “If one of the
requisites for emotional health is acceptance of uncertainty, then religion is
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obviously the unhealthiest state imaginable” (Ellis, 1980a, p. 8), implying by
virtue of the religious person’s extreme pathology that he or she is likely the
hardest to treat. Indeed, he also stated that “the best he can do, if he wants to
change any of the rules that stem from his doctrine, is to change the religion
itself” (Ellis, 1980a, p. 9). However, Ellis later recants some of his earlier
assertions and reports that his Rational Emotive Behavior Therapy is compatible
with some religious views and can be effectively used with patients who have
devout beliefs about God without changing their religion (Ellis, 2000).
Nevertheless, it is difficult to imagine that such evolution in thinking about
religiosity and religious persons, as encouraging as it may be, necessarily
represents a sudden and ubiquitous absence of antireligious views in
psychology. Certainly, this type of anti-religious thinking was common enough in
the not so distant past that it was acceptable for publication in peer-reviewed
journals, which one might assume have some commitment to publish culturally
appropriate materials.
Contrary to these opinions, two meta-analytic studies (Bergin, 1983;
Gartner, Larson, & Allen, 1991) yielded no evidence and inconsistent evidence
respectively, for a link between religiosity and poorer mental health. A more
recent meta-analytic study on religiousness and depression (Smith, McCullough,
& Poll, 2003) found a negative correlation between symptoms and religiousness.
In fact, an overall trend in good mental health was found on scales that
measured anxiety, personality traits, self-control, irrational beliefs, and
depression in those with an intrinsic religious orientation (religion as an end itself
98
as opposed to it being used as a means to another end; Bergin, Masters, &
Richards, 1987; Smith et al., 2003). Moreover, increased associations between
general psychological well-being and religion were demonstrated in a Christian
sample (Francis & Peter, 2002), and improved mental health was associated with
those who use positive religious coping on domains including chronic pain (see
Rippentrop, 2005 for review) and rehabilitation (Kilpatrick & McCullough, 1999).
Indeed, some acknowledge that the perception of religious persons as
irrational, inflexible, and pathological has in fact instilled a fear of psychotherapy
in potential patients who are religiously oriented (Richards & Bergin, 2000).
Members of traditional religious organizations may perceive psychotherapists as
incapable of, or unwilling to, work with them in a manner that is respectful and
sensitive to their religiousness. Religious persons have also articulated fears that
secular therapists may seek to change their religious beliefs or may
misunderstand them and may even not enter therapy as a result (Richards &
Bergin, 2000; Worthington, 1996). If clinicians evaluate a patient’s religiousness
to be an indication of pathology, they may also rate their prognosis more
negatively as a reflection of his or her perceived poorer mental health.
Sociopolitical Influence
Lastly, multicultural training programs stress the importance of
psychologists’ awareness of their sociopolitical views, and its influence on
research and in practice, particularly in the delivery of culturally competent
99
services and patient satisfaction (Fuertes & Brobst, 2002; Redding, 2002; Wester
& Vogel, 2002). Political parties and policy preferences have become
increasingly polarized in recent years, with even the labeling of “liberal” and
“conservative” groups as “red” and “blue” contributing to further divide the
groups, and contributing to the risk of increased conflict between them (Seyle &
Newman, 2006). These groups are very often associated with either secular or
religious worldviews, whether accurately or not, and negative stereotypes and
feelings about either group and their group members and presumed values have
become more charged as well in recent years ( Wallis, 2005). With the current
lack of participation in clinician religious multicultural training, lack of awareness
of the impact of one’s sociopolitical background is a possibility. Stereotypes and
affective charge associated with religious persons or groups prominent in politics
may be generalized to the clinical setting when one is confronted with religiously
oriented patients.
Impact of Religious Neglect or Bias on Treatment
Due to the religiosity gap, a history of conflict between science and
religion that includes the pathologizing of religion, sociopolitical differences that
may affect clinical judgment of religiously diverse patients, and the consideration
of the stereotype and prejudice literature in general, biases are likely to occur. In
fact, the nature of religious bias that may occur in a clinical setting has caused
some to express the concern that “ethical violations may occur when therapists
100
who are religiously uninformed, insensitive, or prejudiced ‘trample on the values’
of religious clients and in so doing alienate, offend, and even harm them”
(Richards & Bergin, 2000, p. 13). Religious bias can be exhibited in many ways.
Selection of Treatment Goals
Bias in the direction of one value system over another may result in the
selection of treatment goals which may conflict with the patient’s preferred
values. For example, goals may focus on themes that devalue self-control in
terms of absolute values and universal ethics consistent with the patient’s
religious belief system, and instead encourage self-expression in terms of
relative values, or they may encourage permissiveness in sex or sex without
long-term responsibilities which may also conflict with the patient’s religious
values (Bergin, 1980). In either case, the psychologist may be unaware of the
patient’s religious beliefs and values and commitment to live accordingly, or he or
she may have prejudice against the patient’s values, seeing the patient as less
desirable or even unhealthy and in need of change to values more similar to
those of the clinician. However, prohibition against such bias is articulated in the
APA Code of Ethics which specifically calls upon psychologists to “be aware of
and respect cultural, individual and role differences” and to “try to eliminate the
effect on their work of those biases” (APA, 2002, Principle E).
Prejudiced or religiously uninformed treatment can also result in bias in
the direction of secular interventions that ignore religious tools that may assist
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the patient in healing. Religious patients may benefit significantly from
interventions that draw on religious themes that promote effective coping or
assist in the process of change and healing. These include prayer, divine
forgiveness, and socialization within their religious community (Kilpatrick &
McCullough, 1999; Rippentrop, 2005).
Empathy
Culture impacts the empathic understanding of others (Ivey, Ivey, &
Simek-Morgan, 1993). The degree to which clinicians are able to empathize with
their religiously diverse patients may contribute significantly to whether they are
able to provide culturally competent services. As a result of affectively charged
feelings about religiously diverse patients and their worldviews, or stereotypic or
prejudiced expectations and evaluations about them, empathy within
clinician/patient dyads may be impacted. When religious diversity training is
lacking and stereotypes or prejudices go unexamined, it is conceivable that
dissimilarity of religious beliefs and values may contribute to a decrease in the
clinician’s ability to assume the perspective of, or have empathic concern for, his
or her dissimilar patients.
Literature on Clinical Judgment of Religious Patients
102
To date, bias studies on the clinical effects of religiously divergent
clinician/patient dyads have been inconsistent (e.g., Bergin, 1991; Beutler &
Bergan, 1991; Gartner, 1990; Hillowe, 1986; Houts & Graham, 1986; Lewis &
Lewis, 1985; O'Connor & Vandenberg, 2005; Reed, 1992; Wadsworth &
Checketts, 1980; Yarhouse & VanOrman, 1999). Methodological concerns and
inappropriate generalization of results often contribute to mixed findings.
Methodological issues include participant self-report of religiosity or patient
religiosity based solely on religious affiliation with no consideration of how
religiosity impacts one’s life (Houts & Graham, 1986; Lewis & Lewis, 1985; Reed,
1992; Wadsworth & Checketts, 1980).
Another methodological issue is little or no attempt to control for social
desirability. As bias is generally discouraged in most social contexts and certainly
when forming clinical judgments, it is notable that any positive results of bias
were found at all (e.g., Gartner, 1986; Gartner, Hohmann, Harmatz, & Larson,
1990; Hillowe, 1986) in studies that did not attempt to control for it, as one might
assume that participants may be motivated to conceal their bias due to social
desirability effects. It is not surprising however, that if a study’s purpose is
transparent, and that purpose is to detect socially undesirable bias, the results
are likely to be negative for bias (e.g., Houts & Graham, 1986; Lewis & Lewis,
1985; Reed, 1992; Wadsworth & Checketts, 1980).
Generalizability of the results of several studies is limited as they did not
use a national sample. Moreover, they typically examined the clinical judgment of
psychologists in geographical regions in which one could reasonably assume
103
religiosity is fairly common such as Tennessee (Houts & Graham, 1986), Iowa
(Lewis & Lewis, 1985), and Utah (Wadsworth & Checketts, 1980). Indeed, one
study often cited in the literature as yielding no results of bias in diagnosis
included only two categories of clinicians: “Latter Day Saints” and “other”
(Wadsworth & Checketts, 1980) .
One study (Houts & Graham, 1986) which failed to find significant bias in
diagnosis was conducted in a rural area assumed to have a more religiously
conservative population (Tennessee) than might otherwise be found nationally or
in urban areas, which precludes generalizability to clinicians in more religiously
liberal states where clinician encounters with religiously conservative patients
may be more infrequent. It is possible that when religiously conservative persons
are a distinct minority of the population, their out-group status may have an
impact on clinicians’ stereotypic expectation of the patient, affective “liking” of the
patient, and ability to empathize with the patient, all of which might impact the
course of treatment. In fact, research indicates (Brown, 1970) that even clinician
first impressions of patients which include personal “liking” for them, has a
significant effect on case outcomes measured by eventual number of sessions,
later assessment of patient progress, type of case termination, clinician
satisfaction with patient progress, and clinician perception of patient satisfaction
with therapy.
Houts and Graham (1986) measured prognosis, pathology, and internal
versus external attributions of patient difficulties as evaluated by clinicians who
self-reported as religious or nonreligious. Clinicians rated vignettes that
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supposedly represented nonreligious, moderately religious, and very religious
patients. Clinicians in this study rated the moderately religious patient, as defined
by doubts about his commitment to, and strength of, religious beliefs, as having
more psychopathology and a more pessimistic prognosis than those with no
mention of religion or those rated as very religious. Indeed, authors found that
clinicians were probably influenced by the amount of doubt the patient exhibited
about his religious beliefs, rather than degree of religiosity. Specifically Houts and
Graham state that “consistent with the cultural legacy of viewing religious beliefs
as a crutch, the individual who expresses less than convincing endorsement of
religious beliefs may be more prone to being viewed as disingenuous and
disturbed” (1986, p. 270). As doubt was introduced into the moderate condition
and not in the others, it makes interpretation of results difficult and extrapolation
to general attitudes about patients of varying degrees of religiosity impossible.
Another study (Lewis & Lewis, 1985) found mixed results. Using a 10minute videotape of a depressed patient, Lewis and Lewis measured counselorperceived patient attractiveness using the Therapist Personal Reaction
Questionnaire, pathology ratings using DSM-IV diagnoses, and a Likert scale
prognostic measure, rated by both religious and nonreligious clinicians
determined by clinician self-report of whether he or she was religiously affiliated.
No significant bias was found on pathology and liking of the patient between
either the religious or the nonreligious depressed patient; however, the patient’s
religiosity was seen as having a large impact on her difficulties. Authors found it
difficult to interpret these results as symptoms of depression between vignettes
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were virtually identical but speculate that whenever religion is a central concern,
it naturally impacts the way they manage their problems, or that religiosity is
perceived to play a causative role in the patient’s problems. Interestingly, both
religious and nonreligious clinicians predicted fewer sessions needed for the
religious patient than the nonreligious patient. Particularly, nonreligious clinicians
rated nonreligious patients as needing almost twice as many sessions as the
religious patient. Authors speculate that finding may reflect clinicians’ belief that
treatment progress may be enhanced by the religious patients’ religious
orientation.
There are several limitations of the above studies. The relatively
undefined dichotomizing of religious versus nonreligious clinicians by self-report
of religious affiliation, rather than using dimensional and more descriptive
categorization of religiousness is problematic (e.g., Houts & Graham, 1986;
Lewis & Lewis, 1985; Reed, 1992; Wadsworth & Checketts, 1980). Recalling that
it is hypothesized that demographic variables are poor characterizations of one’s
specific beliefs and attitudes, negative findings in some of these cases may be a
result of poor clinician group assignment. If indeed studies seek to detect
clinician bias with individuals whose beliefs and values differ from their own,
more dimensional descriptors of one’s religiosity will be a better predictor of
attitudes than will group affiliation alone. In other words, reported religious
affiliation, does not a religious person make. Therefore, interpretation of results of
bias in relation to others who are also merely associated with a religion may not
reflect bias that could be evoked when one is presented with more detailed
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information about the effects of another’s religiousness on behaviors and
attitudes.
Further, several of the studies cited above utilized a between-subjects
design with no attempts to detect favorable bias in the direction of the religious
patient over the nonreligious patient in individual cases, which gone unmeasured
may have mitigated negative bias such that negative bias was undetectable,
thereby compromising results (Houts & Graham, 1986; Lewis & Lewis, 1985;
Reed, 1992). Wadsworth and Checketts (1980) used no control vignettes and
each of the four vignettes presented described religiously affiliated persons,
whether currently active or inactive participants in religious behaviors or beliefs.
Additionally problematic is generalizability to less conservative states. It is
not yet understood what effect continued exposure to values different from one’s
own may have on bias, nor was this effect discussed in any of the findings of the
aforementioned studies. However, current research on the attitudinal effects of
exposure to targets indicates that mere exposure facilitates liking, relative to
attitudes toward targets to which one has no exposure (Zajonc, 1968). So, if one
is a nonreligious clinician in the “Bible belt” immersed in a culture in which the
norm consists of religious persons, is one as likely to have bias against those of
orthodox religious beliefs as one might if one were part of a community in which
religious persons constitute an out-group? Wadsworth and Checketts’ study
examined clinical judgment of Latter-Day Saints and “Other” participants, where
“Other” included all other religions, agnostics, and atheists. The method of group
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assignment in this study often cited for providing evidence against clinician
religious bias, essentially renders any generalization of results impossible.
Another study (Gartner, Hohmann, Harmatz, & Larson, 1990) yielded
results revealing bias. In this study participants rated vignettes of patients
belonging to one of four extreme ideological groups, right wing conservative
religious (Fundamentalist Christian), left wing liberal religious (Atheists
International), right wing political (John Birch Society), and left wing political
(American Socialist Party) groups. Fictitious patients Mr. S and Mr. W were
represented equally in each of either the four ideological categories or a nonideological group. Participants received one set of two vignettes each with either
Mr. S belonging to one of the four ideological groups and Mr. W who had no
ideology, or Mr. W being represented in one of the four ideological categories
and Mr. S who had no ideology. Each subject responded to measures of
empathy, pathology, and perceived maturity of the patients. Using a withinsubjects design on a national sample, significant bias was found on each
variable. This study examined the interaction of patient/clinician religious (and
political) ideological poles from very conservative and very liberal patients, which
is clearly more informative than mere denominational affiliation alone. It also is
different from other studies in that it measured clinical judgment using a national
sample and a within-subjects design. Indeed, a review of the literature reveals
that there is a paucity of research into the effects of divergent clinician/patient
religiosity in a national population of psychologists which, as we have discussed,
may be considered quite religiously liberal compared to the general population.
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In another analogue study, Hillowe (1986) found bias against religious
patients by a homogeneous group of therapists, who evaluated religious patients
as more mentally ill and in need of significantly more sessions to make progress
than their nonreligious counterparts. One significant interaction was found. As
therapists’ nondoctrinal religious attitudes increased, the prognosis of religious
patients was significantly better than for nonreligious patients. He speculates that
as a result of their own experiences these clinicians may believe that religious
patients have a basis of faith and hope that can contribute to improved therapy
outcomes. Hillowe also suggested that his study may have found results where
others did not because previous work typically categorized patients and clinicians
on religious affiliation alone, whereas the religiosity of the patients in his vignettes
was expressed in their beliefs and actions, and clinicians were assessed for
nondoctrinal and traditional religious beliefs as well as for religious affiliation.
