Psychologist Bias in Implicit Responding to Religiously Divergent ...
Psychologist Bias in Implicit Responding to Religiously Divergent ...
Psychologist Bias in Implicit Responding to Religiously Divergent ...
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Volume 2, Issue 1, 2008<br />
<strong>Psychologist</strong> <strong>Bias</strong> <strong>in</strong> <strong>Implicit</strong> Respond<strong>in</strong>g <strong>to</strong> <strong>Religiously</strong> <strong>Divergent</strong> Nonpatient<br />
Targets and Explicit Respond<strong>in</strong>g <strong>to</strong> <strong>Religiously</strong> <strong>Divergent</strong> Patients<br />
Jennifer Ruff, PhD, Cl<strong>in</strong>ical Psychology, Field<strong>in</strong>g Graduate University, drruff@comcast.net<br />
Abstract<br />
This study exam<strong>in</strong>es how psychologists responded <strong>to</strong> a ma<strong>in</strong>stream group believed <strong>to</strong><br />
be most religiously diverse from them, Evangelical Christians (ECs). Cl<strong>in</strong>icians were<br />
presented with two vignettes which described patients with comparable symp<strong>to</strong>ms of<br />
generalized anxiety disorder, who differed on either religiosity or career and volunteer<br />
activity conditions. They rated each on measures of empathy and prognosis. Cl<strong>in</strong>icians<br />
completed a scale that measures attitudes about Christian beliefs that range from<br />
orthodox <strong>to</strong> liberal positions. Cl<strong>in</strong>icians’ au<strong>to</strong>matic respond<strong>in</strong>g <strong>to</strong> EC targets was also<br />
compared <strong>to</strong> au<strong>to</strong>matic respond<strong>in</strong>g <strong>to</strong> Secular or No Religion targets on a timed implicit<br />
measure, which reduces the opportunity <strong>to</strong> censor bias. Liberality of religious attitudes <strong>in</strong><br />
relation <strong>to</strong> Christian beliefs was associated with less cognitive and affective empathy and<br />
a poorer prognosis for the EC patient. On the implicit measure, religiously liberal<br />
cl<strong>in</strong>icians’ attitudes <strong>to</strong>ward Christian beliefs was associated with negative respond<strong>in</strong>g <strong>to</strong><br />
EC targets compared <strong>to</strong> Secular or No Religion targets. Last, given the opportunity <strong>to</strong> do<br />
so, cl<strong>in</strong>icians’ motivation <strong>to</strong> control prejudice reactions did not moderate the effects of<br />
au<strong>to</strong>matic negative respond<strong>in</strong>g <strong>to</strong> EC’s on self-reported expressions of empathy or<br />
prognosis <strong>in</strong> relation <strong>to</strong> the EC vignette patient.<br />
The results of this study have implications for Evangelical Christian patients who may<br />
experience biased cl<strong>in</strong>ical judgment as a result of their religious background. Also,<br />
results should be of <strong>in</strong>terest <strong>to</strong> cl<strong>in</strong>icians who seek <strong>to</strong> provide sensitive and competent<br />
treatment <strong>to</strong> patients who belong <strong>to</strong> religious groups that diverge from their own, and for<br />
whom it is important <strong>to</strong> honor ethics codes which guide cl<strong>in</strong>icians <strong>to</strong> respect group<br />
differences <strong>in</strong> psychotherapy. Lastly, it is suggested that cl<strong>in</strong>ical multicultural tra<strong>in</strong><strong>in</strong>g<br />
programs should <strong>in</strong>clude tra<strong>in</strong><strong>in</strong>g for cl<strong>in</strong>ical work with patients whose religious beliefs<br />
and values are different from those of the cl<strong>in</strong>ician.<br />
A rationale for the study with an extensive literature review is presented <strong>in</strong> Part A,<br />
followed by Part B which <strong>in</strong>cludes the current research.and a summary literature review.<br />
KEY WORDS: bias, stereotype, religion, values, cl<strong>in</strong>ician variables, patient variables,<br />
prejudice, empathy, prognosis, pathology cl<strong>in</strong>ical judgment, implicit processes, explicit<br />
processes, Evangelical Christian, <strong>Implicit</strong> Association Test, conservatism, liberalism,<br />
multicultural, cultural sensitivity, diversity
CLINICIAN RELIGIOSITY AND RESPONSE TO DIVERGENT PATIENT RELIGIOSITY:<br />
AN INVESTIGATION INTO THE EFFECTS OF IMPLICIT AND EXPLICIT<br />
STEREOTYPING ON EMPATHY AND PROGNOSIS IN INITIAL RESPONDING TO<br />
PATIENTS WHO ARE RELIGIOUSLY DIVERSE FROM PSYCHOLOGISTS<br />
A dissertation<br />
submitted<br />
by<br />
JENNIFER<br />
L. RUFF<br />
<strong>to</strong><br />
FIELDING GRADUATE UNIVERSITY<br />
<strong>in</strong> partial fulfillment of the<br />
requirements for the degree of<br />
DOCTOR OF PHILOSOPHY IN PSYCHOLOGY<br />
With an Emphasis <strong>in</strong><br />
Cl<strong>in</strong>ical Psychology<br />
~/i,<br />
--. Charles H. Elflo ,Ph.D<br />
Chair<br />
f!iltlU)<br />
Kjell Erik Rudestam, Ph.D., Associate Dean<br />
Debra Bendell Estroff, Ph.D., Faculty Reader<br />
James Gu<strong>in</strong>ee, Ph.D., Extemal Exam<strong>in</strong>er
Copyright by Jennifer L. Ruff<br />
2008
TABLE OF CONTENTS<br />
PARTS A & B<br />
PART A: Comprehensive Review of the Literature<br />
Page<br />
Introduction ……………………………………………………………………... 1<br />
Diversity and worldview match………………………………………………….. 2<br />
Religiosity: <strong>Psychologist</strong>s and the general U.S. population..……….……... 7<br />
Multicultural tra<strong>in</strong><strong>in</strong>g and application of ethical responsibilities………….. 11<br />
The potential for compromised cl<strong>in</strong>ical efficacy with religious persons…………15<br />
Stereotyp<strong>in</strong>g and prejudice………………………………………………… 15<br />
Discordant values and efficacy of practice………………………………… 20<br />
Other barriers <strong>to</strong> effective treatment……………………………………….. 25<br />
Sociopolitical trends, religiosity, and affect……………………………….. 27<br />
Empathy……………………………………………………………………. 30<br />
Religion and Mental Health………………………………………………... 34<br />
The current research………………………………………………………………. 39<br />
Literature on bias with religious patients……………………………………39<br />
Social desirability…………………………………………………………... 48<br />
<strong>Implicit</strong> versus explicit cognitive processes <strong>in</strong> impression formation……… 50<br />
Summary…………………………………………………………………………… 60<br />
References – Part A …………………………………………………………………62<br />
PART B …………………………………………………………………………….83<br />
Introduction………………………………………………………………………… 84
Religiosity as a diversity variable <strong>in</strong> cl<strong>in</strong>ical psychology………………………….. 85<br />
The “religiosity gap”……………………………………………………….. 86<br />
Religion and multicultural competence……………………………………………. 87<br />
Neglect of religious beliefs and values as a diversity variable……………...87<br />
The potential for stereotyp<strong>in</strong>g and prejudice………………………………. 89<br />
Outcomes and value convergence…………………………………………..93<br />
Religion and mental health………………………………………………… 95<br />
Sociopolitical <strong>in</strong>fluence……………………………………………………. 98<br />
The impact of religious neglect or bias on treatment……………………………… 99<br />
Selection of treatment goals……………………………………………….. 100<br />
Empathy……………………………………………………………………. 101<br />
Literature on cl<strong>in</strong>ical judgment of religious patients………………………………..101<br />
Social desirability……………………………………………………………111<br />
Au<strong>to</strong>matic versus controlled cognitive processes………………………….. 113<br />
Statement of the problem……………………………………………………………121<br />
Variables…………………………………………………………………… 122<br />
Hypotheses…………………………………………………………………. 125<br />
Methods…………………………………………………………………………….. 126<br />
Participants…………………………………………………………………. 127<br />
Measures…………………………………………………………………… 131<br />
Batson’s empathy adjectives………………………………………. 131<br />
Interpersonal Reactivity Index’s Perspective Tak<strong>in</strong>g Scale……….. 132<br />
Cl<strong>in</strong>ical Judgment Scale…………………………………………… 133
Religious Attitude Scale…………………………………………… 134<br />
<strong>Implicit</strong> Association Test…………………………………………... 136<br />
Motivation <strong>to</strong> Control Prejudiced Reactions Scale………………….138<br />
Marlowe Crowne Social Desirability Scale-Short Form……………139<br />
Religious Conservatism Scale ………………………………………140<br />
Procedure……………………………………………………………………....140<br />
Results……………………………………………………………………………… 142<br />
Descriptive statistics……………………………………………………………142<br />
Prelim<strong>in</strong>ary analyses……………………………………………………………148<br />
Hypotheses analyses……………………………………………………………153<br />
Summary of results……………………………………………………………..163<br />
Discussion………………………………………………………………………….. 164<br />
References – Part B..………………………………………………………………..176<br />
Appendix A: Materials provided <strong>to</strong> participants…………………………………... 195<br />
Appendix B: Distribution of variable scores………………………………………..214<br />
Appendix C: Exam<strong>in</strong>ation of Regression Assumptions…………………………… 222<br />
TABLES<br />
Table 1: Sample Demographic and Background Characteristics ……..………........143<br />
Table 2: Descriptive Statistics for Composite Measures……………………………148<br />
Table 3: Normality Statistics for Variables Used <strong>in</strong> Hypothesis Tests……………...150<br />
Table 4: Correlations among Variables Used <strong>in</strong> Hypothesis Tests………………….152<br />
Table 5: Regression of Differences <strong>in</strong> Affective Empathy on <strong>Religiously</strong> Liberal<br />
Attitudes <strong>in</strong> relation <strong>to</strong> Christian Beliefs: Hypothesis 1.........................…….154
Table 6: Regression of Differences <strong>in</strong> Cognitive Empathy on <strong>Religiously</strong> Liberal<br />
Attitudes <strong>in</strong> relation <strong>to</strong> Christian Beliefs: Hypothesis 1……………………..155<br />
Table 7: Regression of Differences <strong>in</strong> Prognosis on Liberal Attitudes <strong>in</strong> relation<br />
To Christian Beliefs: Hypothesis 2………………………………………....156<br />
Table 8: Regression of Differences <strong>in</strong> INA associated with <strong>Religiously</strong> Liberal<br />
Attitudes <strong>in</strong> relation <strong>to</strong> Christian Beliefs: Hypothesis 3…..……………..….157<br />
Table 9: Regression of Affective Empathy Differences with NMR-EC with<br />
Motivation <strong>to</strong> Control Prejudiced Reactions as a Modera<strong>to</strong>r on Liberality of<br />
Attitudes <strong>in</strong> relation <strong>to</strong> Christian Beliefs: Hypothesis 4…………………….159<br />
Table 10: Regression of Cognitive Empathy Differences with NMR-EC with<br />
Motivation <strong>to</strong> Control Prejudiced Reactions as a Modera<strong>to</strong>r on Liberality of<br />
Attitudes <strong>in</strong> relation <strong>to</strong> Christian Beliefs: Hypothesis 4……………………161<br />
Table 11: Regression of Prognosis Differences with NMR-EC with Motivation<br />
<strong>to</strong> Control Prejudiced Respond<strong>in</strong>g as a Modera<strong>to</strong>r on Liberality of Attitudes<br />
<strong>in</strong> relation <strong>to</strong> Christian Beliefs: Hypothesis 5……………………..………..163
Part A Introduction<br />
This paper discusses the potential for psychologist bias aga<strong>in</strong>st religious<br />
patients, particularly religiously conservative Christian patients, as a diversity<br />
issue <strong>in</strong> need of further <strong>in</strong>vestigation. The dissimilarity between the religiosity of<br />
the general American population and that of psychologists is explored through an<br />
exam<strong>in</strong>ation of studies on the religiosity gap. Trends <strong>to</strong>ward psychologists’<br />
secular and comparatively liberal worldviews and values, and the manifestation<br />
of those trends, are exam<strong>in</strong>ed. The status of <strong>in</strong>adequate cl<strong>in</strong>ician multicultural<br />
tra<strong>in</strong><strong>in</strong>g with religious groups and the consequences of the current deficit are also<br />
discussed. The possibility of the culturally <strong>in</strong>sensitive or biased treatment of the<br />
group will also be explored. Fac<strong>to</strong>rs that may contribute <strong>to</strong> differential treatment<br />
may <strong>in</strong>clude differences <strong>in</strong> worldviews and values between cl<strong>in</strong>icians and<br />
religiously oriented patients, <strong>in</strong>adequate tra<strong>in</strong><strong>in</strong>g <strong>in</strong> work<strong>in</strong>g with them as a<br />
diversity group, affective respond<strong>in</strong>g or stereotypic or prejudiced assumptions<br />
about religious patients, and other fac<strong>to</strong>rs found <strong>in</strong> the theoretical and empirical<br />
literature on stereotyp<strong>in</strong>g and prejudice between social groups <strong>in</strong> general. The<br />
effects of bias or <strong>in</strong>sensitivity on the <strong>in</strong>itial impressions of patients, cl<strong>in</strong>ical<br />
empathy, prognosis, pathology, disrespect of the patients’ religious beliefs or<br />
values, patient concerns about enter<strong>in</strong>g “secular” psychotherapy, and value<br />
convergence as a cl<strong>in</strong>ician-perceived variable <strong>in</strong> successful treatment outcomes,<br />
are explored. An analysis of bias studies with religious patients follows, with<br />
further exam<strong>in</strong>ation of some problematic methodology that may contribute <strong>to</strong>
2<br />
mixed f<strong>in</strong>d<strong>in</strong>gs. Lastly, variables that may resolve some previous methodological<br />
shortcom<strong>in</strong>gs <strong>in</strong> the literature and suggest directions for future research are<br />
explored.<br />
Diversity and Worldview Match<br />
Weltanschauung is def<strong>in</strong>ed as “the overall perspective from which one<br />
sees and <strong>in</strong>terprets the world,” and “a collection of beliefs about life and the<br />
universe held by an <strong>in</strong>dividual or a group” (American Heritage Dictionary of the<br />
English Language, 2000). Culture is def<strong>in</strong>ed as the cus<strong>to</strong>mary beliefs, social<br />
forms, and material traits of a racial, religious, or social group (2000). Each<br />
person’s Weltanschauung, or worldview, is often extensively <strong>in</strong>formed by the<br />
culture <strong>in</strong> which he or she is immersed. The <strong>in</strong>dividual’s worldview assists him or<br />
her <strong>in</strong> mak<strong>in</strong>g sense of the world, his or her place with<strong>in</strong> it, and the nature of<br />
<strong>in</strong>terpersonal exchanges with others. Cultural groups may further <strong>in</strong>form the<br />
<strong>in</strong>dividual about worldview perspectives such as which values are important and<br />
which are not, and may guide one’s <strong>in</strong>itiation of, and choice of responses <strong>to</strong>, his<br />
or her experiences (Bilgrave & Deluty, 1998).<br />
Cultural <strong>in</strong>fluence often has such an impact on one’s worldview that it<br />
must be considered by cl<strong>in</strong>icians attempt<strong>in</strong>g <strong>to</strong> have a comprehensive<br />
understand<strong>in</strong>g of their patients. The potential for cl<strong>in</strong>ician bias aga<strong>in</strong>st patients of<br />
various cultural doma<strong>in</strong>s is evident <strong>in</strong> the APA Code of Ethics (APA, 2002),
3<br />
Standards 2.01 and 3.01. Standard 3.01 bans discrim<strong>in</strong>ation aga<strong>in</strong>st multicultural<br />
groups, and 2.01 further expla<strong>in</strong>s multicultural competence (MCC) as<br />
an understand<strong>in</strong>g of fac<strong>to</strong>rs associated with age, gender, gender identity,<br />
race, ethnicity, culture, national orig<strong>in</strong>, religion, sexual orientation,<br />
disability, language, or socioeconomic status is essential for effective<br />
implementation of their services or research, psychologists have or obta<strong>in</strong><br />
the tra<strong>in</strong><strong>in</strong>g, experience, consultation, or supervision necessary <strong>to</strong> ensure<br />
the competence of their services, or they make appropriate referrals (APA,<br />
2002, pp. 1063-1064)<br />
Not only does the APA mandate that psychologists become culturally<br />
competent, but diversity has become so celebrated that it is considered a core<br />
value, and even a fourth force <strong>in</strong> psychology by some (Cheatham, Ivey, Ivey, &<br />
Simek-Morgan, 1980). While ethnicity and race have generated a plethora of<br />
research and become the focus of a significant amount of multicultural education<br />
and tra<strong>in</strong><strong>in</strong>g, by comparison religiosity has been an often overlooked expression<br />
of diversity <strong>in</strong> the literature and <strong>in</strong> diversity tra<strong>in</strong><strong>in</strong>g programs (Yarhouse & Fisher,<br />
2002). Nevertheless, religiosity must be considered from a sensitive and<br />
<strong>in</strong>formed multicultural perspective.<br />
That there is a schism between the scientific worldview and one which<br />
encompasses religious elements has been evident <strong>in</strong> psychology from the early<br />
<strong>in</strong>fluence of Sigmund Freud. Freud described worldview as “an <strong>in</strong>tellectual<br />
construction which solves all the problems of our existence uniformly on the<br />
basis of one overrid<strong>in</strong>g hypothesis” (Freud, 1933/1962, p. 158). He endorsed a
4<br />
scientific worldview, which he compared at length <strong>to</strong> a spiritual worldview, and<br />
claimed that it precluded knowledge of the universe “other than the <strong>in</strong>tellectual<br />
work<strong>in</strong>g over of carefully scrut<strong>in</strong>ized observations” (Freud, 1933/1962, p.159).<br />
Indeed, psychology his<strong>to</strong>rians assert that naturalism, or the “doctr<strong>in</strong>e that<br />
scientific procedures and laws are applicable <strong>to</strong> all phenomena” which also<br />
“assumes that all events <strong>in</strong> the world have a his<strong>to</strong>ry that is understandable <strong>in</strong><br />
terms of identifiable forces” (V<strong>in</strong>ey & K<strong>in</strong>g, 1998, p. 182), has def<strong>in</strong>ed the current<br />
philosophy of scientific th<strong>in</strong>k<strong>in</strong>g s<strong>in</strong>ce Freud’s time. Def<strong>in</strong>ed as such, Albert Ellis,<br />
a notable theorist credited with the development of Rational Emotive Behavioral<br />
Therapy, goes on <strong>to</strong> state that “In regard <strong>to</strong> scientific th<strong>in</strong>k<strong>in</strong>g, it practically goes<br />
without say<strong>in</strong>g that this k<strong>in</strong>d of cerebration is quite antithetical <strong>to</strong> religiosity” (Ellis,<br />
1980, p.9)<br />
S<strong>in</strong>ce Freud’s time, others assert antireligious cl<strong>in</strong>ical perspectives and<br />
theory. More recent antireligious views <strong>in</strong>clude comments made by Wendell<br />
Watters, a respected professor of psychiatry and physician at McMaster<br />
University <strong>in</strong> Ontario, Canada. In reference <strong>to</strong> Christian doctr<strong>in</strong>e and teach<strong>in</strong>gs<br />
he stated that they are “<strong>in</strong>compatible with the development and ma<strong>in</strong>tenance of<br />
sound health, and not only ‘mental’ health,” and that “Simply put, Christian<br />
<strong>in</strong>doctr<strong>in</strong>ation is a form of mental and emotional abuse” (Watters, 1992, p.10). In<br />
reference <strong>to</strong> the majority of membership <strong>in</strong> the American Psychological<br />
Association (APA), Emeritus professor of psychology at Yale University and<br />
author of over 40 books, Seymour Sarason <strong>in</strong> his Centennial Address <strong>to</strong> the APA<br />
stated that there are more than a few psychologists who regard <strong>in</strong>gredients of a
5<br />
religious worldview as a “reflection of irrationality, of superstition, of an<br />
immaturity, of a neurosis,” and that “<strong>in</strong>deed if we learn someone is devoutly<br />
religious, or even tends <strong>in</strong> that direction, we look upon that person with<br />
puzzlement, often conclud<strong>in</strong>g that psychologist obviously had or has personal<br />
problems” (Sarason, 1993). In the Diagnostic and Statistic Manual of Mental<br />
Disorders (DSM-III-R), 12 references <strong>to</strong> religion <strong>in</strong> the Glossary of Technical<br />
Terms were used <strong>to</strong> demonstrate psychopathology (American Psychiatric<br />
Association, 1987).<br />
While it is noted that the latest revision of the DSM, the DSM-IV TR<br />
(American Psychiatric Association, 2000), now <strong>in</strong>cludes more culturally sensitive<br />
language, that antireligious perspectives may have <strong>in</strong>fluenced the cl<strong>in</strong>ical<br />
judgment of psychologists and psychiatrists alike, should not be easily dismissed.<br />
Indeed, there is encourag<strong>in</strong>g evidence that some psychologists’ worldviews have<br />
evolved <strong>in</strong> conjunction with the demands for multiculturally appropriate<br />
perspectives as can be seen <strong>in</strong> the morph<strong>in</strong>g views of Albert Ellis. In one earlier<br />
treatise on religiousness and psychotherapy Ellis states that, “If one of the<br />
requisites for emotional health is acceptance of uncerta<strong>in</strong>ty, then religion is<br />
obviously the unhealthiest state imag<strong>in</strong>able” (Ellis, 1980, p. 8), which also implies<br />
by virtue of the religious person’s extreme pathology that he or she is likely the<br />
hardest <strong>to</strong> treat. Indeed, he also stated that “the best the devout religionists can<br />
do, if they want <strong>to</strong> change any of the rules that stem from their doctr<strong>in</strong>es, is <strong>to</strong><br />
change the religion itself” (Ellis, 1980, p. 31). However, Ellis later recants some of<br />
his earlier assertions and reports that his Rational Emotive Behavior Therapy is
6<br />
compatible with some religious views and can be effectively used with patients<br />
who have devout beliefs about God without chang<strong>in</strong>g their religion (Ellis, 2000).<br />
Nevertheless, it is difficult <strong>to</strong> imag<strong>in</strong>e that such evolution <strong>in</strong> th<strong>in</strong>k<strong>in</strong>g about<br />
religiosity and religious persons, as encourag<strong>in</strong>g as it may be, necessarily<br />
represents a sudden and ubiqui<strong>to</strong>us absence of antireligious views <strong>in</strong><br />
psychology. Certa<strong>in</strong>ly, this type of antireligious th<strong>in</strong>k<strong>in</strong>g was common enough <strong>in</strong><br />
the not so distant past that it was acceptable for publication <strong>in</strong> peer-reviewed<br />
journals, which one might assume have some commitment <strong>to</strong> publish culturally<br />
appropriate materials.<br />
Distance between scientific thought and religion or spirituality has likely<br />
been deliberate on the part of psychologists who sought credibility for the<br />
profession as an empirical and nonspeculative science. Strong scientific ideology<br />
may be a cause of cl<strong>in</strong>ician failure <strong>to</strong> assess religion and religious function<strong>in</strong>g as<br />
a part of patient experience <strong>to</strong> be regarded with seriousness and sensitivity. This<br />
separation may be problematic for several reasons accord<strong>in</strong>g <strong>to</strong> contemporary<br />
psychologists <strong>in</strong>terested <strong>in</strong> the <strong>in</strong>terrelated themes between scientific and<br />
religious thought. Three important themes have emerged <strong>in</strong> the literature<br />
(Bilgrave & Deluty, 1998). The first is that the l<strong>in</strong>es between religion and science<br />
have begun <strong>to</strong> blur as the traditional view of science as strictly rational and<br />
empirical has been challenged. Second, therapists use their values <strong>to</strong> guide their<br />
choice of treatment goals and <strong>in</strong>terventions, whether implicitly or explicitly. Last is<br />
the theme that “religion and psychotherapy, at a deep level of analysis, are<br />
functionally and even structurally equivalent” (1998, p. 2). Nevertheless, the
7<br />
nature of the “secular field” of psychology (Berg<strong>in</strong> & Jensen, 1990) as dissimilar<br />
from that of the general population has been the focus of a fair amount of<br />
attention <strong>in</strong> the literature.<br />
Religiosity: <strong>Psychologist</strong>s and the General U.S. Population<br />
Def<strong>in</strong>itions of the terms “spiritual” and “religious” vary <strong>in</strong> the literature,<br />
although most authors are <strong>in</strong> agreement on core themes. For the purposes of the<br />
current discussion, and <strong>in</strong> agreement with those themes, religious persons will<br />
refer <strong>to</strong> those with affiliations with an organized religion. Religious beliefs are<br />
considered “propositional statements (<strong>in</strong> agreement with some organized<br />
religion) that a person holds <strong>to</strong> be true concern<strong>in</strong>g religion or religious spirituality”<br />
(Worth<strong>in</strong>g<strong>to</strong>n, 1996, p.2). Values are superord<strong>in</strong>ate statements about what a<br />
person considers <strong>to</strong> be important <strong>in</strong> life. Worth<strong>in</strong>g<strong>to</strong>n (1996) def<strong>in</strong>es spiritual as<br />
believ<strong>in</strong>g <strong>in</strong> or valu<strong>in</strong>g some higher power other than what is seen <strong>to</strong> exist <strong>in</strong> the<br />
material world. One may be spiritual and religious, religious but not spiritual,<br />
spiritual but not religious, or neither religious nor spiritual. It is also unders<strong>to</strong>od<br />
that the degree of religiosity and spirituality <strong>in</strong> endorsement of beliefs, adherence<br />
<strong>to</strong> associated values, and participation <strong>in</strong> religious or spiritual behaviors, varies<br />
between persons.<br />
The U.S. population may be considered highly religious, with an estimated<br />
94% of the population endors<strong>in</strong>g belief <strong>in</strong> “God or some universal spirit” (Gallup,<br />
1996), 92% be<strong>in</strong>g affiliated with a religion, 84% report<strong>in</strong>g religion as either very or
8<br />
fairly important <strong>in</strong> their lives, and only 3% deny<strong>in</strong>g any beliefs <strong>in</strong> God. The<br />
majority of the population endorses Judeo-Christian affiliations at 76%, with 72%<br />
of those endors<strong>in</strong>g Protestant or Catholic categories (Gallup, 2006), and other<br />
estimates as high as 84% when respondents were offered more choices of<br />
religion <strong>in</strong>clud<strong>in</strong>g Orthodox Greek and Russian Christian affiliations (NewPort,<br />
2004). The religious affiliation endorsed by the largest group of persons is the<br />
Protestant denom<strong>in</strong>ation at 49%. With<strong>in</strong> the Protestant subgroup, 44% endorsed<br />
the category described as either “born aga<strong>in</strong>” or “Evangelical.” Further, when<br />
Evangelical activities and beliefs were measured and used <strong>to</strong> def<strong>in</strong>e<br />
Evangelicalism, <strong>in</strong>clud<strong>in</strong>g believ<strong>in</strong>g the Bible is the actual word of God, be<strong>in</strong>g<br />
born aga<strong>in</strong> or hav<strong>in</strong>g a born aga<strong>in</strong> experience, and encourag<strong>in</strong>g others <strong>to</strong> believe<br />
<strong>in</strong> or accept Jesus Christ, approximately 53% of Protestants, or 1 <strong>in</strong> 5 Americans<br />
(22%), can be considered Evangelical Christians (Gallup, 2005). Other research<br />
estimates that 90% of Americans pray, 71% belong <strong>to</strong> a church or synagogue,<br />
and 42% attend weekly religious services (Hill et al., 2000).<br />
<strong>Psychologist</strong>s have consistently been associated with lower rates of<br />
religious affiliation compared <strong>to</strong> the U.S. public, and even <strong>to</strong> other cl<strong>in</strong>icians and<br />
academicians. One study (Ragan, Malony, & Beit-Hallahmi, 1980) found that<br />
psychologists were much less orthodox <strong>in</strong> both religion and spirituality than had<br />
been previously seen <strong>in</strong> the general academic population, with 34% of<br />
psychologists deny<strong>in</strong>g the existence of God, compared <strong>to</strong> 23% of other<br />
academicians, and 3% of the general U.S. population (Gallup, 2006). In another<br />
study (Berg<strong>in</strong> & Jensen, 1990), religious preferences were rated <strong>in</strong> an
9<br />
<strong>in</strong>terdiscipl<strong>in</strong>ary group of psychotherapists that <strong>in</strong>cluded marriage and family<br />
therapists, cl<strong>in</strong>ical social workers, psychiatrists, and cl<strong>in</strong>ical psychologists.<br />
Differences were seen <strong>in</strong> atheist, agnostic, or no preference categories with a<br />
cumulative sum of 30% of cl<strong>in</strong>ical psychologists, 24% of psychiatrists, 13% of<br />
marriage and family therapists, 9% of cl<strong>in</strong>ical social workers, and 9% of the U.S.<br />
public. Cl<strong>in</strong>ical psychologists expressed slightly more Judeo-Christian<br />
preferences than psychiatrists at 67% and 65% respectively, but less than cl<strong>in</strong>ical<br />
social workers at 82%, and marriage and family therapists at 76%. However,<br />
more recently, Bilgrave and Deluty (1998) found that only 42% of counsel<strong>in</strong>g and<br />
cl<strong>in</strong>ical psychologists endorsed Judeo-Christian affiliations.<br />
While Ragan et al.’s (1980) f<strong>in</strong>d<strong>in</strong>gs that 34% of cl<strong>in</strong>ical psychologists<br />
denied the existence of God led authors <strong>to</strong> conclude that the atheistic stereotype<br />
of psychologists is supported, they also admit that one cannot predict that any<br />
one psychologist will be an atheist. Others po<strong>in</strong>t <strong>to</strong> substantial endorsement of<br />
the religious and spiritual beliefs of psychologists despite the lower frequency<br />
with which they occur relative <strong>to</strong> other groups. For <strong>in</strong>stance, <strong>in</strong> Ragan’s study,<br />
43% of psychologists endorsed belief <strong>in</strong> some transcendent deity. In another<br />
study (Berg<strong>in</strong> & Jensen, 1990), 33% of cl<strong>in</strong>ical psychologists positively endorsed<br />
the item that “my whole approach <strong>to</strong> life is based on my religion,” and 65%<br />
endorsed the statement, “I try hard <strong>to</strong> live my life accord<strong>in</strong>g <strong>to</strong> my religious<br />
beliefs.” Others challenge the atheistic stereotype (Shafranske & Gorsuch, 1984;<br />
Shafranske & Malony, 1990; Smith & Orl<strong>in</strong>sky, 2004) and <strong>in</strong> particular when the<br />
criteria for spirituality are broadened <strong>to</strong> <strong>in</strong>clude personally mean<strong>in</strong>gful experience
10<br />
and focus on discipl<strong>in</strong>e, purpose, belong<strong>in</strong>g, wholeness, and connectedness,<br />
therapists may have substantial spiritual <strong>in</strong>terests. It has also been hypothesized<br />
that some spiritual and religious <strong>in</strong>terests may be relatively unexpressed due <strong>to</strong><br />
the secular nature of psychologists’ education and practice (Berg<strong>in</strong> & Jensen,<br />
1990).<br />
Further, psychologists’ professional organizations concerned with religion<br />
and psychology are often comprised of a significant portion of religious<br />
psychologists <strong>in</strong>terested <strong>in</strong> the <strong>in</strong>terrelation of the two doma<strong>in</strong>s. APA’s Division<br />
36, the division of the psychology of religion, “recognizes the significance of<br />
religion both <strong>in</strong> the lives of people and the discipl<strong>in</strong>e of psychology” (APA, 2007),<br />
and works <strong>to</strong>ward “the re-establishment of the scientific psychology of religion”.<br />
The Christian Association for Psychological Studies (CAPS) is an organization<br />
largely made up of Evangelical Christian psychologists <strong>in</strong>terested <strong>in</strong> the<br />
<strong>in</strong>tegration of psychology and Evangelical Christianity. Specifically, <strong>in</strong>tegration<br />
concerns how psychological theory and research is relevant <strong>to</strong> Christianity and<br />
the generation of study and dialogue about concepts often associated with their<br />
Evangelical faith such as forgiveness, and gratitude (see Ellens & Sanders,<br />
2006; Lewis-Hall, Gorsuch, Malony, Narramore, & Stewart Van Leeuwam, 2006;<br />
Yangarber-Hicks et al., 2006).<br />
Nevertheless, that there are differences between the psychological<br />
community and the general population on religion and spirituality is clear. As the<br />
current Weltanschauung of the Western world <strong>in</strong>cludes both religious and<br />
scientific-humanistic beliefs and values (Bilgrave & Deluty, 1998), we may
11<br />
assume that like the larger population, patients seek<strong>in</strong>g psychological services<br />
will also have worldviews which possess these elements. Consider<strong>in</strong>g the<br />
potential differences <strong>in</strong> worldview between psychologists and patients, and <strong>in</strong><br />
particular associated values which guide what one considers important and what<br />
one does not, it is worth exam<strong>in</strong><strong>in</strong>g how well prepared psychologists are <strong>to</strong> work<br />
with persons who have religiously <strong>in</strong>fluenced worldviews which may be diverse<br />
from their own.<br />
Multicultural Tra<strong>in</strong><strong>in</strong>g and Application of Ethical Responsibilities<br />
Even though approximately 9 out of 10 persons <strong>in</strong> the US (Gallup, 2006),<br />
and up <strong>to</strong> 65% of psychologists (Berg<strong>in</strong> & Jensen, 1990), report that religious<br />
beliefs are important <strong>in</strong> their lives, only 29% of cl<strong>in</strong>ical psychologists (1990), and<br />
50% of rehabilitation psychologists (Shafranske, 2000), believe that attention <strong>to</strong><br />
those cultural beliefs is important <strong>in</strong> their work with patients. Despite demands for<br />
the ethical and sensitive treatment of diverse groups, and the focus on tra<strong>in</strong><strong>in</strong>g <strong>to</strong><br />
effectively deliver multiculturally competent services, there is a noticeable gap <strong>in</strong><br />
the ethical application of those pr<strong>in</strong>ciples with religious patients (Meyer, 1988;<br />
Yarhouse & VanOrman, 1999; Zeiger & Lewis, 1998).<br />
It may be that as a result of divergent religious beliefs and values,<br />
cl<strong>in</strong>icians who do not consider religion important <strong>in</strong> their own lives may simply not<br />
consider it important <strong>in</strong> the lives of their patients and subsequently <strong>to</strong><br />
psychotherapy. It may also be that cl<strong>in</strong>icians deliberately avoid religiously
12<br />
thematic material for a number of reasons <strong>in</strong>clud<strong>in</strong>g fear of approach<strong>in</strong>g what<br />
may be considered a taboo <strong>to</strong>pic. Fears may arise from awareness of a heavy<br />
humanistic <strong>in</strong>fluence <strong>in</strong> the field and a his<strong>to</strong>ry of disparagement of religion from<br />
the early days of Freud <strong>to</strong> more recent theorists such as Albert Ellis.<br />
Alternatively, cl<strong>in</strong>icians may believe that religious issues are generally unrelated<br />
<strong>to</strong> the cl<strong>in</strong>ical presentation or treatment of their patients. Another possibility is that<br />
they may have personal bias aga<strong>in</strong>st such belief systems or those who hold the<br />
beliefs valuable. Additionally, therapists may feel <strong>in</strong>adequate <strong>in</strong> deal<strong>in</strong>g with<br />
religious material <strong>in</strong> a cl<strong>in</strong>ical sett<strong>in</strong>g. Any of these fac<strong>to</strong>rs may result <strong>in</strong> either<br />
deliberate avoidance of the <strong>to</strong>pic, or the management of religiously thematic<br />