Bias was found against conservative Christian graduate school applicants
in a between-subjects study of full-time professors of clinical psychology in APAaccredited PhD programs in the U.S. (Gartner, 1986). Professors evaluated
“nonreligious,” “Evangelical,” and “integrationist” (those who seek to integrate
psychological theory or research into clinical work with religious persons or those
who study constructs often associated with religion such as forgiveness or
gratitude; see Lewis-Hall, Gorsuch, Malony, Narramore, & Stewart Van
Leeuwam, 2006; Yangarber-Hicks et al., 2006). The professors evidenced
significant differences in bias between “nonreligious” applicants and “evangelical”
and “integrationist” applicants on all four items rated; positive feelings about the
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applicant’s ability to be a good clinical psychologist, doubts about that ability, the
necessity of interviewing that applicant compared to other equally serious
candidates, and the probability of admitting the candidate. As predicted, the
Evangelical was rated more highly than the integrationist, but those differences
were not significant, and both were rated significantly different than the
“nonreligious” applicant. While bias against potential graduate school applicants
cannot be generalized to clinical bias with patients, the processes or
mechanisms that contributed to these results are unknown. Therefore, neither
should the conclusion be drawn that the findings of bias against Evangelicals in
this study, must be unrelated to the potential bias against Evangelical patients.
Lastly, bias was found in another study (O'Connor & Vandenberg, 2005)
that investigated clinicians’ evaluations of religious beliefs drawn from religions
considered most mainstream (Catholic), less mainstream (Mormon), and least
mainstream (Nation of Islam) as comparatively more or less pathological,
specifically in terms of psychosis. Beliefs corresponding to the teachings of each
were articulated by patients in vignettes. Examples included the belief that “the
Holy Spirit has given him a special strength to defend the faith” in relation to the
fictitious Catholic patient, that another “came to believe quite passionately in the
Mormon religion, whose tenets state that he will be transformed into a god after
he dies,” and that as a member of the Nation of Islam, William “believes in the
revelation that a spaceship, the Mother Wheel, has been hovering over the
United States since 1929” (O’Connor & Vandenberg, 2005, p. 612).
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Four sets of these vignettes depicted beliefs such as those above which
were described in religiously specific language, in language that does not identify
a specific religion, and with changes as a result of these beliefs representing
either a no-harm situation (these beliefs deepened his relationship with his
girlfriend), or a harm situation (the change affected a relationship that had
previously been a positive one to the point that the patient considered killing his
girlfriend following a betrayal). Three other distracting vignettes were also used.
Each participant received and rated six vignettes total, consisting of beliefs with
religious language, beliefs with no religious language, and either a no-harm set
or a harm set, along with three distracter vignettes. The hypothesis that beliefs
associated with less mainstream religions would be considered more
pathological was supported, with Catholic beliefs being rated less pathological
than Mormon beliefs, which in turn were rated less pathological than Nation of
Islam beliefs.
When Catholic and Mormon beliefs were associated with their respective
religions they were rated as less pathological than when they were not, but there
was no difference in the pathology rating for Nation of Islam patients in either
case. In both conditions, Nation of Islam beliefs were rated highly and equally
pathological, and significantly more pathological than other religious beliefs
whether identified as religiously based or not. Authors posit that general
familiarity of Catholic and Mormon beliefs, whether identified or not, may have
contributed to this finding, and that it is possible that high pathology ratings of
Nation of Islam beliefs are related to general unfamiliarity with them, or
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something about their content. This is consistent with earlier arguments that
familiarity may influence the evaluation of groups or group members as outgroups who are likely to be evaluated more negatively. Authors express concern
that beliefs of religious traditions were rated as symptoms of severe mental
illnesses potentially having dire consequences for the patient.
Social Desirability
A complicating factor in much of the research on religious bias utilizing
self-reports is social desirability. The MODE (motivation and opportunity as
determinants) model of biased responding suggests that the more sensitive a
domain of evaluation, such as social group evaluation, the more likely
motivational factors will be evoked and represented in explicit self-report
measures (Fazio & Olson, 2003). Social norms discourage prejudice against
cultural groups. Particularly within counseling and clinical psychology,
multicultural diversity issues and the desirability of multicultural awareness and
competence are in the forefront of academic curricula and research (Constantine
& Ladany, 2000). Well-meaning psychologists are interested in cultural
sensitivity, awareness, knowledge, and skills.
Unfortunately, research on multicultural competencies that has sought to
investigate correlations between clinicians’ self-reported competencies and
objective multicultural competency rating by others has found “little relation
between self- and other- rated multicultural competency” when social desirability
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was controlled using the Marlowe Crowne Social Desirability Scale (MCSDS)
(Worthington, Mobley, Franks, & Andreas Tan, 2000). In another study
(Constantine & Ladany, 2000), after controlling for social desirability with the
MCSDS, none of the self-report scores on multicultural competence correlated
with multicultural conceptualization ability as rated by others. Moreover, the
emphasis on empathy in psychotherapy in addition to focus on diversity, likely
contributes to the motivation to respond to explicit measures without empathic or
other bias, whether or not they hold biased beliefs or attitudes or their capacity
for empathy is affected by diversity variables in a natural setting. Not surprisingly
then, there is often a significant discrepancy between self-reported empathy and
empathic accuracy in the literature as measured by other-perceived or otherexperienced empathy (Davis & Kraus, 1997; Graham & Ickes, 1997; Ickes,
Marangoni, & Garcia, 1997). In this context one must consider the results of
studies above on clinician/patient bias that yielded negative results as potentially
being mitigated by social desirability. Examinations of bias against religious or
other social groups should pay particular attention to social desirability effects on
outcomes, as well as seek to uncover the particular processes that contribute to
any biased responding that is detected. One avenue of inquiry may well serve
both purposes: that of implicit or automatic cognitive processes.
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Automatic Versus Controlled Cognitive Processes
Clinicians have the responsibility to thoughtfully consider the patient when
forming clinical judgments, so it is assumed that cognitive processes become
engaged in those efforts. The use of stereotypes in making evaluations in
general may be a natural cognitive strategy to simplify and reduce informational
load. Cognitive theorists explain that “if we, as social perceivers, were to perceive
each individual as an individual, we would be confronted with an enormous
amount of information that would quickly overload our cognitive processing and
storage capacities” (Hamilton & Trolier, 1986, p. 123), and indeed that
stereotyping is not only common but inevitable in ordinary categorization (Erlich,
1973; Hamilton & Trolier, 1986).
In order to simplify information-processing strategies, reduce the amount
of information to be considered, and comprehend a complex world, we
categorize persons into groups. When information is ambiguous, particularly
such as when one encounters a label such as Fundamentalist Christian or
African American, stereotypes of groups may be utilized to assist in that
categorization. So, stereotypes and their negative application, an instance of
prejudice, are still considered by some to be common in today’s society, despite
now being openly discouraged (Devine et al., 2002). As discussed earlier,
research indicates that first impressions early in the therapeutic relationship are
indeed formed about the patient and those impressions affect case outcomes
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(Brown, 1970). What cognitive processes are engaged when making those
impressions? Do those processes rely on stereotypic categorizations?
The research suggests that there are both implict and explicit processes
that are engaged in impression formation, particularly concerning stereotype
maintenance and behaviors resulting from stereotypic attitudes and beliefs. The
research on clinician bias with religious patients has made use of explicit selfreport measures to determine bias. As has been discussed, social desirability
may affect those explicit self-report measures. In order to study stereotype
attitudes and beliefs without social desirability effects, nonreactive implicit
measures that tap into automatic stereotyping have proven useful in the
stereotyping literature (e.g., Banaji, Hardin, & Rothman, 1993; Bargh, Chaiken,
Govender, & Pratto, 1992; Bargh & Pietromonaco, 1982; Devine, 1989; Dovidio,
Kawakami, Johnson, Johnson, & Howard, 1997; Fazio & Olson, 2003; Fazio,
Sanbonmatsu, Powell, & Kardes, 1986; Greenwald & Banaji, 1995; Sherman,
2005). Implicit measures initially purported to capture automatic attitudes that
exist outside of one’s awareness (Greenwald & Banaji, 1995); however, there is
no evidence that because one’s attitudes may manifest outside of one’s
awareness, that one must be unaware that he or she has the relevant attitudes
(Fazio & Olson, 2003). Nevertheless, they do differ from explicit self-report
measures in that responses do not require, and often prohibit, introspection that
may have reactive or censoring elements. Whether or not there is awareness of
the attitude by the subject, that automatic attitudes can be detected without
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introspection suffices to alleviate methodological difficulties in designing
nontransparent studies to capture bias without social desirability confounds.
Activation of attitudes has been seen in priming experiments in which
stereotyped attitudes were activated following the presence of an attitude object
or word (Banaji & Greenwald, 1995; Banaji et al., 1993; Berkowitz & LePage,
1967; Dovidio et al., 1997), word fragment completion tests (Dovidio et al., 1997;
Gilbert & Hixon, 1991; Hense, Penner, & Nelson, 1995), and studies that
examine bias in the tendency to explain stereotype inconsistent information more
often than stereotype congruent information (Sekaquaptewa, Espinoza,
Thompson, Vargas, & von Hippel, 2003). Implicit and explicit self-report
measures have often had low correlations in the domains of prejudice and
stereotyping (e.g., Devine et al., 2002; Greenwald & Banaji, 1995; Rudman,
Greenwald, Mellott, & Schwartz, 1999), but occasionally demonstrate significant
correlations (see Fazio & Olson, 2003 for review).
Automatic stereotype activation has been found in many domains
including ageism (Perdue & Gurtman, 1990), sexism (McKenzie-Mohr & Zanna,
1990), gender stereotyping in judgments of fame (Banaji & Greenwald, 1995),
aggression (Berkowitz & LePage, 1967), race (Greenwald, McGhee, & Schwartz,
1998; Dovidio et al., 1997; Sinclair & Kunda, 1999), and religion (Rudman et al.,
1999). Additionally, numerous studies on implicit processes have demonstrated
predictive validity, including priming procedures (Dovidio, Evans, & Tyler, 1986;
Dovidio et al., 1997; Fazio, Jackson, Dunton, & Williams, 1995; McKenzie-Mohr
& Zanna, 1990; Sherman, Mackie, & Driscoll, 1990), tendencies toward an
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explanatory bias for stereotype inconsistent behaviors (Sekaquaptewa,
Espinoza, Thompson, Vargas, & von Hippel, 2003; Sherman et al., 2005; Sinclair
& Kunda, 1999), the tendency to attribute responsibility to a target's internal
process rather than an external situation, (Sherman et al., 2005), and greater
implicit memory for stereotype consistent information versus stereotype
inconsistent information (Hense et al., 1995).
One of the more well known measures of implicit stereotyping is the
Implicit Association Test (IAT; Greenwald, McGhee, & Schwartz, 1998). The IAT
measures the strength of the association between a targeted group, such as
African Americans, and stereotype congruent or incongruent characterizations
(e.g., welfare, prosperity) or words with evaluative valence (e.g., poison, flower),
measured by response latencies of computer key strokes in correctly
categorizing targeted words. The theory behind the IAT is that it is easier to
decide on a key press in response to words or concepts that are highly
associated with a target group rather than those that are not associated. For
example, in studying race associations, a subject would first practice the
categorization of “Black” and “White” names such as “Latoya” or “Cathy” and
then clearly valenced words which can be described as pleasant (flower) or
unpleasant (poison) into “good” and “bad” categories. Following these practice
categorizations, combinations of valenced words (poison, flower) and racerelated concepts (in this case names) are assigned to the target categories of
either “Black” or “White” and the valence of “good” or “bad.” Participants
designate categorizations by hitting one response key for one group assignment
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so that the individually presented words “LaToya” and “pleasant” are put into the
“Black/good” group assignment and “Cathy” and “poison” are put into the
“bad/White” group assignment with a different key stroke. Then the category
combinations are switched, so that White names and pleasant words are
categorized with the “good/White” category and Black names and unpleasant
words with “bad/Black” category. Latency of responding in each block is
measured in milliseconds. In a race study using these methods (Greenwald et
al., 1998), when Black was paired with unpleasant words, response latencies
were overwhelmingly faster than when Black was paired with pleasant words,
indicating that it was easier for the respondent to associate Black with unpleasant
words.
The IAT as a measure of automatically activated prejudice has come
under some scrutiny. Some researchers believe that shifts in response patterns
and the tendency to categorize nonwords as negative suggest there may be
other causes that contribute to previous findings interpreted as implicit prejudice.
They speculate that difficult trial blocks may facilitate learned response patterns,
and that familiarity with target words versus nonwords may also impact response
patterns (Brendl, Markman, & Messner, 2001). Other experiments on nonsocial
group responding on the IAT as predictive of behavior yielded inconsistent
results.
For example, one study (Karpinski & Hilton, 2001) found no association
between candy bar and apple associations on the IAT and participants’ actual
choice of one over the other. However, Karpinski’s results may be inconsistent
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with other IAT research due to the nature of his selected categories. Apples and
candy bars may be associated with varying valences based on whether health or
taste is more salient to the participant, and which salient feature is the overriding
one when the participant is given the opportunity to choose one. Karpinski and
Hilton (2001) offer the explanation that research on social group associations
using the IAT may merely be the result of environmental exposure to
associations rather than prejudices that one may have about a target group.
However, the data yielded in the measurement of nonwords and apples versus
candy bars are inconsistent with the data found in measures of attitudes about
social groups, and so it is difficult to extrapolate possible reasons for lack of
results in that study to others involving social groups. In contrast to work done
with either nonwords and stimuli with presumably less associated stereotyped
attitudes or affect, the IAT consistently demonstrates in- and out-group biases of
social groups (e.g., Greenwald et al., 1998; Nosek, Banaji, & Greenwald, 2002;
Rudman et al., 1999) and even bias in minimal paradigm work (Ashburn-Nardo et
al., 2001) in which participants are randomly assigned to one of two groups,
having no previous environmental associations with the groups.
Nevertheless, when social groups are being judged, the argument that
automatic activation of associations may be environmentally learned, and not an
accurate measure of internalized prejudice upon which a person will act, cannot
be quickly dismissed. Another explanation may lie within motivational processes
as moderators of automatic associations. The MODE model of prejudice (Fazio,
1990) explicitly points to mixed processes of automatic and deliberative
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processes of responding which contribute to judgments and behavior. Those
processes include spontaneous activation of attitudes and motivation and
opportunity to respond in a controlled manner.
Devine (1989) also asserts a two-stage model of prejudice which includes
both automatic activation of stereotypes by some target feature or label, and
conscious choice-making of whether to act on, or overcome, the activated
stereotype. Her model allows for a less deterministic perspective of the effects of
implicit attitudes, and acknowledges that due to socialization effects of stereotype
information, what may be activated are knowledge structures, or schema, of
common stereotypic data, rather than personally held attitudes about groups.
While the strength of the IAT as a measure of implicit attitudes is purported to be
in the automatic latency of the response, Devine’s model suggests that those
attitudes represented may be overcome by a motivation to respond without
prejudice despite knowledge of stereotypic schema. Plant and Devine (1998)
address “the presence of the rather pervasive external social pressure to
respond without prejudice [that] has created enduring dilemmas for both social
perceivers and social scientists as they try to discern the motivation(s) underlying
(generally socially acceptable) nonprejudiced responses” (1998, p.1) by
examining the importance assigned to both internal and external motivation to
respond without prejudice.
Dunton and Fazio’s Motivation to Control Prejudiced Reactions Scale
(MCPRS; 1997) measures the amount of motivation to control prejudiced
reactions using a two-factor solution. Factor 1 consists of a concern with acting
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prejudiced due to an internal set of standards in which one finds prejudice
personally distasteful and concern with how one may be perceived by others for
acting prejudiced. Factor 2 measures tendencies to restrain oneself from
expressing thoughts and feelings that may cause confrontation with or about
targets of prejudice. Distinct from social desirability measures such as the MCDS
(Crowne & Marlowe, 1960) which measures attempts to respond to self-report
measures for the sake of appearing in a socially acceptable manner, motivation
to control prejudiced measures assesss either origins of motivations to respond
to life situations without prejudice (Plant & Devine, 1998) or the amount of that
motivation (Dunton & Fazio, 1997).
Socialization effects of religiously stereotypical associations may or may
not be ubiquitous in the United States. A consistent pattern of activation of
automatic attitudes about religious persons may or may not merely be the result
of the activation of socially common schematic structures. Interestingly, if such a
pattern existed, and it was to be the only or a very strong contributor to the
activation of automatic attitudes in general, it may be assumed that religious
clinicians would also demonstrate these associations about their own group on
the IAT. However, as the research cited above indicates, implicit measures
consistently demonstrate bias based on in- and out- group membership.
Nevertheless, it is possible that automatic schematic associations may be
activated at least partially as a result of environmental exposure.
It is also reasonable to assume that whether or not one has automatic
associations about a group, some persons may seek to exert control over their
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behavior beyond what automaticity might otherwise dictate. Research that seeks
to thoroughly examine the predictive validity of automatic associations on
behavior may also benefit by examining the role that one’s motivation to control
prejudice may play in moderating those automatic activations. Specifically, the
theory of motivation to control prejudiced reactions as applied to religiously
biased evaluations of clinical patients implies that motivational processes may
moderate any stereotype congruent automatic associations with religious
persons, so that the associations would not affect the evaluator’s behavior,
therefore reducing clinical bias.
Statement of the Problem
The purpose of this study was to examine the potential bias in clinicians
against religiously dissimilar patients. Again, bias here refers to an instance of
prejudice that affects behavior or judgment. In particular, responses to
Evangelical Christian (EC) patients were explored versus responses to patients
with no mention of religion (NMR). Data show that approximately 82% of
Americans can be classified in the Christian categories of Protestant, Catholic, or
“other Christian” (Gallup, 2003 cited in NewPort, 2004). A Christian conservative
group was selected because of its large representation in the American
population today with Gallup estimates as 44% of the total adult population in
2006 endorsing self descriptions of “born-again” or Evangelical Christian,” and
reports that 1 in 5 Americans can be considered Evangelical based on endorsed
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Evangelical beliefs and behaviors (2006). The difference in the estimated
proportion of Evangelical Christians between these methods of group assignment
is notable, and supports earlier discussion about the differences between selfreported religious affiliation versus internalized religiousness and religious
behaviors. However, that both estimates are fairly large is evident. It is further
believed that Evangelicals’ recent sociopolitical presence may elicit affect in
those who have strong opposite sociopolitical leanings and who may not be
aware of the impact of their sociopolitical background on their clinical judgment.
Lastly, it is believed that this large population of conservative Christians may be
the largest group that represents a religious position most diverse in beliefs from
psychologists, a group which endorses less Christian doctrinal adherence in the
literature (Bilgrave & Deluty, 1998).
Variables
Dependent variables were empathy and prognosis. Due to some history of
the assumption or exaggeration of pathology of religious persons in psychology,
and stereotypic expectations such that they are typically illogical and inflexible
(Ellis, 1980), it was hypothesized that clinicians who exhibit bias against them
would perceive them to be more mentally ill, with cognitive traits that may hamper
the process of psychotherapy. Also, consistent with Byrne’s repulsion hypothesis
(Byrne, 1971), religious beliefs and values which are more dissimilar to those of
psychologists may result in negative affect in relation to the group. It was
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believed that negative affect in response to those beliefs and values would result
in clinicians’ reduced empathy with Evangelical patients, who did not
demonstrate motivation to control prejudice. Therefore, clinicians’ religiously
liberal attitude in relation to Christian beliefs (RLACB) was an independent
variable.
Implicit Negative Association with Evangelical Christians was both an
independent and dependent variable as indicated in the hypotheses below. The
effects of two covariates were measured for the purposes of controlling effects as
appropriate, social desirability (SD) and other-religion conservatism (ORC). SD
has been largely uncontrolled in the bias literature and has been shown to have
an impact on results when it was controlled (e.g., Constantine & Ladany, 2000;
Worthington, Mobley, Franks, & Andreas Tan, 2000). As social norms continue to
discourage prejudice and studies have often revealed discrepancies between
self-reported empathy and empathic accuracy as measured by others (Davis &
Kraus, 1997; Graham & Ickes, 1997; Ickes, Marangoni, & Garcia, 1997), it may
be that previous studies did not find results of bias due to social desirability
effects.
Conservatism of other religious groups was also measured as it is not
known what influence religious conservatism in general would have on results. It
was hypothesized that conservatives of other religious groups may not view the
Christian conservative group as an out-group due to the commonality of their
conservatism, and therefore they may not have implicit negative associations
about the group. To assess conservatism of other religious groups, several items
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were given including items that asked respondents to select an estimation of their
personal devoutness in their religious beliefs, practices, and attempts to live in a
scripturally prescribed manner.
It may be difficult to “not have” any preconceived ideas about social
groups, and exposure to some stereotypes of religious groups may be common.
This may be true particularly about conservative Christian groups as their beliefs
often manifest in public behaviors or positions such as influence or presence in
political groups, legislation, and policy-making. It is believed and hoped that
clinicians’ training in the clinical importance of an empathic relationship and
general acceptance of their patients as well as their personal reasons for
controlling prejudice, would have some influence on their motivation to control
prejudiced reactions. Nevertheless, it was hypothesized that those who did not
exhibit motivation to control prejudiced reactions and who demonstrated
stereotypic associations with Evangelical persons, would assign poorer
prognoses to, and demonstrate less empathy with, Evangelical Christian
patients. Put another way, it was hypothesized that those who did not act on
knowledge or beliefs about stereotypes would refrain from doing so because they
were aware that prejudiced responses are socially undesirable, and/or they may
have internal values against responding to others with prejudice. Therefore,
motivation to control prejudiced reactions was predicted to moderate the effect of
automatically activated stereotyping responses on empathic and prognostic bias.
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Hypotheses
Hypothesis #1. Religiously Liberal Attitudes in relation to Christian Beliefs
(RLACB) will be positively related to the difference in empathy expressed toward
Evangelical Christians (ECs) versus No Mention of Religion patients (NMRs),
where difference is determined by EC empathy scores subtracted from NMR
empathy scores.
Hypothesis #2. RLACB will be positively related to the difference in prognosis
expressed toward ECs versus NMRs, where difference is determined by EC
prognosis scores subtracted from NMR prognosis scores.
Hypothesis # 3. RLACB will be positively associated with Implicit Negative
Association (INA) towards ECs.
Hypothesis #4. Motivation to Control Prejudice Reacting (MCPR) will affect the
relation between INA and the difference between empathy expressed toward
ECs versus NMRs, such that as MCPR increases, INA will be less related to the
empathy difference.
Hypothesis #5. MCPR will affect the relation between INA and the difference
between prognosis expressed for ECs versus NMRs, such that as MCPR
increases, INA will be less related to the prognosis difference.
126
Methods
The research design utilized an analogue within-subjects correlational
methodology that included several assessments. Transparency, which may have
affected results of other studies, was addressed in three ways. First, this study
sought to identify automatic attitudes that were activated spontaneously, that is,
without the participant’s ability to use reactive and censoring processes to
mitigate them. Second, this study made efforts to normalize the use of
projections needed to evaluate ambiguous information simulating a more natural
therapeutic environment when some initial hypothesis generation is expected.
The manifestation of any negative content of those projections in bias against the
selected dissimilar religious group is the variable of interest. Third, as social
desirability measured by the Marlowe Crowne Social Desirability Scale has been
successfully used in controlling for social desirability with clinicians in other
studies (e.g., Constantine & Ladany, 2000; Worthington et. al., 2000), a
shortened version of the MCSDS, the MAC-Form C (Reynolds, 1982) was used
to measure social desirability as a covariate in this study to control for the
potential of social desirability confounds on results. Despite the current steps
taken to ensure measurement of clinicians’ uncensored responses, it is uncertain
that all processes, conscious or unconscious, were completely controlled for or
predicted by these measures.
127
Participants
Participants were drawn from a national sample of approximately 3,070
psychologists from the American Psychological Association’s Divisions 42, 29,
12, and 36, the divisions of Independent Practice, Psychotherapy, Clinical
Psychology, and the Psychology of Religion respectively, as well as the
California Psychological Association, the Sacramento Psychological Association,
and the Los Angeles County Psychological Association, through an email
recruitment process utilizing each of their listservs. The total estimated
psychologists subscribing to these listservs are 3070. Each group was believed
to have a large population of psychologists in clinical practice. Division 36, the
American Psychological Association’s Division of the Psychology of Religion,
was also selected because it is believed that there may be a shortage of
conservative religious clinicians within those samples as indicated in the
religiosity gap section of this paper. Due to the nature of Division 36’s members’
interest in the psychology of religion, it was hoped that member participation
would increase that number for comparative purposes. Also, another 415 clinical
psychologist members of the Christian Association for Psychological Studies
(CAPS) received email announcements of the study. In addition, 2,511 email
addresses from public directories of state psychological associations were
initially gathered. After checks to eliminate overlap email addresses, the total
number of psychologists who received a listserv or a personal email request for
participation was approximately 4,896. The 415 members of CAPS who received
128
email announcements were unavailable for review prior to the initial analysis, so
overlap could not be checked and they were not counted in the 4,896 total.
However, after data collection began, several issues prompted the
decision to increase the number of email addresses used for direct emailing.
These included technical difficulties with access to the second website used for
data collection, the Inquisit website (Draine, S., 2006, Inquisit www.inquisit.com),
the elimination of Macintosh users from participation due to the operating
system’s incompatibility with the site, which was an unexpected condition of the
site, and significantly lower response rates from listserv invitations than to direct
email invitations. Therefore, another 5,435 email addresses were collected from
public directories of local chapter psychological associations, psychological
associations listed by orientation and disorder or disorder cluster, and various
universities with public directories. The total number of direct email addresses to
which invitations were distributed was 8,361, after excluding 149 participants who
“opted out” of the invitation to participate.
In the recruitment email, it was requested that all respondents be clinical
psychologists, and information about participants’ degrees was gathered. It is not
known what other differences exist between each group; nevertheless, in an
effort to balance the religiosity of clinicians to some degree and to ensure
adequate sample power, that there may be other sample differences is accepted
and each sample group was used.
In the power analysis, I calculated the sample size based on two sets of
variables to accommodate the hypotheses with the most variables, and therefore
129
the highest N. This model contained predictor set A which consisted of the
covariates social desirability and conservatism as defined by devoutness in
beliefs, rituals, and traditions, and attempts to live according to prescribed
scripture or teachings, and set B which included clinician religiosity. As it was
initially unknown what effect the covariates would have and much of the past
research has failed to detect bias, a reasonable and conservative estimate of
effect size was small with an f-sq of .02 as defined by Cohen (Cohen, 1988). At
.05 level of significance with an f-sq of .02 for each set for a combined effect of
.04, N = 383 for a power of .80.
Response rates from psychologists can be quite varied. In calculations
that included the possibility that each of 2 covariates would be controlled, a 7%
response rate of the initial 5,581 participants (which did not include the 415 from
CAPS who could not be checked for overlap, and the additional 5,435 emails
added following technical caveats) was needed for a power of .80 to detect small
effect sizes. In an attempt to increase participation, one $100 and one $50 cash
prize or donation to Hurricane Katrina victims was offered in a drawing from all
entries made from participating psychologists. The option of receiving a winning
amount in cash was also made. Perhaps more importantly, the utilization of the
internet in the collection of data for this study was viewed as being more
convenient than the use of long forms that may appear daunting and that require
return mailing. Response rates to similar research have been as low as 17%
(Gartner et. al, 1990), but also as high as 62% (Lewis & Lewis, 1985) and 67%
(Ragan et al., 1980) in similar research with paper mailings and no incentives.
130
Due to the convenience of internet accessibility, the addition of 5,435
potential participants added after the power analysis, and the monetary
incentives, it was believed that an adequate number of responses would be
received. Of the 8,361 direct email addresses that were used, 890 were returned
as “undeliverable” indicating an incorrect or outdated email address was
published at the time the addresses were collected, and 282 persons responded
that they were unlicensed, retired, or had Macintosh operating systems. It is
unknown how many of the remaining 7,189 were licensed psychologists that had
Windows Operating Systems and were therefore eligible for participation, so it is
difficult to estimate an accurate response rate from eligible participants. If the
assumption was made that they were all licensed psychologists, the response
rate was 5.3%. It is also notable that 632 participants began the study in the first
data collection website used, Survey Monkey (Finlay, R., 2007,
Surveymonkey.com), 546 completed it in that website, and 394 completed the
entire study including the IAT on the Inquisit website (Draine, S., 2006, Inquisit
www.inquisit.com), which presented the IAT that required that participants have
the Windows Operating System and which experienced technical difficulties
when the first invitations to participate were distributed. Twelve completed IAT
data-sets could not be matched to Survey Monkey data-sets by ID numbers, as
they were likely accessed from different computers at different times due to
technical problems, so they were eliminated from the final data-set. The final
number of usable data-sets was 382.
131
Measures
Batson’s Empathy Adjectives
In studying the dimensional components of empathy in altruistic versus
egoistic helping, Batson (1987) examined two distinct emotional reactions to
someone in distress, personal distress and empathy. While the two reactions
often occur together and both may have motivational consequences in helping
another, feelings of empathy are other-oriented feelings and personal distress is
self-oriented. Batson characterized empathy as a vicarious emotional response
to another in need, and that emotional responding is evoked when the perceiver
is able to adopt the perspective of the person in need. Batson operationalized
empathic emotions through the measurement of the empathy adjectives:
sympathetic, softhearted, moved, warm, compassionate, and tender. Participants
rated how strongly they were feeling each of six adjectives on a 7- point Likert
scale, with 1 representing “not at all” and 7 “extremely.”