material <strong>in</strong> ways which may not respect the patient’s beliefs or value systems.<br />
Currently, levels of tra<strong>in</strong><strong>in</strong>g <strong>in</strong> religious diversity <strong>in</strong> cl<strong>in</strong>ical practice are not<br />
commensurate with the general religiosity of the U.S. public (Brawer, Handal,<br />
Fabrica<strong>to</strong>re, Roberts, & Wajda-Johns<strong>to</strong>n, 2002; Yarhouse & Fisher, 2002). In<br />
response <strong>to</strong> whether religion was covered <strong>in</strong> predoc<strong>to</strong>ral <strong>in</strong>ternship tra<strong>in</strong><strong>in</strong>g<br />
programs, tra<strong>in</strong><strong>in</strong>g direc<strong>to</strong>rs reported that the <strong>to</strong>pic was addressed <strong>in</strong> <strong>in</strong>dividual<br />
supervision “if appropriate,” “it comes up periodically,” “highly variable,” and “only<br />
a couple of supervisors address this issue.” Brawer et al. (2002) also found that<br />
religion as a <strong>to</strong>pic covered <strong>in</strong> APA-accredited graduate programs was largely<br />
unsystematic or it was not covered at all. Another study found that only 5% of<br />
cl<strong>in</strong>ical psychologists had professional religious tra<strong>in</strong><strong>in</strong>g (Shafranske, 1990). An<br />
<strong>in</strong>formal study of cross-cultural and multicultural psychotherapy and counsel<strong>in</strong>g<br />
textbooks revealed a significant lack of coverage of religious aspects of diversity
13<br />
(Richards & Berg<strong>in</strong>, 2000). Although multicultural writers emphasize the<br />
importance of clients’ worldviews and values, religious worldviews and values are<br />
usually not explored <strong>in</strong> multicultural texts at all, or they are given very little<br />
attention.<br />
Some studies found that as a group, counselors (Holcomb-McCoy &<br />
Myers, 1999) and cl<strong>in</strong>icians (Constant<strong>in</strong>e & Ladany, 2000; Worth<strong>in</strong>g<strong>to</strong>n, Mobley,<br />
Franks, & Andreas Tan, 2000) rate themselves as multiculturally competent.<br />
However, self- and other-rat<strong>in</strong>gs of competency <strong>in</strong> cultural case conceptualization<br />
do not necessarily correlate significantly, and self-report measures of cultural<br />
competency have even exhibited no correlation with cultural case<br />
conceptualization ability when social desirability was controlled (Constant<strong>in</strong>e &<br />
Ladany, 2000; R. Worth<strong>in</strong>g<strong>to</strong>n et al., 2000).<br />
Research <strong>in</strong>dicates that levels of multicultural tra<strong>in</strong><strong>in</strong>g and rates of both<br />
affective and cognitive empathy are positively related <strong>to</strong> the ability <strong>to</strong><br />
conceptualize patients’ mental health issues from a diversity perspective when<br />
rated by others (Constant<strong>in</strong>e, 2001) . Further, multicultural tra<strong>in</strong><strong>in</strong>g should<br />
<strong>in</strong>crease awareness of the impact of personal values related <strong>to</strong> religious and<br />
sociopolitical beliefs on the selection of treatment goals and the course of the<br />
treatment process (Fuertes & Brobst, 2002; Holcomb-McCoy & Myers, 1999;<br />
Sue, 1998).<br />
Another study (Hansen et al., 2006) found that among the 91% of cl<strong>in</strong>ician<br />
respondents who rated themselves as somewhat <strong>to</strong> very culturally competent,<br />
there was a significant difference between what they believed <strong>to</strong> be important for
14<br />
culturally competent practice and what they actually did <strong>in</strong> practice. Among<br />
commonly recommended competency practices, several were not performed by<br />
a significant percentage of the group. This <strong>in</strong>cluded 42% who rarely or never<br />
implemented a professional development plan <strong>to</strong> <strong>in</strong>crease their cultural<br />
competence, 39% who rarely or never utilized culturally specific consultation, and<br />
27% who rarely or never referred cultural group members <strong>to</strong> a more qualified<br />
practitioner.<br />
The aforementioned studies exam<strong>in</strong>ed cl<strong>in</strong>ician beliefs and practices<br />
related <strong>to</strong> ethnic and racial groups, which have received significantly more<br />
attention <strong>in</strong> the literature, psychology textbooks, and tra<strong>in</strong><strong>in</strong>g programs than have<br />
the beliefs and practices of religious groups (Richards & Berg<strong>in</strong>, 2000). Logic<br />
would imply that even fewer steps were taken <strong>to</strong>ward cultural competence <strong>in</strong><br />
relation <strong>to</strong> religion by practitioners who have largely reported a lack of concern<br />
for religion <strong>in</strong> their cl<strong>in</strong>ical work.<br />
Cultural competence as perceived by the patient can have an effect on the<br />
patient’s overall satisfaction with treatment. In one study, researchers found a<br />
strong correlation between cultural group members’ rat<strong>in</strong>gs of cl<strong>in</strong>ician cultural<br />
competence and general competency and empathy (Fuertes & Brobst, 2002).<br />
However, significant differences of the variance for m<strong>in</strong>ority groups’ satisfaction<br />
beyond general competency and empathy were expla<strong>in</strong>ed by multicultural<br />
competence.<br />
In summary, there is a deficit <strong>in</strong> tra<strong>in</strong><strong>in</strong>g and education <strong>in</strong> work<strong>in</strong>g with<br />
religious groups. Further, there is often a difference between self- and other-
15<br />
rat<strong>in</strong>gs of multicultural competency. These differences were evidenced <strong>in</strong> rat<strong>in</strong>gs<br />
of competency <strong>in</strong> work<strong>in</strong>g with racially and ethnically diverse patients. As<br />
education and tra<strong>in</strong><strong>in</strong>g <strong>in</strong> work<strong>in</strong>g with racial and ethnic patients is more common<br />
than those concern<strong>in</strong>g cl<strong>in</strong>ical work with religious patients, it is reasonable <strong>to</strong><br />
assume that cultural competence with religious patients may be even more<br />
compromised. Before exam<strong>in</strong><strong>in</strong>g if, and how, the delivery of effective services <strong>to</strong><br />
the group may be affected, it may be helpful <strong>to</strong> first explore the general<br />
stereotyp<strong>in</strong>g and prejudice literature.<br />
The Potential for Compromised Cl<strong>in</strong>ical Efficacy with Religious Persons<br />
Stereotyp<strong>in</strong>g and Prejudice<br />
Stereotyp<strong>in</strong>g can be def<strong>in</strong>ed as the use of expectations or beliefs<br />
associated with a group or group member based on his or her group<br />
membership. Prejudice can be def<strong>in</strong>ed as a valenced evaluation of that group or<br />
group member (Sherman, Conrey, Stroessner, & Azam, 2005). For the purposes<br />
of this paper, bias represents an <strong>in</strong>stance of prejudice, and may manifest <strong>in</strong><br />
either a positive direction, such as bias <strong>to</strong>ward a secular or liberal worldview, or a<br />
negative direction as <strong>in</strong> a bias aga<strong>in</strong>st a religious or conservative worldview.<br />
When there is neglect <strong>in</strong> consider<strong>in</strong>g a group or group member’s cultural
16<br />
differences or the impact of one’s personal beliefs and expectations of that group<br />
or group member <strong>in</strong> a cl<strong>in</strong>ical sett<strong>in</strong>g, bias may occur.<br />
Generally, the stereotyp<strong>in</strong>g and prejudice literature has focused on the<br />
process between groups that are dissimilar on some variable. Byrne’s attraction<br />
paradigm posits that those who are similar <strong>in</strong> some way will be attracted <strong>to</strong> each<br />
other and those that are dissimilar will be repulsed by each other (Byrne, 1971).<br />
Byrne further hypothesized that the similarity and dissimilarity of attitudes and<br />
values is more significant <strong>in</strong> determ<strong>in</strong><strong>in</strong>g attraction or repulsion than are<br />
demographic variables. Bryne showed study participants the attitude scale of a<br />
stranger with either like or discordant attitudes on various <strong>to</strong>pics <strong>in</strong>clud<strong>in</strong>g religion<br />
and politics, and found that “the most negative response <strong>in</strong> the similar attitude<br />
group was more positive than the most positive response <strong>in</strong> the dissimilar attitude<br />
group,” and that the attitude variables were so significant that there was no<br />
overlap between the two conditions.<br />
Subsequent research on the attraction paradigm supports Byrne’s claims<br />
for both the attraction and repulsion phenomenon (Chen & Kenrick, 2002;<br />
Newcomb, 1961); however other research yielded data that supported the<br />
repulsion hypothesis, but not the attraction hypothesis (Rosenbaum, 1986).<br />
Relevant <strong>to</strong> our current concern with potential biased respond<strong>in</strong>g <strong>to</strong> religious<br />
patients by religiously dissimilar cl<strong>in</strong>icians, it is also noted that research that<br />
exam<strong>in</strong>es stereotypes and prejudice for the decades follow<strong>in</strong>g Bryne’s work,<br />
generally focused on negative respond<strong>in</strong>g <strong>to</strong> out-groups. The phenomenon is so<br />
well established that m<strong>in</strong>imal group paradigms, or those groups that differ only <strong>in</strong>
17<br />
irrelevant label<strong>in</strong>g such as assignment <strong>to</strong> group “A” or group “B,” also yielded<br />
prejudiced respond<strong>in</strong>g (Crocker & Schwartz, 1985; Gaertner & Insko, 2000).<br />
The stereotyp<strong>in</strong>g and prejudice literature is volum<strong>in</strong>ous. It encompasses<br />
several processes and many variables. The three categories of processes<br />
<strong>in</strong>volved <strong>in</strong> the development and ma<strong>in</strong>tenance of stereotyp<strong>in</strong>g and prejudice are<br />
motivational, sociocultural, and cognitive (Hil<strong>to</strong>n & Hippel, 1996). Many studies<br />
overlap categories, such as those that exam<strong>in</strong>e the motivational aspects of<br />
reduc<strong>in</strong>g cognitive load (Biernat & Korbrynowicz, 2003), or enhanc<strong>in</strong>g selfevaluation<br />
through social comparison (Brickman & Bulman, 1977; Fest<strong>in</strong>ger,<br />
1954; Taylor & Lobel, 1989).<br />
Sociocultural models <strong>in</strong>clude social comparison perspectives that exam<strong>in</strong>e<br />
how the self is def<strong>in</strong>ed <strong>in</strong> relation <strong>to</strong> others (see Duckitt, Birum, Wagner, &<br />
Plessis, 2002; Brewer & Gardner, 1996; Brickman & Bulman, 1977; Crocker,<br />
McGraw, Thompson, & Ingerman, 1987; Fest<strong>in</strong>ger, 1954; Taylor & Lobel, 1989).<br />
Examples of sociocultural explanations of prejudice <strong>in</strong>clude the effect of social<br />
position and social dom<strong>in</strong>ance orientation on prejudice (Guimond, Dambrun,<br />
Mich<strong>in</strong>ov, & Duarte, 2003), and the tendency <strong>to</strong> compare oneself favorably<br />
aga<strong>in</strong>st a less fortunate target when under threat (Taylor & Lobel, 1989). Other<br />
sociocultural processes are found <strong>in</strong> the <strong>in</strong>- and out-group similarity and<br />
dissimilarity effects literature (Byrne, 1971; Rosenbaum, 1986). Further, the<br />
strength of social identity theory, or the theory that group membership creates<br />
self-identification with an <strong>in</strong>-group that favors the <strong>in</strong>-group at the expense of the
18<br />
out-group, has been explored <strong>in</strong> the m<strong>in</strong>imal group paradigm (Crocker &<br />
Schwartz, 1985; Gaertner & Insko, 2000; Tajfel & Turner, 1986).<br />
Cognitive processes exam<strong>in</strong>e the relationship between variables such as<br />
<strong>in</strong>formation-process<strong>in</strong>g strategies and prejudice (Bodenhausen & Lichtenste<strong>in</strong>,<br />
1987; Hamil<strong>to</strong>n, Sherman, & Ruvolo, 1990; Hamil<strong>to</strong>n & Trolier, 1986). It has long<br />
been hypothesized that stereotyp<strong>in</strong>g can be viewed as a cognitive construct that<br />
is utilized <strong>in</strong> order <strong>to</strong> generate and manage responses <strong>to</strong> an otherwise<br />
overwhelm<strong>in</strong>g amount of <strong>in</strong>formation (Allport, 1954; Bodenhausen & Lichtenste<strong>in</strong>,<br />
1987; Hamil<strong>to</strong>n & Trolier, 1986; Korten, 1973). The use of stereotypes and<br />
stereotype-based expectancies as a <strong>to</strong>ol <strong>to</strong> reduce cognitive load has been<br />
exam<strong>in</strong>ed <strong>in</strong> research on cognitive resource preservation (Biernat &<br />
Korbrynowicz, 2003; Crawford & Skowronski, 1998; Macrae & Milne, 1994;<br />
Yzerbyt & Coull, 1999), as well as research on the relationship between<br />
stereotyp<strong>in</strong>g and cognitive simplicity (Koenig & K<strong>in</strong>g, 1964).<br />
Motivational processes are found <strong>in</strong> much of the stereotype and prejudice<br />
literature, often overlapp<strong>in</strong>g with sociocultural and cognitive explanations. Those<br />
processes <strong>in</strong>clude the motivation <strong>to</strong> <strong>in</strong>crease self-esteem under threat (Crocker &<br />
Luhtanen, 1990), <strong>to</strong> use stereotyp<strong>in</strong>g <strong>to</strong> reduce cognitive load (Biernat &<br />
Korbrynowicz, 2003; Crawford & Skowronski, 1998; Macrae & Milne, 1994;<br />
Yzerbyt & Coull, 1999), and <strong>to</strong> use stereotype <strong>in</strong>formation by those who have a<br />
preference for cognition (Crawford & Skowronski, 1998). The motivation <strong>to</strong><br />
respond without prejudice <strong>to</strong> targets with which one might have knowledge of<br />
stereotyped associations or expectancies has also been of <strong>in</strong>terest (Dev<strong>in</strong>e,
19<br />
Plant, Amodio, Harmon-Jones, & Vance, 2002; Plant & Dev<strong>in</strong>e, 1998).<br />
Specifically, <strong>in</strong> efforts <strong>to</strong> expla<strong>in</strong> differentials <strong>in</strong> how stereotype <strong>in</strong>formation may<br />
be behaviorally expressed, Dev<strong>in</strong>e et al. (2002) and Plant and Dev<strong>in</strong>e (1998)<br />
posit that motivation <strong>to</strong> either suppress stereotype tendencies or ignore<br />
stereotype associations moderates the expression of prejudice.<br />
The effects of both affect and cognition about targets has been exam<strong>in</strong>ed<br />
<strong>in</strong> the literature as well. Stereotype-related affect has been operationalized <strong>in</strong> the<br />
literature <strong>in</strong> several ways <strong>in</strong>clud<strong>in</strong>g “lik<strong>in</strong>g” for targets or target groups (Jussim,<br />
Manis, Nelson, & Soff<strong>in</strong>, 1995), and agreement with mood-affect adjectives about<br />
targets (Jackson & Sullivan, 2001). Stereotype cognition refers <strong>to</strong> beliefs or<br />
expectations about stereotype targets. Research <strong>in</strong>dicates that both affect and<br />
cognition play a role <strong>in</strong> the use of stereotyped and prejudiced respond<strong>in</strong>g.<br />
In summary, it is clear that stereotyp<strong>in</strong>g and prejudice between groups is<br />
common. A large focus of the literature is on understand<strong>in</strong>g various mechanisms<br />
that contribute <strong>to</strong> the development and ma<strong>in</strong>tenance of stereotypes and<br />
prejudiced respond<strong>in</strong>g. The circumstances under which stereotyp<strong>in</strong>g or prejudice<br />
may occur are many. To hypothesize that a cl<strong>in</strong>ician’s emphasis on empathy and<br />
acceptance will necessarily preclude him or her from such a ubiqui<strong>to</strong>us<br />
phenomenon is probably not realistic, although it is hoped that cl<strong>in</strong>icians’ general<br />
tra<strong>in</strong><strong>in</strong>g, cl<strong>in</strong>ical <strong>in</strong>tention, and capacity for <strong>in</strong>trospection at the least will moderate<br />
some of those tendencies. Nonetheless, the possibility of prejudice aga<strong>in</strong>st, and<br />
stereotyp<strong>in</strong>g of, dissimilar groups exists, and cl<strong>in</strong>icians who value empathy and<br />
patient acceptance may also demonstrate biased patterns of respond<strong>in</strong>g. This
20<br />
potential is further evident <strong>in</strong> APA policies that prohibit discrim<strong>in</strong>ation aga<strong>in</strong>st<br />
groups (see APA, 2002 Section 3.01). As Byrne hypothesized, those different <strong>in</strong><br />
values and attitudes may demonstrate even more bias aga<strong>in</strong>st the out-group than<br />
those who are demographically dissimilar. Such may be the case with cl<strong>in</strong>icians<br />
who have religiously diverse attitudes and values than their patients.<br />
Discordant Values and Efficacy of Practice<br />
Without religious tra<strong>in</strong><strong>in</strong>g, <strong>in</strong>sensitive, biased, or un<strong>in</strong>formed approaches<br />
<strong>to</strong> religious patients may significantly impact treatment. For an understand<strong>in</strong>g of<br />
how religiously competent services can be affected by compromised approaches,<br />
one must first look beyond religious affiliation and group membership <strong>to</strong><br />
differences <strong>in</strong> beliefs and values and their behavioral manifestation. Value<br />
systems that arise from religious beliefs are dist<strong>in</strong>ct from the belief system itself.<br />
Recall that religious beliefs can be def<strong>in</strong>ed as “propositional statements (<strong>in</strong><br />
agreement with some organized religion) that a person holds <strong>to</strong> be true<br />
concern<strong>in</strong>g religion or religious spirituality”, and religious values can be def<strong>in</strong>ed<br />
as “superord<strong>in</strong>ate organiz<strong>in</strong>g statements of what a person considers <strong>to</strong> be<br />
important,” that arise from his or her religion (Worth<strong>in</strong>g<strong>to</strong>n, 1996, p.2).<br />
Religious values sometimes stand <strong>in</strong> contrast <strong>to</strong> humanistic values. For<br />
<strong>in</strong>stance, whether one’s particular religious beliefs are consistent with Jewish,<br />
Muslim, or Christian doctr<strong>in</strong>e, a value that arises from each is the importance<br />
placed on some absolute and universal ethics, with less focus on the relative
21<br />
values and situational ethics that are typically encompassed <strong>in</strong> secular<br />
humanistic worldviews. Another religious value is that God is supreme, and<br />
humility and acceptance of div<strong>in</strong>e authority are desirable virtues, rather than<br />
beliefs that either humans are supreme, or no one and noth<strong>in</strong>g is supreme<br />
(Berg<strong>in</strong>, 1980).<br />
In the theoretical literature, other differences between cl<strong>in</strong>ical-humanistic<br />
and theistic values have been proposed and discussed as valuable dist<strong>in</strong>ctions<br />
by proponents of each value system (see Berg<strong>in</strong>, 1980; Walls, 1980) with a third<br />
value system, that of a cl<strong>in</strong>ical-humanistic-atheistic one, added (Ellis, 1980a) .<br />
These themes may appear overly simplistic; however, some contrast<strong>in</strong>g themes<br />
between theistic and cl<strong>in</strong>ical-humanistic values are evident. Some of the thematic<br />
dist<strong>in</strong>ctions that can be made between religious values and humanistic ones are<br />
personal identity that is eternal and derived from the div<strong>in</strong>e and one’s relationship<br />
with the div<strong>in</strong>e, compared with personal identity that is ephemeral and mortal;<br />
love, affection, and self-transcendence as primary, compared with personal<br />
needs and self-actualization as primary; commitment <strong>to</strong> marriage, fidelity, and<br />
loyalty with an emphasis on family life, compared with choice of no marriage,<br />
conventional marriage, or open marriage with emphasis on self-gratification<br />
which considers family life as optional; and personal responsibility for harmful<br />
actions and changes <strong>in</strong> those actions with acceptance of guilt, suffer<strong>in</strong>g, and<br />
contrition as key agents of change, compared with personal responsibility for<br />
one’s own harmful actions with the m<strong>in</strong>imization of guilt, and a focus on relief of<br />
suffer<strong>in</strong>g.
22<br />
In summary, the proposed cl<strong>in</strong>ical-humanistic values can be viewed as<br />
more liberal than their theistic and conservative counterparts. The terms<br />
“conservative” and “liberal” are as operationalized by William S<strong>to</strong>ne, that “a<br />
conservative person is one who is devoted <strong>to</strong> the status quo and who accepts<br />
authority and the norms of society. A liberal is change-oriented and places great<br />
emphasis on <strong>in</strong>dividual freedom, be<strong>in</strong>g opposed <strong>to</strong> the external imposition of<br />
authority” (1994, p. 701). S<strong>to</strong>ne also emphasizes that there are likely no pure<br />
liberals as there are also not likely any pure conservatives, but “that they are all<br />
mixtures, <strong>to</strong> some degree, of oppos<strong>in</strong>g tendencies” (p. 701).<br />
Research <strong>in</strong>dicates that therapists also emphasize values that are more<br />
liberal than those of their clients. They generally endorse lifestyles that are freer,<br />
particularly <strong>in</strong> the sexual area (Khan & Cross, 1983). Differences <strong>in</strong>, and<br />
attitudes <strong>to</strong>ward, sexual values vary <strong>in</strong> relation <strong>to</strong> religious <strong>in</strong>volvement and<br />
political affiliation as well as gender. In one study (Ford & Hendrick, 2003),<br />
politically conservative and Protestant and Catholic therapists endorsed items of<br />
“sex as an expression of love and commitment,” and beliefs about the desirability<br />
of sex as expressed exclusively with<strong>in</strong> marriage and committed relationships,<br />
significantly more than did politically liberal therapists. Nonreligious and Jewish<br />
therapists endorsed greater comfort with homosexuality as natural and same-sex<br />
sexual practices. Politically liberal therapists endorsed items such as<br />
homosexuality as natural, and that marriage provides <strong>to</strong>o many restrictions on<br />
sexual freedom, more frequently than conservative therapists. Overall, therapists<br />
reported be<strong>in</strong>g comfortable work<strong>in</strong>g with a wide variety of sexual values <strong>in</strong>
23<br />
therapy. However, although cl<strong>in</strong>icians report comfortability work<strong>in</strong>g with a variety<br />
of values, they may not be culturally competent <strong>in</strong> do<strong>in</strong>g so with diverse groups.<br />
The values of the cl<strong>in</strong>ician may be reflected <strong>in</strong> the treatment goals they endorse,<br />
which may be discordant with the patients’ value system, or they may ignore the<br />
spiritual or religious function<strong>in</strong>g issues of the patient. Particularly if the therapist is<br />
unaware of the impact of his or her personal values on cl<strong>in</strong>ical work, or biases<br />
aga<strong>in</strong>st the values of others, compromised treatment may result.<br />
The effects of re<strong>in</strong>forcement and nonre<strong>in</strong>forcement of patient values is<br />
evident <strong>in</strong> the outcomes and value convergence literature. Value convergence is<br />
often an <strong>in</strong>dica<strong>to</strong>r of counselor-perceived improved patient outcomes (Beutler &<br />
Bergan, 1991; Worth<strong>in</strong>g<strong>to</strong>n, 1988), however the effects for patient- and otherrated<br />
perceptions of improvement are less strong (Kelly, 1990). One implication<br />
of these f<strong>in</strong>d<strong>in</strong>gs is that cl<strong>in</strong>icians may perceive patients <strong>to</strong> be healthier when<br />
their values more closely match their own. This effect may <strong>in</strong>dicate that valueladen<br />
therapy may seek <strong>to</strong> alter patient values (Beutler, Crago, & Arizmendi,<br />
1986; Beutler & Bergan, 1991; Kelly, 1990; Richards & Berg<strong>in</strong>, 2000;<br />
Worth<strong>in</strong>g<strong>to</strong>n, 1988). As evidenced <strong>in</strong> studies on Carl Rogers’s patterns of<br />
re<strong>in</strong>forcement and nonre<strong>in</strong>forcement of patient verbalizations related <strong>to</strong> values<br />
and differences <strong>in</strong> response style (Murray, 1956; Truax, 1966), even with<strong>in</strong> a<br />
therapy orientation that focuses on acceptance and positive regard, it is <strong>in</strong>dicated<br />
that the values of the therapist <strong>in</strong>fluence the course of therapy, and its perceived<br />
outcomes. Indeed, follow<strong>in</strong>g a discussion on the effects of therapist values on<br />
therapy with religious patients (see Berg<strong>in</strong>, 1980) one author writes, “the fact
24<br />
cited by Berg<strong>in</strong> that, <strong>in</strong> general, the values of psychotherapists differ from the<br />
public’s is not alarm<strong>in</strong>g; it is encourag<strong>in</strong>g”, and further that “we should both<br />
expect and demand that the values of psychotherapists be more carefully<br />
reasoned and, on the whole, more adequate than the values of the general<br />
public” (Walls, 1980, p. 641). Further, Albert Ellis also encouraged therapists <strong>to</strong><br />
capitalize on their power <strong>to</strong> <strong>in</strong>fluence value change <strong>in</strong> their patients (Ellis, 1980).<br />
However, both positions appear <strong>to</strong> be <strong>in</strong> direct conflict with APA’s Pr<strong>in</strong>ciple E<br />
(2002) which discusses cl<strong>in</strong>icians’ responsibility <strong>to</strong> respect group differences.<br />
Also, when a cl<strong>in</strong>ician neglects <strong>to</strong> consider the nature of the patient’s<br />
religious beliefs and values, therapeutic efficacy may be affected, and harm may<br />
even result. In one case of religious neglect <strong>in</strong> therapy, a male therapist work<strong>in</strong>g<br />
with a Latter-Day Sa<strong>in</strong>t (LDS) couple recommended that the couple absta<strong>in</strong> from<br />
sexual relations for the com<strong>in</strong>g week <strong>to</strong> relieve the wife’s feel<strong>in</strong>gs of be<strong>in</strong>g<br />
sexually manipulated. The male therapist then advised the husband <strong>to</strong><br />
masturbate if he found it <strong>to</strong>o difficult <strong>to</strong> refra<strong>in</strong> from be<strong>in</strong>g sexually active, not<br />
realiz<strong>in</strong>g that masturbation was considered a s<strong>in</strong> <strong>in</strong> the LDS church. The therapist<br />
further encouraged the wife <strong>to</strong> seek employment outside of the home when she<br />
relayed feel<strong>in</strong>gs of stress around her homemak<strong>in</strong>g role, aga<strong>in</strong> not realiz<strong>in</strong>g that<br />
they both regarded her homemak<strong>in</strong>g role as sacred and div<strong>in</strong>ely appo<strong>in</strong>ted. The<br />
couple was offended by the therapist’s lack of sensitivity <strong>to</strong> their religious beliefs<br />
and term<strong>in</strong>ated therapy (Richards & Berg<strong>in</strong>, 2000).
25<br />
Other Barriers <strong>to</strong> Effective Treatment<br />
The theoretical and empirical literature also <strong>in</strong>dicates that religious<br />
patients may not receive services comparable <strong>to</strong> those provided <strong>to</strong> secular<br />
patients based on several other fac<strong>to</strong>rs. Those fac<strong>to</strong>rs <strong>in</strong>clude patient<br />
comfortability <strong>in</strong> receiv<strong>in</strong>g services from a secular profession whose values may<br />
be markedly different from their own (Richards & Berg<strong>in</strong>, 2000). It appears there<br />
is public awareness of the differences <strong>in</strong> religious beliefs and values between<br />
cl<strong>in</strong>icians and potential patients and community leaders. Even the most<br />
religiously <strong>in</strong>formed cl<strong>in</strong>ical treatment cannot benefit religious patients if they do<br />
not attend treatment. Many patients express concern that psychologists will not<br />
understand their worldview or may see it as <strong>in</strong>ferior and seek <strong>to</strong> change it, and as<br />
a result many are unlikely <strong>to</strong> seek psychological services (K<strong>in</strong>g, 1978).<br />
Alternately, one analogue study that utilized a young cohort found that some<br />
conservative Christians’ apprehension about therapy does not necessarily<br />
<strong>in</strong>dicate that they will avoid therapy or that their beliefs about therapy as effective<br />
are necessarily compromised (Gu<strong>in</strong>ee & Tracey, 1997).<br />
Reduced credibility and trust with religious patients, communities, and<br />
leaders may occur and contribute <strong>to</strong> patient decisions not <strong>to</strong> avail themselves of<br />
much needed services (Richards & Berg<strong>in</strong>, 2000; Worth<strong>in</strong>g<strong>to</strong>n & Sandage,<br />
2001). While one could argue that it is each person’s responsibility <strong>to</strong> seek<br />
psychological help if he or she needs it, it is also appropriate that health<br />
practitioners prepare themselves <strong>to</strong> provide services that are culturally empathic
26<br />
and competent as they strive <strong>to</strong> serve a diverse public that may have awareness<br />
of therapist’s worldviews and values that may conflict with their own. The<br />
decision not <strong>to</strong> enter therapy can have tragic results. This is illustrated <strong>in</strong> the<br />
case of a depressed religious man who refused <strong>to</strong> enter psychotherapy claim<strong>in</strong>g<br />
that “those immoral anti-God psychotherapists can’t be trusted” (Richards &<br />
Berg<strong>in</strong>, 2000, p.11). His mistrust of psychotherapy unfortunately may have been<br />
shared by his pas<strong>to</strong>r who did not refer him <strong>to</strong> therapy. Six weeks follow<strong>in</strong>g a job<br />
loss, the man committed suicide.<br />
Other cl<strong>in</strong>ical concerns may arise <strong>in</strong> relation <strong>to</strong> religiously oriented issues<br />
<strong>in</strong> therapy. Worth<strong>in</strong>g<strong>to</strong>n and Sandage (2001) cites five such examples. First,<br />
highly religious patients may request religious therapy and may question their<br />
therapist regard<strong>in</strong>g their religious views. The therapist who is unfamiliar and<br />
untra<strong>in</strong>ed <strong>in</strong> work<strong>in</strong>g with highly religious patients may view the question<strong>in</strong>g as<br />
aggressive, defensive, or anxious. Also, patients may <strong>in</strong>sist that religious<br />
<strong>in</strong>fluence not be part of therapy. Next, if the therapist’s approach <strong>to</strong> religion is<br />
implicit, disagreement on some fundamental beliefs may impair even the most<br />
<strong>to</strong>lerant therapists’ ability <strong>to</strong> help. Level of acculturation plays a role <strong>in</strong> the<br />
patient’s religious beliefs and identity, with generational and geographical<br />
<strong>in</strong>fluences sometimes contribut<strong>in</strong>g <strong>to</strong> religious or spiritual confusion. Patients<br />
should also be seen as part of a relational system, <strong>in</strong>clud<strong>in</strong>g as part of a couple,<br />
family, church, or community with variations <strong>in</strong> religious commitment,<br />
development, values, and function<strong>in</strong>g. Lastly, personal sociopolitical and religious<br />
values and preferences may contribute <strong>to</strong> affective or cognitive bias aga<strong>in</strong>st
27<br />
conservative religious persons whose beliefs and values are markedly different<br />
from those of the cl<strong>in</strong>ician, particularly as the impact of the cl<strong>in</strong>ician’s personal<br />
beliefs on therapy goes unexam<strong>in</strong>ed.<br />
Sociopolitical Trends, Religiosity, and Affect<br />
Multicultural tra<strong>in</strong><strong>in</strong>g programs sensitive <strong>to</strong> religious diversity, and<br />
proponents of the representation of sociopolitical diversity <strong>in</strong> psychology, both<br />
emphasize the importance of awareness of the impact of sociopolitical <strong>in</strong>fluences<br />
on both research and cl<strong>in</strong>ical practice (Fuertes & Brobst, 2002; Redd<strong>in</strong>g, 2002;<br />
Wester & Vogel, 2002). Awareness of sociopolitical <strong>in</strong>fluences is key <strong>in</strong> provid<strong>in</strong>g<br />
culturally competent services <strong>to</strong> religiously diverse patients. The relationship<br />
between sociopolitical views and religion is often assumed, and perhaps largely<br />
exaggerated <strong>in</strong> the popular press. However, some evidence for a relationship<br />
between the two has been observed. To exam<strong>in</strong>e the importance of this<br />
relationship and its potential impact on patients, it is necessary <strong>to</strong> briefly discuss<br />
the current sociopolitical trends.<br />
The political literature explores the assumption that liberalism may be<br />
thought of as the opposite of conservatism, and that each is <strong>to</strong> some extent<br />
represented <strong>in</strong> politics by the Republican or Democratic parties (Kerl<strong>in</strong>ger, 1984).<br />
While this unipolar or “polarized” view of the cultural differences of American<br />
sociopolitical groups has been viewed as overly simplistic and reductive, that a
28<br />
political divide <strong>in</strong> America exists is generally agreed upon <strong>in</strong> the social<br />
psychology (Seyle & Newman, 2006) and political (Wallis, 2005) literature.<br />
Further, a trend for religiosity <strong>to</strong> fluctuate with sociopolitical selfidentification<br />
has empirical support. Older studies emphasized the correlation<br />
between <strong>in</strong>creased religiosity and political conservatism (Allport & Ross, 1967;<br />
Batson, 1976; Gorsuch & Aleshire, 1974). More recently and more specifically,<br />
research <strong>in</strong>dicated that Evangelical or born-aga<strong>in</strong> Christians and Mormons were<br />
most likely <strong>to</strong> identify with the Republican Party, while Buddhists, Jews, Muslims,<br />
and those with no religion, had a greater preference for the Democratic Party<br />
(The Graduate Center, 2001) . Another study (W<strong>in</strong>seman, 2005) <strong>in</strong>dicated that<br />
those who reported no religion were more affiliated with liberal ideologies, belong<br />
<strong>to</strong> younger age groups, and were represented with a slight skew <strong>to</strong>ward higher<br />
education (where 12% of “nones” have some college education versus 9% that<br />
have a high school education.) Further, liberal political ideology was associated<br />
with a more secular worldview than a conservative one. Those who reported<br />
hav<strong>in</strong>g no political affiliation were also least likely <strong>to</strong> claim any religious affiliation.<br />
The relationship is explored <strong>in</strong> data provided by the Gallup Organization (M.A.<br />
Strausberg, personal communication, April 17, 2006) <strong>in</strong> which 73% of selfdeclared<br />
politically conservative persons reported that religion is very important<br />
<strong>in</strong> their lives, compared <strong>to</strong> 45% of political liberals. Further, Evangelical<br />
Christians, presumably a fairly conservative group, skew strongly Republican<br />
(Newport & Carroll, 2005).