In an examination across several studies with varying degrees and
dimensions of need situations, Batson reports highly consistent and robust
findings of the independent factor structure of the variables of personal distress
and empathy and support from the work of others which also report similar factor
structures (see Batson, 1987 for review). Factor loadings of .60 from “moved,
compassionate, warm, and softhearted” were found in all six studies examined,
and “sympathetic and tender” in four of five studies that used these adjectives.
132
Correlations between empathy adjectives ranged from .44 to .79 across studies.
Using the other-oriented dimension of empathy, Batson’s empathy adjectives
were used to measure the affective empathy responding to patients in vignettes.
Interpersonal Reactivity Index’s Perspective-Taking Scale
Also, one subscale from the Interpersonal Reactivity Index (IRI; Davis,
1994) is particularly salient to the nature of clinical work. The Perspective-Taking
subscale measures the tendency to adopt the psychological view of others. As
Batson’s adjectives of empathic vicarious responding are believed to arise from
the ability of one to take the perspective of the other, and the nature of
psychological work requires the ability to adopt the psychological view of the
other if one is to be able to work within the patient’s frame of reference, the
Perspective-Taking scale of the IRI will be used. Internal and test-retest reliability
of the IRI are adequate at .70 -.78, and .61- .81 over 2 months, respectively.
Good validity of the IRI is evidenced in the predicted relationships between the
subscales, convergent validity with other empathy measures, and indexes of
social competence, self-esteem, emotionality, and sensitivity (Davis, 1983).
However, the PT subscale items characterize one’s patterns of responding
to others as a dispositional trait. These items were slightly modified to evaluate
the responding of the participant to the patient in each vignette. While the scale
was intended to measure trait perspective taking, the wording of most of the
items lent themselves well to slight modifications. Two items relating to PT
133
behaviors in conflicts are not adaptable to the psychotherapy situation because
of the nature of the interactions in clinical settings, as opposed to social settings,
so they were not used. Those items are “If I’m sure I’m right about something, I
don’t waste much time listening to other people’s arguments,” and “when I’m
upset at someone, I usually try to ‘put myself in his shoes’ for a while.” However,
others such as “I sometimes find it difficult to see things from the ‘other guy’s’
point of view” are relevant to empathic perspective taking within the therapy
relationship and can be easily modified to “I find it difficult to see things from the
patient’s point of view.”
It is not known what effects the modifications would have on the IRI’s
demonstrated reliability or validity. However, the items maintain face validity and
it was believed that the scores would continue to reflect differences withinsubjects in perspective-taking empathy between vignettes. The participants were
asked to respond to five items on a 4-point Likert scale from 0 (does not describe
my current position/feelings with respect to this patient very well) to 4 (describes
my current position/feelings with respect to this patient very well).
Clinical Judgment Scale
Seven clinical judgment scale items borrowed from Graham (1980) were
used to evaluate clinician prognosis. Items included likelihood of clinician
selection for their therapy caseload, and patient likelihood of making substantial
progress measured on a 5-point Likert scale with 0 being least likely and 5 most
134
likely. Additional items measured severity of impairment, motivation for change,
capacity for insight, expectations about continuation of treatment, and likelihood
of making substantial progress, also measured on a 5-point Likert scale with
poorest predictions rated 0 and best predictions rated 5 for each item. There
were no published psychometric properties found for this assessment. One could
argue that the scale has good face validity; however, actual psychometric data
are lacking. As this study utilized a within-subject design, differences between
scores on similar vignettes were believed to be representative of difference in the
clinical judgment of prognosis of hypothetical patients in those vignettes.
Religious Attitude Scale
The Religious Attitude Scale (RAS; Armstrong, Larsen, & Mourer, 1962),
was used to measure participant attitudes toward specific Christian beliefs. The
scale identifies 16 core Christian religious concepts which are followed by three
definitions of each concept. Each definition represents an orthodox, conservative,
or a liberal position in relation to those beliefs. Scores on each of the dimensions
are converted into one continuous score ranging from most orthodox to most
liberal. RAS authors discuss that they conceptualize these positions in a
continuous, rather than categorical manner, although they do not use empirical
support for this position. This conceptualization is consistent with the goal in this
study of assessing potential bias in a group most divergent (in this case most
liberal) from the Evangelical Christian patient.
135
Participants were instructed to select the descriptive phrase for the term
that best describes his or her attitude or behavior in relation to the term. A
sample item includes the Virgin Mary as defined by: a.) Mother of Jesus (C), b)
supposedly the mother of a prophet (L), or c) blessed mother of God (O).
Authors of the scale understood each position to characterize Catholic,
Protestant, and Unitarian positions respectively and standardization was done on
participants who self-identified with those denominational links. Although some
persons in the sample from each of the identified groups reported not agreeing
with some definitions within their category, authors believe this to be an expected
occurrence due to some diversity in religious concepts among groups. However,
in terms of scale validity, authors argue that the distinction between group scores
indicates discrete differences between the groups’ definitions of Christian
concepts.
Test-retest reliability for the scale in a group of 71 nonpsychiatric
participants was .98. The test was normed on 121 participants with mean scores
for the orthodox position 139.50, the conservative position 105.95, and the liberal
position 13.48. Test-retest reliability for concepts within religious groups was .73
for the group of 27 Catholics, .67 among 25 Protestants, and .48 among the 19
Unitarians. Inter-test reliability was .66 among Catholics, .61 among Protestants,
and .72 among Unitarians. Because high scores on the RAS indicate higher
levels of conservatism or orthodoxy and positive correlations were predicted
between more religiously liberal attitudes and bias, all items were reverse scored.
136
Implicit Association Test
The Implicit Association Test (IAT) was used to assess the strength of
implicit associations that indicate existing stereotypic evaluations of the group of
ECs. Specifically, it assessed the strength of participants’ automatic associations
of “Evangelical Christian” (EC) or “Secular or No Religion” (SNR) with words
clearly valenced in terms of pleasantness or unpleasantness, and stimulus
concepts which are presumed to be associated with either group. SNR was
chosen as study vignettes specifically do not mention religion of patients other
than the EC, and the purpose of the study was not to assess attitudes relative to
other religions.
The administration of the IAT in this study, utilized guidelines in the
literature that were established following the investigation of the effects of
variability in the usage and administration of the IAT in over 120 studies (Nosek,
Greenwald, & Banaji, 2005). Positively valenced terms included Marvelous,
Peace, Pleasure, Beautiful, Joyful, Laughter, Lovely, and Wonderful and Happy,
and negatively valenced terms included Tragic, Failure, Agony, Painful, Terrible,
Awful, Hurt, and Nasty. Associations between concepts that may commonly be
associated with EC versus SNR were used in the practice trial blocks for the
purposes of learning the concept dimension. EC concepts included Evangelist,
Religious, Conservative, Traditional, Clergy, Minister, Christ, and SNR concepts
included Activist, Liberal, Atheist, Progressive, Scientist, Agnostic, and Humanist.
137
Procedures and instructions followed Nosek et al.’s (2005) IAT
recommended procedures. Participants proceeded through five blocks of
responding to provide data. Participants were instructed to respond as quickly as
possible while attempting to minimize errors. In the first step, participants
practiced sorting items from the different concepts into superordinate categories,
(e.g., clergy for the EC category and scientist for the SNR category) by using key
presses, either “E” or “I” with left or right middle finger respectively on computer
keyboards. In step 2, the participants learned how to sort the valenced words
according to “Good” or “Bad” categories (e.g., joy for Good and horrible for Bad)
using the same keys. In step 3, sorting tasks were combined so that participants
were alternately categorizing either a stimulus concept or valenced word to either
the EC or Good group or the SNR and Bad group. During this trial for example,
one key was the correct response for EC and Good words, and one key was the
correct response for SNR and Bad words. The order of presentation of learning
blocks was varied by participant order such that one participant was presented
with a learning block that was configured with EC /Good categories combined
first, and the next participant practiced the SNR/Good categories first.
A practice block of 20 trials was completed followed by a brief pause, and
then a second block of 40 trials, referred to as the critical block, was presented.
In step 4, the key assignment was reversed and only stimulus concepts were
sorted into the two target categories (e.g., Minister for EC, Scientist for SNR). In
step 5, the participants sorted valenced word items and stimulus concepts again,
but to a reverse combination of target groups (EC and Bad group, or SNR and
138
Good group). Participants again sorted items into appropriate categories for 20
practice trials and then 40 critical trials. The latencies in the IAT are measured by
calculating the average latency in responding between the two sorting conditions
(steps 3 and 5).
Reviews of the IAT indicate there is good evidence for convergent and
discriminant validity (Nosek, Greenwald, & Banaji, 2005; Greenwald & Nosek,
2001) as well as large effect sizes (Greenwald & Nosek, 2001). Frequent weak
correlations with self-report measures (Greenwald et al., 1998) indicate that the
IAT assesses constructs that are often, but not always (Fazio & Olson, 2003),
distinctive from those assessed in explicit self-report measures. Greenwald and
Nosek (2001) reports test-retest reliability of the IAT averages > .6 and an
internal consistency average of α > .80 (see Greenwald & Nosek, 2001 for
review).
Motivation to Control Prejudice Reactions Scale
Dunton and Fazio’s (Dunton & Fazio, 1997) Motivation to Control
Prejudiced Reactions (MCPR) subscale of Concern With Acting Prejudiced, the
subscale which has demonstrated moderating effects of racial prejudice following
a priming technique (Dunton & Fazio, 1997) was modified for use with religious
patients. The subscale is a nine-item scale that asks participants to indicate the
extent to which they agree or disagree with statements about concern with acting
prejudiced. Participant responses are indicated on a 7- point Likert scale, ranging
139
from -3 (strongly disagree) to +3 (strongly agree). Fazio et al. (1995) found that
the measure predicted scores on the Modern Racism Scale and Dunton and
Fazio (1997) reported further evidence for validity by predicting self-reported
negative attitudes when motivation to control prejudiced reactions was low. High
scores on Dunton and Fazio’s MCPR Scale (1997) indicate higher levels of
MCPR. While the scale measures both external and internal reasons to respond
without prejudice, the current interest is in how much motivation one has as a
moderator to INA, not the origin of that motivation.
Marlowe Crowne Social Desirability Scale-Short Form
The Marlowe Crowne Social Desirability Scale (MCSDS; Crowne &
Marlowe, 1960) has proven useful in controlling for social desirability in research
using self-report measures with clinicians (Constantine & Ladany, 2000; Fuertes
& Brobst, 2002). The MCSDS (Crowne & Marlowe, 1960) is a 33-item true-false
measure which has been used extensively in the literature and is a primary social
desirability measure used at this time. The Marlowe Crowne Social Desirabilityshort form, or the MC-Form C (Reynolds, 1982) was used to measure tendencies
to respond in a socially desirable manner. The MC-Form C developed by
Reynolds (1982) is a 13-item form with a reliability level of .76 which compares
favorably with the reliability of the standard form. The short form validity is
demonstrated in item factor loading, concurrent validation with the Edwards
Social Desirability Scale and total score correlations with the standard MCSDS.
140
Social Desirability was measured using the MC-Form C for the purposes of
detecting its effect on explicit responding in this study.
Religious Conservatism Scale
Lastly, religious conservatism (RC) was measured using three Likert scale
items that assess degree of devoutness about religious beliefs, following
religious traditions or practices, and attempts to live one’s life according to
religious scriptures or teachings. It was hypothesized that conservative persons
of religions other than Christianity may not exhibit bias toward conservative
Christians due to the commonality of their conservative approach to their religion,
such that they may not be considered an out-group. This scale was author
generated and as such, no psychometric properties for this measure are
available. Items required that participants respond to inquiries about their degree
of devoutness in each of three domains: religious beliefs, following religious
traditions or practices, and attempts to live life according to religious scriptures or
teachings. As the items asked participants to respond directly to items about their
adherence to traditional beliefs and behaviors, the measure was presumed to
have face validity.
Procedure
141
Materials that were distributed to psychologists including the vignettes and
measures for those who chose to participate, are contained in Appendix A.
Psychologists were first emailed an invitation to participate in the study, which
was described as a study investigating clinical judgments. Participants were
offered chances to win a $50 or a $100 donation to the American Red Cross’s
Hurricane Recovery Program, a charitable organization of their choice, or cash
prizes in those amounts, with winners selected in a drawing of all participants at
the study’s end. A timed trial of the study revealed the time needed to participate
in the study is approximately 25 minutes, which was disclosed to participants in
the informed consent.
Those who chose to participate in the study were instructed to click on a
website link to Survey Monkey, the first of two data collection websites that was
provided in the invitation email. The link took each participant to the front page of
the study which consisted of an electronic informed consent page. Following
participant agreement to consent terms, including the requirement that they use a
Windows Operating System to complete the last portion of the study, he or she
then entered the study by clicking on another link.
The first task was vignette evaluation. Participants were given instructions
that “It is understood that some of the information presented in the vignettes is
ambiguous, and information required for accurate clinical judgment is lacking.
Due to the fact that this study requires the use of brief vignettes, it is acceptable
and expected that you project a hypothesis about each patient based on all
pieces of information given, ambiguous or otherwise.” Participants were then
142
asked to read two brief vignettes of patients presenting with the same number of
anxiety symptoms of Generalized Anxiety Disorder. In one of these vignettes, the
patient was described as an Evangelical Christian with some discussion of the
salience of his participation in religious activities. In the second vignette, the
patient’s volunteer activities were described, with some follow-up discussion of
the salience of those activities that were comparable to those described for the
Evangelical Christian vignette patient. Order effects for the presentation of each
vignette were controlled by alternating the order of presentation midway through
the study. Conditions were counterbalanced for the relevant conditions only, with
symptoms remaining constant across each condition.
Participants then responded to empathy and prognostic measures for
each vignette. Then the religious beliefs and attitudes, social desirability,
motivation to control prejudiced reactions, and devoutness measures were
administered. After completing these tasks, respondents were asked background
questions including sex, age, education, geographic region, professional degree,
years in clinical practice, and religious affiliation. Finally, participants were then
directed to the IAT.
Results
Descriptive Statistics
143
Prior to examining my data, I prepared it for analysis by creating a code
book, and exploring and cleaning the data. The study did not accept missing
responses, so missing values were not present. Table 1 shows descriptive
statistics for the sample background and demographic characteristics.
The majority of the respondents (60.5%) were female. The respondents had a
broad range of ages, with the 51- to 55- year old group (21.7%) and the 56- to
60- year old group (19.1%) being the largest. Over three-quarters of the
respondents (78.0%) had obtained a doctorate in clinical psychology, with an
additional 12.6% having a doctorate in counseling psychology. The West (32.2%)
and the Northeast (29.8%) were the most common of the eight geographic
regions, and most of the respondents (81.7%) came from urban locations. The
respondents had a broad range of years of clinical experience, with 21-30 years
(25.7%) and 16-20 years (15.7%) as the most common levels of experience.
Only 3.1% of the respondents had fewer than three years of experience, and only
2.6% had 40 or more years of experience. The most common religious affiliations
were Protestant (non-Evangelical; 25.4%), followed by Jewish (18.6%), and
Catholic (14.1%). A substantial percentage of respondents (20.9%) indicated that
they had no religious affiliation (none/Atheist/Agnostic), and 10.7% indicated that
they had a religious affiliation not listed among the seven specific choices.