29<br />
The divide may contribute <strong>to</strong> affectively charged feel<strong>in</strong>gs about whether<br />
and how secular or religious worldviews <strong>in</strong>fluence American politics (Wallis,<br />
2005). Sixty-two percent of Republican college students believe that the impact<br />
of religion on daily American life is decl<strong>in</strong><strong>in</strong>g, and by a marg<strong>in</strong> of 7 <strong>to</strong> 1 believe<br />
this <strong>to</strong> be a “bad th<strong>in</strong>g,” whereas 54% of college Democrats believe religion <strong>to</strong> be<br />
<strong>in</strong>creas<strong>in</strong>g <strong>in</strong> <strong>in</strong>fluence, and by a 2 <strong>to</strong> 1 marg<strong>in</strong> believe this <strong>to</strong> be a “bad th<strong>in</strong>g”<br />
(Shaheen et al., 2006). Differences between political parties <strong>in</strong> whether<br />
politicians should talk openly about their religion, and whether religion should<br />
<strong>in</strong>fluence policy, also reflect that divide.<br />
<strong>Psychologist</strong>s’ ideology has also been explored. Seventy percent of<br />
psychologists identified themselves as Democrat and only 21% as Republican <strong>in</strong><br />
one study (McCl<strong>in</strong><strong>to</strong>ck, Spauld<strong>in</strong>g, & Turner, 1965). In a series of four studies<br />
between 1969 and 1989 (American Enterprise Institute, 1991), 68% of<br />
psychology faculty members self-identified as liberal and only 15% self-identified<br />
as conservative.<br />
Other literature recognizes the lack of sociopolitical diversity <strong>in</strong> the field,<br />
and <strong>in</strong> particular the absence of conservative <strong>in</strong>fluences, and advocates for more<br />
diverse representations and less bias <strong>in</strong> research, policy advocacy, professional<br />
education, and practice (e.g., Brand, 2002; Johnson, Nielson, & Ridley, 2000;<br />
Redd<strong>in</strong>g, 2001; Richards & Davison, 1992; Wester & Vogel, 2002). Redd<strong>in</strong>g<br />
(2001) asserts that due <strong>to</strong> an obvious trend <strong>to</strong>ward sociopolitical homogeneity<br />
with<strong>in</strong> the profession of psychology, and an unspoken assumption that<br />
psychologists must share the same liberal worldview, even psychologists with
30<br />
more sociopolitical or religiously conservative views may be excluded or<br />
marg<strong>in</strong>alized, which <strong>in</strong> turn can have several negative consequences. These<br />
<strong>in</strong>clude the impediment of services <strong>to</strong> conservative patients, biased research on<br />
social policy issues, damage <strong>to</strong> psychology’s credibility with policymakers and<br />
the public as a descriptive rather than a prescriptive science, and discrim<strong>in</strong>ation<br />
aga<strong>in</strong>st scholars and students (2001), particularly those who hold more<br />
conservative worldviews and who are develop<strong>in</strong>g a grow<strong>in</strong>g sense of themselves<br />
as therapists (Wester & Vogel, 2002).<br />
In summary, as recent trends evidence some level of polarity between<br />
political parties, whether exaggerated <strong>in</strong> the popular press or not, and the<br />
relationship between religious conservatism or liberalism and political party<br />
endorsement has been seen <strong>in</strong> the empirical literature, affect surround<strong>in</strong>g either<br />
position may occur. It is possible that any negative affect or biased beliefs about<br />
groups often seen as “polar” opposites <strong>in</strong> worldviews may generalize <strong>to</strong> the<br />
cl<strong>in</strong>ical sett<strong>in</strong>g. Is it possible that empathy might be affected with<strong>in</strong> the<br />
relationship if such “polar” worldviews are present?<br />
Empathy<br />
The concept of empathy has generated a plethora of research follow<strong>in</strong>g<br />
Carl Rogers’ writ<strong>in</strong>gs of its importance <strong>in</strong> psychotherapy. Empathy has been<br />
thought <strong>to</strong> be a primary fac<strong>to</strong>r <strong>in</strong> discrim<strong>in</strong>at<strong>in</strong>g effectiveness of therapy. Indeed,<br />
Rogers (1957) made the case that empathy and related constructs are all that is
31<br />
needed <strong>to</strong> produce positive change <strong>in</strong> a patient. Operationally, empathy has been<br />
described several ways. These <strong>in</strong>clude cognitive dimensions such as vicarious<br />
<strong>in</strong>trospection (Kohut, 1977 p. 459), and affective dimensions or “vicariously<br />
experienced emotion” (Strayer, 1990, p.225). Either of these may be achieved<br />
“through the therapists sensitive ability and will<strong>in</strong>gness <strong>to</strong> understand the client’s<br />
thoughts, feel<strong>in</strong>gs, and struggles from the client’s po<strong>in</strong>t of view,” and “<strong>to</strong> adopt his<br />
frame of reference” (Rogers, 1980, p. 85). It has also been described as see<strong>in</strong>g<br />
the world through the eyes of another (Ivey, Ivey, & Simek-Morgan, 1993).<br />
Various dimensional components of empathy have also been exam<strong>in</strong>ed.<br />
They <strong>in</strong>clude empathic resonance, expressed empathy and received empathy<br />
(Barrett-Lennard, 1981), cognitive perspectives which seek <strong>to</strong> understand the<br />
thoughts and feel<strong>in</strong>gs of others, affective empathy <strong>in</strong> which one seeks <strong>to</strong><br />
experience a sense of feel<strong>in</strong>g and shar<strong>in</strong>g <strong>in</strong> another’s emotions (Mehrabian &<br />
Epste<strong>in</strong>, 1972), and approaches which comb<strong>in</strong>e cognitive and affective aspects<br />
of empathy (Bilgrave & Deluty, 1998; Davis, 1983; Strayer, 1990). Much of<br />
empathy-related theory and research is focused on empathy as a disposition or<br />
personality trait (see Davis, 1994; Duan & Hill, 1996; Eisenberg et al., 1994;<br />
Eisenberg & Lennon, 1983; Hous<strong>to</strong>n, 1990). One perspective often used <strong>in</strong> the<br />
psychological literature is Davis’s (1994) multidimensional approach <strong>to</strong> empathy.<br />
Davis’s Interpersonal Reactivity Index measures four dimensions of empathy.<br />
The constructs are Personal Distress, or the tendency <strong>to</strong> experience discomfort<br />
<strong>in</strong> response <strong>to</strong> the distress of others; Fantasy, which is the ability <strong>to</strong> transpose<br />
oneself <strong>in</strong><strong>to</strong> imag<strong>in</strong>ary situations; and particularly salient <strong>to</strong> the psychotherapist is
32<br />
Perspective Tak<strong>in</strong>g or the tendency <strong>to</strong> adopt the psychological view of others;<br />
and Empathic Concern or the tendency <strong>to</strong> experience warmth, concern, and<br />
compassion for others.<br />
Acceptance as a foundation <strong>to</strong> empathy has also been discussed (Ivey et<br />
al., 1993; Rogers, 1957). Rogers’ theory of unconditional positive regard as<br />
necessary for an effective therapeutic relationship, underscores the importance<br />
of acceptance of the patient. He further describes specific actions and skills <strong>in</strong><br />
demonstrat<strong>in</strong>g an empathic attitude and <strong>in</strong> communicat<strong>in</strong>g empathy and<br />
understand<strong>in</strong>g of the client. These skills generally <strong>in</strong>clude reflective statements<br />
that deliberately preclude the <strong>in</strong>fluence or communication of one’s own thoughts<br />
or ideas. It is reasonable <strong>to</strong> assume that if the <strong>in</strong>fluence of one’s thoughts or<br />
ideas goes unexam<strong>in</strong>ed, that this may be difficult or even impossible <strong>to</strong> do.<br />
Culture also impacts the understand<strong>in</strong>g of, and empathy for, others (Ivey<br />
et al., 1993). Cl<strong>in</strong>icians’ ability <strong>to</strong> empathize with their religiously diverse patients<br />
may significantly affect whether or not they are able <strong>to</strong> provide culturally<br />
competent services. In multicultural psychotherapy, Ivey et al. (1993) posit that<br />
“the concept of respectfully enter<strong>in</strong>g the other person’s world has profound<br />
implications” which echoes APA mandates that “multicultural empathy requires<br />
that we respect worldviews different from our own” (1993, p.25). Further, Ridley<br />
and L<strong>in</strong>gle (1996) def<strong>in</strong>ed cultural empathy as the therapist’s tendency <strong>to</strong><br />
understand the experience of culturally diverse patients based on the therapists’<br />
<strong>in</strong>terpretations of “cultural data.” Ivey et al. (1993) stipulated that positive regard<br />
as a precursor <strong>to</strong> empathy requires that we f<strong>in</strong>d positives <strong>in</strong> that data, and
33<br />
positives with<strong>in</strong> the worldviews and attitudes of culturally diverse patients.<br />
F<strong>in</strong>d<strong>in</strong>g positives <strong>in</strong> a worldview with which one may strongly disagree, or that<br />
one has strong negative affect about, may be difficult for the most empathic<br />
psychotherapist.<br />
Subtle messages of approval or disapproval of worldviews with which one<br />
disagrees, has negative affect about, or which is judged <strong>in</strong>ferior or unhealthy,<br />
may be communicated <strong>to</strong> the patient, perhaps without the awareness of the<br />
therapist. Patterns of respond<strong>in</strong>g may manifest <strong>in</strong> duration and frequency of eye<br />
contact, affirm<strong>in</strong>g or disconfirm<strong>in</strong>g facial expressions, verbalizations, or gestures.<br />
Even Carl Rogers evidenced repeated patterns of re<strong>in</strong>forcement or<br />
nonre<strong>in</strong>forcement of value-laden patient communications (Truax, 1966) and<br />
similarity of patient style of expression (Murray, 1956). His patterns of respond<strong>in</strong>g<br />
were noted <strong>to</strong> lead <strong>to</strong> altered patient behavior, despite presumed attempts <strong>to</strong><br />
respond <strong>in</strong> an accept<strong>in</strong>g and empathic manner without <strong>in</strong>fluence of his own<br />
thoughts, ideas, or feel<strong>in</strong>gs.<br />
When work<strong>in</strong>g with religiously diverse patients, particularly those whose<br />
religious worldviews and values may elicit affective charge or negative cognitive<br />
appraisals, it may be more difficult <strong>to</strong> have empathy for the dissimilar patient,<br />
than the religiously similar patient. One study of dimensional empathy <strong>in</strong>dicated<br />
that therapists high <strong>in</strong> affective and cognitive empathy demonstrated <strong>in</strong>creased<br />
cultural conceptualization skills, and those high <strong>in</strong> affective empathy were more<br />
aware of cultural fac<strong>to</strong>rs <strong>in</strong> conceptualization that those with low empathy<br />
(Constant<strong>in</strong>e, 2001). In another study (Burkard & Knox, 2004), psychologists who
34<br />
were will<strong>in</strong>g <strong>to</strong> acknowledge the impact of race <strong>in</strong> patients’ lives, demonstrated<br />
more empathy than those rated as “color bl<strong>in</strong>d” or racist.<br />
In conclusion, empathy is viewed as a corners<strong>to</strong>ne of psychotherapy that<br />
seeks <strong>to</strong> understand and respect the patient’s experience. However, even<br />
cl<strong>in</strong>icians who most value an empathic stance <strong>to</strong>ward their patients may be<br />
unaware of respond<strong>in</strong>g that alters the patient’s behavior. <strong>Implicit</strong> or explicit<br />
patterns of respond<strong>in</strong>g may be value-laden enough <strong>to</strong> change the course of<br />
therapy and treatment outcomes. Explicit recommendations <strong>to</strong> encourage value<br />
change are <strong>in</strong> contradiction <strong>to</strong> APA’s guidance (see APA, 2002, Pr<strong>in</strong>ciple E)<br />
about respect<strong>in</strong>g group differences. For obvious reasons, respond<strong>in</strong>g <strong>to</strong> patients’<br />
cultural values <strong>in</strong> a way that explicitly encourages change, clearly impacts one’s<br />
ability <strong>to</strong> communicate empathy and positive regard for the worldview that is<br />
perceived <strong>to</strong> be <strong>in</strong> need of change. If <strong>in</strong>deed it is true that empathy is key <strong>in</strong><br />
form<strong>in</strong>g a therapeutic relationship and effect<strong>in</strong>g treatment outcomes, impaired<br />
empathy with diverse groups can impact the course and efficacy of treatment.<br />
Religion and Mental Health<br />
In addition <strong>to</strong> the possibility of transferr<strong>in</strong>g negative affect associated with<br />
the cl<strong>in</strong>ician’s personal religious and/or sociopolitical beliefs and experiences <strong>to</strong><br />
the therapeutic sett<strong>in</strong>g, therapists may have cognitive appraisals of religious<br />
patients as more mentally ill than their nonreligious counterparts. If cl<strong>in</strong>icians<br />
believe there is an association between religiosity and poor mental health, <strong>in</strong>itial
35<br />
impressions of the patient may be affected. Initial impressions of patients which<br />
<strong>in</strong>clude personal lik<strong>in</strong>g for the patient, therapist assessment of patient’s potential<br />
for change, and ease of patient expression, may have an effect on treatment<br />
outcomes <strong>in</strong> several ways. These <strong>in</strong>clude therapist satisfaction with patient<br />
progress, therapist perception of patient satisfaction, and type of term<strong>in</strong>ation<br />
(Brown, 1970). Also, the patient’s religiosity or associated values may be<br />
targeted for change if it is evaluated as a contribu<strong>to</strong>r <strong>to</strong> poor mental health.<br />
Lastly, the patient who is viewed <strong>to</strong> have poorer mental health may also be seen<br />
<strong>to</strong> have a poorer prognosis. Expectations that are based on stereotyped<br />
<strong>in</strong>formation have been associated with effects on <strong>in</strong>formation process<strong>in</strong>g and<br />
judgments, <strong>in</strong>formation seek<strong>in</strong>g and hypothesis test<strong>in</strong>g, and <strong>in</strong>terpersonal<br />
behavior via self-fulfill<strong>in</strong>g prophecies (Hamil<strong>to</strong>n et al., 1990). It is reasonable <strong>to</strong><br />
assume that therapists may also be affected by expectations of patient prognosis<br />
or outcomes based on stereotyped appraisals of their religiosity and<br />
subsequently adjust their cl<strong>in</strong>ical approach accord<strong>in</strong>gly.<br />
As we have seen, his<strong>to</strong>rically there has been some disparagement of<br />
religion with<strong>in</strong> the field of psychology for various reasons. Sigmund Freud<br />
offered that God is “noth<strong>in</strong>g but an exalted father” (Freud, 1913/2000, p. 256),<br />
and that all faith was at least neurotically determ<strong>in</strong>ed (Freud, 1913/2000, pp. 174-<br />
281). Freud either ignored healthy and nonpathological faith or simply did not<br />
believe that it existed. His aggrandizement of the scientific worldview and<br />
sweep<strong>in</strong>g disparagement of those who endorse religious and spiritual beliefs is<br />
echoed 67 years later by Albert Ellis. Prior <strong>to</strong> recant<strong>in</strong>g some of his views
36<br />
recently (Ellis, 2000), Ellis was clear <strong>in</strong> articulat<strong>in</strong>g his beliefs that religious<br />
persons are quite emotionally disturbed, and even suffer from the most severe of<br />
disturbances (Ellis, 1980, p. 8).<br />
Ideological <strong>in</strong>fluences are evident <strong>in</strong> psychological scales purported <strong>to</strong><br />
assess mental health or development. These do not consider an understand<strong>in</strong>g<br />
of the religious persons’ worldview and may characterize religious persons as<br />
Ellis describes, irrational and dogmatic, and even morally less well developed<br />
(see Altemeyer & Hunsberger, 1992; Richards & Davison, 1992) . C.S. Lewis<br />
cautions aga<strong>in</strong>st hold<strong>in</strong>g up a view of Christianity that a small child might take<br />
and present<strong>in</strong>g it <strong>in</strong> its concretized and overly simplistic form as an expression of<br />
the whole breadth and depth of Christian religious thought (Lewis, 2001). For<br />
<strong>in</strong>stance, the assessment of narrow-m<strong>in</strong>ded authoritarian fundamentalism can be<br />
attributed <strong>to</strong> antireligious, and overly reductive ideological statements <strong>in</strong> the<br />
Religious Fundamentalism Scale (Altemeyer & Hunsberger, 1992). This scale<br />
forces religious persons <strong>to</strong> choose between severely concrete “unsympathetic<br />
normative assumptions” (Watson et al., 2003) or deny<strong>in</strong>g their religious beliefs.<br />
An example of such splitt<strong>in</strong>g is the statement “whenever science and sacred<br />
scripture conflict, science must be wrong,” rather than a more culturally<br />
appropriate alternative such as “God’s hand is <strong>in</strong> all creation and <strong>in</strong> all truth; so<br />
conflicts between faith and science should not frighten us, but rather <strong>in</strong>spire us <strong>to</strong><br />
seek God’s truth” (2003).<br />
Unfortunately, claims made by figures such as Freud (1913/2000), Ellis<br />
(1980), and (Watters, 1992), that religious persons are irrational, neurotic, and
37<br />
generally emotionally unhealthy, and that religious psychologists may be<br />
assumed <strong>to</strong> have or have had personal problems (Sarason, 1993) cannot be<br />
easily dismissed. They have been made over time by <strong>in</strong>fluential psychologists,<br />
and they may represent the views of other psychologists or may further <strong>in</strong>fluence<br />
the therapist’s conceptualization of religious persons. On the heels of those<br />
claims, whether there is a relationship between religion and mental health is a<br />
question worth <strong>in</strong>vestigat<strong>in</strong>g.<br />
Contrary <strong>to</strong> broad assertions about the relationship between poor mental<br />
health and religiosity, two meta-analytic studies (Berg<strong>in</strong>, 1983; Gartner, Larson, &<br />
Allen, 1991) yielded no evidence and <strong>in</strong>consistent evidence respectively. A<br />
careful review of the literature (Gartner et al., 1991) revealed that differences <strong>in</strong><br />
variables and measures may contribute <strong>to</strong> former mixed f<strong>in</strong>d<strong>in</strong>gs. For example,<br />
trends <strong>to</strong>ward negative religious cop<strong>in</strong>g (religious discontent, punish<strong>in</strong>g God<br />
reappraisals) are associated with poorer mental health, while positive religious<br />
cop<strong>in</strong>g (seek<strong>in</strong>g spiritual support, religious forgiveness, and benevolent religious<br />
reappraisal) is expressed more frequently and associated with better mental<br />
health (Pargament, Smith, Koenig, & Perez, 1998). The differences <strong>in</strong> f<strong>in</strong>d<strong>in</strong>gs <strong>in</strong><br />
the two styles of religious cop<strong>in</strong>g emphasize that when draw<strong>in</strong>g conclusions<br />
about religiosity and mental health, it is as important <strong>to</strong> operationalize and<br />
dist<strong>in</strong>guish between types of religiosity, as it is <strong>to</strong> dist<strong>in</strong>guish between good and<br />
bad therapy.<br />
Also, extr<strong>in</strong>sic religiosity (religiosity used as a means <strong>to</strong> another end such<br />
as <strong>in</strong>creased social status) moderated an overall mild association between
38<br />
religiousness and fewer depressive symp<strong>to</strong>ms, while positive religious cop<strong>in</strong>g<br />
and an <strong>in</strong>tr<strong>in</strong>sic orientation (one <strong>in</strong> which religion is an end <strong>in</strong> itself) were<br />
associated with lower levels of depression (Smith, McCullough, & Poll, 2003) as<br />
well as lower levels of manifest anxiety (Berg<strong>in</strong>, Masters, & Richards, 1987).<br />
Moreover, <strong>in</strong>creased associations between general psychological well-be<strong>in</strong>g and<br />
religion were demonstrated <strong>in</strong> a Christian sample (Francis & Peter, 2002), and<br />
positive religious cop<strong>in</strong>g has been consistently associated with improved mental<br />
health <strong>in</strong> patients experienc<strong>in</strong>g chronic pa<strong>in</strong> (see Rippentrop, 2005 for review)<br />
and rehabilitation (Kilpatrick & McCullough, 1999). Lastly, a review of religiosity<br />
and mental health was summarized by the conclusion that “devout religiousness<br />
and frequent <strong>in</strong>volvement <strong>in</strong> both private and public religious activities are<br />
associated with better mental health” (Koenig, 1997 p. 101).<br />
In summary, <strong>in</strong> this section we have briefly explored the frequent use of<br />
stereotyp<strong>in</strong>g and prejudice of out-groups under various conditions and for various<br />
reasons. Further, we have explored whether or not the effect of psychologists’<br />
emphasis on empathy and acceptance precludes them from respond<strong>in</strong>g <strong>to</strong> their<br />
religious patients <strong>in</strong> ways that are culturally compromised or with less positive<br />
regard than their nonreligious counterparts. We have discussed the potential for<br />
affect <strong>to</strong> be associated with cl<strong>in</strong>icians’ responses <strong>to</strong> religious, and <strong>in</strong> particular<br />
religiously conservative, patients. Several fac<strong>to</strong>rs were explored that can<br />
contribute <strong>to</strong> the un<strong>in</strong>formed, neglectful, or biased respond<strong>in</strong>g <strong>to</strong> religiously<br />
diverse patients. These <strong>in</strong>clude the lack of multicultural tra<strong>in</strong><strong>in</strong>g with an emphasis<br />
on the need for the personal evaluation of the impact of one’s sociopolitical
39<br />
ideology, personal beliefs and prejudices, and tra<strong>in</strong><strong>in</strong>g specific <strong>to</strong> assess<strong>in</strong>g,<br />
understand<strong>in</strong>g, and work<strong>in</strong>g with persons with religious worldviews. Liberal<br />
trends <strong>in</strong> academic, cl<strong>in</strong>ical, and research psychology have been discussed, and<br />
have been recognized and discussed by those <strong>in</strong>terested <strong>in</strong> sociopolitical<br />
pluralism which <strong>in</strong>cludes a more adequate representation of sociopolitical<br />
diversity <strong>in</strong> psychology. Cognitive evaluations of religious persons as neurotic,<br />
irrational, illogical, emotionally unhealthy, and dogmatic have been demonstrated<br />
by primary theorists and implicitly validated through the publication of these<br />
antireligious views. Given these considerations, what does the literature <strong>to</strong> date<br />
on cl<strong>in</strong>ical bias with religious patients yield?<br />
The Current Research<br />
Literature on <strong>Bias</strong> with Religious Patients<br />
Studies on bias aga<strong>in</strong>st religious patients have been <strong>in</strong>consistent <strong>to</strong> date.<br />
Methodological concerns <strong>in</strong>dicate that conclusions and generalizability of results<br />
should be considered carefully. Negative f<strong>in</strong>d<strong>in</strong>gs were reported <strong>in</strong> several<br />
studies with problematic methodology.<br />
Reed (1992) <strong>in</strong>vestigated cl<strong>in</strong>ician assessment of pathology and prognosis<br />
of religious or nonreligious couples who were referred for adoption evaluations.<br />
No bias was found <strong>in</strong> this study. Another study with negative results often cited <strong>in</strong><br />
the literature is Wadsworth and Checketts’ study (1980) of potential cl<strong>in</strong>ical bias
40<br />
<strong>in</strong> cl<strong>in</strong>ician/patient dyads with dissimilar religious values. Houts and Graham<br />
(1986) also found no cl<strong>in</strong>ical bias <strong>in</strong> prognosis, pathology, and <strong>in</strong>ternal versus<br />
external attributions of patient difficulties with religious patients. However, other<br />
studies uncovered bias (Gartner, 1990; O'Connor & Vandenberg, 2005.). A<br />
closer look at each study is warranted <strong>to</strong> understand f<strong>in</strong>d<strong>in</strong>gs more clearly and <strong>in</strong><br />
determ<strong>in</strong><strong>in</strong>g directions for future research that seeks <strong>to</strong> resolve <strong>in</strong>consistent<br />
results and methodological shortcom<strong>in</strong>gs.<br />
Two studies (Houts & Graham, 1986; Lewis & Lewis, 1985) failed <strong>to</strong> f<strong>in</strong>d<br />
significant bias <strong>in</strong> the assessment of pathology with religious persons. Both of<br />
these studies were conducted us<strong>in</strong>g populations <strong>in</strong> geographical regions which<br />
may be presumed <strong>to</strong> be conservative (the South and the Midwest). It is not<br />
known what impact ongo<strong>in</strong>g exposure <strong>to</strong> a culture dissimilar <strong>to</strong> one’s own may<br />
have on stereotype or prejudice formation and ma<strong>in</strong>tenance of the group. In other<br />
words, it is possible that the dissimilar group’s status as an outgroup has less<br />
impact on stereotyp<strong>in</strong>g when there is significantly more familiarization with the<br />
group, than with groups that are <strong>in</strong> the m<strong>in</strong>ority and may thereby be more easily<br />
perceived as deviat<strong>in</strong>g from the norm.<br />
Work on the attitud<strong>in</strong>al effects of exposure <strong>to</strong> a target <strong>in</strong>dicate that mere<br />
exposure facilitates lik<strong>in</strong>g, relative <strong>to</strong> attitudes <strong>to</strong>ward targets <strong>to</strong> which one has no<br />
exposure (Zajonc, 1968). This exposure effect, or the phenomenon that<br />
“familiarity breeds lik<strong>in</strong>g,” is demonstrated <strong>in</strong> <strong>in</strong>terpersonal attractiveness<br />
research <strong>in</strong> which a target is perceived as more <strong>in</strong>telligent and attractive when<br />
exposure occurs more frequently. It is possible that this effect may moderate
41<br />
biased respond<strong>in</strong>g <strong>in</strong> areas <strong>in</strong> which religious groups are the norm, and thereby<br />
more familiar <strong>to</strong> cl<strong>in</strong>icians. Research <strong>in</strong>dicates that cl<strong>in</strong>ician first impressions of<br />
patients which <strong>in</strong>clude “lik<strong>in</strong>g” for them, has a significant effect on outcomes<br />
<strong>in</strong>clud<strong>in</strong>g evaluation of patient progress, eventual number of sessions,<br />
assessment of patient progress, cl<strong>in</strong>ician satisfaction with patient progress, and<br />
type of term<strong>in</strong>ation (Brown, 1970). If ongo<strong>in</strong>g exposure <strong>to</strong> a cultural group or<br />
group member may <strong>in</strong>crease one’s perception of a group member’s <strong>in</strong>telligence<br />
or attractiveness, and first impressions of patients <strong>in</strong>clud<strong>in</strong>g “lik<strong>in</strong>g” have<br />
significant effects on treatment outcomes, there is potential that <strong>in</strong> a geographical<br />
location where a religiously conservative person is a dist<strong>in</strong>ct m<strong>in</strong>ority and may be<br />
quite dissimilar <strong>in</strong> beliefs and values <strong>to</strong> a cl<strong>in</strong>ician, <strong>in</strong>itial impressions of the<br />
patient based on any affect or cognitive evaluations about his or her religiosity<br />
unmoderated by familiarity, may significantly impact treatment outcomes.<br />
Further, Houts and Graham’s study (1986) reported no bias <strong>in</strong> prognosis,<br />
pathology, and <strong>in</strong>ternal versus external attributions of patient difficulties, as<br />
evaluated by either religious or nonreligious cl<strong>in</strong>icians. In this study, groups of<br />
patients were assigned categories of either no mention of religion, moderately<br />
religious, or very religious. No bias was found aga<strong>in</strong>st those designated <strong>to</strong> the<br />
very religious category relative <strong>to</strong> the other two groups, but bias was found<br />
aga<strong>in</strong>st the moderately religious category. Closer exam<strong>in</strong>ation of the moderately<br />
religious group reveals that persons <strong>in</strong> that group expressed doubt about their<br />
religious beliefs. It is difficult <strong>to</strong> reconcile doubt about religious beliefs with a<br />
“moderate” religious belief system. This group was rated as hav<strong>in</strong>g more
42<br />
psychopathology and a poorer prognosis than the other two groups.<br />
Interpretation of results <strong>in</strong> this study should be made with caution as the category<br />
designations are not representative of the descriptive narrative <strong>in</strong> the vignette.<br />
The group assignment of cl<strong>in</strong>icians as either religious or nonreligious may also<br />
be problematic. Recall<strong>in</strong>g Byrne’s theory that attitudes and values have more of<br />
an impact on attraction and repulsion than do demographics, dicho<strong>to</strong>mous<br />
label<strong>in</strong>g of one’s religiosity appears reductive. Interpretations made based on<br />
data yielded between groups assigned <strong>in</strong> such a manner should be undertaken<br />
with caution.<br />
Similarly, Lewis and Lewis (1985) measured pathology, prognosis, and<br />
patient attractiveness rated by religious and nonreligious cl<strong>in</strong>icians, as<br />
determ<strong>in</strong>ed by cl<strong>in</strong>ician self-report about whether he or she was religiously<br />
affiliated. No significance was found on pathology and lik<strong>in</strong>g of the patient;<br />
however, the patient’s religiosity had a significant effect on cl<strong>in</strong>ician perception of<br />
her difficulties. Both religious and nonreligious cl<strong>in</strong>icians predicted fewer sessions<br />
would be needed for progress with the religious patient than with the nonreligious<br />
patient. Of particular <strong>in</strong>terest is that nonreligious cl<strong>in</strong>icians rated nonreligious<br />
patients as need<strong>in</strong>g almost twice as many sessions as the religious patient.<br />
Authors speculate that this f<strong>in</strong>d<strong>in</strong>g may reflect cl<strong>in</strong>icians’ belief that treatment<br />
progress may be enhanced by the religious patient’s religious background.<br />
In another study often cited for f<strong>in</strong>d<strong>in</strong>g no bias <strong>in</strong> the cl<strong>in</strong>ical evaluation of<br />
religious patients (Wadsworth & Checketts, 1980), only Latter-Day Sa<strong>in</strong>ts and<br />
“other” subjects were evaluated, and they were evaluated by psychologists <strong>in</strong>
43<br />
Utah. Clearly, generaliz<strong>in</strong>g these results <strong>to</strong> cl<strong>in</strong>icians from other geographic<br />
regions or <strong>to</strong> patients of other religious backgrounds is problematic. Also <strong>in</strong> this<br />
study, Wadsworth used no control vignettes and each of the four vignettes used<br />
described religiously affiliated persons, whether they were currently active or<br />
<strong>in</strong>active participants <strong>in</strong> religious beliefs or behaviors.<br />
Another study that did not f<strong>in</strong>d bias (Reed, 1992) used a between-subjects<br />
design <strong>to</strong> measure psychologists’ reactions on a pathology measure <strong>to</strong> one of<br />
four patient vignettes. The patient vignettes characterized either a deeply<br />
religious or strongly atheist position, or a newly religious or newly atheistic<br />
position. This study is <strong>in</strong>terest<strong>in</strong>g <strong>in</strong> its approach <strong>to</strong> expand on other research<br />
(i.e., Houts & Graham, 1986) that <strong>in</strong>dicated that stability of religious position may<br />
be a fac<strong>to</strong>r <strong>in</strong> cl<strong>in</strong>icians’ determ<strong>in</strong>ation of pathology. However, cl<strong>in</strong>ician religiosity<br />
was not considered <strong>in</strong> the analysis and us<strong>in</strong>g a homogenous group <strong>to</strong> evaluate<br />
vignettes <strong>in</strong> a between-subjects design may have mitigated negative bias such<br />
that it was undetectable.<br />
There are limitations <strong>in</strong> each of the studies discussed. One limitation is the<br />
relatively undef<strong>in</strong>ed dicho<strong>to</strong>mization of religious versus nonreligious cl<strong>in</strong>icians<br />
and/or patients represented <strong>in</strong> vignettes. The use of more descriptive<br />
categorizations of religiousness that discloses more <strong>in</strong>formation about religious<br />
beliefs and values, or the extent <strong>to</strong> which religious beliefs or behaviors are made<br />
manifest <strong>in</strong> one’s life, might yield more helpful <strong>in</strong>formation. Dimensional and<br />
descriptive narratives would be more appropriate than categorical assignment if<br />
research seeks <strong>to</strong> detect cl<strong>in</strong>ical bias with <strong>in</strong>dividuals who differ from them <strong>in</strong>
44<br />
religious beliefs and behaviors rather than labels. Negative f<strong>in</strong>d<strong>in</strong>gs could be the<br />
result of poor cl<strong>in</strong>ician group assignment. In other words, religious affiliation does<br />
not a religious person make, and many levels and dimensions of religiosity may<br />
be represented <strong>in</strong> those categorical assignments.<br />
Another limitation is the <strong>in</strong>ability <strong>to</strong> generalize results from research<br />
conducted <strong>in</strong> areas that may be presumed <strong>to</strong> have a fairly substantial religious<br />
population. It may be that bias would have been found <strong>in</strong> similar studies<br />
conducted <strong>in</strong> more religiously liberal areas or on a national sample. We have<br />
seen that research on the exposure effect <strong>in</strong>dicates that exposure <strong>to</strong> religiously<br />
diverse groups may contribute <strong>to</strong> an <strong>in</strong>crease <strong>in</strong> cl<strong>in</strong>icians’ perception of patients’<br />
<strong>in</strong>telligence and attractiveness, and therefore potentially affect cl<strong>in</strong>icians’<br />
judgment of pathology, prognosis, or empathy. Perhaps their out-group status is<br />
less pronounced as they become more familiar. Generalizability of f<strong>in</strong>d<strong>in</strong>gs <strong>to</strong><br />
areas <strong>in</strong> which one has limited exposure <strong>to</strong> religiously diverse groups, or <strong>to</strong> a<br />
national population of cl<strong>in</strong>icians, may be unwarranted.<br />
Also, each of the studies above utilized a between-subjects design with no<br />
attempts <strong>to</strong> detect favorable bias <strong>in</strong> the direction of the religious patient<br />
compared <strong>to</strong> the nonreligious patient. Therefore, negative bias may have been<br />
mitigated so that it was undetectable, compromis<strong>in</strong>g results. Lastly, social<br />
desirability was not controlled <strong>in</strong> any of the studies above. With the emphasis on<br />
cl<strong>in</strong>ical empathy and patient acceptance, and fairly ubiqui<strong>to</strong>us social disapproval<br />
of prejudice, it is reasonable <strong>to</strong> assume that social desirability could have<br />
affected cl<strong>in</strong>ician respond<strong>in</strong>g <strong>in</strong> each of the studies.
45<br />
In a with<strong>in</strong>-subjects study that did reveal biased results, vignettes of<br />
patients belong<strong>in</strong>g <strong>to</strong> extreme ideological groups were rated (Gartner, Hohmann,<br />
Harmatz, & Larson, 1990). Groups that were represented were right w<strong>in</strong>g<br />
religious, left w<strong>in</strong>g religious, right w<strong>in</strong>g political, or left w<strong>in</strong>g political groups.<br />
Fictitious patients were represented equally <strong>in</strong> each of either the four ideological<br />
categories or a nonideological group. This with<strong>in</strong>-subjects design measured<br />
reactions of psychologists <strong>to</strong> both nonideological categories and one of the four<br />
ideological categories. Subjects rated the patient on measures of empathy,<br />
pathology, and perceived maturity of the patient. Us<strong>in</strong>g a national sample of<br />
cl<strong>in</strong>icians, significant bias was found on every variable. As this study explored<br />
cl<strong>in</strong>ician reaction <strong>to</strong> liberal and conservative ideological poles, the vignettes were<br />
more <strong>in</strong>formative about the patients than if they had been identified by religious<br />
affiliation alone. It is also important <strong>to</strong> note that this study utilized a with<strong>in</strong>subjects<br />
design <strong>in</strong> a national sample of psychologists, which may be considered<br />
more religiously liberal than the general public.<br />
Another study found bias aga<strong>in</strong>st religious patients who were rated as<br />
more mentally ill and <strong>in</strong> need of more sessions <strong>to</strong> make progress compared <strong>to</strong><br />
their nonreligious counterparts by a group of homogenous therapists (Hillowe,<br />
1986). In this study, therapists’ traditional and nondoctr<strong>in</strong>al religiosity was<br />
measured. Interest<strong>in</strong>gly, as therapists’ nondoctr<strong>in</strong>al religious attitudes <strong>in</strong>creased,<br />
the prognosis of religious patients <strong>in</strong>creased relative <strong>to</strong> nonreligous patients’<br />
prognostic rat<strong>in</strong>gs. Hillowe speculated that his study may have found results<br />
where others did not because of dicho<strong>to</strong>mous categorization of therapists <strong>in</strong>
46<br />
previous work, whereas the religiosity of the vignette patients and cl<strong>in</strong>icians <strong>in</strong> his<br />
study were descriptive <strong>in</strong> terms of expressed beliefs and behaviors, and<br />
measured on the dimensions of traditional or nontraditional religiosity. He also<br />
believes that the <strong>in</strong>teraction found between nondoctr<strong>in</strong>ally religious cl<strong>in</strong>icians and<br />
more positive prognostic rat<strong>in</strong>gs of religious patients may be due <strong>to</strong> the cl<strong>in</strong>icians’<br />
beliefs that religious patients may share a base of faith and hope that will assist<br />
them <strong>in</strong> the therapy process <strong>to</strong>ward more optimistic outcomes.<br />
<strong>Bias</strong> was found <strong>in</strong> another study (O'Connor & Vandenberg, 2005) that<br />
used a between-subjects design and <strong>in</strong>vestigated cl<strong>in</strong>icians’ evaluation of<br />
religious beliefs as more or less pathological <strong>in</strong> terms of psychosis, depend<strong>in</strong>g on<br />
religious beliefs that are most ma<strong>in</strong>stream (Catholic), less ma<strong>in</strong>stream (Mormon),<br />
and least ma<strong>in</strong>stream (Nation of Islam.) The doctr<strong>in</strong>e of each religion was<br />
represented by correspond<strong>in</strong>g beliefs articulated by patients <strong>in</strong> vignettes. Beliefs<br />
<strong>in</strong>cluded that one patient “came <strong>to</strong> believe quite passionately <strong>in</strong> the Mormon<br />
religion, whose tenets state that he will be transformed <strong>in</strong><strong>to</strong> a god after he dies,”<br />
that the Catholic patient believed “the Holy Spirit has given him a special strength<br />
<strong>to</strong> defend the faith,” and that the patient who was a member of the Nation of<br />
Islam “believes <strong>in</strong> the revelation that a spaceship, the Mother Wheel, has been<br />
hover<strong>in</strong>g over the United States s<strong>in</strong>ce 1929.” Four sets of vignettes depicted the<br />
various beliefs described <strong>in</strong> either religiously specific language, or <strong>in</strong> language<br />
that does not identify a specific religion, or with changes as a result of these<br />
beliefs represent<strong>in</strong>g either a no-harm situation (these beliefs deepened his<br />
relationship with his girlfriend), or a harm situation (the change affected a
47<br />
relationship that had previously been a positive one <strong>to</strong> the po<strong>in</strong>t that the patient<br />
considered kill<strong>in</strong>g his girlfriend follow<strong>in</strong>g a betrayal). Three other distract<strong>in</strong>g<br />
vignettes were also used. Each participant received and rated 6 vignettes <strong>to</strong>tal,<br />
consist<strong>in</strong>g of 3 distracter vignettes, the religious, the nonreligious, and either no<br />
harm, or harm vignettes.<br />
Less ma<strong>in</strong>stream religions were considered more pathological, with<br />
Catholic beliefs be<strong>in</strong>g rated less pathological than Mormon beliefs, and Mormon<br />
beliefs rated less pathological than Nation of Islam beliefs. When Catholic and<br />
Mormon beliefs were associated with their religions <strong>in</strong> the vignettes, they were<br />
rated as less pathological than when they were not. However, there was no<br />
difference <strong>in</strong> the pathology rat<strong>in</strong>g for Nation of Islam patients <strong>in</strong> either case, with<br />
Nation of Islam beliefs rated highly and equally pathological, and significantly<br />
more pathological than Mormon or Catholic beliefs, whether identified as related<br />
<strong>to</strong> religion or not. Authors speculated that general familiarity with Catholic and<br />
Mormon beliefs may have contributed <strong>to</strong> the f<strong>in</strong>d<strong>in</strong>g that they were less<br />
pathological, and that high pathology rat<strong>in</strong>gs of Nation of Islam beliefs may be<br />
related <strong>to</strong> the subject’s general unfamiliarity with them or someth<strong>in</strong>g about their<br />
content. It should be noted that the religious beliefs <strong>in</strong> this study were rated as<br />
symp<strong>to</strong>ms of the most severe mental illnesses, potentially hav<strong>in</strong>g serious<br />
consequences for the patient.<br />
Lastly, <strong>in</strong> another study, bias was found aga<strong>in</strong>st conservative Evangelical<br />
Christian school applicants by a national sample of professors of cl<strong>in</strong>ical<br />
psychology <strong>in</strong> APA -accredited doc<strong>to</strong>ral programs (Gartner, 1986). This between-
48<br />
subjects study revealed that professors were less likely <strong>to</strong> admit applicants who<br />
were either identified as born-aga<strong>in</strong>, or who hoped <strong>to</strong> <strong>in</strong>tegrate their faith and<br />
their practice of psychology, compared <strong>to</strong> similar applicants who did not mention<br />
religion. Although the Evangelical applicant was rated higher than the<br />
<strong>in</strong>tegrationist applicant, the differences were not significant. <strong>Bias</strong> aga<strong>in</strong>st<br />
psychology graduate student applicants by psychology professors cannot be<br />
generalized <strong>to</strong> bias aga<strong>in</strong>st patients by cl<strong>in</strong>icians; however, the f<strong>in</strong>d<strong>in</strong>gs of bias by<br />
psychologists aga<strong>in</strong>st a conservative Christian group <strong>in</strong> a between-subjects study<br />
are notable as bias presumably occurr<strong>in</strong>g between religiously dissimilar groups.<br />
Authors also note that artificially limit<strong>in</strong>g the number of religious psychologists<br />
<strong>in</strong><strong>to</strong> doc<strong>to</strong>ral programs, cont<strong>in</strong>ues <strong>to</strong> perpetuate the underrepresentation of<br />
conservative religious persons <strong>in</strong> the field. As we have seen, this has implications<br />
for those who may be unlikely <strong>to</strong> seek psychological services from secular<br />
psychologists (K<strong>in</strong>g, 1978).<br />
Social Desirability<br />
Another fac<strong>to</strong>r that may complicate the results of the religious bias<br />
research that is worth <strong>in</strong>vestigat<strong>in</strong>g <strong>in</strong> more depth is social desirability. Social<br />
norms discourage prejudice aga<strong>in</strong>st cultural groups and group members. It is<br />
logical that s<strong>in</strong>ce all of the studies discussed used self-report measures <strong>in</strong><br />
evaluat<strong>in</strong>g groups of various religious orientations, there is a possibility that<br />
cl<strong>in</strong>icians may have responded <strong>to</strong> those measures <strong>in</strong> a socially desirable manner.
49<br />
In fact, the MODE model of biased respond<strong>in</strong>g suggests that the more sensitive a<br />
doma<strong>in</strong> is, such as social group evaluation over evaluation of food preferences<br />
for example, the more likely responses will be <strong>in</strong>fluenced by social desirability<br />
effects (Fazio & Olson, 2003). The MODE model emphasizes motivation and<br />
opportunity as determ<strong>in</strong>ants <strong>in</strong> respond<strong>in</strong>g with bias. Motivation may be either<br />
<strong>in</strong>ternally driven, such as that which may occur when one has a set of <strong>in</strong>ternal<br />
standards that do not approve of stereotyp<strong>in</strong>g or prejudiced respond<strong>in</strong>g. Also,<br />
motivation may be externally driven, so that one may refra<strong>in</strong> from respond<strong>in</strong>g <strong>in</strong> a<br />
biased manner <strong>to</strong> avoid the disapproval of others. Accord<strong>in</strong>g <strong>to</strong> the MODE model<br />
of biased respond<strong>in</strong>g, if one has the motivation and the opportunity <strong>to</strong> respond<br />
without prejudice, one will likely attempt <strong>to</strong> do so.<br />
Multicultural diversity and the desirability of cultural awareness and<br />
competence are emphasized <strong>in</strong> psychological research and current academic<br />
curricula (Constant<strong>in</strong>e & Ladany, 2000). <strong>Psychologist</strong>s are often aware of the<br />
need for awareness, knowledge, and skills <strong>in</strong> work<strong>in</strong>g with culturally diverse<br />
patients. They may have knowledge of stereotype <strong>in</strong>formation about social<br />
groups but work <strong>to</strong> control prejudiced respond<strong>in</strong>g for either <strong>in</strong>ternal or external<br />
reasons. However, when social desirability was controlled us<strong>in</strong>g the Marlow<br />
Crowne Social Desirability Scale (MCSDS), one study on cultural competencies<br />
yielded little correlation between competencies measured by explicit self-report<br />
versus objective other-rated measures (Worth<strong>in</strong>g<strong>to</strong>n et al., 2000), and no<br />
correlation was found <strong>in</strong> another study (Constant<strong>in</strong>e & Ladany, 2000).
50<br />
In addition <strong>to</strong> the focus on cultural competence <strong>in</strong> cl<strong>in</strong>ical work, the<br />
emphasis on empathy and patient acceptance may also contribute <strong>to</strong> socially<br />
desirable respond<strong>in</strong>g. The motivation <strong>to</strong> respond without empathic bias on selfreport<br />
measures may not be a reflection of respond<strong>in</strong>g <strong>to</strong> similar patients <strong>in</strong> a<br />
natural sett<strong>in</strong>g. Also, self-reported empathy may not correlate with a patient’s felt<br />
sense of empathy or empathy as perceived by others. The literature <strong>in</strong>dicates<br />
that there are often significant differences <strong>in</strong> self-reported empathic respond<strong>in</strong>g<br />
and empathy as experienced or perceived by others (Davis & Kraus, 1997;<br />
Graham & Ickes, 1997; Ickes, Marangoni, & Garcia, 1997). As a result of these<br />
f<strong>in</strong>d<strong>in</strong>gs, one must consider the results of the religious bias literature as<br />
potentially be<strong>in</strong>g mitigated by social desirability.<br />
<strong>Implicit</strong> versus Explicit Cognitive Processes <strong>in</strong> Impression Formation<br />
Given the nature of the cl<strong>in</strong>ician’s responsibility <strong>to</strong> evaluate patients<br />
thoughtfully when form<strong>in</strong>g cl<strong>in</strong>ical judgments, cognitive processes should<br />
naturally be engaged <strong>in</strong> efforts <strong>to</strong> form a cl<strong>in</strong>ical impression. The use of<br />
stereotypes <strong>in</strong> impression formation has been expla<strong>in</strong>ed as a method of<br />
simplify<strong>in</strong>g and reduc<strong>in</strong>g <strong>in</strong>formation for the purposes of efficiently manag<strong>in</strong>g<br />
what otherwise may be an overwhelm<strong>in</strong>g amount of <strong>in</strong>formation, which may<br />
subsequently overload cognitive processes (Allport, 1954; Erlich, 1973; Hamil<strong>to</strong>n<br />
& Trolier, 1986). Some theorists believe the use of stereotypes <strong>to</strong> assist <strong>in</strong> social<br />
categorization is <strong>in</strong>evitable (Erlich, 1973; Hamil<strong>to</strong>n & Trolier, 1986). Simply put, <strong>in</strong>
51<br />
order <strong>to</strong> simplify <strong>in</strong>formation-process<strong>in</strong>g tasks, reduce and organize the<br />
<strong>in</strong>formation <strong>to</strong> be evaluated <strong>in</strong> a manner that makes it manageable, and <strong>to</strong> make<br />
sense of a complex world of social <strong>in</strong>formation, we categorize persons <strong>in</strong><strong>to</strong><br />
groups. When one encounters a group member or group label such as African<br />
American or Evangelical Christian, if other <strong>in</strong>formation is lack<strong>in</strong>g, stereotypes<br />
may be utilized <strong>to</strong> assist <strong>in</strong> effectively categoriz<strong>in</strong>g the <strong>in</strong>dividual. Some theorists<br />
posit that stereotypes are still common <strong>in</strong> <strong>to</strong>day’s society, despite that they are<br />
openly discouraged (Dev<strong>in</strong>e et al., 2002). Particularly when <strong>in</strong>formation may be<br />
ambiguous <strong>in</strong> the early stages of treatment, stereotype applications may be more<br />
frequently utilized and may have more of an impact on first impressions, and<br />
subsequently on treatment outcomes.<br />
Impression formation utilizes both explicit and implicit cognitive processes.<br />
In particular, stereotype formation, ma<strong>in</strong>tenance, and behavior result<strong>in</strong>g from<br />
stereotype attitudes and beliefs, is often the result of a complex comb<strong>in</strong>ation of<br />
motivational, cognitive, and sociocultural processes. The research on bias with<br />
religious patients has made use of self-report measures <strong>to</strong> <strong>in</strong>vestigate bias <strong>in</strong><br />
empathy, pathology, prognosis, and patient maturity among other variables. The<br />
explicit self-report measures used offer research respondents the opportunity <strong>to</strong><br />
reflect and react <strong>to</strong> questions, potentially allow<strong>in</strong>g censorship of those responses<br />
for a variety of reasons. These <strong>in</strong>clude externally motivated social desirability<br />
effects, or those based on a set of <strong>in</strong>ternal standards that rejects stereotyped or<br />
biased respond<strong>in</strong>g. It may be assumed <strong>to</strong> some degree that if a cl<strong>in</strong>ician utilizes a<br />
personal set of <strong>in</strong>ternal standards that discourage biased respond<strong>in</strong>g <strong>to</strong> research
52<br />
queries, those same standards will tend <strong>to</strong> discourage biased respond<strong>in</strong>g <strong>in</strong> a<br />
natural sett<strong>in</strong>g. However, if social desirability is one’s primary motivation <strong>to</strong><br />
respond <strong>in</strong> an unbiased manner, that motivation is not likely <strong>to</strong> motivate unbiased<br />
respond<strong>in</strong>g <strong>in</strong> natural sett<strong>in</strong>gs where one’s responses will not be judged by<br />
others.<br />
Other measures have been helpful <strong>in</strong> captur<strong>in</strong>g attitudes and beliefs about<br />
social groups or group members, without allow<strong>in</strong>g the subject the opportunity <strong>to</strong><br />
censor responses. <strong>Implicit</strong> measures purport <strong>to</strong> capture attitudes outside of one’s<br />
awareness, or <strong>in</strong> a manner that does not require, or <strong>in</strong>deed may prohibit,<br />
<strong>in</strong>trospection that may have censor<strong>in</strong>g or react<strong>in</strong>g elements. Whether or not the<br />
subject has an awareness of hav<strong>in</strong>g the relevant attitude, the detection of<br />
au<strong>to</strong>matic attitudes compared <strong>to</strong> those endorsed <strong>in</strong> an explicit manner, has<br />
shown promise <strong>in</strong> alleviat<strong>in</strong>g methodological difficulties <strong>in</strong> captur<strong>in</strong>g biased<br />
respond<strong>in</strong>g without social desirability confounds.<br />
Explicit self-report measures and implicit measures of attitude activation<br />
often exhibit low correlations <strong>in</strong> the stereotyp<strong>in</strong>g and prejudice literature (Dev<strong>in</strong>e<br />
et al., 2002; Greenwald & Banaji, 1995; Rudman, Greenwald, Mellott, &<br />
Schwartz, 1999), although not always (see Fazio & Olson, 2003 for review).<br />
<strong>Implicit</strong> processes have been explored <strong>in</strong> several doma<strong>in</strong>s <strong>in</strong>clud<strong>in</strong>g religion<br />
(Rudman et al., 1999), aggression (Berkowitz & LePage, 1967), sexism<br />
(McKenzie-Mohr & Zanna, 1990), and race (Dovidio, Kawakami, Johnson,<br />
Johnson, & Howard, 1997; Greenwald, McGhee, & Schwartz, 1998; S<strong>in</strong>clair &<br />
Kunda, 1999).
53<br />
Au<strong>to</strong>matic activation of attitudes has been seen <strong>in</strong> prim<strong>in</strong>g experiments <strong>in</strong><br />
which attitudes have been detected follow<strong>in</strong>g prim<strong>in</strong>g with some attitude object or<br />
word (Banaji & Greenwald, 1995; Banaji, Hard<strong>in</strong>, & Rothman, 1993; Berkowitz &<br />
LePage, 1967; Dovidio et al., 1997). For <strong>in</strong>stance, developmental psychologist<br />
Leonard Berkowitz found that the presentation of an aggression-provok<strong>in</strong>g cue<br />
such as a rifle, elicited aggressive responses (Berkowitz & LePage, 1967).<br />
In another study, females were rated by respondents as more dependent than<br />
males for the same behaviors follow<strong>in</strong>g dependence but not neutral primes, and<br />
males were rated more aggressive than females follow<strong>in</strong>g aggression primes but<br />
not neutral primes (Banaji et al., 1993).<br />
Activation of au<strong>to</strong>matic attitudes has also been seen <strong>in</strong> word fragment<br />
completion tests (Dovidio et al., 1997; Gilbert & Hixon, 1991; Hense, Penner, &<br />
Nelson, 1995). In one study utiliz<strong>in</strong>g word fragment completion tasks, Gilbert and<br />
Hixon (1991) demonstrated the utilization of stereotypes as a cognitive resource<br />
<strong>to</strong>ol. In this study, <strong>in</strong> experiment 1, an Asian research confederate elicited<br />
stereotypic completions of word fragments when subjects were cognitively<br />
occupied, but not when they were not busy. In experiment 2, when stereotype<br />
activation occurred, busy subjects were more likely than not busy subjects <strong>to</strong><br />
apply the activated stereotypes. Other research exam<strong>in</strong>es the tendency <strong>to</strong><br />
expla<strong>in</strong> stereotype <strong>in</strong>congruent <strong>in</strong>formation more often than stereotype consistent<br />
<strong>in</strong>formation (Sekaquaptewa, Esp<strong>in</strong>oza, Thompson, Vargas, & von Hippel, 2003),<br />
,and tendencies <strong>to</strong> attribute responsibility <strong>to</strong> a stereotype target’s <strong>in</strong>ternal process
54<br />
rather than <strong>to</strong> his or her external situation (Sekaquaptewa et al., 2003; Sherman<br />
et al., 2005).<br />
Au<strong>to</strong>matic attitudes have also been demonstrated <strong>to</strong> have predictive<br />
validity on behavior. In one experiment (Dovidio et al., 1997), Caucasians high <strong>in</strong><br />
implicit prejudice had greater <strong>in</strong>dications of anxiety when <strong>in</strong>teract<strong>in</strong>g with an<br />
African American partner than with another Caucasian partner. In other research,<br />
(Sherman, Mackie, & Driscoll, 1990), subjects’ evaluations and preferences for<br />
targets were predicted by passively activated categories of prime-relevant versus<br />
prime-irrelevant dimensions. Exposure <strong>to</strong> pornography <strong>in</strong> another study predicted<br />
ability <strong>to</strong> recall physical characteristics and sexual motivation <strong>to</strong>ward a female<br />
experimenter (McKenzie-Mohr & Zanna, 1990). In other research, higher levels<br />
of prejudice predicted more attention <strong>to</strong> process<strong>in</strong>g stereotype <strong>in</strong>consistent,<br />
compared <strong>to</strong> stereotype consistent <strong>in</strong>formation (J. W. Sherman et al., 2005).<br />
A well known measure of implicit stereotyp<strong>in</strong>g that has received attention<br />
<strong>in</strong> the literature is the <strong>Implicit</strong> Association Test (IAT; Greenwald et al., 1998). The<br />
IAT measures the strength of associations between target groups or members of<br />
target groups and stereotype congruent or <strong>in</strong>congruent words or concepts. The<br />
strength of the association is measured <strong>in</strong> response time. The theory beh<strong>in</strong>d the<br />
IAT is that it is easier <strong>to</strong> select words or concepts that are highly associated with<br />
a target, rather than select<strong>in</strong>g words or concepts that are not associated with a<br />
target. Therefore reaction times will be faster when categories are matched with<br />
associated words or concepts.
55<br />
For example, associations are made between a target group such as<br />
African Americans and clearly valenced words (e.g., poison, flower) and<br />
stereotype congruent or <strong>in</strong>congruent characterizations (e.g., wealth, welfare).<br />
Categorizations are designated by one key stroke for one group assignment and<br />
another key stroke for another group assignment. The latency <strong>in</strong> respond<strong>in</strong>g <strong>to</strong><br />
<strong>in</strong>structions <strong>to</strong> categorize valenced words or concepts with either target groups or<br />
other groups us<strong>in</strong>g computer key strokes represents the strength of the implicit<br />
associations held by the subject. For <strong>in</strong>stance, the categorization of Black<br />
stereotype congruent names such as “La<strong>to</strong>ya” and White stereotype congruent<br />
names such as “Cathy” is practiced. Then the categorization of words with a<br />
clear pleasant or unpleasant valence such as “flower” or “poison” is practiced.<br />
Follow<strong>in</strong>g these practice categorizations, comb<strong>in</strong>ation of the valenced words and<br />
race related concepts (or names <strong>in</strong> this case) are assigned <strong>to</strong> target categories.<br />
Individually presented Black names and pleasant words are assigned <strong>to</strong> the<br />
“Black/pleasant” category, and White names and unpleasant words are put <strong>in</strong><strong>to</strong><br />
the “White/unpleasant” category. Then the category comb<strong>in</strong>ations are switched<br />
so that Black names and unpleasant words are assigned <strong>to</strong> the<br />
“Black/unpleasant” group, and White names and pleasant words are assigned <strong>to</strong><br />
the “White/pleasant” group. Latency of respond<strong>in</strong>g <strong>to</strong> each categorization for<br />
each group<strong>in</strong>g comb<strong>in</strong>ation is measured <strong>in</strong> milleseconds. In a race study utiliz<strong>in</strong>g<br />
these methods, (Greenwald et al., 1998), when Black names were paired with<br />
unpleasant words, response time was significantly faster than when they were
56<br />
paired with pleasant words, <strong>in</strong>dicat<strong>in</strong>g a negative implicit association with Black<br />
names.<br />
The IAT as a measure of implicit associations has been criticized by some<br />
(Brendl, Markman, & Messner, 2001; Karp<strong>in</strong>ski & Hil<strong>to</strong>n, 2001). There is some<br />
speculation that shifts <strong>in</strong> response patterns may <strong>in</strong>dicate that learned response<br />
patterns are facilitated <strong>in</strong> difficult trial blocks. Also, critics claim that the tendency<br />
<strong>to</strong> categorize familiar words faster than nonwords suggests that other fac<strong>to</strong>rs<br />
may contribute <strong>to</strong> previous f<strong>in</strong>d<strong>in</strong>gs <strong>in</strong>terpreted as implicit prejudice. Conclusions<br />
drawn by authors from experiments on nonsocial group respond<strong>in</strong>g as predictive<br />
of behavior caused them <strong>to</strong> question the validity of the IAT as a measure of<br />
implicit respond<strong>in</strong>g <strong>to</strong> social groups (Karp<strong>in</strong>ski & Hil<strong>to</strong>n, 2001). In Karp<strong>in</strong>ski and<br />
Hil<strong>to</strong>n’s study (2001), candy bar and apple associations us<strong>in</strong>g the IAT did not<br />
correlate with participant behavior when given the choice of select<strong>in</strong>g either a<br />
candy bar or an apple <strong>to</strong> eat. Authors assert that previous results about social<br />
group associations that were <strong>in</strong>terpreted as prejudiced or stereotyped respond<strong>in</strong>g<br />
may have been premature. They posit that the associations demonstrated may<br />
have been a reflection of environmental exposure rather than prejudices aga<strong>in</strong>st<br />
a target group. However, Karp<strong>in</strong>kis’ own results may be <strong>in</strong>consistent with other<br />
IAT research due <strong>to</strong> the nature of his groups. Apples and candy bars may have<br />
vary<strong>in</strong>g valences depend<strong>in</strong>g on whether health or taste is more salient <strong>to</strong> the<br />
participant, and which dimension is more salient at the time the participant is<br />
confronted with a choice of the food rather than the category designation.<br />
Research results with groups such as words versus nonwords and apples versus
57<br />
candy bars are not consistent with research that exam<strong>in</strong>es responses <strong>to</strong> social<br />
groups. The results and causal <strong>in</strong>ferences of one cannot be extrapolated <strong>to</strong> the<br />
other. The IAT consistently demonstrated <strong>in</strong>- and out-group biases of social<br />
groups (Greenwald et al., 1998; Nosek, Banaji, & Greenwald, 2002; Rudman et<br />
al., 1999), and social group bias has even been found <strong>in</strong> m<strong>in</strong>imal paradigm<br />
research (Ashburn-Nardo, Voils, & Monteith, 2001), when group assignment is<br />
random and participants have no previous environmental association with the<br />
target group.<br />
However, the possibility that the au<strong>to</strong>matic activation of attitudes about<br />
social groups may be environmentally learned is one that cannot be lightly<br />
dismissed. General research on social groups suggests that stereotypic<br />
associations of social groups are <strong>in</strong>deed often well learned, as is evident <strong>in</strong> the<br />
ability <strong>to</strong> effectively use stereotype “congruent” or “<strong>in</strong>congruent” concepts.<br />
However, even though there is evidence for predictive validity of implicit<br />
measures, not all associations result <strong>in</strong> prejudiced respond<strong>in</strong>g. Further<br />
explanation may lie with<strong>in</strong> motivational processes as modera<strong>to</strong>rs of au<strong>to</strong>matic<br />
associations.<br />
The MODE model of prejudice (Fazio, 1990) specifically posits that both<br />
explicit and implicit processes of respond<strong>in</strong>g contribute <strong>to</strong> attitudes, judgments,<br />
and behaviors. Those processes <strong>in</strong>clude the au<strong>to</strong>matic activation of attitudes and<br />
the motivation and opportunity <strong>to</strong> respond <strong>to</strong> those attitudes with deliberation.<br />
Similarly, Dev<strong>in</strong>e (1989) asserts that both au<strong>to</strong>matic activation of attitudes and<br />
conscious decision mak<strong>in</strong>g about whether <strong>to</strong> judge a target and act on those
58<br />
attitudes, contribute <strong>to</strong> response patterns <strong>to</strong> social groups. These two-stage<br />
models of prejudice are a less determ<strong>in</strong>istic perspective of the mean<strong>in</strong>g and<br />
impact of implicit attitudes, although they acknowledge the socialization effects of<br />
stereotype <strong>in</strong>formation. Dev<strong>in</strong>e posits that what may be activated and captured<br />
by measures such as the IAT are knowledge structures or schema of common<br />
stereotype data, rather than <strong>in</strong>ternalized attitudes about a group. She expla<strong>in</strong>s<br />
that <strong>in</strong> addition <strong>to</strong> one’s knowledge of stereotype <strong>in</strong>formation, one has the ability<br />
<strong>to</strong> choose <strong>to</strong> act on that knowledge or not. Dev<strong>in</strong>e’s two-stage model suggests<br />
that attitudes captured by the IAT may not have predictive validity because they<br />
do not represent <strong>in</strong>ternalized prejudices, but only stereotype knowledge and that<br />
one has the motivation <strong>to</strong> respond without prejudice <strong>to</strong> that knowledge. Plant and<br />
Dev<strong>in</strong>e (1998, p. 1) address “the presence of the rather pervasive external social<br />
pressure <strong>to</strong> respond without prejudice [that] has created endur<strong>in</strong>g dilemmas for<br />
both social perceivers and social scientists as they try <strong>to</strong> discern the<br />
motivation(s) underly<strong>in</strong>g (generally socially acceptable) nonprejudiced<br />
responses” by explor<strong>in</strong>g the importance of motivations <strong>to</strong> respond without<br />
prejudice.<br />
Similarly, Dun<strong>to</strong>n and Fazio’s Motivation <strong>to</strong> Control Prejudiced Reactions<br />
Scale (MCPRS; 1997) is concerned with one’s motivation <strong>to</strong> control prejudiced<br />
respond<strong>in</strong>g. As Plant and Dev<strong>in</strong>e po<strong>in</strong>t out, social perceivers may experience a<br />
dilemma <strong>in</strong> choos<strong>in</strong>g between stereotype knowledge and motivations <strong>to</strong> respond<br />
without prejudice. Social perceivers will likely be differentially motivated <strong>to</strong><br />
respond <strong>to</strong> prejudice or stereotype data. The MCPRS measures the amount of
59<br />
motivation <strong>to</strong> control prejudiced reactions us<strong>in</strong>g a two-fac<strong>to</strong>r solution. Fac<strong>to</strong>r 1<br />
consists of concern with act<strong>in</strong>g prejudiced due <strong>to</strong> an <strong>in</strong>ternal set of standards <strong>in</strong><br />
which prejudice is found distasteful or unacceptable, and concern about how one<br />
may be perceived by others for act<strong>in</strong>g <strong>in</strong> a prejudiced manner. Fac<strong>to</strong>r 2<br />
measures tendencies <strong>to</strong> restra<strong>in</strong> oneself from express<strong>in</strong>g prejudice due <strong>to</strong> the<br />
possibility of confrontation with or about targets of prejudice. Motivation <strong>to</strong> control<br />
prejudiced reactions can be differentiated from social desirability measures such<br />
as the MCDS (Crowne & Marlowe, 1960). The MCDS measures attempts <strong>to</strong><br />
respond <strong>to</strong> self-report measures <strong>in</strong> a socially acceptable manner, whereas<br />
motivation <strong>to</strong> control prejudice measures assess orig<strong>in</strong>s of motivations <strong>to</strong><br />
respond <strong>to</strong> situations without prejudice (Plant & Dev<strong>in</strong>e, 1998) or the amount of<br />
that motivation (Dun<strong>to</strong>n & Fazio, 1997).<br />
The socialization effects of religious stereotype congruent associations<br />
may or may not be ubiqui<strong>to</strong>us <strong>in</strong> the United States, although common knowledge<br />
of their nature dictates that they are <strong>in</strong>deed common. The activation of such<br />
attitudes may be the result of environmentally learned associations and/or<br />
<strong>in</strong>ternalized prejudices. An <strong>in</strong>terest<strong>in</strong>g note when consider<strong>in</strong>g whether IAT results<br />
reflect stereotype schema or <strong>in</strong>ternalized prejudices is that one would expect that<br />
group members would also demonstrate those associations with their own<br />
groups, if the associations only represented environmentally learned data, s<strong>in</strong>ce<br />
socialization probably exposes them <strong>to</strong> stereotypes about their own group.<br />
However, implicit measures consistently demonstrate bias, or knowledge of<br />
stereotype data, based on <strong>in</strong>- and out- group membership. If one has au<strong>to</strong>matic
60<br />
associations about a group, it is assumed that one may seek <strong>to</strong> control the effect<br />
of those associations. Future research that purports <strong>to</strong> exam<strong>in</strong>e the predictive<br />
validity of au<strong>to</strong>matic associations on behavior may also benefit from exam<strong>in</strong><strong>in</strong>g<br />
the role of motivation <strong>to</strong> control prejudice <strong>in</strong> moderat<strong>in</strong>g those attitudes. As<br />
applied <strong>to</strong> research on cl<strong>in</strong>ician bias with religious patients, motivational<br />
processes may moderate any au<strong>to</strong>matic negative associations with religious<br />
persons, so that associations do not dictate the evalua<strong>to</strong>rs’ cl<strong>in</strong>ical judgment.<br />
Summary<br />
There is a schism <strong>in</strong> the scientific worldview and the religious one.<br />
<strong>Psychologist</strong>s differ statistically from the general U.S. public on measures of<br />
religiosity, religious affiliation, and the importance of religion <strong>in</strong> their lives. There<br />
are clear sociopolitical trends <strong>to</strong>ward liberal worldviews <strong>in</strong> the psychological<br />
community. Psychological publications have published disparag<strong>in</strong>g comments<br />
about religious persons and their mental health. Similar commentary about racial<br />
or ethnic m<strong>in</strong>orities is not likely <strong>to</strong> be given the same consideration, giv<strong>in</strong>g<br />
validation <strong>to</strong> the hypothesis that the antireligious views held by some researchers<br />
and prom<strong>in</strong>ent theorists, may be shared by others <strong>in</strong> the psychological<br />
community. Assertions have been made and published that psychologist value<br />
judgments are, and should be, more carefully considered and more adequate<br />
than those of the general public.
61<br />
The religiosity gap and the general focus on multiculturalism and cultural<br />
competency has been the impetus for some research on potential bias with<br />
religious persons. Unfortunately, that research is scant relative <strong>to</strong> work <strong>in</strong> other<br />
cultural doma<strong>in</strong>s, and has often had methodological difficulties that did not<br />
adequately address transparency or social desirability confounds. Research that<br />
yielded positive results of bias often utilized a national population and a with<strong>in</strong>subjects<br />
design, which is likely <strong>to</strong> be more impervious <strong>to</strong> those concerns. That<br />
positive results of bias were found <strong>in</strong> any studies that utilized self-report<br />
measures <strong>in</strong> a society <strong>in</strong> which bias is discouraged, should be viewed as<br />
significant. Also, when social desirability is controlled, results are more likely <strong>to</strong><br />
be an accurate reflection of the bias that exists <strong>in</strong> a sample than when it is not<br />
controlled. Social desirability has been effectively controlled <strong>in</strong> research us<strong>in</strong>g<br />
psychologist samples, a group likely <strong>to</strong> be savvy <strong>to</strong> the purposes of such<br />
measures. Nevertheless, religious bias studies may benefit from the use of<br />
implicit measures of stereotype activation. The stereotyp<strong>in</strong>g literature<br />
emphasizes implicit measures <strong>in</strong> which response patterns are not likely <strong>to</strong> be<br />
affected by censor<strong>in</strong>g or reactive elements. Given that some attitudes<br />
au<strong>to</strong>matically activated may be environmentally learned but not acted upon,<br />
predictions about cl<strong>in</strong>ical judgments should not be <strong>in</strong>ferred from such results<br />
alone. It is hoped that <strong>in</strong> a psychologist population, motivation <strong>to</strong> control<br />
prejudiced reactions may moderate the effect of any au<strong>to</strong>matically activated<br />
attitudes about religious persons that do exist.
62<br />
References – Part A<br />
Allport, G. W. (1954). The nature of prejudice. Read<strong>in</strong>g, MA: Addison-Wesley.<br />
Allport, G. W., & Ross, M. J. (1967). Personal religious orientation and prejudice.<br />
Journal of Personality and Social Psychology, 5(4), 432-443.<br />
Altemeyer, B., & Hunsberger, B. (1992). Authoritarianism, religious<br />
fundamentalism, quest, and prejudice. International Journal for the<br />
Psychology of Religion, 2, 113-133.<br />
The American Enterprise Institute. (1991). Politics of the Professoriate. The<br />
American enterprise. 2(4), 86-87. Author<br />
American Heritage Dictionary of the English Language. (2000). Bos<strong>to</strong>n:<br />
Hough<strong>to</strong>n Miffl<strong>in</strong>.<br />
American Psychiatric Association. (1987). The diagnostic and statistical manual<br />
of mental disorders third revision. Wash<strong>in</strong>g<strong>to</strong>n, DC: Author.<br />
APA. (2002). Ethical pr<strong>in</strong>ciples of psychologists and code of conduct. American<br />
<strong>Psychologist</strong>, 57(12), 1060-1073.<br />
APA. (2007). Psychology of Religion (APA Div. 36 website). Retrieved January 5,<br />
2007, from http://www.apa.org/divisions/div36/<br />
Ashburn-Nardo, L., Voils, C. I., & Monteith, M. J. (2001). <strong>Implicit</strong> associations as<br />
the seeds of <strong>in</strong>tergroup bias: How easily do they take root? Journal of<br />
Personality and Social Psychology, 81(5), 789-799.