Table 1
Sample Demographic and Background Characteristics (N=382)
Frequency
Percentage
144
Gender
Male
151
39.5
Female
231
60.5
20-29
10
2.6
30-35
24
6.3
36-40
33
8.6
41-45
42
11.0
46-50
50
13.1
51-55
83
21.7
56-60
73
19.1
61-65
43
11.3
66+
24
6.3
Doctorate Clinical Psychology
298
78.0
Doctorate Counseling Psychology
48
12.6
Doctorate Education or Related
10
2.6
Other
26
6.8
Northeast
114
29.8
Southeast
22
5.8
North
0
0.0
Age
Education
Geographic Region
145
Frequency
Percentage
Midwest
45
11.8
South
22
5.8
Northwest
9
2.4
Southwest
47
12.3
West
123
32.2
Rural
70
18.3
Urban
312
81.7
1-2
12
3.1
3-5
38
9.9
6-10
57
14.9
11-15
57
14.9
16-20
60
15.7
21-30
98
25.7
31-40
50
13.1
40+
10
2.6
Buddhist
17
4.5
Catholic
54
14.1
Evangelical
20
5.2
Primary Location
Years in Clinical Practice
Religious Affiliation
146
Frequency
Percentage
Protestant (non-Evangelical)
97
25.4
Hindu
0
0.0
Jewish
71
18.6
Muslim
2
.5
None/Atheist/Agnostic
80
20.9
Other
41
10.7
Table 2 provides descriptive statistics for the measures used. Of primary
interest in this table are the reliability coefficients. The affective empathy scores
(from the Batson scale) had high reliability, with values of .90 for both Evangelical
Christian (EC) and No Mention of Religion (NMR) vignette patients. For the
cognitive empathy scores (from the Interpersonal Reactivity Index), the
reliabilities were lower but still adequate at .73 for both EC and NMR. Initially, the
reliability of the prognosis scales was only .52 (for EC) and .50 (for NMR).
Further examination revealed that Item 7 in the scale lowered reliability. There
was a strong negative correlation (-.50) between Item 7 (which is reverse
scored), and Item 8. When Item 7 is removed, the reliability coefficients
increased to .64 (for EC) and .58 (for NMR). Examining Item 7 indicates that
respondents may not have interpreted this question in the intended manner as
will be explored in the discussion section of this study. While the coefficients of
.64 and .58 are still lower than would be desired, they were deemed adequate to
147
include the prognosis scales in the hypothesis tests. For the motivation to control
prejudice reactions scale, the reliability was .73 and for social desirability scores
(from the MAC-Form C) the reliability was .76. The religiously liberal attitudes in
relation to Christian beliefs (.91) and the religious conservatism scale (.93) both
had high reliability coefficients.
148
Table 2
Descriptive Statistics for Composite Measures (N=382)
Min.
Max.
M
SD
Α
Affective Empathy EC
6
42
24.62
6.91
.90
Affective Empathy NMR
6
42
25.01
6.84
.90
Cognitive Empathy EC
7
20
15.78
3.34
.73
Cognitive Empathy NMR
8
20
16.20
3.08
.73
Prognosis Vignette EC1
14
32
25.15
3.45
.64
Prognosis Vignette NMR1
15
33
25.86
3.02
.58
Motivation to Control Prejudice
Reactions
34
89
58.60
10.40
.73
Social Desirability
0
13
4.49
2.95
.76
RLACB
0
31
18.25
7.99
.91
Religious Conservatism
3
12
7.21
3.09
.93
Compatible Test
161
3193
1242.21 402.76
Incompatible Test
572
2218
1170.28 315.48
-1240
2213
Implicate Negative Association
1
71.93
430.76
Without Item 7 as discussed in the text.
Preliminary Analyses
Several preliminary analyses were run prior to examining the hypotheses.
Distributions were checked to make sure that the data conformed to normality
149
assumptions of the test. Figures A1 through A8 in Appendix B display the
frequency distributions with superimposed normal distributions for social
desirability, religious conservatism, religiously liberal attitudes toward Christian
beliefs, NMR-EC affective empathy, NMR-EC cognitive empathy, NMR-EC
prognosis, implicit negative associations, and motivation to control prejudice
scores. No outliers were found.
Table 3 contains the normality statistics of each measure. Religious
conservatism and religiously liberal attitudes in relation to Christian beliefs
(RLACB) scores were somewhat negatively kurtotic, and NMR-EC affective
empathy scores were somewhat positively kurtotic. However, no transformations
were performed because the sample size is large (N=382), providing robustness
against violations of normality assumptions. Also, skewness is generally
considered more problematic than kurtosis (Tabachnick & Fidel, 1996).
Additionally, while the skewness value for several variables was statistically
significant (i.e., when divided by the standard error of skewness exceeds 2), this
is primarily due to the large sample size in the current study (and therefore the
small standard errors). The largest value of skewness is .48, and values in this
range do not pose a problem for the statistical methods employed in this study,
particularly given the large sample size.
150
Table 3
Normality Statistics for Variables Used in Hypothesis Tests (N=382)
Skewness
SESkewness
Kurtosis
SEKurtosis
Social Desirability
.48
.12
-.49
.25
Religious Conservatism
-.03
.12
-1.28
.25
RLACB
-.48
.12
-1.01
.25
NMR-EC Affective Empathy
Difference
.44
.12
4.61
.25
NMR-EC Cognitive Empathy
Difference
.11
.12
-.21
.25
NMR-EC Prognosis Difference
.07
.12
2.06
.25
Implicit Negative Association
.43
.12
2.37
.25
Motivation to Control Prejudice
Reactions
.18
.12
-.39
.25
Regression assumptions of homoscedasticity and the normality of
residuals within each regression were examined and are contained in Appendix
C which shows residual histograms (designed to test the assumption of the
normality of residuals) and residual equality scatterplots (designed to test the
assumption of homoscedasticity). In each figure, the regression residuals were
normally distributed and the assumption of homoscedasticity was approximated.
It was determined that the untransformed scores were adequate.
Table 4 contains the correlations among the eight key variables in this
study. Some of these correlations will be discussed in relation to specific
151
hypothesis tests; however, several will also be discussed here. First, the first
column of Table 4 shows that social desirability scores were not significantly
correlated with any of the other variables in the study. Therefore, social
desirability will be excluded as a covariate from all subsequent analyses.
Second, the correlation between religiously liberal attitudes in relation to
Christian beliefs and religious conservatism was very high (r=-.66, p<.001). As
the intent was to control for conservatism in religions other than Christian
religions, the high correlation between religious conservatism and high Religious
Attitude Scale (RAS) scores indicates that the religious conservatism scale
captures the same conservatism measured in the RAS, Christian conservatism.
Therefore, whatever variance conservatism might explain, RAS already explains.
In addition to being redundant, controlling for conservatism will significantly
reduce the ability of RAS scores to explain variance. Therefore, neither social
desirability nor religious conservatism will be included as covariates in the
hypothesis tests. Finally, the remainder of the correlation matrix shows that the
main independent, dependent, and moderator variables have correlations
ranging from -.06 to .51, indicating that multicollinearity is not a problem in this
study.
152
Table 4
Correlations among Variables Used in Hypothesis Tests (N=382)
1.
2.
3.
4.
5.
6.
1. Social
Desirability
1.00
2. Religious
Conservatism
.05
1.00
3. RLACB
.03
.66***
4. NMR-EC
Affective Empathy
Difference
.04
.19***
.18***
5. NMR-EC
Cognitive
Empathy
Difference
.02
-.16** .18*** .33***
6. NMR-EC
Prognosis
Difference
.03
-.13** .18*** .37*** .20***
1.00
7. Implicit
Negative
Association
-.02
.51***
.35***
8. Motivation to
Control Prejudice
Reactions
-.05
.12*
7.
8.
1.00
-.06
1.00
1.00
.06
.09
.12*
1.00
.07
.01
.06
-.04
1.00
*p<.05; **p<.01; ***p<.001
A final set of preliminary analyses was performed to determine if there
were differences on the key variables for this study based on the order of
presentation of the vignettes. Specifically, 240 of the participants viewed the
153
NMR vignette first and 142 viewed the EC vignette first, and if the order of
presentation resulted in differences in scores, controlling for order of presentation
would be necessary. Six independent samples t-tests were performed to
compare the two groups. Results showed no statistically significant difference for
RLACB (t(380)=-.72, p=.474), NMR-EC affective empathy differences (t(380)=1.45, p=.149), NMR-EC cognitive empathy differences (t(380)=-1.42, p=.156),
NMR-EC prognosis differences (t(380)=1.36, p=.176), Implicit Negative
Association (INA) scores (t(380)=-.15, p=.882), or Motivation to Control Prejudice
Reactions (MCPR) scores (t(380)=-1.08, p=.282). Therefore, there was no need
to control for order of presentation in the hypothesis tests.
Hypotheses Analyses
In the first hypothesis, the independent variable was Religiously Liberal
Attitudes in relation to Christian Beliefs (RLACB) as measured by the RAS, and
the dependent variable was Empathy. Empathy was measured by both the
Perspective-Taking (PT) subscale of the Interpersonal Reactivity Index (IRI) and
Batson’s empathy adjectives for each vignette, where difference refers to EC
empathy scores subtracted from NMR empathy scores. Therefore analyses were
performed separately for the affective empathy difference and the cognitive
empathy difference. The results of the regression analysis with the NMR-EC
affective empathy score as the dependent variable are shown in Table 5. Overall,
RLACB scores explained 4% of the variance in the NMR-EC affective empathy
154
difference score, which was statistically significant, F(1,380)=14.38, p<.001. The
positive regression coefficient for RLACB (β=.19, p<.001) indicates that more
RLACB corresponded to larger NMR-EC affective empathy differences. This
indicates that individuals who had more religiously liberal attitudes in relation to
Christian beliefs tended to have more affective empathy toward the patient in the
NMR vignette than toward the patient in the EC vignette.
Table 5
Regression of Differences in Affective Empathy on Religiously Liberal Attitudes
in relation to Christian Beliefs: Hypothesis 1, (N=382)
Constant
B
SEB
-1.22
.46
.09
.02
RLACB
β
.19
t
p
-2.63
.009
3.79
<.001
Note. R2=.04, F(1,380)=14.38, p<.001.
Table 6 shows the results of the regression analysis with the NMR-EC
cognitive empathy scores as the dependent variable. RLACB scores explained
3% of the variance in the NMR-EC cognitive empathy difference, which was
statistically significant, F(1,380)=12.55, p<.001. Again, RLACB had a positive
regression coefficient (β=.18, p<.001), indicating that those with more liberal
attitudes in relation to Christian beliefs tended to have more cognitive empathy
toward NMRs than toward ECs.
155
Table 6
Regression of Differences in Cognitive Empathy on Religiously Liberal Attitudes
in relation to Christian Beliefs: Hypothesis 1, (N=382)
Constant
B
SEB
-11.16
.85
.15
.04
RLACB
β
.18
t
p
-13.20
<.001
3.54
<.001
Note. R2=.03, F(1,380)=12.55, p<.001.
In the second hypothesis, RLACB was the independent variable and
prognosis was the dependent variable as measured on the clinical judgment
scale for each vignette. The difference in prognosis was determined by EC
prognosis scores subtracted from NRM prognosis scores. Table 7 shows the
results of the regression analysis with NRM-EC prognosis difference scores as
the dependent variable. RLACB scores explained 3% of the variance in NRM-EC
difference scores, and this was statistically significant, F(1,380)=12.27, p<.001.
Three percent of the variance explained is quite small, and it is likely that it was
found due to the power of the study and its large sample size. As with the
empathy scores, the regression coefficient for prognosis differences was positive
(β=.18, p<.001), indicating that the participants perceived a more positive
prognosis for the patient described in the NMR vignette than the patient
described in the EC vignette.
156
Table 7
Regression of Differences in Prognosis on Liberal Attitudes in relation to
Christian Beliefs: Hypothesis 2, (N=382)
B
SEB
Constant
-.50
.38
RLACB
.07
.02
β
.18
t
P
-1.32
.187
3.50
<.001
Note. R2=.03, F(1,380)=12.27, p<.001.
The third hypothesis was that RLACB was positively associated with INA.
Table 8 shows the results of the regression analysis with RLACB scores as
predictors of INA scores. RLACB scores explained 26% of the variance in INA
scores, and this was statistically significant, F(1,380)=131.66, p<.001. RLACB
had a positive regression coefficient (β=.51, p<.001), indicating that those with
more liberal attitudes in relation to Christian beliefs tended to have higher INA
scores, that is, they tended to have stronger implicit negative associations toward
ECs compared to those in the Secular or No Religion (SNR) category.
157
Table 8
Regression of Differences in INA associated with Religiously Liberal Attitudes in
relation to Christian Beliefs: Hypothesis 3 (N=382)
Constant
RLACB
B
SEB
-427.29
47.48
27.36
2.38
β
.51
t
p
-9.00
<.001
11.47
<.001
Note. R2=.26, F(1,380)=131.66, p<.001.
The fourth hypothesis predicted that MCPR will moderate the effect of INA
on empathy such that as MCPR increases, INA will be less related to empathy
differences. As is recommended by Baron and Kenny (1986), two regressions
were run. Also, following procedures for examining moderation in multiple
regression analyses (e.g., Aiken & West, 1991, p. 9), the predictor variables (INA
and MCPR) were centered prior to computing the interaction (product) term, so
that the variables were less correlated, therefore reducing multicollinearity. In the
first block of the regression analysis, the effects of INA and MCPR were entered
as predictors, and in the second block the centered product between INA and
MCPR was entered as a predictor.
The results of the regression analysis with NMR-EC affective empathy
differences as the dependent variable are shown in Table 9. In Block 1 of the
analysis, only 1% of the variance in the NMR-EC affective empathy difference
score was explained, and this was not statistically significant, F(2,379)=1.69,
158
p=.186. This indicates that INA is not related to affective empathy expressed
between groups. In Block 2, the change in R2 with the addition of the interaction
term was .00, and this was not statistically significant, F(1,378)=.98, p=.322. The
regression indicates that the inclusion of the product term in Block 2 of the model
did not result in an increase in prediction, and therefore it is concluded that
MCPR does not moderate the relationship between INA and NMR-EC affective
empathy difference scores.
159
Table 9
Regression of Affective Empathy Differences with NMR-EC with Motivation to
Control Prejudice Reactions as a moderator on Liberality of Attitudes in relation
to Christian Beliefs: Hypothesis 4, (N=382)
B
SEB
Constant
.39
.19
INA
.00
.00
MCPR
.03
.02
Constant
.40
.19
INA
.00
.00
MCPR
.03
INA x MCPR
.00
Β
T
p
2.09
.038
.06
1.16
.248
.08
1.47
.142
2.12
.035
.07
1.30
.195
.02
.08
1.52
.129
.00
.05
.99
.322
Block 1
Block 2
Note. Block 1 R2=.01, F(2,379)=1.69, p=.186; Block 2 Change R2=.00,
F(1,378)=.98, p=.322.