63<br />
Banaji, M. R., & Greenwald, A. G. (1995). <strong>Implicit</strong> gender stereotyp<strong>in</strong>g <strong>in</strong><br />
judgments of fame. Journal of Personality and Social Psychology, 68(2),<br />
181-198.<br />
Banaji, M. R., Hard<strong>in</strong>, C., & Rothman, A. J. (1993). <strong>Implicit</strong> stereotyp<strong>in</strong>g <strong>in</strong> person<br />
judgment. Journal of Personality and Social Psychology, 65(2), 272-281.<br />
Barrett-Lennard, G. (1981). The empathy cycle: Ref<strong>in</strong>ement of a nuclear concept.<br />
Journal of Counsel<strong>in</strong>g and Cl<strong>in</strong>ical Psychology, 28(2), 91-100<br />
Batson, D. C. (1976). Religion as prosocial: Agent or double agent? Journal for<br />
the Scientific Study of Religion, 15(1), 29-45.<br />
Berg<strong>in</strong>, A. (1980). Psychotherapy and religious values. Journal of Consult<strong>in</strong>g and<br />
Cl<strong>in</strong>ical Psychology, 48(1), 95-105.<br />
Berg<strong>in</strong>, A., & Jensen, J. P. (1990). Religiosity of psychotherapists: A national<br />
survey. Psychotherapy, 27(1), 3-7.<br />
Berg<strong>in</strong>, A. E. (1983). Religiosity and mental health: A critical reevaluation and<br />
meta-analysis. Professional Psychology: Research and Practice, 14(2),<br />
170-184.<br />
Berg<strong>in</strong>, A. E., Masters, K. S., & Richards, S. P. (1987). Religiousness and mental<br />
health reconsidered: A study of an <strong>in</strong>tr<strong>in</strong>sically religious sample. Journal of<br />
Counsel<strong>in</strong>g and Cl<strong>in</strong>ical Psychology, 34(2), 197-204.<br />
Berkowitz, L., & LePage, A. (1967). Weapons as aggression-elicit<strong>in</strong>g stimuli.<br />
Journal of Personality and Social Psychology, 7(2), 202-207.<br />
Beutler, L.E., Crago, M., & Arizmendi, T. G. (1986). Therapist variables <strong>in</strong><br />
psychotherapy process and outcome. In S. L. Garfield & A. Berg<strong>in</strong> (Eds.),
64<br />
Handbook of psychotherapy and behavior change (pp. 257-310). New<br />
York: Wiley & Sons.<br />
Beutler, L. E., & Bergan, J. (1991). Value change <strong>in</strong> counsel<strong>in</strong>g and<br />
psychotherapy: A search for scientific credibility. Journal of Counsel<strong>in</strong>g<br />
Psychology, 38(1), 16-24.<br />
Biernat, M., & Korbrynowicz, D. (2003). Stereotypes and shift<strong>in</strong>g standards:<br />
Some paradoxical effects of cognitive load. Journal of Applied Social<br />
Psychology, 33(10), 2060-2079.<br />
Bilgrave, D. P., & Deluty, R. H. (1998). Religious beliefs and therapeutic<br />
orientations of cl<strong>in</strong>ical and counsel<strong>in</strong>g psychologists. Journal for the<br />
Scientific Study of Religion, 37(2), 329-349.<br />
Bodenhausen, G. V., & Lichtenste<strong>in</strong>, M. (1987). Social stereotypes and<br />
<strong>in</strong>formation-process<strong>in</strong>g strategies: The impact of task complexity. Journal<br />
of Personality and Social Psychology, 52(5), 871-880.<br />
Brand, J. L. (2002). Can pluralism be <strong>in</strong><strong>to</strong>lerant? American <strong>Psychologist</strong>, 57(4),<br />
299-300.<br />
Brawer, P. A., Handal, P. J., Fabrica<strong>to</strong>re, A. N., Roberts, R., & Wajda-Johns<strong>to</strong>n,<br />
V. A. (2002). Tra<strong>in</strong><strong>in</strong>g and education <strong>in</strong> religion/spirituality with<strong>in</strong> APAaccredited<br />
cl<strong>in</strong>ical psychology programs. Professional Psychology:<br />
Research and Practice, 33(2), 203-206.<br />
Brendl, C. M., Markman, A. B., & Messner, C. (2001). How do <strong>in</strong>direct measures<br />
of evaluation work? Evaluat<strong>in</strong>g the <strong>in</strong>ference of prejudice <strong>in</strong> the <strong>Implicit</strong>
65<br />
Association Test. Journal of Personality and Social Psychology, 81(5),<br />
760-773.<br />
Brewer, M. B., & Gardner, W. (1996). Who is this "we"? Levels of collective<br />
identity and self representations. Journal of Personality and Social<br />
Psychology, 71(1), 83-93.<br />
Brickman, P., & Bulman, R. J. (1977). Pleasure and pa<strong>in</strong> <strong>in</strong> social comparison. In<br />
J. M. Suls & R. L. Miller (Eds.), Social comparison processes: Theoretical<br />
and empirical perspectives (pp. 149-186). Wash<strong>in</strong>g<strong>to</strong>n DC: Hemisphere.<br />
Brown, R. D. (1970). Experienced and <strong>in</strong>experienced counselors' first<br />
impressions of client and case outcomes: Are first impressions last<strong>in</strong>g?<br />
Journal of Counsel<strong>in</strong>g Psychology, 17(6), 550-558.<br />
Burkard, A. W., & Knox, S. (2004). Effect of therapist color-bl<strong>in</strong>dness on empathy<br />
and attributions <strong>in</strong> cross-cultural counsel<strong>in</strong>g. Journal of Counsel<strong>in</strong>g<br />
Psychology, 51(4), 387-397.<br />
Byrne, D. (1971). The attraction paradigm. New York: Academic Press.<br />
Cheatham, H. E., Ivey, A. E., Ivey, M. B., & Simek-Morgan, L. (1980).<br />
Multicultural counsel<strong>in</strong>g and therapy: Chang<strong>in</strong>g the foundations of the<br />
field. In A. E. Ivey, M. B. Ivey, & L. Simek-Morgan (Eds.), Counsel<strong>in</strong>g and<br />
psychotherapy: A multicultural perspective (3rd ed., p. 94). Needham<br />
Heights, MA: Allyn & Bacon.<br />
Chen, F. F., & Kenrick, D. T. (2002). Repulsion or attraction? Group membership<br />
and assumed attitude similarity. Journal of Personality and Social<br />
Psychology, 83(1), 111-125.
66<br />
Constant<strong>in</strong>e, M. G. (2001). Multicultural tra<strong>in</strong><strong>in</strong>g, theoretical orientation, empathy,<br />
and multicultural case conceptualization ability <strong>in</strong> counselors. Journal of<br />
Mental Health Counsel<strong>in</strong>g, 23(4), 357-372.<br />
Constant<strong>in</strong>e, M. G., & Ladany, N. (2000). Self-report multicultural counsel<strong>in</strong>g<br />
competence scales: Their relation <strong>to</strong> social desirability attitudes and<br />
multicultural case conceptualization ability. Journal of Counsel<strong>in</strong>g<br />
Psychology, 47(2), 155.<br />
Crawford, M., T., & Skowronski, J. J. (1998). When motivated thought leads <strong>to</strong><br />
heightened bias: High need for cognition can enhance the impact of<br />
stereotypes on memory. Society for Personality and Social Psychology<br />
Inc, 24(10), 1075-1088.<br />
Crocker, J., & Luhtanen, R. (1990). Collective self-esteem and <strong>in</strong>group bias.<br />
Journal of Personality and Social Psychology, 58(1), 60-67.<br />
Crocker, J., McGraw, K., M., Thompson, L. L., & Ingerman, C. (1987). Downward<br />
comparison, prejudice, and evaluation of others: Effects of self esteem<br />
and threat. Journal of Personality and Social Psychology, 52(5), 907-916.<br />
Crocker, J., & Schwartz, J. M. (1985). Prejudice and <strong>in</strong>group favoritism <strong>in</strong> a<br />
m<strong>in</strong>imal <strong>in</strong>tergroup situation: Effects on self esteem. Personality and<br />
Social Psychology Bullet<strong>in</strong>, 11, 379-386.<br />
Crowne, D. P., & Marlowe, D. (1960). A new scale of desirability <strong>in</strong>dependent of<br />
psychopathology. Journal of Consult<strong>in</strong>g Psychology, 24, 349-354.
67<br />
Davis, M. H. (1983). Measur<strong>in</strong>g <strong>in</strong>dividual differences <strong>in</strong> empathy: Evidence for a<br />
multidimensional approach. Journal of Personality and Social Psychology,<br />
44(1), 113-126.<br />
Davis, M. H. (1994). Empathy: A social psychological approach. Madison, WI:<br />
Brown & Benchmark.<br />
Davis, M. H., & Kraus, L. A. (1997). Personality and empathic accuracy. In<br />
Empathic accuracy (pp. 145-167). New York: Guilford Press.<br />
Dev<strong>in</strong>e, P. G. (1989). Stereotypes and prejudice: Their au<strong>to</strong>matic and controlled<br />
components. Journal of Personality and Social Psychology, 56(1), 5-18.<br />
Dev<strong>in</strong>e, P., Plant, E. A., Amodio, D. M., Harmon-Jones, E., & Vance, S. L.<br />
(2002). The regulation of explicit and implicit race bias: The role of<br />
motivations <strong>to</strong> respond without prejudice. Journal of Personality and Social<br />
Psychology, 82(5), 835-848.<br />
Dovidio, J. F., Kawakami, K., Johnson, C., Johnson, B., & Howard, A. (1997). On<br />
the nature of prejudice: Au<strong>to</strong>matic and controlled processes. Journal of<br />
Experimental Social Psychology, 33, 510-540.<br />
Duan, H., & Hill, C., (1996). The current state of empathy research. Journal of<br />
Counsel<strong>in</strong>g Psychology, 43(3), 261-274<br />
Duckitt, J., Birum, I., Wagner, C., & Plessis, I. d. (2002). The psychological bases<br />
of ideology and prejudice: Test<strong>in</strong>g a dual process model. Journal of<br />
Personality and Social Psychology, 83(1), 75-93.
68<br />
Dun<strong>to</strong>n, B. C., & Fazio, R. H. (1997). An <strong>in</strong>dividual difference measure of<br />
motivation <strong>to</strong> control prejudice reactions. Society for Personality and<br />
Social Psychology Inc, 23(3), 316-326.<br />
Eisenberg, N., Fabes, R., Murphy, B., Karbon, M., Maszk, P., Smith, M., O'Boyle,<br />
C., Suh, K. (1994). The relations of emotionality and regulation <strong>to</strong><br />
dispositional and situational empathy-related respond<strong>in</strong>g. Journal of<br />
Personality and Social Psychology, 66(4), 776-797<br />
Eisenberg, N., & Lennen, R. (1983). Sex differences <strong>in</strong> empathy and related<br />
capacities. Psychological Bullet<strong>in</strong>, 99(1), 100-131<br />
Ellens, J. H., & Sanders, R. K. (2006). Fifty years of CAPS: The direc<strong>to</strong>r's<br />
perspectives. Journal of Psychology and Christianity, 25(4), 311-321.<br />
Ellis, A. (1980a). The case aga<strong>in</strong>st religion: A psychotherapist's view and the<br />
case aga<strong>in</strong>st religiosity. Aust<strong>in</strong>, TX: American Atheist Press.<br />
Ellis, A. (1980b). Psychotherapy and atheistic values: A response <strong>to</strong> A.E.Berg<strong>in</strong>'s<br />
"Psychotherapy and Religious Values." Journal of Consult<strong>in</strong>g and Cl<strong>in</strong>ical<br />
Psychology, 48(5), 635-639.<br />
Ellis, A. (2000). Can rational-emotive behavior therapy (REBT) be effectively<br />
used with people who have devout beliefs <strong>in</strong> God and religion?<br />
Professional Psychology: Research and Practice, 31(1), 29-33.<br />
Erlich, H. J. (1973). The social psychology of prejudice. New York: Wiley.<br />
Fazio, R. H. (1990). Multiple processes by which attitude guides behavior: The<br />
MODE model as an <strong>in</strong>tegrative framework. In M. P. Zanna (Ed.),
69<br />
Advances <strong>in</strong> experimental social psychology (pp. 75-109). New York:<br />
Academic Press.<br />
Fazio, R. H., & Olson, M. A. (2003). <strong>Implicit</strong> measures <strong>in</strong> social cognition<br />
research: Their mean<strong>in</strong>g and use. Annual Review of Psychology, 54, 297-<br />
327.<br />
Fest<strong>in</strong>ger, L. (1954). A theory of social comparison processes. Human Relations,<br />
7, 117-140.<br />
Ford, M. P., & Hendrick, S. (2003). Therapists' sexual values for self and clients:<br />
Implications for practice and tra<strong>in</strong><strong>in</strong>g. Professional Psychology: Research<br />
and Practice, 34(1), 80-87.<br />
Francis, L. J., & Peter, K. (2002). The relationship between psychological wellbe<strong>in</strong>g<br />
and Christian faith and practice <strong>in</strong> an Australian population sample.<br />
Journal for the Scientific study of religion, 41(1), 179-184.<br />
Freud, S. (1962). The question of Weltanschauung. In J. Strachey (Ed.), The<br />
standard edition of the complete psychological works of Sigmund Freud<br />
(pp. 158-162). London: Hogarth Press. (Orig<strong>in</strong>al work published 1933).<br />
Freud, S. (2000). Totem and taboo. In Totem and taboo: Resemblances between<br />
the psychic lives of savages and neurotics. (A. A. Brill, Trans.). Amherst,<br />
NY: Prometheus Books. (Orig<strong>in</strong>al work published 1913).<br />
Fuertes, J. N., & Brobst, K. (2002). Client's rat<strong>in</strong>gs of counselor multicultural<br />
competency. Cultural Diversity and Ethnic M<strong>in</strong>ority Psychology, 8(3), 214-<br />
223.
70<br />
Gaertner, L., & Insko, C. A. (2000). Intergroup discrim<strong>in</strong>ation <strong>in</strong> the m<strong>in</strong>imal group<br />
paradigm: Categorization, reciprocation, or fear? Journal of Personality<br />
and Social Psychology, 79(1), 77-94.<br />
The Gallup poll: Public op<strong>in</strong>ion <strong>in</strong> 1996. (1996). Wilm<strong>in</strong>g<strong>to</strong>n, DE: Scholarly<br />
Resources.<br />
The Gallup Poll. (2005). Retrieved August 1, 2006, from<br />
http://poll.gallup.com/content/default.aspx?ci=16519<br />
The Gallup Poll. (2006). Retrieved August 1, 2006, from<br />
http://bra<strong>in</strong>.gallup.com/documents/question.aspx?question=72715&Advan<br />
ced=0&SearchConType=1&SearchTypeAll=Universal%20spirit<br />
Gartner, J. (1986). Antireligious prejudice <strong>in</strong> admissions <strong>to</strong> doc<strong>to</strong>ral programs <strong>in</strong><br />
cl<strong>in</strong>ical psychology. Professional Psychology: Research and Practice,<br />
17(5), 473-475.<br />
Gartner, J. (1990). The effect of client and counselor values on cl<strong>in</strong>ical judgment.<br />
Counsel<strong>in</strong>g & Values, 35(1), 58-63.<br />
Gartner, J., Hohmann, A., Harmatz, M., & Larson, D. (1990). The effect of patient<br />
and cl<strong>in</strong>ician ideology on cl<strong>in</strong>ical judgment: A study of ideological<br />
countertransference. Psychotherapy, 27, 98-106.<br />
Gartner, J., Larson, D. B., & Allen, G. D. (1991). Religious commitment and<br />
mental health: A review of the empirical literature. Journal of Psychology<br />
and Theology, 19(1), 6-25.
71<br />
Gilbert, D. T., & Hixon, J. G. (1991). The trouble of th<strong>in</strong>k<strong>in</strong>g: Activation and<br />
application of stereotypic beliefs. Journal of Personality and Social<br />
Psychology, 60(4), 509-517.<br />
Gorsuch, R. L., & Aleshire, D. (1974). Christian faith and ethnic prejudice: A<br />
review and <strong>in</strong>terpretation of research. Journal for the Scientific Study of<br />
Religion, 13(3), 281-307.<br />
The Graduate Center. (2001). American Religious Identification Survey.<br />
Retrieved August 1, 2006, from<br />
http://ww.gc.cuny.edu/faculty/research_briefs/aris/key_f<strong>in</strong>d<strong>in</strong>gs.htm<br />
Graham, T., & Ickes, W. (1997). When women's <strong>in</strong>tuition isn't greater than men's.<br />
In W. Ickes (Ed.), Empathic accuracy. New York: Guilford Press.<br />
Greenwald, A. G., & Banaji, M. R. (1995). <strong>Implicit</strong> social cognition: Attitudes, selfesteem,<br />
and stereotypes. Psychological Review, 102(1), 4-27.<br />
Greenwald, A. G., McGhee, D. E., & Schwartz, J. L. K. (1998). Measur<strong>in</strong>g<br />
<strong>in</strong>dividual differences <strong>in</strong> implicit cognition: The <strong>Implicit</strong> Association Test.<br />
Journal of Personality and Social Psychology, 74(6), 1464-1480.<br />
Guimond, S., Dambrun, M., Mich<strong>in</strong>ov, N., & Duarte, S. (2003). Does social<br />
dom<strong>in</strong>ance generate prejudice: Integrat<strong>in</strong>g <strong>in</strong>dividual and contextual<br />
determ<strong>in</strong>ants of <strong>in</strong>tergroup cognitions. Journal of Personality and Social<br />
Psychology, 84(4), 697-721.<br />
Gu<strong>in</strong>ee, J., & Tracey, T. (1997). Effects of religiosity and problem type on<br />
counselor description rat<strong>in</strong>g. Journal of Counsel<strong>in</strong>g and Development,<br />
76(1), 65-73.
72<br />
Hamil<strong>to</strong>n, D. L., Sherman, J. W., & Ruvolo, C. M. (1990). Stereotyped-based<br />
expectancies: Effects on <strong>in</strong>formation process<strong>in</strong>g and social behavior.<br />
Journal of Social Issues, 46(2), 35-60.<br />
Hamil<strong>to</strong>n, D. L., & Trolier, T. K. (1986). Stereotypes and stereotyp<strong>in</strong>g: An<br />
overview of the cognitive approach. In J. F. Dovidio & S. L. Gaertner<br />
(Eds.), Prejudice, discrim<strong>in</strong>ation, and racism (pp. 127-163). Orlando, FL:<br />
Academic Press.<br />
Hansen, N. D., Randazzo, K. V., Schwartz, A., Marshall, M., Kalis, D., Frazier,<br />
R., et al. (2006). Do we practice what we preach: An explora<strong>to</strong>ry survey of<br />
multicultural psychotherapy competencies. Professional Psychology:<br />
Research and Practice, 37(1), 66-74.<br />
Hense, R. L., Penner, L. A., & Nelson, D. L. (1995). <strong>Implicit</strong> memory for age<br />
stereotypes. Social Cognition, 13(4), 339-415.<br />
Hill, P. C., Pargament, K. I., Hood, R. W., McCullough, M. E., Swyers, J. P.,<br />
Larson, D. B., et al. (2000). Conceptualiz<strong>in</strong>g religion and spirituality: Po<strong>in</strong>ts<br />
of commonality, po<strong>in</strong>ts of departure. Journal for the Theory of Social<br />
Behavior, 30, 51-77.<br />
Hillowe, B. V. (1986). Effects of religiosity of therapist and patient on cl<strong>in</strong>ical<br />
judgment (Paper). 94th Annual Convention of the American Psychological<br />
Association, Wash<strong>in</strong>g<strong>to</strong>n, DC.<br />
Hil<strong>to</strong>n, J. L., & Hippel, W. v. (1996). Stereotypes. Annual Review of Psychology,<br />
47, 237-271.
73<br />
Holcomb-McCoy, C. C., & Myers, J. E. (1999). Multicultural competence and<br />
counselor tra<strong>in</strong><strong>in</strong>g: A national survey. Journal of Counsel<strong>in</strong>g and<br />
Development, 77(3), 294-303.<br />
Hous<strong>to</strong>n, D. A. (1990). Empathy and the self: Cognitive and emotional <strong>in</strong>fluences<br />
on the evaluation of negative affect <strong>in</strong> others. Journal of Personality and<br />
Social Psychology, 59(5), (859-868)<br />
Houts, A. C., & Graham, K. (1986). Can religion make you crazy? Impact of client<br />
and therapist religious values on cl<strong>in</strong>ical judgments. Journal of Consult<strong>in</strong>g<br />
and Cl<strong>in</strong>ical Psychology, 54(2), 267-271.<br />
Ickes, W., Marangoni, C., & Garcia, S. (1997). Study<strong>in</strong>g empathic accuracy <strong>in</strong> a<br />
cl<strong>in</strong>ically relevant context. New York: Guilford Press.<br />
Ivey, A. E., Ivey, M. B., & Simek-Morgan, L. (Eds.). (1993). Counsel<strong>in</strong>g and<br />
psychotherapy: A multicultural perspective. Needham Heights, MA: Simon<br />
& Shuster.<br />
Jackson, L. A., & Sullivan, L. A. (2001). Cognition and affect <strong>in</strong> evaluations of<br />
stereotyped group members. The Journal of Social Psychology, 129(5),<br />
659-672.<br />
Johnson, B. W., Nielson, S. L., & Ridley, C. R. (2000). <strong>Religiously</strong> sensitive<br />
rational emotive behavior therapy: Elegant solutions and ethical risks.<br />
Professional Psychology: Research and Practice, 31(1), 14-20.<br />
Jussim, L., Manis, M., Nelson, T. E., & Soff<strong>in</strong>, S. (1995). Prejudice, stereotypes,<br />
and label<strong>in</strong>g effects: Sources of bias <strong>in</strong> person perception. Journal of<br />
Personality and Social Psychology, 68(2), 228-246.
74<br />
Karp<strong>in</strong>ski, A., & Hil<strong>to</strong>n, J. L. (2001). Attitudes and the <strong>Implicit</strong> Association Test.<br />
Journal of Personality and Social Psychology, 81(5), 774-788.<br />
Kelly, T. A. (1990). The role of values <strong>in</strong> psychotherapy: Review and<br />
methodological critique. Cl<strong>in</strong>ical Psychology Review, 10, 171-186.<br />
Kerl<strong>in</strong>ger, F. N. (1984). Liberalism and conservatism: The nature and structure of<br />
social attitudes. Hillsdale, NJ: Lawrence Elrbaum Associates.<br />
Khan, J. A., & Cross, D. G. (1983). Mental health professional and client values:<br />
Similar or different? Australian Journal of Sex, Marriage and Family, 4, 71-<br />
78.<br />
Kilpatrick, S. D., & McCullough, M. E. (1999). Religion and spirituality <strong>in</strong><br />
rehabilitation psychology. Rehabilitation Psychology, 44(4), 388-402.<br />
K<strong>in</strong>g, R. (1978). Evangelical Christians and professional counsel<strong>in</strong>g: A conflict of<br />
values? Journal of Psychology and Theology, 6, 276-281.<br />
Koenig, F. W., & K<strong>in</strong>g, M. B. Jr. (1964). Cognitive simplicity and outgroup<br />
stereotypes. Social Forces, 42(3), 324-327.<br />
Koenig, F. W. (1997). Is religion good for your health? The effects of religion on<br />
physical and mental health. New York: Haworth Press.<br />
Kohut, H. (1977). The res<strong>to</strong>ration of the self. New York: International Universities<br />
Press<br />
Korten, F. F. (1973). The stereotype as a cognitive construct. The Journal of<br />
Social Psychology, 90, 29-39.<br />
Lewis, C. S. (Ed.). (2001). Mere Christianity . San Francisco: Harper.
75<br />
Lewis-Hall, E., Gorsuch, R., Malony, H. N., Narramore, S. B., & Stewart Van<br />
Leeuwam, M. (2006). Dialogue, embodiment, and the unity of faith and<br />
learn<strong>in</strong>g: A conversation on <strong>in</strong>tegration <strong>in</strong> a postmodern age. Journal of<br />
Psychology and Christianity, 25(4), 331-338.<br />
Lewis, K. N., & Lewis, D. A. (1985). Impact of religious affiliation on therapists'<br />
judgments of patients. Journal of Counsel<strong>in</strong>g and Cl<strong>in</strong>ical Psychology,<br />
53(6), 926-932.<br />
Macrae, N. C., & Milne, A. B. (1994). Stereotypes as energy-sav<strong>in</strong>g devices: A<br />
peek <strong>in</strong>side the cognitive <strong>to</strong>olbox. Journal of Personality and Social<br />
Psychology, 66(1), 37-47.<br />
McCl<strong>in</strong><strong>to</strong>ck, C. G., Spauld<strong>in</strong>g, C. B., & Turner, H. A. (1965). Political orientations<br />
of academically affiliated psychologists. American <strong>Psychologist</strong>, 20, 211-<br />
221.<br />
McKenzie-Mohr, D., & Zanna, M. P. (1990). Treat<strong>in</strong>g women as sexual objects:<br />
Look <strong>to</strong> the (gender schematic) male who has viewed pornography.<br />
Personality and Social Psychology Bullet<strong>in</strong>, 16(2), 296-308.<br />
Mehrabian, A., Epste<strong>in</strong>, N. (1972). A measure of emotional empathy. Journal of<br />
Personality, 40(4), 525-543<br />
Meyer, M. S. (1988). Ethical pr<strong>in</strong>ciples of psychologists and religious diversity.<br />
Professional Psychology: Research and Practice, 19(5), 486-488.<br />
Murray, E. J. (1956). A content-analysis method for study<strong>in</strong>g psychotherapy.<br />
Psychological Monographs, 70(13).
76<br />
Newcomb, T. M. (1961). The acqua<strong>in</strong>tance process. New York: Holt, R<strong>in</strong>ehart, &<br />
W<strong>in</strong>s<strong>to</strong>n.<br />
NewPort, F. (2004). A look at Americans and religion <strong>to</strong>day. Retrieved March 28,<br />
2006, from<br />
http://speak<strong>in</strong>goffaith.publicradio.org/programs/godsofbus<strong>in</strong>ess/galluppoll.<br />
shtml<br />
Newport, F., & Carroll, J. (2005). Another look at Evangelicals <strong>in</strong> America <strong>to</strong>day.<br />
Retrieved August 1, 2006, from<br />
http://poll.gallup.com/content/default.aspx?ci=20242&pg=1<br />
Nosek, B. A., Banaji, M. R., & Greenwald, A. G. (2002). Harvest<strong>in</strong>g implicit group<br />
attitudes and beliefs from a demonstration web site. Group Dynamics:<br />
Theory, Research, and Practice, 6(1), 101-115.<br />
O'Connor, S., & Vandenberg, B. (2005). Psychosis or faith? Cl<strong>in</strong>icians'<br />
assessment of religious beliefs. Journal of Consult<strong>in</strong>g and Cl<strong>in</strong>ical<br />
Psychology, 73(4), 610-616.<br />
Pargament, K. I., Smith, B. W., Koenig, H. G., & Perez, L. (1998). Patterns of<br />
positive and negative religious cop<strong>in</strong>g with major life stressors. Journal for<br />
the Scientific Study of Religion, 37(4), 710-724.<br />
Plant, E. A., & Dev<strong>in</strong>e, P. G. (1998). Internal and external motivation <strong>to</strong> respond<br />
without prejudice. Journal of Personality and Social Psychology, 75(3),<br />
811-832.
77<br />
Ragan, C., Malony, H. N., & Beit-Hallahmi, B. (1980). <strong>Psychologist</strong>s and religion:<br />
Professional fac<strong>to</strong>rs and personal belief. Review of Religious Research,<br />
21, 208-127.<br />
Redd<strong>in</strong>g, R. E. (2001). Sociopolitical diversity <strong>in</strong> psychology: The case for<br />
pluralism. American <strong>Psychologist</strong>, 56(3), 205-215.<br />
Redd<strong>in</strong>g, R. E. (2002). Grappl<strong>in</strong>g with a diverse conception of diversity. American<br />
<strong>Psychologist</strong>, 57(4), 300-301.<br />
Reed, P. R. (1992). <strong>Psychologist</strong>s' views of a patient's religiousness.<br />
Psychological Reports, 70, 1031-1036.<br />
Richards, S. P., & Berg<strong>in</strong>, A. (2000). Handbook of psychotherapy and religious<br />
diversity. Wash<strong>in</strong>g<strong>to</strong>n, DC: American Psychological Association.<br />
Richards, S. P., & Davison, M. L. (1992). Religious bias <strong>in</strong> moral development<br />
research: A psychometric <strong>in</strong>vestigation. Journal for the Scientific Study of<br />
Religion, 31(4), 467-485.<br />
Ridley, C. R., & L<strong>in</strong>gle, D. W. (Eds.). (1996). Cultural empathy <strong>in</strong> multicultural<br />
counsel<strong>in</strong>g: A multidimensional process model (4th ed.). Thousand Oaks,<br />
CA: Sage.<br />
Rippentrop, A. E. (2005). A review of the role of religion and spirituality <strong>in</strong> chronic<br />
pa<strong>in</strong> populations. Rehabilitation Psychology, 50(3), 278-284.<br />
Rogers, C. (1957). The necessary and sufficient conditions of therapeutic<br />
personality change. Journal of Consult<strong>in</strong>g Psychology, 21, 95-103.<br />
Rogers, C. (1980). A way of be<strong>in</strong>g. Bos<strong>to</strong>n: Hough<strong>to</strong>n Miffl<strong>in</strong>.
78<br />
Rosenbaum, M. E. (1986). The repulsion hypothesis: On the nondevelopment of<br />
relationships. Journal of Personality and Social Psychology, 51(6), 1156-<br />
1166.<br />
Rudman, L. A., Greenwald, A. G., Mellott, D. S., & Schwartz, J. L. K. (1999).<br />
Measur<strong>in</strong>g the au<strong>to</strong>matic components of prejudice: Flexibility and<br />
generality of the <strong>Implicit</strong> Association Test. Social Cognition, 17(4), 437-<br />
465.<br />
Sarason, S. (1993) American psychology, and the needs for transcendence and<br />
community. American Journal of Community Psychology, 21(2).<br />
Sekaquaptewa, D., Esp<strong>in</strong>oza, P., Thompson, M., Vargas, P., & von Hippel, W.<br />
(2003). Stereotypic explana<strong>to</strong>ry bias: <strong>Implicit</strong> stereotyp<strong>in</strong>g as a predic<strong>to</strong>r of<br />
discrim<strong>in</strong>ation. Journal of Experimental Social Psychology, 39, 75-82.<br />
Seyle, D. C., & Newman, M. L. (2006). A house divided?: The psychology of Red<br />
and Blue America. American <strong>Psychologist</strong>, 61(6), 571-580.<br />
Shafranske, E. (1990). Cl<strong>in</strong>ical psychologists' religious and spiritual orientations<br />
and their practice of psychotherapy. Psychotherapy, 27, 72-78.<br />
Shafranske, E. (2000). Religious <strong>in</strong>volvement and professional practices of<br />
psychiatrists and other mental health professionals. Psychiatric Annals,<br />
30(8), 525-532.<br />
Shafranske, E., & Gorsuch, R. (1984). Fac<strong>to</strong>rs associated with the perception of<br />
spirituality <strong>in</strong> psychotherapy. The Journal of Transpersonal Psychology,<br />
16(2), 231-241.
79<br />
Shafranske, E., & Malony, N. H. (1990). California psychologists' religiosity and<br />
psychotherapy. Journal of Religion and Health, 29(3), 219-232.<br />
Shaheen, J., McLaughl<strong>in</strong>, C., K<strong>in</strong>g, D., Volpe, J. D., Perez, E., Phillips, J., et al.<br />
(2006). Redef<strong>in</strong><strong>in</strong>g political attitudes and activism: A poll by Harvard's<br />
Institute of Politics. Retrieved August 12, 2006, from<br />
http://www.iop.harvard.edu/pdfs/survey/spr<strong>in</strong>g_poll_2006_execsumm.pdf<br />
Sherman, J. W., Conrey, F. R., Stroessner, S. J., & Azam, O. A. (2005).<br />
Prejudice and stereotype ma<strong>in</strong>tenance processes: Attention, attribution,<br />
and <strong>in</strong>dividuation. Journal of Personality and Social Psychology, 89(4),<br />
607-622.<br />
Sherman, S. J., Mackie, D. M., & Driscoll, D. M. (1990). Prim<strong>in</strong>g and the<br />
differential use of dimensions <strong>in</strong> evaluation. Personality and Social<br />
Psychology Bullet<strong>in</strong>, 16(3), 405-418.<br />
S<strong>in</strong>clair, L., & Kunda, Z. (1999). Reactions <strong>to</strong> a Black professional: Motivated<br />
<strong>in</strong>hibition and activation of conflict<strong>in</strong>g stereotypes. Journal of Personality<br />
and Social Psychology, 77(5), 885-904.<br />
Smith, T. B., McCullough, M. E., & Poll, J. (2003). Religiousness and depression:<br />
Evidence for a ma<strong>in</strong> effect and the moderat<strong>in</strong>g <strong>in</strong>fluence of stressful life<br />
events. Psychological Bullet<strong>in</strong>, 129(4), 614-636.<br />
Smith, D. P., & Orl<strong>in</strong>sky, D. E. (2004). Religious and spiritual experience among<br />
psychotherapists. Psychotherapy: Theory, Research, Practice, Tra<strong>in</strong><strong>in</strong>g,<br />
41(2), 144-151.
80<br />
S<strong>to</strong>ne, W. F. (1994). Conservatism/liberalism. In encyclopedia of human behavior<br />
(p. 701). San Diego, CA: Academic Press<br />
Strayer, J. (1990). Affective and cognitive perspectives on empathy. In N.<br />
Eisenberg & J. Strayer (Eds.), Empathy and its development (pp. 218-<br />
229). Cambridge: Cambridge University Press.<br />
Sue, S. (1998). In search of cultural competence <strong>in</strong> psychotherapy and<br />
counsel<strong>in</strong>g. American <strong>Psychologist</strong>, 53(4), 440-448.<br />
Tajfel, H., Turner, J.C., In S (1986). The social identity theory of <strong>in</strong>ter-group<br />
behavior. In S. Worchel & L.W. Aust<strong>in</strong> (Eds.) Psychology of <strong>in</strong>ter-group<br />
relations. Chicago: Nelson-Hall<br />
Taylor, S. E, & Lobel, M. (1989). Social comparison activity under threat:<br />
Downward evaluation and upward contacts. Psychological Review, 96(4),<br />
569-575.<br />
Truax, C. B. (1966). Re<strong>in</strong>forcement and nonre<strong>in</strong>forcement <strong>in</strong> Rogerian<br />
psychotherapy. Journal of Abnormal Psychology, 71, 1-9.<br />
V<strong>in</strong>ey, W., & K<strong>in</strong>g, D. B. (1998). A his<strong>to</strong>ry of psychology: Ideas and content (2nd<br />
ed.). Bos<strong>to</strong>n: Allyn & Bacon.<br />
Wadsworth, R. D., & Checketts, K. T. (1980). Influence of religious affiliation on<br />
psychodiagnosis. Journal of Consult<strong>in</strong>g and Cl<strong>in</strong>ical Psychology, 48, 234-<br />
240.<br />
Wallis, J. (2005). God's politics: Why the right gets it wrong and the left doesn't<br />
get it. San Francisco: Harper Coll<strong>in</strong>s.
81<br />
Walls, G. B. (1980). Values and psychotherapy: A comment on "Psychotherapy<br />
and religious values." Journal of Consult<strong>in</strong>g and Cl<strong>in</strong>ical Psychology,<br />
48(5), 640-641.<br />
Watson, P. J., Sawyers, P., Morris, R. J., Carpenter, M. L., Jimenez, R. S.,<br />
Jonas, K. A., et al. (2003). Reanalysis with<strong>in</strong> a Christian ideological<br />
surround: Relationships of <strong>in</strong>tr<strong>in</strong>sic religious orientation with<br />
fundamentalism and right w<strong>in</strong>g authoritarianism. Journal of Psychology<br />
and Theology, 31(4), 315-328.<br />
Watters, W. W. (1992). Deadly doctr<strong>in</strong>e: Health, illness, and Christian God talk.<br />
Buffalo, NY: Prometheus Books.<br />
Wester, S. R., & Vogel, D. L. (2002). The emperor's new clothes: Sociopolitical<br />
diversity <strong>in</strong> psychology. American <strong>Psychologist</strong>, 57(4), 295.<br />
W<strong>in</strong>seman, A. (2005). Religion <strong>in</strong> America: Who has none? Retrieved August 1,<br />
2006, from http://poll.gallup.com/content/default.aspx?ci=20329<br />
Worth<strong>in</strong>g<strong>to</strong>n, E. L. (1988). Understand<strong>in</strong>g the values of religious clients: A model<br />
and its application <strong>to</strong> counsel<strong>in</strong>g. Journal of Counsel<strong>in</strong>g Psychology, 35(2),<br />
166-174.<br />
Worth<strong>in</strong>g<strong>to</strong>n, E. L. (1996). Empirical research on religion and psychotherapeutic<br />
processes and outcomes: A 10-year review and research prospectus.<br />
Psychological Bullet<strong>in</strong>, 119(3), 448-487.<br />
Worth<strong>in</strong>g<strong>to</strong>n, E. L., & Sandage, S. (2001). Religion and spirituality.<br />
Psychotherapy: Theory, Research, Practice, Tra<strong>in</strong><strong>in</strong>g, 38(4), 473-478.
82<br />
Worth<strong>in</strong>g<strong>to</strong>n, R., Mobley, M., Franks, R. P., & Andreas Tan, J. (2000).<br />
Multicultural counsel<strong>in</strong>g competencies: Verbal content, counselor<br />
attributions, and social desirability. Journal of Counsel<strong>in</strong>g Psychology,<br />
47(4), 460-468.<br />
Yangarber-Hicks, N., Behenskyh, C., Cann<strong>in</strong>g, S., Flanagan, K., Gibson, N.,<br />
Hicks, M., et al. (2006). Invitation <strong>to</strong> the table conversation: A few diverse<br />
perspectives on <strong>in</strong>tegration. Journal of Psychology and Christianity, 25(4),<br />
338-353.<br />
Yarhouse, M. A., & Fisher, W. (2002). Levels of tra<strong>in</strong><strong>in</strong>g <strong>to</strong> address religion <strong>in</strong><br />
cl<strong>in</strong>ical practice. Psychotherapy: Theory, Research, Practice, Tra<strong>in</strong><strong>in</strong>g,<br />
39(2), 171-176.<br />
Yarhouse, M. A., & VanOrman, B. T. (1999). When psychologists work with<br />
religious clients: Applications of general pr<strong>in</strong>ciples of ethical conduct.<br />
Professional Psychology: Research and Practice, 30(6), 557-562.<br />
Yzerbyt, V. Y., & Coull, A. (1999). Fenc<strong>in</strong>g off the deviant: The role of cognitive<br />
resources <strong>in</strong> the ma<strong>in</strong>tenance of stereotypes. Journal of Personality and<br />
Social Psychology, 77(3), 449-462.<br />
Zajonc, R. B. (1968). Attitud<strong>in</strong>al effects of mere exposure. Journal of Personality<br />
and Social Psychology, 9, 2.<br />
Zeiger, M., & Lewis, J. E. (1998). The spiritually responsible therapist: Religious<br />
material <strong>in</strong> the psychotherapeutic sett<strong>in</strong>g. Psychotherapy: Theory,<br />
Research, Practice, Tra<strong>in</strong><strong>in</strong>g, 35(3), 415-424.
83<br />
CLINICIAN RELIGIOSITY AND RESPONSE TO DIVERGENT PATIENT RELIGIOSITY:<br />
AN INVESTIGATION INTO THE EFFECTS OF IMPLICIT AND EXPLICIT<br />
STEREOTYPING ON EMPATHY AND PROGNOSIS IN INITIAL RESPONDING TO<br />
PATIENTS WHO ARE RELIGIOUSLY DIVERSE FROM PSYCHOLOGISTS<br />
PART B
84<br />
Introduction<br />
Multiculturalism has been called the fourth force <strong>in</strong> psychology by some<br />
(Cheatham, Ivey, Ivey, & Simek-Morgan, 1980) and has been treated with<br />
commensurate significance <strong>in</strong> the APA’s Code of Ethics (APA, 2002). Further,<br />
the Code of Ethics bans discrim<strong>in</strong>ation aga<strong>in</strong>st multicultural groups <strong>in</strong> Standard<br />
3.01 and addresses competence <strong>in</strong> Standard 2.01 which stipulates that<br />
an understand<strong>in</strong>g of fac<strong>to</strong>rs associated with age, gender, gender identity,<br />
race, ethnicity, culture, national orig<strong>in</strong>, religion, sexual orientation,<br />
disability, language, or socioeconomic status is essential for effective<br />
implementation of their services or research, psychologists have or obta<strong>in</strong><br />
the tra<strong>in</strong><strong>in</strong>g, experience, consultation, or supervision necessary <strong>to</strong> ensure<br />
the competence of their services, or they make appropriate referrals<br />
(APA, 2002, pp. 1063-1064)<br />
An <strong>in</strong>vestigation <strong>in</strong><strong>to</strong> cl<strong>in</strong>ician approaches <strong>to</strong> religious patients is warranted for<br />
several reasons. These <strong>in</strong>clude that the addition of religion as a group addressed<br />
by APA multicultural mandates is fairly recent, that there is a his<strong>to</strong>ry of<br />
controversial relationship between science and religion, and that there is<br />
evidence of divergent religious values between patients and cl<strong>in</strong>icians. Further,<br />
the current but scant research <strong>in</strong> this area yields confus<strong>in</strong>g and sometimes<br />
seem<strong>in</strong>gly contradic<strong>to</strong>ry results.
85<br />
Religiosity as a Diversity Variable <strong>in</strong> Cl<strong>in</strong>ical Psychology<br />
Psychology has its roots <strong>in</strong> philosophy and may therefore be considered a<br />
close relative <strong>to</strong> theology when considered from an epistemological perspective.<br />
However, psychology has had <strong>to</strong> elbow its way <strong>in</strong><strong>to</strong> respectable stand<strong>in</strong>g among<br />
the hard sciences which may have caused a deliberate and excessive distance<br />
from this realm of human experience. For example, early psychologists struggled<br />
with issues concern<strong>in</strong>g the selection of methodologies and methodological purity<br />
as psychology cont<strong>in</strong>ued <strong>to</strong> develop as a discipl<strong>in</strong>e with<strong>in</strong> the sciences, even<br />
such that “the very scientific status of psychology h<strong>in</strong>ges, from some po<strong>in</strong>ts of<br />
view, on methodological purity” (V<strong>in</strong>ey & K<strong>in</strong>g, 1998, p. 24), a paradigm which<br />
has been <strong>in</strong>consistent with that which frames much of religious thought. The<br />
schism between the two is often evident <strong>in</strong> the scientific literature. For <strong>in</strong>stance,<br />
the National Academy of Sciences (1984, p. 6) claims that science and religion<br />
are “separate and mutually exclusive realms of human thought”, while other<br />
positions (Jones, 1994) emphasize that there are similarities, specifically with<br />
ways of know<strong>in</strong>g and attempts <strong>to</strong> structure understand<strong>in</strong>g of a complex<br />
existence. At the least, it is safe <strong>to</strong> assume that with<strong>in</strong> the practice of cl<strong>in</strong>ical<br />
psychology, patients br<strong>in</strong>g subjective worldviews, beliefs, and values <strong>in</strong><strong>to</strong> the<br />
therapeutic environment, many of which are <strong>in</strong>formed by their religious<br />
orientations.
86<br />
The “Religiosity Gap”<br />
Inasmuch as there are <strong>in</strong>vigorat<strong>in</strong>g arguments on either side about the<br />
essence or compatibility of the scientific and religious realms, the fact rema<strong>in</strong>s<br />
that a large portion of the population holds, and is <strong>in</strong>fluenced by, religious views.<br />
In fact, <strong>in</strong> the United States an estimated 94% of the population believes <strong>in</strong> “God<br />
or some universal spirit” (Gallup, 1996). The general population has also<br />
consistently endorsed religion as either “very important” or “fairly important” <strong>in</strong><br />
their lives, with 85% endorsement of these items <strong>in</strong> 1996 (Gallup) and 84% <strong>in</strong><br />
2006 (Gallup). Seventy-six percent of the population endorsed Judeo-Christian<br />
religious affiliations <strong>in</strong> the categories Protestant, Catholic, Jewish, Orthodox (1%<br />
of <strong>to</strong>tal <strong>in</strong>clud<strong>in</strong>g both Jews and Christians) and Mormon, with 49% of those<br />
endors<strong>in</strong>g Protestant and 23% endors<strong>in</strong>g Catholic affiliations. In addition <strong>to</strong> the<br />
forced Judeo-Christian categories, 11% percent endorsed “other” (which may or<br />
may not consist of other Judeo-Christian affiliations), 11% selected the category<br />
“none”, and 1% were “undesignated” (Gallup, 2006). Other research (Hill et al.,<br />
2000) <strong>in</strong>dicates that 90% of Americans pray, 71% belong <strong>to</strong> a church or<br />
synagogue, and 42% attend religious services weekly.<br />
<strong>Psychologist</strong>s have typically had lower rates of traditional religious<br />
affiliation than the general population (Shafranske, 2000), lower rates than other<br />
mental health professionals <strong>in</strong>clud<strong>in</strong>g social workers, psychiatrists, and marriage<br />
and family therapists (Berg<strong>in</strong> & Jensen, 1990), and lower rates than other<br />
professionals <strong>in</strong> the natural sciences <strong>in</strong> general (Long, 1971). In one study
87<br />
(Ragan, Malony, & Beit-Hallahmi, 1980) of 522 psychologists (a 2% random<br />
sample of the APA with a 67% response rate of usable questionnaires), 43% of<br />
members endorsed belief <strong>in</strong> some deity, and 34% denied the existence of God.<br />
Bilgrave and Deluty (1998) exam<strong>in</strong>ed the beliefs of a sample of 237<br />
psychologists (a 51% return rate of usable questionnaires) that <strong>in</strong>cluded 56%<br />
cl<strong>in</strong>ical- and 44% counsel<strong>in</strong>g- psychologists drawn from selected divisions of the<br />
APA. They found that 66% of participants <strong>in</strong> this sample endorsed beliefs which<br />
<strong>in</strong>cluded “God or a Universal Spirit” compared with 94% of the general population<br />
(Gallup, 1996), and 43% endorsed Judeo-Christian affiliations compared <strong>to</strong> the<br />
aforementioned estimate of 76% of the general population (Gallup, 2006). Other<br />
affiliations endorsed <strong>in</strong> the study were 15% “other,” 12% agnostic, 8% Eastern,<br />
and 6% atheist (Bilgrave & Deluty, 1998). The divergence between psychologists<br />
and the public <strong>in</strong> endorsement of religious affiliation and religious beliefs has<br />
been referred <strong>to</strong> <strong>in</strong> the literature as the “religiosity gap” (Richards & Berg<strong>in</strong>,<br />
2000).<br />
Religion and Multicultural Competence<br />
Neglect of Religious Beliefs and Values as a Diversity Variable<br />
Religious values are dist<strong>in</strong>ct from the beliefs from which they arise.<br />
Consistent with def<strong>in</strong>itions found elsewhere <strong>in</strong> the literature, Worth<strong>in</strong>g<strong>to</strong>n (1996)<br />
def<strong>in</strong>es religious beliefs as “propositional statements (<strong>in</strong> agreement with some
88<br />
organized religion) that a person holds <strong>to</strong> be true concern<strong>in</strong>g religion or religious<br />
spirituality”, and religious values as “superord<strong>in</strong>ate organiz<strong>in</strong>g statements of what<br />
a person considers important” that arise from his or her preferred religious<br />
beliefs. Religion is considered a cultural group (Richards & Berg<strong>in</strong>, 2000;<br />
Shafranske, 1996; Merriam-Webster, 2003) whose members’ beliefs and values<br />
can <strong>in</strong>fluence their worldview sufficiently <strong>to</strong> prompt the APA <strong>to</strong> mandate<br />
competencies <strong>in</strong> work<strong>in</strong>g with them, as with ethnic, racial, and other multicultural<br />
groups (APA, 2002). Also consistent with directives <strong>in</strong> work<strong>in</strong>g with other<br />
multicultural groups, there is a need for a culturally sensitive approach <strong>to</strong> their<br />
treatment.<br />
However, current levels of tra<strong>in</strong><strong>in</strong>g <strong>in</strong> religious diversity <strong>in</strong> cl<strong>in</strong>ical practice<br />
are not commensurate with what one would expect based on the religiosity of the<br />
U.S. public (Brawer, Handal, Fabrica<strong>to</strong>re, Roberts, & Wajda-Johns<strong>to</strong>n, 2002;<br />
Yarhouse & Fisher, 2002). One study reported that only 5% of cl<strong>in</strong>ical<br />
psychologists had religious professional tra<strong>in</strong><strong>in</strong>g (Shafranske, 1990). In another<br />
study (Brawer et al., 2002), when tra<strong>in</strong><strong>in</strong>g direc<strong>to</strong>rs <strong>in</strong> predoc<strong>to</strong>ral <strong>in</strong>ternship<br />
tra<strong>in</strong><strong>in</strong>g programs responded <strong>to</strong> whether the <strong>to</strong>pic of religion was covered <strong>in</strong> their<br />
tra<strong>in</strong><strong>in</strong>g program, they reported that the <strong>to</strong>pic was addressed sporadically. Also <strong>in</strong><br />
Brawer’s study, it was found that if the <strong>to</strong>pic of religion was covered <strong>in</strong> APAaccredited<br />
tra<strong>in</strong><strong>in</strong>g programs it was largely unsystematic, or it was not covered at<br />
all.<br />
Given the f<strong>in</strong>d<strong>in</strong>gs that the majority of Americans report that religious and<br />
spiritual beliefs are important <strong>in</strong> their lives and the APA policy about
89<br />
competencies <strong>in</strong> cl<strong>in</strong>ical work with religious persons, it is <strong>in</strong>terest<strong>in</strong>g <strong>to</strong> note that<br />
not only is there such little participation <strong>in</strong> religious diversity tra<strong>in</strong><strong>in</strong>g programs,<br />
but also <strong>in</strong> a study that <strong>in</strong>vestigated values considered relevant <strong>to</strong> therapy, only<br />
29% of cl<strong>in</strong>icians consider those beliefs important <strong>in</strong> their work with patients<br />
(Berg<strong>in</strong>, 1991). The relative dis<strong>in</strong>terest compared <strong>to</strong> the <strong>in</strong>terest of the general<br />
population could be the result of several fac<strong>to</strong>rs. These <strong>in</strong>clude deliberate<br />
avoidance of religion result<strong>in</strong>g from fear of explor<strong>in</strong>g the <strong>to</strong>pic <strong>in</strong> cl<strong>in</strong>ical work,<br />
personal bias aga<strong>in</strong>st it, the judgment that religious beliefs are simply unrelated<br />
<strong>to</strong> the cl<strong>in</strong>ical needs of patients, or general neglect of the <strong>to</strong>pic as a result of its<br />
relative unimportance <strong>to</strong> the psychologist’s own life. However, given the<br />
importance of religion <strong>to</strong> the general public, cl<strong>in</strong>icians may <strong>in</strong>deed undervalue the<br />
impact that a religiously <strong>in</strong>fluenced worldview may have on a comprehensive and<br />
respectful understand<strong>in</strong>g of the patient’s experience and cl<strong>in</strong>ical presentation.<br />
The Potential for Stereotyp<strong>in</strong>g and Prejudice<br />
Stereotyp<strong>in</strong>g, def<strong>in</strong>ed as the use of beliefs or expectations associated with<br />
a group or group member based on group membership, and prejudice, def<strong>in</strong>ed<br />
as a valenced evaluation of that group or group member (Sherman, Conrey,<br />
Stroessner, & Azam, 2005) aga<strong>in</strong>st religious belief systems or the values<br />
consistent with a religious worldview can contribute <strong>to</strong> bias <strong>in</strong> cl<strong>in</strong>ical work. <strong>Bias</strong><br />
for the purposes of this paper is operationalized as an <strong>in</strong>stance of prejudice.<br />
Neglect <strong>in</strong> consider<strong>in</strong>g religious worldviews for any reason may result <strong>in</strong> the
90<br />
exhibition of positive bias <strong>in</strong> the direction of secular worldviews and/or negative<br />
bias aga<strong>in</strong>st religious worldviews <strong>in</strong> treatment. Particularly without religious<br />
multicultural tra<strong>in</strong><strong>in</strong>g, cl<strong>in</strong>icians may be unaware of how their beliefs and value<br />
systems can affect the therapeutic process, selection of treatment goals, and<br />
subtle re<strong>in</strong>forcements of shifts <strong>in</strong> the patients’ own value system. Further, if<br />
cl<strong>in</strong>icians do consider religious themes important <strong>in</strong> their work with patients, it is<br />
important <strong>to</strong> know how those beliefs and values are <strong>in</strong>terpreted by cl<strong>in</strong>icians who<br />
may have very different worldviews.<br />
Before exam<strong>in</strong><strong>in</strong>g the impact of religious stereotyp<strong>in</strong>g or prejudice <strong>in</strong> more<br />
depth, it is helpful <strong>to</strong> have some basic knowledge of the variety of processes and<br />
variables that contribute <strong>to</strong> either. The literature on stereotyp<strong>in</strong>g and prejudice<br />
development and ma<strong>in</strong>tenance is volum<strong>in</strong>ous and encompasses several<br />
processes and exam<strong>in</strong>es many variables (Hil<strong>to</strong>n & Hippel, 1996). Primarily there<br />
are three categories of processes: sociocultural, motivational, and cognitive.<br />
Sociocultural models of stereotyp<strong>in</strong>g and prejudice <strong>in</strong>clude social comparison<br />
models (Brewer & Gardner, 1996; Brickman & Bulman, 1977; Crocker, McGraw,<br />
Thompson, & Ingerman, 1987; Fest<strong>in</strong>ger, 1954; Taylor & Lobel, 1989), social<br />
identity theory (Tajfel & Turner, 1979), social position effects on prejudice<br />
(Guimond, Dambrun, Mich<strong>in</strong>ov, & Duarte, 2003), and <strong>in</strong>- and out-group similarity<br />
and dissimilarity effects (Byrne, 1971; Rosenbaum, 1986). Motivational<br />
processes exam<strong>in</strong>e the use of stereotype <strong>in</strong>formation by those who have a<br />
preference for cognition (Crawford & Skowronski, 1998), a need for <strong>in</strong>creased<br />
self-esteem under threat (Crocker & Luhtanen, 1990), and use of stereotyp<strong>in</strong>g <strong>to</strong>
91<br />
reduce cognitive load (Biernat & Korbrynowicz, 2003; Crawford & Skowronski,<br />
1998; Macrae & Milne, 1994; Yzerbyt & Coull, 1999). Cognitive processes focus<br />
on <strong>in</strong>formation-process<strong>in</strong>g strategies (Bodenhausen & Lichtenste<strong>in</strong>, 1987;<br />
Hamil<strong>to</strong>n, Sherman, & Ruvolo, 1990; Hamil<strong>to</strong>n & Trolier, 1986), stereotyp<strong>in</strong>g as a<br />
cognitive construct (Korten, 1973), and the relationship between stereotyp<strong>in</strong>g and<br />
cognitive simplicity (Koenig & K<strong>in</strong>g, 1964).<br />
The effects of both affect and cognition have been exam<strong>in</strong>ed <strong>to</strong>gether <strong>in</strong><br />
the literature. Affect has been operationalized several ways <strong>in</strong>clud<strong>in</strong>g agreement<br />
with mood-affect adjectives follow<strong>in</strong>g evaluations of stereotype targets (Jackson<br />
& Sullivan, 2001), and “lik<strong>in</strong>g” for target groups (Jussim, Manis, Nelson, & Soff<strong>in</strong>,<br />
1995). Cognition is often def<strong>in</strong>ed by beliefs about stereotyped targets (Jackson &<br />
Sullivan, 2001; Jussim et al., 1995). Also, the effect of <strong>in</strong>duced happ<strong>in</strong>ess on<br />
stereotypic judgments has been explored (Bodenhausen, Kramer, & Susser,<br />
1994).<br />
The categories <strong>in</strong> many of these studies overlap as the literature cont<strong>in</strong>ues<br />
<strong>to</strong> more narrowly def<strong>in</strong>e the mechanisms by which bias occurs. Still other<br />
literature looks <strong>to</strong> motivational processes that moderate prejudice, with some<br />
emphasis on the value that many place on respond<strong>in</strong>g without prejudice for the<br />
purposes of ma<strong>in</strong>ta<strong>in</strong><strong>in</strong>g <strong>in</strong>terpersonal harmony and/or due <strong>to</strong> an <strong>in</strong>trapersonal<br />
value system that disapproves of prejudiced behavior (Dev<strong>in</strong>e, Plant, Amodio,<br />
Harmon-Jones, & Vance, 2002; Dun<strong>to</strong>n & Fazio, 1997). Yet other work exam<strong>in</strong>es<br />
the phenomenon of rebound effects of stereotype suppression, or the tendency
92<br />
for stronger stereotyp<strong>in</strong>g behaviors <strong>to</strong> follow attempts at suppress<strong>in</strong>g stereotypes<br />
(Macrae, Bodenhausen, Milne, & Jetten, 1994).<br />
The possibility of prejudice and stereotyp<strong>in</strong>g of culturally diverse groups <strong>in</strong><br />
cl<strong>in</strong>ical work is evident <strong>in</strong> that there are policies prohibit<strong>in</strong>g discrim<strong>in</strong>ation aga<strong>in</strong>st<br />
those groups (see APA, 2002 Section 3.01). The social psychology literature<br />
consistently shows negative stereotyp<strong>in</strong>g of members of dissimilar groups<br />
(Ashburn-Nardo, Voils, & Monteith, 2001; Dev<strong>in</strong>e et al., 2002; Jussim et al.,<br />
1995; Sears & Rowe, 2003; Sherman et al., 2005). Byrne (1971) offers the<br />
hypothesis that the average person is less attracted <strong>to</strong>, and maybe even dislikes,<br />
people whose values, attitudes, beliefs, and op<strong>in</strong>ions are different from his or her<br />
own. Research on Byrne’s repulsion paradigm (Rosenbaum, 1986) exam<strong>in</strong>ed<br />
participants’ responses <strong>to</strong> persons with similar and dissimilar attitudes on a<br />
number of dimensions, and contrast<strong>in</strong>g with controls, the study yielded significant<br />
differences <strong>in</strong> repulsion rat<strong>in</strong>gs for those with dissimilar attitudes. In another<br />
study (Chen & Kenrick, 2002), the repulsion hypothesis was demonstrated <strong>in</strong><br />
three experiments after participants learned of dissimilar controversial attitude<br />
positions of others. Further, the effects of <strong>in</strong>- and out-group bias are<br />
demonstrated <strong>in</strong> m<strong>in</strong>imal group paradigms, which refer <strong>to</strong> bias effects when<br />
groups differ only <strong>in</strong> label assignment (Tajfel & Turner, 1979; Gaertner & Insko,<br />
2000).<br />
In summary, it is evident that the circumstances under which stereotyp<strong>in</strong>g<br />
or prejudice may occur are many. Much of the theoretical and research literature<br />
focuses on similarity and dissimilarity of groups as a precursor <strong>to</strong> stereotyp<strong>in</strong>g
93<br />
and prejudice under those varied conditions, even when that difference is only<br />
implied or completely ambiguous as is the case <strong>in</strong> the m<strong>in</strong>imal group paradigm.<br />
Even with cl<strong>in</strong>ical tra<strong>in</strong><strong>in</strong>g that emphasizes the impact of empathy and patient<br />
acceptance as a significant part of successful cl<strong>in</strong>ical treatment, practitioners who<br />
value these approaches may also demonstrate biased patterns of respond<strong>in</strong>g.<br />
Cl<strong>in</strong>icians’ biased respond<strong>in</strong>g <strong>to</strong> dissimilar patients can take many forms <strong>in</strong> a<br />
cl<strong>in</strong>ical sett<strong>in</strong>g. Areas <strong>in</strong> which bias effects might manifest range from trends <strong>in</strong><br />
value convergence <strong>to</strong> decreased empathy and the selection of treatment goals<br />
which conflict with the patients’ preferred values and worldview. An exam<strong>in</strong>ation<br />
of the forms that cl<strong>in</strong>ical bias may take will beg<strong>in</strong> with a brief discussion of the<br />
implications of the value convergence literature.<br />
Outcomes and Value Convergence<br />
Initial similarity of cl<strong>in</strong>ician and patient demographic variables <strong>in</strong>clud<strong>in</strong>g<br />
SES, ethnicity, gender, and age has been shown <strong>to</strong> have an effect on<br />
relationship enhancement and even treatment outcomes (Beutler, Crago, &<br />
Arizmendi, 1986; Kim, Gladys, & Ahn, 2005). Consistent with Byrne’s theory,<br />
Beutler and Bergan (1991) posit that the role of values may have an even greater<br />
impact on treatment bias than the roles of age, ethnicity, and gender, which often<br />
do not accurately represent group members’ attitudes and values. Further, value<br />
convergence is often an <strong>in</strong>dica<strong>to</strong>r of counselor-perceived improved patient<br />
outcomes (Beutler & Bergan, 1991; Worth<strong>in</strong>g<strong>to</strong>n, 1988). However, these results
94<br />
are <strong>in</strong>consistent (Beutler, Machado, & Neufeldt, 1994; Beutler et al., 2004), and<br />
the effect is less strong for other- and client-rated perceptions of improvement<br />
than for counselor-perceived improvements (Kelly, 1990). Nonetheless, the<br />
phenomenon that cl<strong>in</strong>icians consider patients healthier when their values more<br />
closely match their own may be evidence that judgments are be<strong>in</strong>g made about<br />
preferable value systems.<br />
Also, the process by which value shifts occur may <strong>in</strong>dicate subtle<br />
re<strong>in</strong>forcement of movement <strong>in</strong> the direction of or away from particular values.<br />
Even cl<strong>in</strong>icians who <strong>in</strong>tend <strong>to</strong> be nondirective may be unaware of subtle<br />
messages of approval or disapproval communicated <strong>to</strong> the patient, such as<br />
frequency and duration of eye contact and affirm<strong>in</strong>g or disconfirm<strong>in</strong>g facial<br />
expressions, gestures, and verbalizations. Repeated occurrences of<br />
discrim<strong>in</strong>a<strong>to</strong>ry re<strong>in</strong>forcement and nonre<strong>in</strong>forcement were seen <strong>in</strong> two<br />
<strong>in</strong>dependent studies of Carl Rogers demonstrat<strong>in</strong>g Rogerian therapy, <strong>in</strong> which<br />
patterns of respond<strong>in</strong>g based on value preferences (Truax, 1966), and similarity<br />
of patient style of expression and other response classes (Murray, 1956), altered<br />
patient behavior. S<strong>in</strong>ce Rogerian therapy is well known for its emphasis on<br />
unconditional positive regard and patient-led processes, it should be recognized<br />
that even the most nondirective, accept<strong>in</strong>g therapeutic stances may have<br />
embedded with<strong>in</strong>, value preferences that <strong>in</strong>fluence treatment. Some (Ellis, 1980)<br />
have even encouraged cl<strong>in</strong>icians <strong>to</strong> emphasize value stances <strong>to</strong> capitalize on<br />
value convergence research, despite guidance of the APA Code of Ethics <strong>to</strong><br />
respect group differences (APA, 2002, Pr<strong>in</strong>ciple E). The effect of value
95<br />
convergence is a concern for cl<strong>in</strong>icians and researchers who recognize the<br />
power of the therapist as an agent of change whose <strong>in</strong>fluence may be better<br />
described as one of “persuasion and conversion rather than one of heal<strong>in</strong>g”<br />
(Beutler et al., 2004).<br />
Religion and Mental Health<br />
More overtly, cl<strong>in</strong>icians may direct conscious challenges <strong>to</strong> the patient’s<br />
religious belief system or the values that arise from it, if cl<strong>in</strong>icians believe it <strong>to</strong> be<br />
less desirable than their own or pathological <strong>in</strong> some way. Sigmund Freud<br />
repeatedly professed op<strong>in</strong>ions that God is “noth<strong>in</strong>g but an exalted father” (Freud<br />
1913/2000, p. 256), and that all faith was at least neurotically determ<strong>in</strong>ed (Freud,<br />
1913/2000, pp. 174-281), ignor<strong>in</strong>g healthy and nonpathological faith. More<br />
recently, Albert Ellis stated that religion is illogical and questioned what changes<br />
religious persons could make without giv<strong>in</strong>g up their religious beliefs, which he<br />
claimed were characterized by <strong>in</strong>flexibility and devout “shoulds, oughts, and<br />
musts,” and even saw religion as evidence of the most severe emotional<br />
disturbance (Ellis, 1980, p. 31), although he later recants some of his earlier<br />
positions (see Ellis, 2000).<br />
Other and recent antireligious views <strong>in</strong>clude comments made by Wendell<br />
Watters, a respected professor of psychiatry and physician at McMaster<br />
University <strong>in</strong> Ontario, Canada. In reference <strong>to</strong> Christian doctr<strong>in</strong>e and teach<strong>in</strong>gs<br />
he stated that they are “<strong>in</strong>compatible with the development and ma<strong>in</strong>tenance of
96<br />
sound health, and not only ‘mental’ health,” and that “Simply put, Christian<br />
<strong>in</strong>doctr<strong>in</strong>ation is a form of mental and emotional abuse” (Watters, 1992, p.10). In<br />
reference <strong>to</strong> the majority of membership <strong>in</strong> the American Psychological<br />
Association (APA), Emeritus professor of psychology at Yale University and<br />
author of over 40 books, Seymour Sarason, <strong>in</strong> his Centennial Address <strong>to</strong> the<br />
APA stated that there are more than a few psychologists who regard <strong>in</strong>gredients<br />
of a religious worldview as a “reflection of irrationality, of superstition, of an<br />
immaturity, of a neurosis,” and that “<strong>in</strong>deed if we learn someone is devoutly<br />
religious, or even tends <strong>in</strong> that direction, we look upon that person with<br />
puzzlement, often conclud<strong>in</strong>g that psychologist obviously had or has personal<br />
problems” (Sarason, 1993, p. 187). In the Diagnostic and Statistic Manual of<br />
Mental Disorders (DSM-III-R), 12 references <strong>to</strong> religion <strong>in</strong> the Glossary of<br />
Technical Terms were used <strong>to</strong> demonstrate psychopathology (American<br />
Psychiatric Association, 1987).<br />
While it is noted that the latest revision of the DSM, the DSM-IV TR<br />
(American Psychiatric Association, 2000), now <strong>in</strong>cludes more culturally sensitive<br />
language, that antireligious perspectives may have <strong>in</strong>fluenced the cl<strong>in</strong>ical<br />
judgment of psychologists and psychiatrists alike, should not be easily dismissed.<br />
Indeed, there is encourag<strong>in</strong>g evidence that some psychologists’ worldviews have<br />
evolved <strong>in</strong> conjunction with the demands for multiculturally appropriate<br />
perspectives as can be seen <strong>in</strong> the morph<strong>in</strong>g views of Albert Ellis. In one earlier<br />
treatise on religiousness and psychotherapy Ellis states that, “If one of the<br />
requisites for emotional health is acceptance of uncerta<strong>in</strong>ty, then religion is
97<br />
obviously the unhealthiest state imag<strong>in</strong>able” (Ellis, 1980a, p. 8), imply<strong>in</strong>g by<br />
virtue of the religious person’s extreme pathology that he or she is likely the<br />
hardest <strong>to</strong> treat. Indeed, he also stated that “the best he can do, if he wants <strong>to</strong><br />
change any of the rules that stem from his doctr<strong>in</strong>e, is <strong>to</strong> change the religion<br />
itself” (Ellis, 1980a, p. 9). However, Ellis later recants some of his earlier<br />
assertions and reports that his Rational Emotive Behavior Therapy is compatible<br />
with some religious views and can be effectively used with patients who have<br />
devout beliefs about God without chang<strong>in</strong>g their religion (Ellis, 2000).<br />
Nevertheless, it is difficult <strong>to</strong> imag<strong>in</strong>e that such evolution <strong>in</strong> th<strong>in</strong>k<strong>in</strong>g about<br />
religiosity and religious persons, as encourag<strong>in</strong>g as it may be, necessarily<br />
represents a sudden and ubiqui<strong>to</strong>us absence of antireligious views <strong>in</strong><br />
psychology. Certa<strong>in</strong>ly, this type of anti-religious th<strong>in</strong>k<strong>in</strong>g was common enough <strong>in</strong><br />
the not so distant past that it was acceptable for publication <strong>in</strong> peer-reviewed<br />
journals, which one might assume have some commitment <strong>to</strong> publish culturally<br />
appropriate materials.<br />
Contrary <strong>to</strong> these op<strong>in</strong>ions, two meta-analytic studies (Berg<strong>in</strong>, 1983;<br />
Gartner, Larson, & Allen, 1991) yielded no evidence and <strong>in</strong>consistent evidence<br />
respectively, for a l<strong>in</strong>k between religiosity and poorer mental health. A more<br />
recent meta-analytic study on religiousness and depression (Smith, McCullough,<br />
& Poll, 2003) found a negative correlation between symp<strong>to</strong>ms and religiousness.<br />
In fact, an overall trend <strong>in</strong> good mental health was found on scales that<br />
measured anxiety, personality traits, self-control, irrational beliefs, and<br />
depression <strong>in</strong> those with an <strong>in</strong>tr<strong>in</strong>sic religious orientation (religion as an end itself
98<br />
as opposed <strong>to</strong> it be<strong>in</strong>g used as a means <strong>to</strong> another end; Berg<strong>in</strong>, Masters, &<br />
Richards, 1987; Smith et al., 2003). Moreover, <strong>in</strong>creased associations between<br />
general psychological well-be<strong>in</strong>g and religion were demonstrated <strong>in</strong> a Christian<br />
sample (Francis & Peter, 2002), and improved mental health was associated with<br />