The results of the regression analysis with NMR-EC cognitive empathy
differences as the dependent variable are shown in Table 10. In Block 1, only 1%
of the variance in NMR-EC cognitive empathy differences was explained, and
this was not statistically significant, F(2,379)=1.64, p=.196, indicating that
cognitive empathy was not related to INA. The addition of the product term in
Block 2 increased the variance explained by 1%, but again this was not
statistically significant, F(1,378)=3.39, p=.067. Therefore, we can conclude that
160
MCPR does not moderate the relationship between INA and the NMR-EC
cognitive empathy difference scores. It should also be noted that INA did become
statistically significant in Block 2 (β=.11, p=.039), indicating that higher INA
scores were associated with greater NMR-EC cognitive empathy differences (i.e.,
those with implicit negative associations regarding ECs relative to NMRs showed
slightly more cognitive empathy toward NMRs relative to ECs). The regression
coefficient (.11) was similar to the correlation between these measures (.09) in
Table 4, although the bivariate correlation did not reach the level of statistical
significance.
161
Table 10
Regression of Cognitive Empathy Differences with NMR-EC with Motivation to
Control Prejudice Reactions as a moderator on Liberality of Attitudes in relation
to Christian Beliefs: Hypothesis 4, (N=382)
B
SEB
-8.42
.34
INA
.00
.00
MCPR
.01
.03
-8.39
.34
INA
.00
.00
MCPR
.01
INA x MCPR
.00
β
t
p
-24.52
<.001
.09
1.79
.074
.02
.32
.750
-24.51
<.001
.11
2.07
.039
.03
.02
.42
.677
.00
.10
1.84
.067
Block 1
Constant
Block 2
Constant
Note. Block 1 R2=.01, F(2,379)=1.64, p=.196; Block 2 Change R2=.01,
F(1,378)=3.39, p=.067.
The fifth hypothesis was that MCPR will moderate the effect of INA on
prognosis expressed for ECs versus NMRs, such that as MCPR increases, INA
will be less related to the prognosis difference. Table 11 shows the results of the
regression analysis performed to test this hypothesis. In Block 1, 2% of the
variance in NMR-EC prognosis differences was explained, and this was
statistically significant, F(2,379)=3.57, p=.029. The regression coefficients in
162
Table 11 indicate that INA was statistically significant as a predictor of NMR-EC
prognosis differences (β=.12, p=.017), with the positive regression coefficient
indicating that those with higher INA scores (i.e., those with a positive perception
of NMRs relative to ECs) also tended to have greater NMR-EC prognosis
differences (i.e., more positive perceptions of the prognosis for NMRs versus
ECs). When the interaction term was entered in Block 2, the change in variance
explained was 0%, which was not statistically significant, F(1,378)=.14, p=.711.
This indicates that MCPR did not moderate the relationship between INA and the
NMR-EC difference score.
163
Table 11
Regression of Prognosis Differences with NMR-EC with Motivation to Control
Prejudice Responding as a moderator on Liberality of Attitudes in relation to
Christian Beliefs: Hypothesis 5, (N=382)
B
SEB
Constant
.71
.15
INA
.00
.00
MCPR
.02
.01
Constant
.72
.15
INA
.00
.00
MCPR
.02
INA x MCPR
.00
β
t
p
4.67
<.001
.12
2.40
.017
.06
1.27
.204
4.68
<.001
.13
2.42
.016
.01
.07
1.29
.198
.00
.02
.37
.711
Block 1
Block 2
Note. Block 1 R2=.02, F(2,379)=3.57, p=.029; Block 2 Change R2=.00,
F(1,378)=.14, p=.711.
Summary of Results
Hypothesis 1 was supported by the data. For both affective and cognitive
empathy, there was significantly less empathy expressed in relation to the
Evangelical patient relative to the patient whose religion was not mentioned.
Hypothesis 2 was also supported. There was a significantly poorer prognosis
164
expressed in relation to the Evanglical patient relative to the patient whose
religion was not mentioned. Using the IAT, a timed measure designed to detect
attitudes of participants without giving them the opportunity to censor biased
responding, Hypothesis 3 was also supported. Those clinicians with more liberal
attitudes in relation to Christian beliefs demonstrated stronger negative
associations toward the Evangelical Christian target group than the Secular or
No Religion target on the IAT. Hypotheses 4 and 5 were not supported in this
study. Participants’ motivation to control prejudice responding had no moderating
effect on implicit responding to the Christian target group in relation to explicit
responding to vignette patients on empathy and prognosis measures.
Discussion
This study examined whether clinicians with more religiously liberal
attitudes in relation to Christian beliefs responded differently to an Evangelical
Christian vignette patient than to a vignette patient whose religion was not
mentioned, and whether they responded with more negative associations to
Evangelical Christian targets than to Secular or No Religion targets on an implicit
measure. The difference between the religiosity of psychologists and the general
public has been referred to as the religiosity gap (Richards & Bergin, 2000).
Seventy-six percent of the population endorsed Judeo-Christian affiliations of
Protestant, Catholic, Jewish, Orthodox, and Mormon recently (Gallup, 2006), and
in this study, 63.3% of psychologists endorsed Judeo-Christian categories. The
165
difference is notable, but markedly different from previous research in which 43%
endorsed these affiliations (Bilgrave & Deluty, 1998). It is likely that this study
yielded a higher percentage of psychologists with Judeo-Christian affiliations as a
result of efforts to balance the religious backgrounds of participants by recruiting
participants from organizations like the Christian Association for Psychological
Studies, and the American Psychological Association’s Division of the
Psychology of Religion. Nevertheless, distinct differences in the Evangelical
category are noted in that only 5.2% of psychologists endorsed this affiliation in
this study compared to estimates of 22% of the general public (Gallup, 2005).
The results of this study revealed that religiously liberal clinicians’ empathy
for, and prognosis for, patients who are described as Evangelical Christian is
significantly different than for patients whose religion is not mentioned. This
finding of religious bias extends the clinical religious bias literature to date.
Particularly, it is significant in that this study controlled for problematic
methodology and design in other research that did not find bias (e.g., Houts &
Graham, 1986; Lewis & Lewis, 1985; Reed, 1992; Wadsworth & Checketts,
1980). These problems include the use of dichotomous or categorical religious
group assignments of participants, social desirability effects in particular related
to the exclusive use of self-report measures of bias, between-subjects design,
small sample sizes, and samples largely derived from rural areas in which
religiously conservative persons might not be considered dissimilar, or as
members of an outgroup.
166
First, as discussed in the review of religious bias literature, previous
studies that did not find bias were often conducted in rural areas in which
religious persons may not be considered an out-group. As we have seen,
stereotyping has been consistently demonstrated in the literature with members
of out-groups. A national population of psychologists from a broad geographic
area was solicited for participation in this study to control for that potential
problem and to increase generalizability of findings. This sample consisted of
psychologists from all geographic regions; however, a large portion of
participants indicated they were from urban areas. Stereotyping of this group
may be more common in urban areas, in which one might assume religiously
conservative persons might be considered part of a more distinct out-group.
Also, social desirability and transparency, which may have been
problematic in other studies, were addressed in this study in several ways. First,
social desirability was assessed for potential use as a covariate. However, it did
not correlate with other variables in this study and so it was not used as a
covariate. It is interesting that bias was detected without having to control for
social desirability in this study, despite that it is reasonable to expect that its
effects may impact results in any bias or stereotyping studies. However, it may
not have been necessary to control for social desirability here for several
reasons. First, efforts to conceal variables of interest in bias research, unless
successfully executed, may inadvertently contribute to an increase in socially
desirable responding. In other words, the implication of covert attempts to
uncover information about participants could cue the participant that there may
167
be a variable of interest that some might consider worth concealing. However,
projections about ambiguous information, often presented in preliminary
therapeutic work with patients, are likely to be common as clinicians form their
initial impressions about new patients with limited information. In this study,
attempts were made to normalize that process prior to the presentation of the
vignettes so that evaluations could more closely approximate a natural
therapeutic setting. So, it may not have been as desirable to conceal projections
of expectations about vignette patients in this study.
Also, liberality of clinician religiousness in relation to Christian beliefs was
the independent variable in this study, rather than self-report of religious
affiliation, or self-designation to dichotomous groups such as religious versus
nonreligious, which may not be an adequate method of group assignment since
group affiliation does not describe religiosity or religious beliefs or values in many
cases. Results indicate that religiously liberal clinicians in this sample are biased
against religiously conservative Christian groups or group members, and are less
likely to conceal their bias due to social desirability than those who merely
identify membership or affiliation with a particular religious group.
Further, the IAT was used to reduce reactive and censoring elements
employed in the expression of bias. A correlation between clinician religious
liberality and automatic negative associations was found, indicating that
religiously liberal clinicians have some bias against the Evangelical Christian
group. In particular, negative associations about Evangelicals predicted a poorer
prognosis for the Evangelical patient compared to the patient whose religion was
168
not mentioned. In light of this finding, and that differences were found in the selfreport expressed empathy in relation to the vignettes, it is interesting that
negative associations with the Evangelical target did not predict differences in
affective empathic responding to the hypothetical Evangelical patient. The reason
for this finding is unclear. While the stereotyping literature has examined
cognitive evaluations of targets as well as affective responding to targets, a
preponderance of the literature did not yield data about the relationship between
the two variables that would assist in clarifying this finding, nor did it offer any
explanations in relation to the interaction of affective and cognitive empathy. It
may be that something about the ability to express affective empathy toward
Evangelical Christian patients is different than the general evaluative valence that
clinicians associate with Evangelical Christians in general. It may also be that for
those clinicians whose automatic negative associations were related to poorer
prognosis for, and less cognitive affect with, Evangelical patients, there were
some strong negative stereotypic beliefs which are unrelated to the ability to
have affective empathy for the Evangelical patient.
However, it should be noted that it is likely that flawed logic was used in
the manner in which this study attempted to control for clinician religious
conservatism. Because conservatism was so highly correlated with endorsement
of Christian beliefs, removing the effects of conservatism would also likely have
eliminated the ability of scores on the religious attitude scale to explain any
difference in either the implicit or the explicit measures. So conservatism was not
controlled in this study.
169
Overall, these results have significant implications for patients who are
religiously dissimilar to clinicians. If clinicians estimate a poorer prognosis for
patients based on religious group as they did in this study, it may be because
they presume that pathology exists that is more severe than would be estimated
for comparable patients from other religious groups, or from those with no
religious affiliation. The literature does not support a correlation between
religiosity and poor mental health. In fact, religiosity is associated with lower
levels of depression (Smith, McCullough, & Poll, 2003), anxiety (Bergin, Masters,
& Richards, 1987), positive religious coping with chronic pain (see Rippentrop,
2005 for review), and rehabilitation efforts (Kilpatrick & McCullough, 1999). A
comprehensive review indicated that those with devout internally motivated
religiousness and participation in religious activities such as prayer, scripture
reading, and attendance at church or synagogue are associated with increased
mental health including lower rates of anxiety, depression, suicidality, less death
anxiety, substance abuse, and higher life satisfaction, self-esteem, greater well
being, happiness, adjustment, social support, internal locus of control and marital
adjustment and satisfaction, and quicker recovery from depression (see Koenig,
1997, pp. 101-102).
Cognitive appraisals of religious patients as more mentally ill than their
nonreligious counterparts can affect initial impressions of the patient, liking of the
patient, the ease with which a patient may feel free to express him- or herself,
and the clinician’s assessment of the patient’s potential for change. There are
several ways this can impact the patient including therapist satisfaction with
170
patient progress, perception of patient satisfaction, and type of termination
(Brown, 1970). Additionally, expectations that are based on stereotyped
information have been associated with effects on information processing and
judgments, information seeking and hypothesis testing, and interpersonal
behavior via self-fulfilling prophecies (Hamilton et al., 1990). Clearly, clinicians
may not be impervious to these effects and may adjust their clinical approaches
accordingly.
Last, if the patient’s religiosity or associated values are determined to be a
contributor to poorer mental health or an impediment to therapeutic progress in
some way, they may be targeted for change. Targeting patient values for change
because they are seen as less favorable than the clinician’s own values although
they have not been found to be pathological, may be problematic for therapists
who strive to be culturally sensitive and competent and who value acceptance
and positive regard for the patient as integral to successful treatment, and for
patients whose religiosity and associated values may be disrespected or
otherwise insensitively treated. Additionally, this can present a violation of ethical
mandates that require clinicians to respect cultural differences of diverse groups.
It is likely, and at least hoped that such unfounded bias is unintended and
operates outside of the clinician’s awareness.
Empathy has long been considered a cornerstone of an effective
therapeutic relationship in which the clinician seeks to understand the patient’s
experience (Ivey et al., 1993; Rogers, 1957). Bias in empathy has been related to
the clinician’s ability to conceptualize a patient’s mental health issues from a
171
multicultural perspective when rated by others (Constantine, 2001). Group
member ratings of general and cultural competence have also been associated
with empathy, and competence as perceived by the patient can have an effect on
the patient’s overall satisfaction with treatment (Fuertes & Brobst, 2002). In
relation to existing clinician religious bias, it is notable that some religious
persons have expressed fears that therapists will judge them or seek to change
their religion or associated values (Richards & Bergin, 2000, p. 13), which is
likely to be related to the religious person’s perception of potential psychologist
preference or bias for his or her values over the patient’s.
The results of this study have implications for clinician multicultural training
programs. Given that bias was found in this study, it is a concern that clinicians
who experience automatic negative bias against such a large portion of the
general population, do not successfully moderate their negative responding to
the group when given the opportunity to use deliberation in doing so. Devine
(1989) posited the theory that one’s negative automatic associations need not be
deterministic in relation to one’s behavior, if one is sufficiently motivated not to
act upon the association. Further, the MODE model of prejudice (Fazio & Olson,
2003) posits that the more sensitive a domain of evaluation, such as social group
evaluation, the more likely motivational factors in concealing that bias will be
represented in self-report measures.
As clinicians can generally be assumed to use thoughtful consideration in
making clinical judgments, these results suggest that there are beliefs about
religious conservative persons that affect clinical judgment such that clinicians
172
give a poorer prognosis to them, and that they do not believe these beliefs to be
in need of censorship. As it has not been demonstrated that religious persons are
more pathological than nonreligious persons, and in fact that their religiosity is
often associated with better mental health, the nature of clinician’s beliefs about
this group such that they are believed to have a poorer prognosis than their
nonreligious counterparts, is of interest and may be considered a variable for
future research.
Diversity training is often synonymous with racial and ethnic multicultural
approaches to treatment and education. As such, religiosity is an often
overlooked expression of diversity in training programs and the diversity literature
(Yarhouse & Fisher, 2002). If religiosity is to be considered from an informed and
sensitive multicultural perspective, it is indicated that training programs should
undertake to educate clinicians about culturally appropriate and competent
treatment of religiously dissimilar patients. Multicultural education and literature
should also endeavor to increase awareness about the impact of variables such
as sociopolitical influence that are often presumed to be correlated with
religiosity, and that influence on bias with religiously dissimilar patients (Fuertes
& Brobst, 2002). This is particularly salient as affective charge has been
increasingly associated with religiosity or religious values in the political domain
(Wallis, 2005).