those who use positive religious cop<strong>in</strong>g on doma<strong>in</strong>s <strong>in</strong>clud<strong>in</strong>g chronic pa<strong>in</strong> (see<br />
Rippentrop, 2005 for review) and rehabilitation (Kilpatrick & McCullough, 1999).<br />
Indeed, some acknowledge that the perception of religious persons as<br />
irrational, <strong>in</strong>flexible, and pathological has <strong>in</strong> fact <strong>in</strong>stilled a fear of psychotherapy<br />
<strong>in</strong> potential patients who are religiously oriented (Richards & Berg<strong>in</strong>, 2000).<br />
Members of traditional religious organizations may perceive psychotherapists as<br />
<strong>in</strong>capable of, or unwill<strong>in</strong>g <strong>to</strong>, work with them <strong>in</strong> a manner that is respectful and<br />
sensitive <strong>to</strong> their religiousness. Religious persons have also articulated fears that<br />
secular therapists may seek <strong>to</strong> change their religious beliefs or may<br />
misunderstand them and may even not enter therapy as a result (Richards &<br />
Berg<strong>in</strong>, 2000; Worth<strong>in</strong>g<strong>to</strong>n, 1996). If cl<strong>in</strong>icians evaluate a patient’s religiousness<br />
<strong>to</strong> be an <strong>in</strong>dication of pathology, they may also rate their prognosis more<br />
negatively as a reflection of his or her perceived poorer mental health.<br />
Sociopolitical Influence<br />
Lastly, multicultural tra<strong>in</strong><strong>in</strong>g programs stress the importance of<br />
psychologists’ awareness of their sociopolitical views, and its <strong>in</strong>fluence on<br />
research and <strong>in</strong> practice, particularly <strong>in</strong> the delivery of culturally competent
99<br />
services and patient satisfaction (Fuertes & Brobst, 2002; Redd<strong>in</strong>g, 2002; Wester<br />
& Vogel, 2002). Political parties and policy preferences have become<br />
<strong>in</strong>creas<strong>in</strong>gly polarized <strong>in</strong> recent years, with even the label<strong>in</strong>g of “liberal” and<br />
“conservative” groups as “red” and “blue” contribut<strong>in</strong>g <strong>to</strong> further divide the<br />
groups, and contribut<strong>in</strong>g <strong>to</strong> the risk of <strong>in</strong>creased conflict between them (Seyle &<br />
Newman, 2006). These groups are very often associated with either secular or<br />
religious worldviews, whether accurately or not, and negative stereotypes and<br />
feel<strong>in</strong>gs about either group and their group members and presumed values have<br />
become more charged as well <strong>in</strong> recent years ( Wallis, 2005). With the current<br />
lack of participation <strong>in</strong> cl<strong>in</strong>ician religious multicultural tra<strong>in</strong><strong>in</strong>g, lack of awareness<br />
of the impact of one’s sociopolitical background is a possibility. Stereotypes and<br />
affective charge associated with religious persons or groups prom<strong>in</strong>ent <strong>in</strong> politics<br />
may be generalized <strong>to</strong> the cl<strong>in</strong>ical sett<strong>in</strong>g when one is confronted with religiously<br />
oriented patients.<br />
Impact of Religious Neglect or <strong>Bias</strong> on Treatment<br />
Due <strong>to</strong> the religiosity gap, a his<strong>to</strong>ry of conflict between science and<br />
religion that <strong>in</strong>cludes the pathologiz<strong>in</strong>g of religion, sociopolitical differences that<br />
may affect cl<strong>in</strong>ical judgment of religiously diverse patients, and the consideration<br />
of the stereotype and prejudice literature <strong>in</strong> general, biases are likely <strong>to</strong> occur. In<br />
fact, the nature of religious bias that may occur <strong>in</strong> a cl<strong>in</strong>ical sett<strong>in</strong>g has caused<br />
some <strong>to</strong> express the concern that “ethical violations may occur when therapists
100<br />
who are religiously un<strong>in</strong>formed, <strong>in</strong>sensitive, or prejudiced ‘trample on the values’<br />
of religious clients and <strong>in</strong> so do<strong>in</strong>g alienate, offend, and even harm them”<br />
(Richards & Berg<strong>in</strong>, 2000, p. 13). Religious bias can be exhibited <strong>in</strong> many ways.<br />
Selection of Treatment Goals<br />
<strong>Bias</strong> <strong>in</strong> the direction of one value system over another may result <strong>in</strong> the<br />
selection of treatment goals which may conflict with the patient’s preferred<br />
values. For example, goals may focus on themes that devalue self-control <strong>in</strong><br />
terms of absolute values and universal ethics consistent with the patient’s<br />
religious belief system, and <strong>in</strong>stead encourage self-expression <strong>in</strong> terms of<br />
relative values, or they may encourage permissiveness <strong>in</strong> sex or sex without<br />
long-term responsibilities which may also conflict with the patient’s religious<br />
values (Berg<strong>in</strong>, 1980). In either case, the psychologist may be unaware of the<br />
patient’s religious beliefs and values and commitment <strong>to</strong> live accord<strong>in</strong>gly, or he or<br />
she may have prejudice aga<strong>in</strong>st the patient’s values, see<strong>in</strong>g the patient as less<br />
desirable or even unhealthy and <strong>in</strong> need of change <strong>to</strong> values more similar <strong>to</strong><br />
those of the cl<strong>in</strong>ician. However, prohibition aga<strong>in</strong>st such bias is articulated <strong>in</strong> the<br />
APA Code of Ethics which specifically calls upon psychologists <strong>to</strong> “be aware of<br />
and respect cultural, <strong>in</strong>dividual and role differences” and <strong>to</strong> “try <strong>to</strong> elim<strong>in</strong>ate the<br />
effect on their work of those biases” (APA, 2002, Pr<strong>in</strong>ciple E).<br />
Prejudiced or religiously un<strong>in</strong>formed treatment can also result <strong>in</strong> bias <strong>in</strong><br />
the direction of secular <strong>in</strong>terventions that ignore religious <strong>to</strong>ols that may assist
101<br />
the patient <strong>in</strong> heal<strong>in</strong>g. Religious patients may benefit significantly from<br />
<strong>in</strong>terventions that draw on religious themes that promote effective cop<strong>in</strong>g or<br />
assist <strong>in</strong> the process of change and heal<strong>in</strong>g. These <strong>in</strong>clude prayer, div<strong>in</strong>e<br />
forgiveness, and socialization with<strong>in</strong> their religious community (Kilpatrick &<br />
McCullough, 1999; Rippentrop, 2005).<br />
Empathy<br />
Culture impacts the empathic understand<strong>in</strong>g of others (Ivey, Ivey, &<br />
Simek-Morgan, 1993). The degree <strong>to</strong> which cl<strong>in</strong>icians are able <strong>to</strong> empathize with<br />
their religiously diverse patients may contribute significantly <strong>to</strong> whether they are<br />
able <strong>to</strong> provide culturally competent services. As a result of affectively charged<br />
feel<strong>in</strong>gs about religiously diverse patients and their worldviews, or stereotypic or<br />
prejudiced expectations and evaluations about them, empathy with<strong>in</strong><br />
cl<strong>in</strong>ician/patient dyads may be impacted. When religious diversity tra<strong>in</strong><strong>in</strong>g is<br />
lack<strong>in</strong>g and stereotypes or prejudices go unexam<strong>in</strong>ed, it is conceivable that<br />
dissimilarity of religious beliefs and values may contribute <strong>to</strong> a decrease <strong>in</strong> the<br />
cl<strong>in</strong>ician’s ability <strong>to</strong> assume the perspective of, or have empathic concern for, his<br />
or her dissimilar patients.<br />
Literature on Cl<strong>in</strong>ical Judgment of Religious Patients
102<br />
To date, bias studies on the cl<strong>in</strong>ical effects of religiously divergent<br />
cl<strong>in</strong>ician/patient dyads have been <strong>in</strong>consistent (e.g., Berg<strong>in</strong>, 1991; Beutler &<br />
Bergan, 1991; Gartner, 1990; Hillowe, 1986; Houts & Graham, 1986; Lewis &<br />
Lewis, 1985; O'Connor & Vandenberg, 2005; Reed, 1992; Wadsworth &<br />
Checketts, 1980; Yarhouse & VanOrman, 1999). Methodological concerns and<br />
<strong>in</strong>appropriate generalization of results often contribute <strong>to</strong> mixed f<strong>in</strong>d<strong>in</strong>gs.<br />
Methodological issues <strong>in</strong>clude participant self-report of religiosity or patient<br />
religiosity based solely on religious affiliation with no consideration of how<br />
religiosity impacts one’s life (Houts & Graham, 1986; Lewis & Lewis, 1985; Reed,<br />
1992; Wadsworth & Checketts, 1980).<br />
Another methodological issue is little or no attempt <strong>to</strong> control for social<br />
desirability. As bias is generally discouraged <strong>in</strong> most social contexts and certa<strong>in</strong>ly<br />
when form<strong>in</strong>g cl<strong>in</strong>ical judgments, it is notable that any positive results of bias<br />
were found at all (e.g., Gartner, 1986; Gartner, Hohmann, Harmatz, & Larson,<br />
1990; Hillowe, 1986) <strong>in</strong> studies that did not attempt <strong>to</strong> control for it, as one might<br />
assume that participants may be motivated <strong>to</strong> conceal their bias due <strong>to</strong> social<br />
desirability effects. It is not surpris<strong>in</strong>g however, that if a study’s purpose is<br />
transparent, and that purpose is <strong>to</strong> detect socially undesirable bias, the results<br />
are likely <strong>to</strong> be negative for bias (e.g., Houts & Graham, 1986; Lewis & Lewis,<br />
1985; Reed, 1992; Wadsworth & Checketts, 1980).<br />
Generalizability of the results of several studies is limited as they did not<br />
use a national sample. Moreover, they typically exam<strong>in</strong>ed the cl<strong>in</strong>ical judgment of<br />
psychologists <strong>in</strong> geographical regions <strong>in</strong> which one could reasonably assume
103<br />
religiosity is fairly common such as Tennessee (Houts & Graham, 1986), Iowa<br />
(Lewis & Lewis, 1985), and Utah (Wadsworth & Checketts, 1980). Indeed, one<br />
study often cited <strong>in</strong> the literature as yield<strong>in</strong>g no results of bias <strong>in</strong> diagnosis<br />
<strong>in</strong>cluded only two categories of cl<strong>in</strong>icians: “Latter Day Sa<strong>in</strong>ts” and “other”<br />
(Wadsworth & Checketts, 1980) .<br />
One study (Houts & Graham, 1986) which failed <strong>to</strong> f<strong>in</strong>d significant bias <strong>in</strong><br />
diagnosis was conducted <strong>in</strong> a rural area assumed <strong>to</strong> have a more religiously<br />
conservative population (Tennessee) than might otherwise be found nationally or<br />
<strong>in</strong> urban areas, which precludes generalizability <strong>to</strong> cl<strong>in</strong>icians <strong>in</strong> more religiously<br />
liberal states where cl<strong>in</strong>ician encounters with religiously conservative patients<br />
may be more <strong>in</strong>frequent. It is possible that when religiously conservative persons<br />
are a dist<strong>in</strong>ct m<strong>in</strong>ority of the population, their out-group status may have an<br />
impact on cl<strong>in</strong>icians’ stereotypic expectation of the patient, affective “lik<strong>in</strong>g” of the<br />
patient, and ability <strong>to</strong> empathize with the patient, all of which might impact the<br />
course of treatment. In fact, research <strong>in</strong>dicates (Brown, 1970) that even cl<strong>in</strong>ician<br />
first impressions of patients which <strong>in</strong>clude personal “lik<strong>in</strong>g” for them, has a<br />
significant effect on case outcomes measured by eventual number of sessions,<br />
later assessment of patient progress, type of case term<strong>in</strong>ation, cl<strong>in</strong>ician<br />
satisfaction with patient progress, and cl<strong>in</strong>ician perception of patient satisfaction<br />
with therapy.<br />
Houts and Graham (1986) measured prognosis, pathology, and <strong>in</strong>ternal<br />
versus external attributions of patient difficulties as evaluated by cl<strong>in</strong>icians who<br />
self-reported as religious or nonreligious. Cl<strong>in</strong>icians rated vignettes that
104<br />
supposedly represented nonreligious, moderately religious, and very religious<br />
patients. Cl<strong>in</strong>icians <strong>in</strong> this study rated the moderately religious patient, as def<strong>in</strong>ed<br />
by doubts about his commitment <strong>to</strong>, and strength of, religious beliefs, as hav<strong>in</strong>g<br />
more psychopathology and a more pessimistic prognosis than those with no<br />
mention of religion or those rated as very religious. Indeed, authors found that<br />
cl<strong>in</strong>icians were probably <strong>in</strong>fluenced by the amount of doubt the patient exhibited<br />
about his religious beliefs, rather than degree of religiosity. Specifically Houts and<br />
Graham state that “consistent with the cultural legacy of view<strong>in</strong>g religious beliefs<br />
as a crutch, the <strong>in</strong>dividual who expresses less than conv<strong>in</strong>c<strong>in</strong>g endorsement of<br />
religious beliefs may be more prone <strong>to</strong> be<strong>in</strong>g viewed as dis<strong>in</strong>genuous and<br />
disturbed” (1986, p. 270). As doubt was <strong>in</strong>troduced <strong>in</strong><strong>to</strong> the moderate condition<br />
and not <strong>in</strong> the others, it makes <strong>in</strong>terpretation of results difficult and extrapolation<br />
<strong>to</strong> general attitudes about patients of vary<strong>in</strong>g degrees of religiosity impossible.<br />
Another study (Lewis & Lewis, 1985) found mixed results. Us<strong>in</strong>g a 10-<br />
m<strong>in</strong>ute videotape of a depressed patient, Lewis and Lewis measured counselorperceived<br />
patient attractiveness us<strong>in</strong>g the Therapist Personal Reaction<br />
Questionnaire, pathology rat<strong>in</strong>gs us<strong>in</strong>g DSM-IV diagnoses, and a Likert scale<br />
prognostic measure, rated by both religious and nonreligious cl<strong>in</strong>icians<br />
determ<strong>in</strong>ed by cl<strong>in</strong>ician self-report of whether he or she was religiously affiliated.<br />
No significant bias was found on pathology and lik<strong>in</strong>g of the patient between<br />
either the religious or the nonreligious depressed patient; however, the patient’s<br />
religiosity was seen as hav<strong>in</strong>g a large impact on her difficulties. Authors found it<br />
difficult <strong>to</strong> <strong>in</strong>terpret these results as symp<strong>to</strong>ms of depression between vignettes
105<br />
were virtually identical but speculate that whenever religion is a central concern,<br />
it naturally impacts the way they manage their problems, or that religiosity is<br />
perceived <strong>to</strong> play a causative role <strong>in</strong> the patient’s problems. Interest<strong>in</strong>gly, both<br />
religious and nonreligious cl<strong>in</strong>icians predicted fewer sessions needed for the<br />
religious patient than the nonreligious patient. Particularly, nonreligious cl<strong>in</strong>icians<br />
rated nonreligious patients as need<strong>in</strong>g almost twice as many sessions as the<br />
religious patient. Authors speculate that f<strong>in</strong>d<strong>in</strong>g may reflect cl<strong>in</strong>icians’ belief that<br />
treatment progress may be enhanced by the religious patients’ religious<br />
orientation.<br />
There are several limitations of the above studies. The relatively<br />
undef<strong>in</strong>ed dicho<strong>to</strong>miz<strong>in</strong>g of religious versus nonreligious cl<strong>in</strong>icians by self-report<br />
of religious affiliation, rather than us<strong>in</strong>g dimensional and more descriptive<br />
categorization of religiousness is problematic (e.g., Houts & Graham, 1986;<br />
Lewis & Lewis, 1985; Reed, 1992; Wadsworth & Checketts, 1980). Recall<strong>in</strong>g that<br />
it is hypothesized that demographic variables are poor characterizations of one’s<br />
specific beliefs and attitudes, negative f<strong>in</strong>d<strong>in</strong>gs <strong>in</strong> some of these cases may be a<br />
result of poor cl<strong>in</strong>ician group assignment. If <strong>in</strong>deed studies seek <strong>to</strong> detect<br />
cl<strong>in</strong>ician bias with <strong>in</strong>dividuals whose beliefs and values differ from their own,<br />
more dimensional descrip<strong>to</strong>rs of one’s religiosity will be a better predic<strong>to</strong>r of<br />
attitudes than will group affiliation alone. In other words, reported religious<br />
affiliation, does not a religious person make. Therefore, <strong>in</strong>terpretation of results of<br />
bias <strong>in</strong> relation <strong>to</strong> others who are also merely associated with a religion may not<br />
reflect bias that could be evoked when one is presented with more detailed
106<br />
<strong>in</strong>formation about the effects of another’s religiousness on behaviors and<br />
attitudes.<br />
Further, several of the studies cited above utilized a between-subjects<br />
design with no attempts <strong>to</strong> detect favorable bias <strong>in</strong> the direction of the religious<br />
patient over the nonreligious patient <strong>in</strong> <strong>in</strong>dividual cases, which gone unmeasured<br />
may have mitigated negative bias such that negative bias was undetectable,<br />
thereby compromis<strong>in</strong>g results (Houts & Graham, 1986; Lewis & Lewis, 1985;<br />
Reed, 1992). Wadsworth and Checketts (1980) used no control vignettes and<br />
each of the four vignettes presented described religiously affiliated persons,<br />
whether currently active or <strong>in</strong>active participants <strong>in</strong> religious behaviors or beliefs.<br />
Additionally problematic is generalizability <strong>to</strong> less conservative states. It is<br />
not yet unders<strong>to</strong>od what effect cont<strong>in</strong>ued exposure <strong>to</strong> values different from one’s<br />
own may have on bias, nor was this effect discussed <strong>in</strong> any of the f<strong>in</strong>d<strong>in</strong>gs of the<br />
aforementioned studies. However, current research on the attitud<strong>in</strong>al effects of<br />
exposure <strong>to</strong> targets <strong>in</strong>dicates that mere exposure facilitates lik<strong>in</strong>g, relative <strong>to</strong><br />
attitudes <strong>to</strong>ward targets <strong>to</strong> which one has no exposure (Zajonc, 1968). So, if one<br />
is a nonreligious cl<strong>in</strong>ician <strong>in</strong> the “Bible belt” immersed <strong>in</strong> a culture <strong>in</strong> which the<br />
norm consists of religious persons, is one as likely <strong>to</strong> have bias aga<strong>in</strong>st those of<br />
orthodox religious beliefs as one might if one were part of a community <strong>in</strong> which<br />
religious persons constitute an out-group? Wadsworth and Checketts’ study<br />
exam<strong>in</strong>ed cl<strong>in</strong>ical judgment of Latter-Day Sa<strong>in</strong>ts and “Other” participants, where<br />
“Other” <strong>in</strong>cluded all other religions, agnostics, and atheists. The method of group
107<br />
assignment <strong>in</strong> this study often cited for provid<strong>in</strong>g evidence aga<strong>in</strong>st cl<strong>in</strong>ician<br />
religious bias, essentially renders any generalization of results impossible.<br />
Another study (Gartner, Hohmann, Harmatz, & Larson, 1990) yielded<br />
results reveal<strong>in</strong>g bias. In this study participants rated vignettes of patients<br />
belong<strong>in</strong>g <strong>to</strong> one of four extreme ideological groups, right w<strong>in</strong>g conservative<br />
religious (Fundamentalist Christian), left w<strong>in</strong>g liberal religious (Atheists<br />
International), right w<strong>in</strong>g political (John Birch Society), and left w<strong>in</strong>g political<br />
(American Socialist Party) groups. Fictitious patients Mr. S and Mr. W were<br />
represented equally <strong>in</strong> each of either the four ideological categories or a nonideological<br />
group. Participants received one set of two vignettes each with either<br />
Mr. S belong<strong>in</strong>g <strong>to</strong> one of the four ideological groups and Mr. W who had no<br />
ideology, or Mr. W be<strong>in</strong>g represented <strong>in</strong> one of the four ideological categories<br />
and Mr. S who had no ideology. Each subject responded <strong>to</strong> measures of<br />
empathy, pathology, and perceived maturity of the patients. Us<strong>in</strong>g a with<strong>in</strong>subjects<br />
design on a national sample, significant bias was found on each<br />
variable. This study exam<strong>in</strong>ed the <strong>in</strong>teraction of patient/cl<strong>in</strong>ician religious (and<br />
political) ideological poles from very conservative and very liberal patients, which<br />
is clearly more <strong>in</strong>formative than mere denom<strong>in</strong>ational affiliation alone. It also is<br />
different from other studies <strong>in</strong> that it measured cl<strong>in</strong>ical judgment us<strong>in</strong>g a national<br />
sample and a with<strong>in</strong>-subjects design. Indeed, a review of the literature reveals<br />
that there is a paucity of research <strong>in</strong><strong>to</strong> the effects of divergent cl<strong>in</strong>ician/patient<br />
religiosity <strong>in</strong> a national population of psychologists which, as we have discussed,<br />
may be considered quite religiously liberal compared <strong>to</strong> the general population.
108<br />
In another analogue study, Hillowe (1986) found bias aga<strong>in</strong>st religious<br />
patients by a homogeneous group of therapists, who evaluated religious patients<br />
as more mentally ill and <strong>in</strong> need of significantly more sessions <strong>to</strong> make progress<br />
than their nonreligious counterparts. One significant <strong>in</strong>teraction was found. As<br />
therapists’ nondoctr<strong>in</strong>al religious attitudes <strong>in</strong>creased, the prognosis of religious<br />
patients was significantly better than for nonreligious patients. He speculates that<br />
as a result of their own experiences these cl<strong>in</strong>icians may believe that religious<br />
patients have a basis of faith and hope that can contribute <strong>to</strong> improved therapy<br />
outcomes. Hillowe also suggested that his study may have found results where<br />
others did not because previous work typically categorized patients and cl<strong>in</strong>icians<br />
on religious affiliation alone, whereas the religiosity of the patients <strong>in</strong> his vignettes<br />
was expressed <strong>in</strong> their beliefs and actions, and cl<strong>in</strong>icians were assessed for<br />
nondoctr<strong>in</strong>al and traditional religious beliefs as well as for religious affiliation.<br />
<strong>Bias</strong> was found aga<strong>in</strong>st conservative Christian graduate school applicants<br />
<strong>in</strong> a between-subjects study of full-time professors of cl<strong>in</strong>ical psychology <strong>in</strong> APAaccredited<br />
PhD programs <strong>in</strong> the U.S. (Gartner, 1986). Professors evaluated<br />
“nonreligious,” “Evangelical,” and “<strong>in</strong>tegrationist” (those who seek <strong>to</strong> <strong>in</strong>tegrate<br />
psychological theory or research <strong>in</strong><strong>to</strong> cl<strong>in</strong>ical work with religious persons or those<br />
who study constructs often associated with religion such as forgiveness or<br />
gratitude; see Lewis-Hall, Gorsuch, Malony, Narramore, & Stewart Van<br />
Leeuwam, 2006; Yangarber-Hicks et al., 2006). The professors evidenced<br />
significant differences <strong>in</strong> bias between “nonreligious” applicants and “evangelical”<br />
and “<strong>in</strong>tegrationist” applicants on all four items rated; positive feel<strong>in</strong>gs about the
109<br />
applicant’s ability <strong>to</strong> be a good cl<strong>in</strong>ical psychologist, doubts about that ability, the<br />
necessity of <strong>in</strong>terview<strong>in</strong>g that applicant compared <strong>to</strong> other equally serious<br />
candidates, and the probability of admitt<strong>in</strong>g the candidate. As predicted, the<br />
Evangelical was rated more highly than the <strong>in</strong>tegrationist, but those differences<br />
were not significant, and both were rated significantly different than the<br />
“nonreligious” applicant. While bias aga<strong>in</strong>st potential graduate school applicants<br />
cannot be generalized <strong>to</strong> cl<strong>in</strong>ical bias with patients, the processes or<br />
mechanisms that contributed <strong>to</strong> these results are unknown. Therefore, neither<br />
should the conclusion be drawn that the f<strong>in</strong>d<strong>in</strong>gs of bias aga<strong>in</strong>st Evangelicals <strong>in</strong><br />
this study, must be unrelated <strong>to</strong> the potential bias aga<strong>in</strong>st Evangelical patients.<br />
Lastly, bias was found <strong>in</strong> another study (O'Connor & Vandenberg, 2005)<br />
that <strong>in</strong>vestigated cl<strong>in</strong>icians’ evaluations of religious beliefs drawn from religions<br />
considered most ma<strong>in</strong>stream (Catholic), less ma<strong>in</strong>stream (Mormon), and least<br />
ma<strong>in</strong>stream (Nation of Islam) as comparatively more or less pathological,<br />
specifically <strong>in</strong> terms of psychosis. Beliefs correspond<strong>in</strong>g <strong>to</strong> the teach<strong>in</strong>gs of each<br />
were articulated by patients <strong>in</strong> vignettes. Examples <strong>in</strong>cluded the belief that “the<br />
Holy Spirit has given him a special strength <strong>to</strong> defend the faith” <strong>in</strong> relation <strong>to</strong> the<br />
fictitious Catholic patient, that another “came <strong>to</strong> believe quite passionately <strong>in</strong> the<br />
Mormon religion, whose tenets state that he will be transformed <strong>in</strong><strong>to</strong> a god after<br />
he dies,” and that as a member of the Nation of Islam, William “believes <strong>in</strong> the<br />
revelation that a spaceship, the Mother Wheel, has been hover<strong>in</strong>g over the<br />
United States s<strong>in</strong>ce 1929” (O’Connor & Vandenberg, 2005, p. 612).
110<br />
Four sets of these vignettes depicted beliefs such as those above which<br />
were described <strong>in</strong> religiously specific language, <strong>in</strong> language that does not identify<br />
a specific religion, and with changes as a result of these beliefs represent<strong>in</strong>g<br />
either a no-harm situation (these beliefs deepened his relationship with his<br />
girlfriend), or a harm situation (the change affected a relationship that had<br />
previously been a positive one <strong>to</strong> the po<strong>in</strong>t that the patient considered kill<strong>in</strong>g his<br />
girlfriend follow<strong>in</strong>g a betrayal). Three other distract<strong>in</strong>g vignettes were also used.<br />
Each participant received and rated six vignettes <strong>to</strong>tal, consist<strong>in</strong>g of beliefs with<br />
religious language, beliefs with no religious language, and either a no-harm set<br />
or a harm set, along with three distracter vignettes. The hypothesis that beliefs<br />
associated with less ma<strong>in</strong>stream religions would be considered more<br />
pathological was supported, with Catholic beliefs be<strong>in</strong>g rated less pathological<br />
than Mormon beliefs, which <strong>in</strong> turn were rated less pathological than Nation of<br />
Islam beliefs.<br />
When Catholic and Mormon beliefs were associated with their respective<br />
religions they were rated as less pathological than when they were not, but there<br />
was no difference <strong>in</strong> the pathology rat<strong>in</strong>g for Nation of Islam patients <strong>in</strong> either<br />
case. In both conditions, Nation of Islam beliefs were rated highly and equally<br />
pathological, and significantly more pathological than other religious beliefs<br />
whether identified as religiously based or not. Authors posit that general<br />
familiarity of Catholic and Mormon beliefs, whether identified or not, may have<br />
contributed <strong>to</strong> this f<strong>in</strong>d<strong>in</strong>g, and that it is possible that high pathology rat<strong>in</strong>gs of<br />
Nation of Islam beliefs are related <strong>to</strong> general unfamiliarity with them, or
111<br />
someth<strong>in</strong>g about their content. This is consistent with earlier arguments that<br />
familiarity may <strong>in</strong>fluence the evaluation of groups or group members as outgroups<br />
who are likely <strong>to</strong> be evaluated more negatively. Authors express concern<br />
that beliefs of religious traditions were rated as symp<strong>to</strong>ms of severe mental<br />
illnesses potentially hav<strong>in</strong>g dire consequences for the patient.<br />
Social Desirability<br />
A complicat<strong>in</strong>g fac<strong>to</strong>r <strong>in</strong> much of the research on religious bias utiliz<strong>in</strong>g<br />
self-reports is social desirability. The MODE (motivation and opportunity as<br />
determ<strong>in</strong>ants) model of biased respond<strong>in</strong>g suggests that the more sensitive a<br />
doma<strong>in</strong> of evaluation, such as social group evaluation, the more likely<br />
motivational fac<strong>to</strong>rs will be evoked and represented <strong>in</strong> explicit self-report<br />
measures (Fazio & Olson, 2003). Social norms discourage prejudice aga<strong>in</strong>st<br />
cultural groups. Particularly with<strong>in</strong> counsel<strong>in</strong>g and cl<strong>in</strong>ical psychology,<br />
multicultural diversity issues and the desirability of multicultural awareness and<br />
competence are <strong>in</strong> the forefront of academic curricula and research (Constant<strong>in</strong>e<br />
& Ladany, 2000). Well-mean<strong>in</strong>g psychologists are <strong>in</strong>terested <strong>in</strong> cultural<br />
sensitivity, awareness, knowledge, and skills.<br />
Unfortunately, research on multicultural competencies that has sought <strong>to</strong><br />
<strong>in</strong>vestigate correlations between cl<strong>in</strong>icians’ self-reported competencies and<br />
objective multicultural competency rat<strong>in</strong>g by others has found “little relation<br />
between self- and other- rated multicultural competency” when social desirability
112<br />
was controlled us<strong>in</strong>g the Marlowe Crowne Social Desirability Scale (MCSDS)<br />
(Worth<strong>in</strong>g<strong>to</strong>n, Mobley, Franks, & Andreas Tan, 2000). In another study<br />
(Constant<strong>in</strong>e & Ladany, 2000), after controll<strong>in</strong>g for social desirability with the<br />
MCSDS, none of the self-report scores on multicultural competence correlated<br />
with multicultural conceptualization ability as rated by others. Moreover, the<br />
emphasis on empathy <strong>in</strong> psychotherapy <strong>in</strong> addition <strong>to</strong> focus on diversity, likely<br />
contributes <strong>to</strong> the motivation <strong>to</strong> respond <strong>to</strong> explicit measures without empathic or<br />
other bias, whether or not they hold biased beliefs or attitudes or their capacity<br />
for empathy is affected by diversity variables <strong>in</strong> a natural sett<strong>in</strong>g. Not surpris<strong>in</strong>gly<br />
then, there is often a significant discrepancy between self-reported empathy and<br />
empathic accuracy <strong>in</strong> the literature as measured by other-perceived or otherexperienced<br />
empathy (Davis & Kraus, 1997; Graham & Ickes, 1997; Ickes,<br />
Marangoni, & Garcia, 1997). In this context one must consider the results of<br />
studies above on cl<strong>in</strong>ician/patient bias that yielded negative results as potentially<br />
be<strong>in</strong>g mitigated by social desirability. Exam<strong>in</strong>ations of bias aga<strong>in</strong>st religious or<br />
other social groups should pay particular attention <strong>to</strong> social desirability effects on<br />
outcomes, as well as seek <strong>to</strong> uncover the particular processes that contribute <strong>to</strong><br />
any biased respond<strong>in</strong>g that is detected. One avenue of <strong>in</strong>quiry may well serve<br />
both purposes: that of implicit or au<strong>to</strong>matic cognitive processes.