The findings of this study extend the literature on stereotyping. Byrne’s
attraction paradigm (1971) posits that those who are similar are more attracted to
each other and those who are dissimilar will be repulsed by each other.
173
Importantly, he hypothesized that similarity and dissimilarity based on values and
attitudes are more important in determining attraction or repulsion than are
demographic variables. As has been discussed, religious affiliation does not a
religious person make. Methods of group designation by self-report of religious
affiliation or membership tell little of the effects of that association on one’s
beliefs or attitudes. The findings of this study, which assessed attitudes toward
core Christian beliefs rather than endorsement of affiliation or membership with a
religious group, supports Byrne’s theory.
This study also adds to the growing body of literature on negative
automatic associations with social out-groups. Self-report measures of
stereotyping or bias may compromise research results as prejudice is generally
viewed as socially unacceptable, thereby increasing motivation to conceal bias,
stereotyped beliefs, or prejudiced responding. Negative automatic associations
were associated with the group most religiously diverse from the religiously
conservative target. Recalling that some posit that automatic associations are
demonstrated on the basis of common social knowledge of stereotypes rather
than personally held beliefs (Karpinski & Hilton, 2001), this study indicates that
the participant’s beliefs are a primary factor in determining negative
characterization of the group.
There are several limitations to this study. The large representation of
urban clinicians in this sample may have contributed to the findings of bias if
religiously conservative persons are considered an out-group in those areas. The
sample also largely consisted of those belonging to psychological organizations,
174
which were also presumably internet savvy since the completion of the survey
required internet use and even that the participants download a plug-in for the
Implicit Association Test (IAT). It is unknown what differences there may be
between this group and others who differ on these characteristics.
Item 7 from the prognosis measure was deleted due to its lack of
correlation to other variables. It is not understood why the item did not correlate
with other variables. A review of both items 7 and 8 revealed that participants
may have interpreted the items in much the same way and did not differentiate
between the intention of each. Items 7 and 8 ask participants to rate “the number
of therapy sessions required for this patient to make substantial progress,” and
“number of sessions you expect that this patient will attend therapy” respectively.
Also, there were considerable technical difficulties in the administration of
the IAT portion of this study. Many participants who began the study, could not,
or did not, finish it. Further, as one participant pointed out, there may be
differences between psychologists who used MacIntosh operating systems, and
those who used Windows Operating Systems which was required for the IAT
portion of the study. It is not known what differences there may be between the
two groups. Last, while it is difficult to estimate a response rate to this study due
to technical problems, the Windows Operating System requirement, and a
population which included unlicensed psychologists who were excluded from the
study, the response rate overall was low.
The results of this study indicate that more research would be helpful in
determining which clinician or patient variables are related to religious bias, and
175
how they are related, and continued investigations into the specific processes
that predict religious bias, the origins, nature, and application of that bias, and
whether biases are specific to certain groups are also of interest. Future research
in the area of clinician religious bias would be of service to religiously dissimilar
patients if it were to seek data that could better inform and assist multicultural
training programs in their efforts to provide culturally competent and informed
clinical services to these patients. It is hoped that this and similar research
succeeds in facilitating interest in cultural training and in the literature to more
adequately address issues related to competent, respectful, and sensitive
treatment of religious persons and their religiously informed values.
176
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ed.). Boston: Allyn & Bacon.
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psychodiagnosis. Journal of Consulting and Clinical Psychology, 48, 234240.
Wallis, J. (2005). God's politics: Why the right gets it wrong and the left doesn't
get it. San Francisco: Harper Collins.
Watters, W. W. (1992). Deadly doctrine: Health, illness, and Christian God talk.
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the table conversation: A few diverse perspectives on integration. Journal
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195
Appendix A:
Materials Provided to Participants
Invitation to Participate in Research Study
Dear Licensed Psychologist,
I am writing to request your participation in an online research study. This study
examines factors and processes associated with clinical judgment which includes
a unique measure that I hope you enjoy. This research is intended to complete
my requirements for the doctoral dissertation at the Anonymous University in
fulfillment of the PhD in Clinical Psychology under the supervision of Anonymous,
Ph.D. The requirement for participants is that they must be licensed
psychologists. Please note that unfortunately this study is not MAC compatible at
this time.
I understand that your time is valuable, and as such, your participation is greatly
appreciated. At the study’s end, there will be an opportunity to enter two
drawings, one each for $100 and $50 prizes of either a contribution in your name
to the American Red Cross’s Hurricane Recovery Program that serves victims
affected by Hurricanes Katrina, Rita and Wilma, or a cash prize in either amount.
The anticipated length of time to take this study is approximately 25 minutes.
Again, as data collected in this study is part of my doctoral dissertation, your time
and effort is most sincerely appreciated.
I hope you find the study interesting!
Here is the link to the informed consent and the survey:
Sincerely,
Anonymous
196
Informed Consent Form
Please note that this study is not MAC compatible
Factors Associated with Psychologists’ Clinical Judgment
You have been asked to participate in a dissertation research study conducted
by Anonymous, a doctoral student in the School of Clinical Psychology at
Anonymous. Participation in this research is voluntary. As such, the results of this
research will be published in Anonymous’s doctoral dissertation and possibly in
journals, books, or presentations. It involves the examination of various factors
that relate to psychologists’ clinical judgment and is expected to contribute to
psychology by providing a more thorough understanding of how those factors
affect clinical practice, and essentially increase patient retention and maximize
outcomes.
This study involves several survey instruments. You will be directed to a page
that will request that you download a program that is necessary to accept and
store your responses, which will then be transmitted to the website host for data
analysis at the conclusion of your participation. Please note the specific security
measures that will be taken to ensure that your information is protected and that
the downloaded program is used solely for data collection purposes, found later
in this consent form. You will first be asked to read and respond to questions
about two clinical vignettes. Several other brief instruments will follow, in which
you will be asked to respond to items that measure various attitudes that may
play a role in explicit processes utilized in making clinical judgments. Last, you
will be asked to complete a timed measure that assesses implicit processes also
believed to be a contributing factor in making clinical judgments.
With the understanding that your time is valuable, a drawing will be held at the
study’s end for the chance to win one of two prizes; either a $100 or $50
donation in your name to either the American Red Cross’s Hurricane Recovery
Program that serves victims affected by Hurricanes Katrina, Rita and Wilma and
others, the charitable organization of your choice, or the option of cash in those
amounts. Participation in this study is expected to take approximately 25
minutes.
Your responses in this study are kept anonymous and information gathered is
used solely for the purposes of this research. Data is transmitted to the host
server using SSL, which is standard data encryption technology for secure data
transmission on the web. You will not be asked to provide any identifying data,
unless you choose to enter the drawing at the study’s end. Personally identifying
197
data entered into the drawings will be separated from the study response data,
prior to any review or analysis and discarded immediately following the
conclusion of the drawing. All data will be accessible to only the researcher and
her committee, and a research assistant who has signed a Confidential
Assistance Agreement.
There are no known or suspected risks associated with participation in this study.
However, should you find anything disturbing about the study, please feel free to
exit it at any time. Only data from completed studies will be saved, and if you
choose to exit or refuse participation in the study you may do so without penalty.
If you would like a summary of the results of this study, or if you have any
questions about this research, please feel free to email Anonymous at
Anonymous or call (818) 634-9022. An electronic summary of results can be
emailed to you at the conclusion of the study at your request. For questions, you
may also contact the dissertation committee’s chair, Anonymous, PhD., at
Anonymous University.
The Institutional Review Board at Anonymous retains access to signed consent
forms. As this is an online study, clicking the SUBMIT button below serves as
your electronic signature on your agreement to the informed consent terms. You
may print and keep a copy of this agreement for your records. Please click the
SUBMIT button to signify your informed consent and to be taken to the study.
198
Introduction to Vignettes
It is understood that some of the information presented in vignette studies is
ambiguous, and information required for carefully considered clinical judgment is
lacking. Due to the fact that this study requires the use of brief vignettes, it is
acceptable and expected that you project a hypothesis about each patient based on
any and all pieces of information given, ambiguous or otherwise. Please read the two
following vignettes. Following each, you will be asked to make some clinical
judgments based on the information given.
199
Condition I: Vignette #1
Mr. Dean, a 35 year old married Caucasian male, presents to treatment with multiple
symptoms. He reports that he suffers from dizziness, sweaty palms, and tension in
his chest. He often feels edgy and irritable, and he has been having difficulty focusing
at work, where he is a sales manager at a local telecommunications company. He
notices that he often has worrisome thoughts that are intrusive and distracting and he
has left work on several occasions when they have become intolerable.
Mr. Dean formerly spent some time socializing with coworkers on occasional
weekends, entertaining at his home or watching sports events with them. He also
states that he is an Evangelical Christian who was an active member of the
Evangelical Free Church until the last year and a half. He was also politically active in
advocating for causes related to his faith and derived satisfaction from participating in
activities that he believed represented his faith and God’s will. He complains that he
misses social activities with coworkers and religious and political activities. While he
is still capable of enjoying these activities, he has often had to leave events when his
symptoms became “intolerable”. He has since reduced his outings significantly.
He has fears of failing in his job despite having a history of reasonable career
success, fears that his wife will leave him, although there is no evidence that she is
unhappy, and fears that he is falling short of the expectations of his faith, though he
cannot point to evidence that supports these fears. Recently he has become
discouraged about this continued pattern and feels that his worry is out of control. He
states that when he returns home at the end of the day, he is irritable and tired but
feels he must appear “normal” to his wife and children. He expresses concerns that
he needs to be seen as “perfect”.
Having consulted with physicians on several occasions regarding dizziness, sweaty
palms, and muscle tension, Mr. Dean understands that there are no medical causes
for his symptoms. He has no therapy experience in his past, and is attending at the
urging of a coworker, who has some knowledge of Mr. Dean’s experiences.
200
Condition I: Vignette II
Mr. Bowery is a 32 year old divorced Caucasian man who comes to therapy with
several complaints. Mr. Bowery reports that worries frequently, and that he his worry
has increased in the last year. He states that at times he also has increased heart
rate, feels lightheaded, and that his hands shake. He wakens in the early morning
hours, feeling agitated and unable to sleep. He is tired during the day and finds it
difficult to make decisions at work, where he is a junior architect in a successful
company. Historically, his work performance has been marked by achievement and
recognition, however he worries that he will be unable to maintain that success and
move ahead in his career. He has recently also become afraid that others will notice
his symptoms or that they will begin to effect his work. As Mr. Bowery’s career
advancement is a primary focus of his life, he is considerably distressed by his fears
of failure.
Mr. Bowery has enjoyed an active social life, having a circle of good friends with
whom he has enjoyed skiing, snowboarding and other activities. He has been
married once and was divorced when 27 years old. He reports that he has had two
meaningful relationships with women in the past 5 years and that someday he would
like to be married again. He reports that he worries that he will not “find the right one”
and may not marry again. Mr. Bowery states that he formerly found it rewarding to
volunteer his time as a mentor to boys in a local boys’ foster home. He had also
developed friendships there with other mentors and felt as though his volunteer
activities imparted some special purpose in his life. Mr. Bowery reports being able to
enjoy these activities still, except that lately his symptoms have left him feeling
fatigued and he has been “unable to keep up” with social and volunteer activities
alike. Mr. Bowery also reports that although he used to be excited about his work and
his career path, often working overtime on important projects, he is spending less
and less time at work.
Mr. Bowery has been cleared of any medical diagnosis that may be contributing to
his symptoms. He has been feeling down lately as his symptoms continue and is
seeking assistance in therapy on the advice of a mentor at the boy’s home.
201
Condition II: Vignette I
Mr. Dean, a 35 year old married Caucasian male, presents to treatment with multiple
symptoms. He reports that he suffers from dizziness, sweaty palms, and tension in
his chest. He often feels edgy and irritable, and he has been having difficulty focusing
at work, where he is a sales manager at a local telecommunications company. He
notices that he often has worrisome thoughts that are intrusive and distracting and he
has left work on several occasions when they have become intolerable.
Mr. Dean formerly spent some time socializing with coworkers on occasional
weekends, entertaining at his home or watching sports events with them. Mr. Dean
states that he formerly found it rewarding to volunteer his time as a mentor to boys in
a local boys’ foster home. He had also developed friendships there with other
mentors and felt as though his volunteer activities imparted some special purpose in
his life. Mr. Dean reports that he would like to participate in these activities still,
except that lately his worry and other symptoms have left him feeling fatigued and he
has been “unable to keep up” with social and volunteer activities alike. While he is
still capable of enjoying these activities, he has often had to leave events when his
symptoms became “intolerable”. He has since reduced his outings significantly.
He has fears of failing in his job despite having a history of reasonable career
success, fears that his wife will leave him although there is no evidence that she is
unhappy, and fears that he is falling short of the expectations of his faith, though he
cannot point to evidence that supports those fears. Recently he has become
discouraged about this continued pattern and feels that his worry is out of control. He
states that when he returns home at the end of the day, he is irritable and tired but
feels he must appear “normal” to his wife and children. He expresses concerns that
he needs to be seen as “perfect”.
Having consulted with physicians on several occasions regarding dizziness, sweaty
palms, and muscle tension, Mr. Dean understands that there are no medical causes
for his symptoms. He has no therapy experience in his past, and is attending on the
advice of a mentor at the boy’s home, who has some knowledge of Mr. Dean’s
experiences.
202
Condition II: Vignette II
Mr. Bowery is a 32 year old divorced Caucasian man who comes to therapy with
several complaints. Mr. Bowery reports that he worries frequently, and that he his
worry has increased in the last year. He states that at times he also has increased
heart rate, feels lightheaded, and that his hands shake. He wakens in the early
morning hours, feeling agitated and unable to sleep. He is tired during the day and
finds it difficult to make decisions at work, where he is a junior architect in a
successful company. Historically, his work performance has been marked by
achievement and recognition, however he worries that he will be unable to maintain
that success and move ahead in his career. He has recently also become afraid that
others will notice his symptoms or that they will begin to effect his work. As Mr.
Bowery’s career advancement is a primary focus of his life, he is considerably
distressed by his unfounded fears of failure.
Mr. Bowery has enjoyed an active social life, having a circle of good friends with
whom he has enjoyed skiing, snowboarding and other activities. He has been
married once and was divorced when 27 years old. He reports that he has had two
meaningful relationships with women in the past 5 years and that someday he would
like to be married again. He reports that he worries that he will not “find the right one”
and may not marry again. He also states that he is an Evangelical Christian who was
an active member of the Evangelical Free Church until the last year and a half. He
was also politically active in advocating for causes related to his faith and derived
satisfaction from participating in activities that he believed represented his faith and
God’s will. He complains that he misses social activities with friends and religious and
political activities. Mr. Bowery also reports that although he used to be excited about
his work and his career path, often working overtime on important projects, he is
spending less and less time at work. He stated that he has left work or volunteer or
social activities due to his symptoms.
Mr. Bowery has been cleared of any medical diagnosis that may be contributing to
his symptoms. He has been feeling down lately as his symptoms continue and is
seeking assistance in therapy at the urging of a coworker.
203
Measures
Empathy
Affective Empathy: Batson’s empathy adjectives
Please indicate on a 7-point scale from 1 (not at all) – 7 (extremely) how strongly you
feel each emotion when thinking about this patient.
1.)
2.)
3.)
4.)
5.)
6.)
sympathetic
moved
compassionate
tender
warm
softhearted
1
1
1
1
1
1
2
2
2
2
2
2
3
3
3
3
3
3
4
4
4
4
4
4
5
5
5
5
5
5
6
6
6
6
6
6
7
7
7
7
7
7
Cognitive Empathy: The Perspective Taking Scale of the Interpersonal Reactivity
Index
Please indicate the degree to which the items below describe your response to this
patient on a five-point scale running from 0 (does not describe me well) to 4
(describes me very well).
1. I have a hard time seeing things from this patient’s point of view. 0 1 2 3 4
2. I am able to look at this patient’s side of things when making judgments. 0 1 2
34
3. I am able to understand this patient better by imaging how things look from his
perspective. 0 1 2 3 4
4. Before making a judgment about this patient, I imagine how it would feel to be
in his place.
01234
204
Prognosis
Please rate the patient on each of the following items:
1.) Appropriateness for therapy. 0 (least appropriate) – 4 (most appropriate)
34
012
2.) Selection for your caseload. 0 (least likely to select) – 4 (most likely to select)
01234
3.) Severity of impairment.
impaired)* 0 1 2 3 4
0 (most severely impaired) – 4 (least severely
4.) Motivation for change.
34
0 (least motivated) – 4 (most motivated)
012
5.) Capacity for insight.
insight)
01234
0 (least capacity for insight) – 4 (most capacity for
6.) Likelihood of making substantial progress. 0 (least likelihood) – 4 (most likelihood
for making substantial progress)
01234
7.) Number of therapy sessions required for this patient to make substantial progress.
0.) 1-5 1.) 6-10 2.) 11-15 3.) 16-20 4.) 21+ *
8.) Number of sessions you expect this patient will attend therapy
0.) 1-5 1.) 6-10 2.) 11-15 3.) 16-20 4.) 21+
*Reverse coded
205
Motivation to Control Prejudiced Reactions
Please indicate the degree to which you agree or disagree with the following
statements on a scale ranging from -3 (strongly disagree) to +3 (strongly agree)
1. In today’s society it is important that one not be perceived as prejudiced in any
manner. -3, -2, -1, 0, +1, +2, +3
2. I always express my thoughts and feelings, regardless of how controversial
they might be. R* -3, -2, -1, 0, +1, +2, +3
3. I get angry with myself when I have a thought or feeling that might be
considered prejudiced. -3, -2, -1, 0, +1, +2, +3
4. If I were participating in a class discussion and a person of another religion
expressed an opinion with which I disagreed, I would be hesitant to express
my viewpoint.
-3, -2, -1, 0, +1, +2, +3
5. Going through life worrying about whether you might offend someone is just
more trouble than it’s worth. R
-3, -2, -1, 0, +1, +2, +3
6. It’s important to me that other people think I’m not prejudiced.
-3, -2, -1, 0, +1, +2, +3
7. I feel it’s important to behave according to society’s standards.
-3, -2, -1, 0, +1, +2, +3
8. I’m careful not to offend my friends, but I don’t worry about offending people I
don’t know or don’t like. R
-3, -2, -1, 0, +1, +2, +3
9. I think it’s important to speak one’s mind rather than worry about offending
someone. R
-3, -2, -1, 0, +1, +2, +3
10. It’s never acceptable to express one’s prejudices.
-3, -2, -1, 0, +1, +2, +3
11. I feel guilty when I have a negative thought or feeling about a person of
another religion person.
-3, -2, -1, 0, +1, +2, +3
206
12. When speaking to a person of another religion, it’s important to me that he/she
not think I’m prejudiced.
-3, -2, -1, 0, +1, +2, +3
13. It bothers me a great deal when I think I’ve offended someone, so I’m always
careful to consider other people’s feelings.
-3, -2, -1, 0, +1, +2, +3
14. If I have a prejudiced thought or feeling, I keep it to myself.
-3, -2, -1, 0, +1, +2, +3
15. I would never tell jokes that might offend others.
-3, -2, -1, 0, +1, +2, +3
16. I’m not afraid to tell others what I think, even when I know they disagree with
me. R
-3, -2, -1, 0, +1, +2, +3
*Reverse coded
207
Social Desirability: Marlowe Crowne- Form C
Please read and respond to each statement as either true (T) or false (F) about your
own behavior, feelings, or attitude
1. It is sometimes hard for me to go on with my work if I am not encouraged. T F
2. I sometimes feel resentful when I don’t get my way. T F
3. On a few occasions, I have given up doing something because I thought too
little of my ability. T F
4. There have been times when I felt like rebelling against people in authority
even though I knew they were right. T F
5. No matter who I’m talking too, I’m always a good listener.* T F
6. There have been occasions when I took advantage of someone. T F
7. I’m always willing to admit it when I make a mistake.* T F
8. I sometimes try to to get even rather than forgive and forget. T F
9. I am always courteous, even to people who are disagreeable.* T F
10. I have never been irked when people expressed ideas very different from my
own.* T F
11. There have been times when I was quite jealous of the good fortunes of
others. T F
12. I am sometimes irritated by people who ask favors of me. T F
13. I have never deliberately said something that hurt someone’s feelings.* T F
*Reverse coded
208
Religious Attitude Scale
Select and check for each item the one descriptive phrase that would best describe
your attitude. (Scores are indicated in parentheses such that 0 = liberal, 1=
conservative, and 2 = orthodox positions)
1.
a.)
b.)
c.)
God
spiritual, guiding force (1)
All-powerful creator of the universe (2)
Man-made explanation of the unknown (0)
2.
a.)
b.)
c.)
Jesus
wise prophet and successful crusader (0)
God manifest in man (1)
Son of God (2)
3.
a.)
b.)
c.)
Holy Ghost
third person of the Blessed Trinity (2)
God revealed in spiritual form (1)
Supposedly a divine being (0)
4.
a.)
b.)
c.)
Virgin Mary
mother of Jesus (1)
Supposedly the mother of a prophet (0)
Blessed mother of God (2)
5.
a.)
b.)
c.)
Saints
agents effecting communication between God and man (2)
good people living or having lived Christian lives (1)
humans falsely elevated to holiness (0)
6.
a.)
b.)
c.)
Angels
heavenly beings created in God’s likeness (2)
revelation of God’s ways (1)
manmade symbols of goodness (0)
7.
a.)
b.)
c.)
Devils
manmade symbols of evil (0)
our temptations to do evil (1)
fallen angels (2)
8.
a.)
b.)
c.)
Heaven
peaceful state of mind (0)
the place of eternal happiness for only those who are saved (2)
future life in the kingdom of God (1)
9. Hell
a.) threat of future punishment for man’s sins (1)
209
b.) our earthly suffering (0)
c.) place of eternal punishment for the damned (2)
10. Soul
a.) Personality (0)
b.) spiritual part of man, linking him to God (1)
c.) Immortal, immaterial part of man (2)
11. Sin
a.) falling short of our best and our misdeeds towards others (0)
b.) transgression against God’s laws (2)
c.) breaking an established moral and religious code (1)
12. Salvation
a.) saving one’s soul, which is the ultimate end of man’s creation (2)
b.) submitting to God’s will (1)
c.) having fulfilled one’s purpose in life (0)
13. Miracles
a.) illustrations explaining God’s ways (1)
b.) unusual occurrences which do have a logical explanation (0)
c.) unusual acts produced through the power of God (2)
14. Bible
a.) book of history and moral behavior (0)
b.) book of reverent religious writings (1)
c.) revealed word of God (2)
15. Prayer
a.) attempts at magical wish fulfillment (0)
b.) religious meditation (1)
c.) communication with God (2)
16. Rituals and sacraments
a.) means of achieving grace (2)
b.) manmade actions for the pleasure of mythical beings (0)
c.) symbolic actions during worship (1)
210
Conservatism Scale
Please assess your degree of devoutness about your own religious beliefs
0
1
not at all/
slightly devout
does not apply
2
3
somewhat
very devout
devout
Please assess your degree of devoutness in following your religious traditions or
practices
0
1
not at all/
slightly devout
does not apply
2
3
somewhat
very devout
devout
Please assess your attempts to live your life according to your religious scriptures or
teachings
0
don’t attempt
at all/ does
not apply
1
attempt
slightly
2
attempt
somewhat
3
attempt very much
211
Background Questionnaire
Please respond to the following background questions:
1. Sex.
A. M
B. F
2. Age.
A.
B.
C.
D.
E.
F.
G.
H.
I.
20-29
30-35
36-40
41-45
46-50
51-55
56-60
61-65
66+
3. Education.
A. Doctorate Clinical Psychology
B. Doctorate Counseling Psychology
C. Doctorate Education or related
D. Other
3. Geographic Region
A. Northeast
B. Southeast
C. North
D. Midwest
E. South
F. Northwest
G. Southwest
H. West
4. Primary Location as urban or rural
A. Rural
5. Years in clinical practice
A. 1-2
B. 3-5
C. 6-10
D. 11-15
E. 16-20
F. 21-30
G. 31-40
H. 40+
6. Religious Affiliation
A. Buddhist
B. Christian-Catholic
B. Urban
212
C. Christian- Evangelical
D. Christian- Protestant (all other denominations excluding Evangelical)
E. Hindu
F. Jewish
G. Muslim
H. None/Atheist/Agnostic
I. Other
This measure will be the last prior to the IAT. Following this there will be a notice:
“You will now be directed to the final portion of the study, which should take
approximately 5 minutes to complete. You will be asked to download a small plug-in
(Active-X) that will allow for responses to be time. This plug-in cannot and does not
gather any data from your computer other than what is required for data collection. I
hope that you will continue on through this last piece as partial data is not usable in
this study. Thank you for your continued participation!”
213
Implicit Association Test
The implicit association test is not a measure, but a method of measuring automatic
attitudes. It requires a process of categorization of concepts or words on line or on a
dedicated computer. Therefore it cannot be replicated here. Demonstrations of the
IAT can be seen at the following site:
https://implicit.harvard.edu/implicit/demo/measureyourattitudes.html
That having been said, some text is available. After completion of the measure,
participants will be given feedback. An example of this would be:
Below is a summary of your average response time for two different configurations:
When good words were matched with the Evangelical Christian category, your
response time was xxxx milliseconds.
When good words were matched with the Secular/No Religion category, your
response time was xxxx milliseconds.
Did you respond much more quickly to one of the configurations than the other? If so,
that configuration may be more consistent with your attitudes about these categories.
Please press ENTER to end the study.
On the next page a text box reads:
Thank you for participating in this study. If you would like to be entered in the drawing
for the $50 and the $100 prizes, please type your email address in the box below.
Winners will be notified by email.
214
Appendix B: Distribution of Variable Scores
Histograms
60
50
Frequency
40
30
20
10
0
0.00
2.50
5.00
7.50
10.00
Social Desirability
Figure B1. Distribution of social desirability scores.
12.50
215
100
Frequency
80
60
40
20
0
0.00
2.00
4.00
6.00
8.00
Religious Conservatism
Figure B2. Distribution of religious conservatism scores.
10.00
12.00
216
40
Frequency
30
20
10
0
0.00
10.00
20.00
30.00
Liberality of Christian Beliefs
Figure B3. Distribution of religious liberality in relation to Christian beliefs scores.
217
100
Frequency
80
60
40
20
0
-20.00
-10.00
0.00
10.00
NMR - EC Affective Empathy Difference
Figure B4. Distribution of NMR – EC affective empathy difference scores.
20.00
218
50
Frequency
40
30
20
10
0
-30.00
-20.00
-10.00
0.00
10.00
NMR - EC Cognitive Empathy Difference
Figure B5. Distribution of NMR – EC cognitive empathy difference scores.
20.00
219
80
Frequency
60
40
20
0
-15.00
-10.00
-5.00
0.00
5.00
NMR - EC Prognosis Difference
Figure B6. Distribution of NMR – EC prognosis scores.
10.00
15.00
220
100
Frequency
80
60
40
20
0
-2000.00
-1000.00
0.00
1000.00
Implicit Negative Associations
Figure B7. Distribution of implicit negative association scores.
2000.00
3000.00
221
50
Frequency
40
30
20
10
0
30.00
40.00
50.00
60.00
70.00
80.00
Motivation to Control Prejudice Reactions
Figure B8. Distribution of motivation to control prejudice reactions scores.
90.00
222
Appendix C: Examination of Regression Assumptions
100
Frequency
80
60
40
20
0
-5.0
-2.5
0.0
2.5
Regression Standardized Residual
5.0
Regression Standardized Residual
5.0
2.5
0.0
-2.5
-5.0
-3
-2
-1
0
1
Regression Standardized Predicted Value
2
Figure C1. Residual normality histogram and residual equality scatterplot for
regression analysis with NMR-EC affective empathy difference scores as the
dependent variable for hypothesis 1.
223
40
Frequency
30
20
10
0
-2
0
2
Regression Standardized Residual
4
Regression Standardized Residual
4
2
0
-2
-3
-2
-1
0
1
Regression Standardized Predicted Value
2
Figure C2. Residual normality histogram and residual equality scatterplot for
regression analysis with NMR-EC cognitive empathy difference scores as the
dependent variable for hypothesis 1.
224
80
Frequency
60
40
20
0
-4
-2
0
2
Regression Standardized Residual
4
Regression Standardized Residual
4
2
0
-2
-4
-3
-2
-1
0
1
Regression Standardized Predicted Value
2
Figure C3. Residual normality histogram and residual equality scatterplot for
regression analysis with NMR-EC prognosis difference scores as the dependent
variable for hypothesis 2.
225
80
Frequency
60
40
20
0
-4
-2
0
2
Regression Standardized Residual
4
6
-2
-1
0
1
Regression Standardized Predicted Value
2
Regression Standardized Residual
6
4
2
0
-2
-4
-3
Figure C4. Residual normality histogram and residual equality scatterplot for
regression analysis with INA scores as the dependent variable for hypothesis 2.
226
120
100
Frequency
80
60
40
20
0
-5.0
-2.5
0.0
2.5
Regression Standardized Residual
5.0
Regression Standardized Residual
5.0
2.5
0.0
-2.5
-5.0
-4
-2
0
2
4
Regression Standardized Predicted Value
6
Figure C5. Residual normality histogram and residual equality scatterplot for
regression analysis with NMR-EC affective empathy differences as the dependent
variable for hypothesis 4.
227
50
Frequency
40
30
20
10
0
-2
0
2
Regression Standardized Residual
4
Regression Standardized Residual
4
2
0
-2
-5.0
-2.5
0.0
2.5
Regression Standardized Predicted Value
5.0
Figure C6. Residual normality histogram and residual equality scatterplot for
regression analysis with NMR-EC cognitive empathy differences as the dependent
variable for hypothesis 4.
228
80
Frequency
60
40
20
0
-4
-2
0
2
Regression Standardized Residual
4
Regression Standardized Residual
4
2
0
-2
-4
-6
-4
-2
0
2
Regression Standardized Predicted Value
4
Figure C7. Residual normality histogram and residual equality scatterplot for
regression analysis with NMR-EC prognosis differences as the dependent variable
for hypothesis 5