113<br />
Au<strong>to</strong>matic Versus Controlled Cognitive Processes<br />
Cl<strong>in</strong>icians have the responsibility <strong>to</strong> thoughtfully consider the patient when<br />
form<strong>in</strong>g cl<strong>in</strong>ical judgments, so it is assumed that cognitive processes become<br />
engaged <strong>in</strong> those efforts. The use of stereotypes <strong>in</strong> mak<strong>in</strong>g evaluations <strong>in</strong><br />
general may be a natural cognitive strategy <strong>to</strong> simplify and reduce <strong>in</strong>formational<br />
load. Cognitive theorists expla<strong>in</strong> that “if we, as social perceivers, were <strong>to</strong> perceive<br />
each <strong>in</strong>dividual as an <strong>in</strong>dividual, we would be confronted with an enormous<br />
amount of <strong>in</strong>formation that would quickly overload our cognitive process<strong>in</strong>g and<br />
s<strong>to</strong>rage capacities” (Hamil<strong>to</strong>n & Trolier, 1986, p. 123), and <strong>in</strong>deed that<br />
stereotyp<strong>in</strong>g is not only common but <strong>in</strong>evitable <strong>in</strong> ord<strong>in</strong>ary categorization (Erlich,<br />
1973; Hamil<strong>to</strong>n & Trolier, 1986).<br />
In order <strong>to</strong> simplify <strong>in</strong>formation-process<strong>in</strong>g strategies, reduce the amount<br />
of <strong>in</strong>formation <strong>to</strong> be considered, and comprehend a complex world, we<br />
categorize persons <strong>in</strong><strong>to</strong> groups. When <strong>in</strong>formation is ambiguous, particularly<br />
such as when one encounters a label such as Fundamentalist Christian or<br />
African American, stereotypes of groups may be utilized <strong>to</strong> assist <strong>in</strong> that<br />
categorization. So, stereotypes and their negative application, an <strong>in</strong>stance of<br />
prejudice, are still considered by some <strong>to</strong> be common <strong>in</strong> <strong>to</strong>day’s society, despite<br />
now be<strong>in</strong>g openly discouraged (Dev<strong>in</strong>e et al., 2002). As discussed earlier,<br />
research <strong>in</strong>dicates that first impressions early <strong>in</strong> the therapeutic relationship are<br />
<strong>in</strong>deed formed about the patient and those impressions affect case outcomes
114<br />
(Brown, 1970). What cognitive processes are engaged when mak<strong>in</strong>g those<br />
impressions? Do those processes rely on stereotypic categorizations?<br />
The research suggests that there are both implict and explicit processes<br />
that are engaged <strong>in</strong> impression formation, particularly concern<strong>in</strong>g stereotype<br />
ma<strong>in</strong>tenance and behaviors result<strong>in</strong>g from stereotypic attitudes and beliefs. The<br />
research on cl<strong>in</strong>ician bias with religious patients has made use of explicit selfreport<br />
measures <strong>to</strong> determ<strong>in</strong>e bias. As has been discussed, social desirability<br />
may affect those explicit self-report measures. In order <strong>to</strong> study stereotype<br />
attitudes and beliefs without social desirability effects, nonreactive implicit<br />
measures that tap <strong>in</strong><strong>to</strong> au<strong>to</strong>matic stereotyp<strong>in</strong>g have proven useful <strong>in</strong> the<br />
stereotyp<strong>in</strong>g literature (e.g., Banaji, Hard<strong>in</strong>, & Rothman, 1993; Bargh, Chaiken,<br />
Govender, & Prat<strong>to</strong>, 1992; Bargh & Pietromonaco, 1982; Dev<strong>in</strong>e, 1989; Dovidio,<br />
Kawakami, Johnson, Johnson, & Howard, 1997; Fazio & Olson, 2003; Fazio,<br />
Sanbonmatsu, Powell, & Kardes, 1986; Greenwald & Banaji, 1995; Sherman,<br />
2005). <strong>Implicit</strong> measures <strong>in</strong>itially purported <strong>to</strong> capture au<strong>to</strong>matic attitudes that<br />
exist outside of one’s awareness (Greenwald & Banaji, 1995); however, there is<br />
no evidence that because one’s attitudes may manifest outside of one’s<br />
awareness, that one must be unaware that he or she has the relevant attitudes<br />
(Fazio & Olson, 2003). Nevertheless, they do differ from explicit self-report<br />
measures <strong>in</strong> that responses do not require, and often prohibit, <strong>in</strong>trospection that<br />
may have reactive or censor<strong>in</strong>g elements. Whether or not there is awareness of<br />
the attitude by the subject, that au<strong>to</strong>matic attitudes can be detected without
115<br />
<strong>in</strong>trospection suffices <strong>to</strong> alleviate methodological difficulties <strong>in</strong> design<strong>in</strong>g<br />
nontransparent studies <strong>to</strong> capture bias without social desirability confounds.<br />
Activation of attitudes has been seen <strong>in</strong> prim<strong>in</strong>g experiments <strong>in</strong> which<br />
stereotyped attitudes were activated follow<strong>in</strong>g the presence of an attitude object<br />
or word (Banaji & Greenwald, 1995; Banaji et al., 1993; Berkowitz & LePage,<br />
1967; Dovidio et al., 1997), word fragment completion tests (Dovidio et al., 1997;<br />
Gilbert & Hixon, 1991; Hense, Penner, & Nelson, 1995), and studies that<br />
exam<strong>in</strong>e bias <strong>in</strong> the tendency <strong>to</strong> expla<strong>in</strong> stereotype <strong>in</strong>consistent <strong>in</strong>formation more<br />
often than stereotype congruent <strong>in</strong>formation (Sekaquaptewa, Esp<strong>in</strong>oza,<br />
Thompson, Vargas, & von Hippel, 2003). <strong>Implicit</strong> and explicit self-report<br />
measures have often had low correlations <strong>in</strong> the doma<strong>in</strong>s of prejudice and<br />
stereotyp<strong>in</strong>g (e.g., Dev<strong>in</strong>e et al., 2002; Greenwald & Banaji, 1995; Rudman,<br />
Greenwald, Mellott, & Schwartz, 1999), but occasionally demonstrate significant<br />
correlations (see Fazio & Olson, 2003 for review).<br />
Au<strong>to</strong>matic stereotype activation has been found <strong>in</strong> many doma<strong>in</strong>s<br />
<strong>in</strong>clud<strong>in</strong>g ageism (Perdue & Gurtman, 1990), sexism (McKenzie-Mohr & Zanna,<br />
1990), gender stereotyp<strong>in</strong>g <strong>in</strong> judgments of fame (Banaji & Greenwald, 1995),<br />
aggression (Berkowitz & LePage, 1967), race (Greenwald, McGhee, & Schwartz,<br />
1998; Dovidio et al., 1997; S<strong>in</strong>clair & Kunda, 1999), and religion (Rudman et al.,<br />
1999). Additionally, numerous studies on implicit processes have demonstrated<br />
predictive validity, <strong>in</strong>clud<strong>in</strong>g prim<strong>in</strong>g procedures (Dovidio, Evans, & Tyler, 1986;<br />
Dovidio et al., 1997; Fazio, Jackson, Dun<strong>to</strong>n, & Williams, 1995; McKenzie-Mohr<br />
& Zanna, 1990; Sherman, Mackie, & Driscoll, 1990), tendencies <strong>to</strong>ward an
116<br />
explana<strong>to</strong>ry bias for stereotype <strong>in</strong>consistent behaviors (Sekaquaptewa,<br />
Esp<strong>in</strong>oza, Thompson, Vargas, & von Hippel, 2003; Sherman et al., 2005; S<strong>in</strong>clair<br />
& Kunda, 1999), the tendency <strong>to</strong> attribute responsibility <strong>to</strong> a target's <strong>in</strong>ternal<br />
process rather than an external situation, (Sherman et al., 2005), and greater<br />
implicit memory for stereotype consistent <strong>in</strong>formation versus stereotype<br />
<strong>in</strong>consistent <strong>in</strong>formation (Hense et al., 1995).<br />
One of the more well known measures of implicit stereotyp<strong>in</strong>g is the<br />
<strong>Implicit</strong> Association Test (IAT; Greenwald, McGhee, & Schwartz, 1998). The IAT<br />
measures the strength of the association between a targeted group, such as<br />
African Americans, and stereotype congruent or <strong>in</strong>congruent characterizations<br />
(e.g., welfare, prosperity) or words with evaluative valence (e.g., poison, flower),<br />
measured by response latencies of computer key strokes <strong>in</strong> correctly<br />
categoriz<strong>in</strong>g targeted words. The theory beh<strong>in</strong>d the IAT is that it is easier <strong>to</strong><br />
decide on a key press <strong>in</strong> response <strong>to</strong> words or concepts that are highly<br />
associated with a target group rather than those that are not associated. For<br />
example, <strong>in</strong> study<strong>in</strong>g race associations, a subject would first practice the<br />
categorization of “Black” and “White” names such as “La<strong>to</strong>ya” or “Cathy” and<br />
then clearly valenced words which can be described as pleasant (flower) or<br />
unpleasant (poison) <strong>in</strong><strong>to</strong> “good” and “bad” categories. Follow<strong>in</strong>g these practice<br />
categorizations, comb<strong>in</strong>ations of valenced words (poison, flower) and racerelated<br />
concepts (<strong>in</strong> this case names) are assigned <strong>to</strong> the target categories of<br />
either “Black” or “White” and the valence of “good” or “bad.” Participants<br />
designate categorizations by hitt<strong>in</strong>g one response key for one group assignment
117<br />
so that the <strong>in</strong>dividually presented words “LaToya” and “pleasant” are put <strong>in</strong><strong>to</strong> the<br />
“Black/good” group assignment and “Cathy” and “poison” are put <strong>in</strong><strong>to</strong> the<br />
“bad/White” group assignment with a different key stroke. Then the category<br />
comb<strong>in</strong>ations are switched, so that White names and pleasant words are<br />
categorized with the “good/White” category and Black names and unpleasant<br />
words with “bad/Black” category. Latency of respond<strong>in</strong>g <strong>in</strong> each block is<br />
measured <strong>in</strong> milliseconds. In a race study us<strong>in</strong>g these methods (Greenwald et<br />
al., 1998), when Black was paired with unpleasant words, response latencies<br />
were overwhelm<strong>in</strong>gly faster than when Black was paired with pleasant words,<br />
<strong>in</strong>dicat<strong>in</strong>g that it was easier for the respondent <strong>to</strong> associate Black with unpleasant<br />
words.<br />
The IAT as a measure of au<strong>to</strong>matically activated prejudice has come<br />
under some scrut<strong>in</strong>y. Some researchers believe that shifts <strong>in</strong> response patterns<br />
and the tendency <strong>to</strong> categorize nonwords as negative suggest there may be<br />
other causes that contribute <strong>to</strong> previous f<strong>in</strong>d<strong>in</strong>gs <strong>in</strong>terpreted as implicit prejudice.<br />
They speculate that difficult trial blocks may facilitate learned response patterns,<br />
and that familiarity with target words versus nonwords may also impact response<br />
patterns (Brendl, Markman, & Messner, 2001). Other experiments on nonsocial<br />
group respond<strong>in</strong>g on the IAT as predictive of behavior yielded <strong>in</strong>consistent<br />
results.<br />
For example, one study (Karp<strong>in</strong>ski & Hil<strong>to</strong>n, 2001) found no association<br />
between candy bar and apple associations on the IAT and participants’ actual<br />
choice of one over the other. However, Karp<strong>in</strong>ski’s results may be <strong>in</strong>consistent
118<br />
with other IAT research due <strong>to</strong> the nature of his selected categories. Apples and<br />
candy bars may be associated with vary<strong>in</strong>g valences based on whether health or<br />
taste is more salient <strong>to</strong> the participant, and which salient feature is the overrid<strong>in</strong>g<br />
one when the participant is given the opportunity <strong>to</strong> choose one. Karp<strong>in</strong>ski and<br />
Hil<strong>to</strong>n (2001) offer the explanation that research on social group associations<br />
us<strong>in</strong>g the IAT may merely be the result of environmental exposure <strong>to</strong><br />
associations rather than prejudices that one may have about a target group.<br />
However, the data yielded <strong>in</strong> the measurement of nonwords and apples versus<br />
candy bars are <strong>in</strong>consistent with the data found <strong>in</strong> measures of attitudes about<br />
social groups, and so it is difficult <strong>to</strong> extrapolate possible reasons for lack of<br />
results <strong>in</strong> that study <strong>to</strong> others <strong>in</strong>volv<strong>in</strong>g social groups. In contrast <strong>to</strong> work done<br />
with either nonwords and stimuli with presumably less associated stereotyped<br />
attitudes or affect, the IAT consistently demonstrates <strong>in</strong>- and out-group biases of<br />
social groups (e.g., Greenwald et al., 1998; Nosek, Banaji, & Greenwald, 2002;<br />
Rudman et al., 1999) and even bias <strong>in</strong> m<strong>in</strong>imal paradigm work (Ashburn-Nardo et<br />
al., 2001) <strong>in</strong> which participants are randomly assigned <strong>to</strong> one of two groups,<br />
hav<strong>in</strong>g no previous environmental associations with the groups.<br />
Nevertheless, when social groups are be<strong>in</strong>g judged, the argument that<br />
au<strong>to</strong>matic activation of associations may be environmentally learned, and not an<br />
accurate measure of <strong>in</strong>ternalized prejudice upon which a person will act, cannot<br />
be quickly dismissed. Another explanation may lie with<strong>in</strong> motivational processes<br />
as modera<strong>to</strong>rs of au<strong>to</strong>matic associations. The MODE model of prejudice (Fazio,<br />
1990) explicitly po<strong>in</strong>ts <strong>to</strong> mixed processes of au<strong>to</strong>matic and deliberative
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processes of respond<strong>in</strong>g which contribute <strong>to</strong> judgments and behavior. Those<br />
processes <strong>in</strong>clude spontaneous activation of attitudes and motivation and<br />
opportunity <strong>to</strong> respond <strong>in</strong> a controlled manner.<br />
Dev<strong>in</strong>e (1989) also asserts a two-stage model of prejudice which <strong>in</strong>cludes<br />
both au<strong>to</strong>matic activation of stereotypes by some target feature or label, and<br />
conscious choice-mak<strong>in</strong>g of whether <strong>to</strong> act on, or overcome, the activated<br />
stereotype. Her model allows for a less determ<strong>in</strong>istic perspective of the effects of<br />
implicit attitudes, and acknowledges that due <strong>to</strong> socialization effects of stereotype<br />
<strong>in</strong>formation, what may be activated are knowledge structures, or schema, of<br />
common stereotypic data, rather than personally held attitudes about groups.<br />
While the strength of the IAT as a measure of implicit attitudes is purported <strong>to</strong> be<br />
<strong>in</strong> the au<strong>to</strong>matic latency of the response, Dev<strong>in</strong>e’s model suggests that those<br />
attitudes represented may be overcome by a motivation <strong>to</strong> respond without<br />
prejudice despite knowledge of stereotypic schema. Plant and Dev<strong>in</strong>e (1998)<br />
address “the presence of the rather pervasive external social pressure <strong>to</strong><br />
respond without prejudice [that] has created endur<strong>in</strong>g dilemmas for both social<br />
perceivers and social scientists as they try <strong>to</strong> discern the motivation(s) underly<strong>in</strong>g<br />
(generally socially acceptable) nonprejudiced responses” (1998, p.1) by<br />
exam<strong>in</strong><strong>in</strong>g the importance assigned <strong>to</strong> both <strong>in</strong>ternal and external motivation <strong>to</strong><br />
respond without prejudice.<br />
Dun<strong>to</strong>n and Fazio’s Motivation <strong>to</strong> Control Prejudiced Reactions Scale<br />
(MCPRS; 1997) measures the amount of motivation <strong>to</strong> control prejudiced<br />
reactions us<strong>in</strong>g a two-fac<strong>to</strong>r solution. Fac<strong>to</strong>r 1 consists of a concern with act<strong>in</strong>g
120<br />
prejudiced due <strong>to</strong> an <strong>in</strong>ternal set of standards <strong>in</strong> which one f<strong>in</strong>ds prejudice<br />
personally distasteful and concern with how one may be perceived by others for<br />
act<strong>in</strong>g prejudiced. Fac<strong>to</strong>r 2 measures tendencies <strong>to</strong> restra<strong>in</strong> oneself from<br />
express<strong>in</strong>g thoughts and feel<strong>in</strong>gs that may cause confrontation with or about<br />
targets of prejudice. Dist<strong>in</strong>ct from social desirability measures such as the MCDS<br />
(Crowne & Marlowe, 1960) which measures attempts <strong>to</strong> respond <strong>to</strong> self-report<br />
measures for the sake of appear<strong>in</strong>g <strong>in</strong> a socially acceptable manner, motivation<br />
<strong>to</strong> control prejudiced measures assesss either orig<strong>in</strong>s of motivations <strong>to</strong> respond<br />
<strong>to</strong> life situations without prejudice (Plant & Dev<strong>in</strong>e, 1998) or the amount of that<br />
motivation (Dun<strong>to</strong>n & Fazio, 1997).<br />
Socialization effects of religiously stereotypical associations may or may<br />
not be ubiqui<strong>to</strong>us <strong>in</strong> the United States. A consistent pattern of activation of<br />
au<strong>to</strong>matic attitudes about religious persons may or may not merely be the result<br />
of the activation of socially common schematic structures. Interest<strong>in</strong>gly, if such a<br />
pattern existed, and it was <strong>to</strong> be the only or a very strong contribu<strong>to</strong>r <strong>to</strong> the<br />
activation of au<strong>to</strong>matic attitudes <strong>in</strong> general, it may be assumed that religious<br />
cl<strong>in</strong>icians would also demonstrate these associations about their own group on<br />
the IAT. However, as the research cited above <strong>in</strong>dicates, implicit measures<br />
consistently demonstrate bias based on <strong>in</strong>- and out- group membership.<br />
Nevertheless, it is possible that au<strong>to</strong>matic schematic associations may be<br />
activated at least partially as a result of environmental exposure.<br />
It is also reasonable <strong>to</strong> assume that whether or not one has au<strong>to</strong>matic<br />
associations about a group, some persons may seek <strong>to</strong> exert control over their
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behavior beyond what au<strong>to</strong>maticity might otherwise dictate. Research that seeks<br />
<strong>to</strong> thoroughly exam<strong>in</strong>e the predictive validity of au<strong>to</strong>matic associations on<br />
behavior may also benefit by exam<strong>in</strong><strong>in</strong>g the role that one’s motivation <strong>to</strong> control<br />
prejudice may play <strong>in</strong> moderat<strong>in</strong>g those au<strong>to</strong>matic activations. Specifically, the<br />
theory of motivation <strong>to</strong> control prejudiced reactions as applied <strong>to</strong> religiously<br />
biased evaluations of cl<strong>in</strong>ical patients implies that motivational processes may<br />
moderate any stereotype congruent au<strong>to</strong>matic associations with religious<br />
persons, so that the associations would not affect the evalua<strong>to</strong>r’s behavior,<br />
therefore reduc<strong>in</strong>g cl<strong>in</strong>ical bias.<br />
Statement of the Problem<br />
The purpose of this study was <strong>to</strong> exam<strong>in</strong>e the potential bias <strong>in</strong> cl<strong>in</strong>icians<br />
aga<strong>in</strong>st religiously dissimilar patients. Aga<strong>in</strong>, bias here refers <strong>to</strong> an <strong>in</strong>stance of<br />
prejudice that affects behavior or judgment. In particular, responses <strong>to</strong><br />
Evangelical Christian (EC) patients were explored versus responses <strong>to</strong> patients<br />
with no mention of religion (NMR). Data show that approximately 82% of<br />
Americans can be classified <strong>in</strong> the Christian categories of Protestant, Catholic, or<br />
“other Christian” (Gallup, 2003 cited <strong>in</strong> NewPort, 2004). A Christian conservative<br />
group was selected because of its large representation <strong>in</strong> the American<br />
population <strong>to</strong>day with Gallup estimates as 44% of the <strong>to</strong>tal adult population <strong>in</strong><br />
2006 endors<strong>in</strong>g self descriptions of “born-aga<strong>in</strong>” or Evangelical Christian,” and<br />
reports that 1 <strong>in</strong> 5 Americans can be considered Evangelical based on endorsed
122<br />
Evangelical beliefs and behaviors (2006). The difference <strong>in</strong> the estimated<br />
proportion of Evangelical Christians between these methods of group assignment<br />
is notable, and supports earlier discussion about the differences between selfreported<br />
religious affiliation versus <strong>in</strong>ternalized religiousness and religious<br />
behaviors. However, that both estimates are fairly large is evident. It is further<br />
believed that Evangelicals’ recent sociopolitical presence may elicit affect <strong>in</strong><br />
those who have strong opposite sociopolitical lean<strong>in</strong>gs and who may not be<br />
aware of the impact of their sociopolitical background on their cl<strong>in</strong>ical judgment.<br />
Lastly, it is believed that this large population of conservative Christians may be<br />
the largest group that represents a religious position most diverse <strong>in</strong> beliefs from<br />
psychologists, a group which endorses less Christian doctr<strong>in</strong>al adherence <strong>in</strong> the<br />
literature (Bilgrave & Deluty, 1998).<br />
Variables<br />
Dependent variables were empathy and prognosis. Due <strong>to</strong> some his<strong>to</strong>ry of<br />
the assumption or exaggeration of pathology of religious persons <strong>in</strong> psychology,<br />
and stereotypic expectations such that they are typically illogical and <strong>in</strong>flexible<br />
(Ellis, 1980), it was hypothesized that cl<strong>in</strong>icians who exhibit bias aga<strong>in</strong>st them<br />
would perceive them <strong>to</strong> be more mentally ill, with cognitive traits that may hamper<br />
the process of psychotherapy. Also, consistent with Byrne’s repulsion hypothesis<br />
(Byrne, 1971), religious beliefs and values which are more dissimilar <strong>to</strong> those of<br />
psychologists may result <strong>in</strong> negative affect <strong>in</strong> relation <strong>to</strong> the group. It was
123<br />
believed that negative affect <strong>in</strong> response <strong>to</strong> those beliefs and values would result<br />
<strong>in</strong> cl<strong>in</strong>icians’ reduced empathy with Evangelical patients, who did not<br />
demonstrate motivation <strong>to</strong> control prejudice. Therefore, cl<strong>in</strong>icians’ religiously<br />
liberal attitude <strong>in</strong> relation <strong>to</strong> Christian beliefs (RLACB) was an <strong>in</strong>dependent<br />
variable.<br />
<strong>Implicit</strong> Negative Association with Evangelical Christians was both an<br />
<strong>in</strong>dependent and dependent variable as <strong>in</strong>dicated <strong>in</strong> the hypotheses below. The<br />
effects of two covariates were measured for the purposes of controll<strong>in</strong>g effects as<br />
appropriate, social desirability (SD) and other-religion conservatism (ORC). SD<br />
has been largely uncontrolled <strong>in</strong> the bias literature and has been shown <strong>to</strong> have<br />
an impact on results when it was controlled (e.g., Constant<strong>in</strong>e & Ladany, 2000;<br />
Worth<strong>in</strong>g<strong>to</strong>n, Mobley, Franks, & Andreas Tan, 2000). As social norms cont<strong>in</strong>ue <strong>to</strong><br />
discourage prejudice and studies have often revealed discrepancies between<br />
self-reported empathy and empathic accuracy as measured by others (Davis &<br />
Kraus, 1997; Graham & Ickes, 1997; Ickes, Marangoni, & Garcia, 1997), it may<br />
be that previous studies did not f<strong>in</strong>d results of bias due <strong>to</strong> social desirability<br />
effects.<br />
Conservatism of other religious groups was also measured as it is not<br />
known what <strong>in</strong>fluence religious conservatism <strong>in</strong> general would have on results. It<br />
was hypothesized that conservatives of other religious groups may not view the<br />
Christian conservative group as an out-group due <strong>to</strong> the commonality of their<br />
conservatism, and therefore they may not have implicit negative associations<br />
about the group. To assess conservatism of other religious groups, several items
124<br />
were given <strong>in</strong>clud<strong>in</strong>g items that asked respondents <strong>to</strong> select an estimation of their<br />
personal devoutness <strong>in</strong> their religious beliefs, practices, and attempts <strong>to</strong> live <strong>in</strong> a<br />
scripturally prescribed manner.<br />
It may be difficult <strong>to</strong> “not have” any preconceived ideas about social<br />
groups, and exposure <strong>to</strong> some stereotypes of religious groups may be common.<br />
This may be true particularly about conservative Christian groups as their beliefs<br />
often manifest <strong>in</strong> public behaviors or positions such as <strong>in</strong>fluence or presence <strong>in</strong><br />
political groups, legislation, and policy-mak<strong>in</strong>g. It is believed and hoped that<br />
cl<strong>in</strong>icians’ tra<strong>in</strong><strong>in</strong>g <strong>in</strong> the cl<strong>in</strong>ical importance of an empathic relationship and<br />
general acceptance of their patients as well as their personal reasons for<br />
controll<strong>in</strong>g prejudice, would have some <strong>in</strong>fluence on their motivation <strong>to</strong> control<br />
prejudiced reactions. Nevertheless, it was hypothesized that those who did not<br />
exhibit motivation <strong>to</strong> control prejudiced reactions and who demonstrated<br />
stereotypic associations with Evangelical persons, would assign poorer<br />
prognoses <strong>to</strong>, and demonstrate less empathy with, Evangelical Christian<br />
patients. Put another way, it was hypothesized that those who did not act on<br />
knowledge or beliefs about stereotypes would refra<strong>in</strong> from do<strong>in</strong>g so because they<br />
were aware that prejudiced responses are socially undesirable, and/or they may<br />
have <strong>in</strong>ternal values aga<strong>in</strong>st respond<strong>in</strong>g <strong>to</strong> others with prejudice. Therefore,<br />
motivation <strong>to</strong> control prejudiced reactions was predicted <strong>to</strong> moderate the effect of<br />
au<strong>to</strong>matically activated stereotyp<strong>in</strong>g responses on empathic and prognostic bias.
125<br />
Hypotheses<br />
Hypothesis #1. <strong>Religiously</strong> Liberal Attitudes <strong>in</strong> relation <strong>to</strong> Christian Beliefs<br />
(RLACB) will be positively related <strong>to</strong> the difference <strong>in</strong> empathy expressed <strong>to</strong>ward<br />
Evangelical Christians (ECs) versus No Mention of Religion patients (NMRs),<br />
where difference is determ<strong>in</strong>ed by EC empathy scores subtracted from NMR<br />
empathy scores.<br />
Hypothesis #2. RLACB will be positively related <strong>to</strong> the difference <strong>in</strong> prognosis<br />
expressed <strong>to</strong>ward ECs versus NMRs, where difference is determ<strong>in</strong>ed by EC<br />
prognosis scores subtracted from NMR prognosis scores.<br />
Hypothesis # 3. RLACB will be positively associated with <strong>Implicit</strong> Negative<br />
Association (INA) <strong>to</strong>wards ECs.<br />
Hypothesis #4. Motivation <strong>to</strong> Control Prejudice React<strong>in</strong>g (MCPR) will affect the<br />
relation between INA and the difference between empathy expressed <strong>to</strong>ward<br />
ECs versus NMRs, such that as MCPR <strong>in</strong>creases, INA will be less related <strong>to</strong> the<br />
empathy difference.<br />
Hypothesis #5. MCPR will affect the relation between INA and the difference<br />
between prognosis expressed for ECs versus NMRs, such that as MCPR<br />
<strong>in</strong>creases, INA will be less related <strong>to</strong> the prognosis difference.
126<br />
Methods<br />
The research design utilized an analogue with<strong>in</strong>-subjects correlational<br />
methodology that <strong>in</strong>cluded several assessments. Transparency, which may have<br />
affected results of other studies, was addressed <strong>in</strong> three ways. First, this study<br />
sought <strong>to</strong> identify au<strong>to</strong>matic attitudes that were activated spontaneously, that is,<br />
without the participant’s ability <strong>to</strong> use reactive and censor<strong>in</strong>g processes <strong>to</strong><br />
mitigate them. Second, this study made efforts <strong>to</strong> normalize the use of<br />
projections needed <strong>to</strong> evaluate ambiguous <strong>in</strong>formation simulat<strong>in</strong>g a more natural<br />
therapeutic environment when some <strong>in</strong>itial hypothesis generation is expected.<br />
The manifestation of any negative content of those projections <strong>in</strong> bias aga<strong>in</strong>st the<br />
selected dissimilar religious group is the variable of <strong>in</strong>terest. Third, as social<br />
desirability measured by the Marlowe Crowne Social Desirability Scale has been<br />
successfully used <strong>in</strong> controll<strong>in</strong>g for social desirability with cl<strong>in</strong>icians <strong>in</strong> other<br />
studies (e.g., Constant<strong>in</strong>e & Ladany, 2000; Worth<strong>in</strong>g<strong>to</strong>n et. al., 2000), a<br />
shortened version of the MCSDS, the MAC-Form C (Reynolds, 1982) was used<br />
<strong>to</strong> measure social desirability as a covariate <strong>in</strong> this study <strong>to</strong> control for the<br />
potential of social desirability confounds on results. Despite the current steps<br />
taken <strong>to</strong> ensure measurement of cl<strong>in</strong>icians’ uncensored responses, it is uncerta<strong>in</strong><br />
that all processes, conscious or unconscious, were completely controlled for or<br />
predicted by these measures.
127<br />
Participants<br />
Participants were drawn from a national sample of approximately 3,070<br />
psychologists from the American Psychological Association’s Divisions 42, 29,<br />
12, and 36, the divisions of Independent Practice, Psychotherapy, Cl<strong>in</strong>ical<br />
Psychology, and the Psychology of Religion respectively, as well as the<br />
California Psychological Association, the Sacramen<strong>to</strong> Psychological Association,<br />
and the Los Angeles County Psychological Association, through an email<br />
recruitment process utiliz<strong>in</strong>g each of their listservs. The <strong>to</strong>tal estimated<br />
psychologists subscrib<strong>in</strong>g <strong>to</strong> these listservs are 3070. Each group was believed<br />
<strong>to</strong> have a large population of psychologists <strong>in</strong> cl<strong>in</strong>ical practice. Division 36, the<br />
American Psychological Association’s Division of the Psychology of Religion,<br />
was also selected because it is believed that there may be a shortage of<br />
conservative religious cl<strong>in</strong>icians with<strong>in</strong> those samples as <strong>in</strong>dicated <strong>in</strong> the<br />
religiosity gap section of this paper. Due <strong>to</strong> the nature of Division 36’s members’<br />
<strong>in</strong>terest <strong>in</strong> the psychology of religion, it was hoped that member participation<br />
would <strong>in</strong>crease that number for comparative purposes. Also, another 415 cl<strong>in</strong>ical<br />
psychologist members of the Christian Association for Psychological Studies<br />
(CAPS) received email announcements of the study. In addition, 2,511 email<br />
addresses from public direc<strong>to</strong>ries of state psychological associations were<br />
<strong>in</strong>itially gathered. After checks <strong>to</strong> elim<strong>in</strong>ate overlap email addresses, the <strong>to</strong>tal<br />
number of psychologists who received a listserv or a personal email request for<br />
participation was approximately 4,896. The 415 members of CAPS who received
128<br />
email announcements were unavailable for review prior <strong>to</strong> the <strong>in</strong>itial analysis, so<br />
overlap could not be checked and they were not counted <strong>in</strong> the 4,896 <strong>to</strong>tal.<br />
However, after data collection began, several issues prompted the<br />
decision <strong>to</strong> <strong>in</strong>crease the number of email addresses used for direct email<strong>in</strong>g.<br />
These <strong>in</strong>cluded technical difficulties with access <strong>to</strong> the second website used for<br />
data collection, the Inquisit website (Dra<strong>in</strong>e, S., 2006, Inquisit www.<strong>in</strong>quisit.com),<br />
the elim<strong>in</strong>ation of Mac<strong>in</strong><strong>to</strong>sh users from participation due <strong>to</strong> the operat<strong>in</strong>g<br />
system’s <strong>in</strong>compatibility with the site, which was an unexpected condition of the<br />
site, and significantly lower response rates from listserv <strong>in</strong>vitations than <strong>to</strong> direct<br />
email <strong>in</strong>vitations. Therefore, another 5,435 email addresses were collected from<br />
public direc<strong>to</strong>ries of local chapter psychological associations, psychological<br />
associations listed by orientation and disorder or disorder cluster, and various<br />
universities with public direc<strong>to</strong>ries. The <strong>to</strong>tal number of direct email addresses <strong>to</strong><br />
which <strong>in</strong>vitations were distributed was 8,361, after exclud<strong>in</strong>g 149 participants who<br />
“opted out” of the <strong>in</strong>vitation <strong>to</strong> participate.<br />
In the recruitment email, it was requested that all respondents be cl<strong>in</strong>ical<br />
psychologists, and <strong>in</strong>formation about participants’ degrees was gathered. It is not<br />
known what other differences exist between each group; nevertheless, <strong>in</strong> an<br />
effort <strong>to</strong> balance the religiosity of cl<strong>in</strong>icians <strong>to</strong> some degree and <strong>to</strong> ensure<br />
adequate sample power, that there may be other sample differences is accepted<br />
and each sample group was used.<br />
In the power analysis, I calculated the sample size based on two sets of<br />
variables <strong>to</strong> accommodate the hypotheses with the most variables, and therefore
129<br />
the highest N. This model conta<strong>in</strong>ed predic<strong>to</strong>r set A which consisted of the<br />
covariates social desirability and conservatism as def<strong>in</strong>ed by devoutness <strong>in</strong><br />
beliefs, rituals, and traditions, and attempts <strong>to</strong> live accord<strong>in</strong>g <strong>to</strong> prescribed<br />
scripture or teach<strong>in</strong>gs, and set B which <strong>in</strong>cluded cl<strong>in</strong>ician religiosity. As it was<br />
<strong>in</strong>itially unknown what effect the covariates would have and much of the past<br />
research has failed <strong>to</strong> detect bias, a reasonable and conservative estimate of<br />
effect size was small with an f-sq of .02 as def<strong>in</strong>ed by Cohen (Cohen, 1988). At<br />
.05 level of significance with an f-sq of .02 for each set for a comb<strong>in</strong>ed effect of<br />
.04, N = 383 for a power of .80.<br />
Response rates from psychologists can be quite varied. In calculations<br />
that <strong>in</strong>cluded the possibility that each of 2 covariates would be controlled, a 7%<br />
response rate of the <strong>in</strong>itial 5,581 participants (which did not <strong>in</strong>clude the 415 from<br />
CAPS who could not be checked for overlap, and the additional 5,435 emails<br />
added follow<strong>in</strong>g technical caveats) was needed for a power of .80 <strong>to</strong> detect small<br />
effect sizes. In an attempt <strong>to</strong> <strong>in</strong>crease participation, one $100 and one $50 cash<br />
prize or donation <strong>to</strong> Hurricane Katr<strong>in</strong>a victims was offered <strong>in</strong> a draw<strong>in</strong>g from all<br />
entries made from participat<strong>in</strong>g psychologists. The option of receiv<strong>in</strong>g a w<strong>in</strong>n<strong>in</strong>g<br />
amount <strong>in</strong> cash was also made. Perhaps more importantly, the utilization of the<br />
<strong>in</strong>ternet <strong>in</strong> the collection of data for this study was viewed as be<strong>in</strong>g more<br />
convenient than the use of long forms that may appear daunt<strong>in</strong>g and that require<br />
return mail<strong>in</strong>g. Response rates <strong>to</strong> similar research have been as low as 17%<br />
(Gartner et. al, 1990), but also as high as 62% (Lewis & Lewis, 1985) and 67%<br />
(Ragan et al., 1980) <strong>in</strong> similar research with paper mail<strong>in</strong>gs and no <strong>in</strong>centives.
130<br />
Due <strong>to</strong> the convenience of <strong>in</strong>ternet accessibility, the addition of 5,435<br />
potential participants added after the power analysis, and the monetary<br />
<strong>in</strong>centives, it was believed that an adequate number of responses would be<br />
received. Of the 8,361 direct email addresses that were used, 890 were returned<br />
as “undeliverable” <strong>in</strong>dicat<strong>in</strong>g an <strong>in</strong>correct or outdated email address was<br />
published at the time the addresses were collected, and 282 persons responded<br />
that they were unlicensed, retired, or had Mac<strong>in</strong><strong>to</strong>sh operat<strong>in</strong>g systems. It is<br />
unknown how many of the rema<strong>in</strong><strong>in</strong>g 7,189 were licensed psychologists that had<br />
W<strong>in</strong>dows Operat<strong>in</strong>g Systems and were therefore eligible for participation, so it is<br />
difficult <strong>to</strong> estimate an accurate response rate from eligible participants. If the<br />
assumption was made that they were all licensed psychologists, the response<br />
rate was 5.3%. It is also notable that 632 participants began the study <strong>in</strong> the first<br />
data collection website used, Survey Monkey (F<strong>in</strong>lay, R., 2007,<br />
Surveymonkey.com), 546 completed it <strong>in</strong> that website, and 394 completed the<br />
entire study <strong>in</strong>clud<strong>in</strong>g the IAT on the Inquisit website (Dra<strong>in</strong>e, S., 2006, Inquisit<br />
www.<strong>in</strong>quisit.com), which presented the IAT that required that participants have<br />
the W<strong>in</strong>dows Operat<strong>in</strong>g System and which experienced technical difficulties<br />
when the first <strong>in</strong>vitations <strong>to</strong> participate were distributed. Twelve completed IAT<br />
data-sets could not be matched <strong>to</strong> Survey Monkey data-sets by ID numbers, as<br />
they were likely accessed from different computers at different times due <strong>to</strong><br />
technical problems, so they were elim<strong>in</strong>ated from the f<strong>in</strong>al data-set. The f<strong>in</strong>al<br />
number of usable data-sets was 382.
131<br />
Measures<br />
Batson’s Empathy Adjectives<br />
In study<strong>in</strong>g the dimensional components of empathy <strong>in</strong> altruistic versus<br />
egoistic help<strong>in</strong>g, Batson (1987) exam<strong>in</strong>ed two dist<strong>in</strong>ct emotional reactions <strong>to</strong><br />
someone <strong>in</strong> distress, personal distress and empathy. While the two reactions<br />
often occur <strong>to</strong>gether and both may have motivational consequences <strong>in</strong> help<strong>in</strong>g<br />
another, feel<strong>in</strong>gs of empathy are other-oriented feel<strong>in</strong>gs and personal distress is<br />
self-oriented. Batson characterized empathy as a vicarious emotional response<br />
<strong>to</strong> another <strong>in</strong> need, and that emotional respond<strong>in</strong>g is evoked when the perceiver<br />
is able <strong>to</strong> adopt the perspective of the person <strong>in</strong> need. Batson operationalized<br />
empathic emotions through the measurement of the empathy adjectives:<br />
sympathetic, softhearted, moved, warm, compassionate, and tender. Participants<br />
rated how strongly they were feel<strong>in</strong>g each of six adjectives on a 7- po<strong>in</strong>t Likert<br />
scale, with 1 represent<strong>in</strong>g “not at all” and 7 “extremely.”<br />
In an exam<strong>in</strong>ation across several studies with vary<strong>in</strong>g degrees and<br />
dimensions of need situations, Batson reports highly consistent and robust<br />
f<strong>in</strong>d<strong>in</strong>gs of the <strong>in</strong>dependent fac<strong>to</strong>r structure of the variables of personal distress<br />
and empathy and support from the work of others which also report similar fac<strong>to</strong>r<br />
structures (see Batson, 1987 for review). Fac<strong>to</strong>r load<strong>in</strong>gs of .60 from “moved,<br />
compassionate, warm, and softhearted” were found <strong>in</strong> all six studies exam<strong>in</strong>ed,<br />
and “sympathetic and tender” <strong>in</strong> four of five studies that used these adjectives.
132<br />
Correlations between empathy adjectives ranged from .44 <strong>to</strong> .79 across studies.<br />
Us<strong>in</strong>g the other-oriented dimension of empathy, Batson’s empathy adjectives<br />
were used <strong>to</strong> measure the affective empathy respond<strong>in</strong>g <strong>to</strong> patients <strong>in</strong> vignettes.<br />
Interpersonal Reactivity Index’s Perspective-Tak<strong>in</strong>g Scale<br />
Also, one subscale from the Interpersonal Reactivity Index (IRI; Davis,<br />
1994) is particularly salient <strong>to</strong> the nature of cl<strong>in</strong>ical work. The Perspective-Tak<strong>in</strong>g<br />
subscale measures the tendency <strong>to</strong> adopt the psychological view of others. As<br />
Batson’s adjectives of empathic vicarious respond<strong>in</strong>g are believed <strong>to</strong> arise from<br />
the ability of one <strong>to</strong> take the perspective of the other, and the nature of<br />
psychological work requires the ability <strong>to</strong> adopt the psychological view of the<br />
other if one is <strong>to</strong> be able <strong>to</strong> work with<strong>in</strong> the patient’s frame of reference, the<br />
Perspective-Tak<strong>in</strong>g scale of the IRI will be used. Internal and test-retest reliability<br />
of the IRI are adequate at .70 -.78, and .61- .81 over 2 months, respectively.<br />
Good validity of the IRI is evidenced <strong>in</strong> the predicted relationships between the<br />
subscales, convergent validity with other empathy measures, and <strong>in</strong>dexes of<br />
social competence, self-esteem, emotionality, and sensitivity (Davis, 1983).<br />
However, the PT subscale items characterize one’s patterns of respond<strong>in</strong>g<br />
<strong>to</strong> others as a dispositional trait. These items were slightly modified <strong>to</strong> evaluate<br />
the respond<strong>in</strong>g of the participant <strong>to</strong> the patient <strong>in</strong> each vignette. While the scale<br />
was <strong>in</strong>tended <strong>to</strong> measure trait perspective tak<strong>in</strong>g, the word<strong>in</strong>g of most of the<br />
items lent themselves well <strong>to</strong> slight modifications. Two items relat<strong>in</strong>g <strong>to</strong> PT
133<br />
behaviors <strong>in</strong> conflicts are not adaptable <strong>to</strong> the psychotherapy situation because<br />
of the nature of the <strong>in</strong>teractions <strong>in</strong> cl<strong>in</strong>ical sett<strong>in</strong>gs, as opposed <strong>to</strong> social sett<strong>in</strong>gs,<br />
so they were not used. Those items are “If I’m sure I’m right about someth<strong>in</strong>g, I<br />
don’t waste much time listen<strong>in</strong>g <strong>to</strong> other people’s arguments,” and “when I’m<br />
upset at someone, I usually try <strong>to</strong> ‘put myself <strong>in</strong> his shoes’ for a while.” However,<br />
others such as “I sometimes f<strong>in</strong>d it difficult <strong>to</strong> see th<strong>in</strong>gs from the ‘other guy’s’<br />
po<strong>in</strong>t of view” are relevant <strong>to</strong> empathic perspective tak<strong>in</strong>g with<strong>in</strong> the therapy<br />
relationship and can be easily modified <strong>to</strong> “I f<strong>in</strong>d it difficult <strong>to</strong> see th<strong>in</strong>gs from the<br />
patient’s po<strong>in</strong>t of view.”<br />
It is not known what effects the modifications would have on the IRI’s<br />
demonstrated reliability or validity. However, the items ma<strong>in</strong>ta<strong>in</strong> face validity and<br />
it was believed that the scores would cont<strong>in</strong>ue <strong>to</strong> reflect differences with<strong>in</strong>subjects<br />
<strong>in</strong> perspective-tak<strong>in</strong>g empathy between vignettes. The participants were<br />
asked <strong>to</strong> respond <strong>to</strong> five items on a 4-po<strong>in</strong>t Likert scale from 0 (does not describe<br />
my current position/feel<strong>in</strong>gs with respect <strong>to</strong> this patient very well) <strong>to</strong> 4 (describes<br />
my current position/feel<strong>in</strong>gs with respect <strong>to</strong> this patient very well).<br />
Cl<strong>in</strong>ical Judgment Scale<br />
Seven cl<strong>in</strong>ical judgment scale items borrowed from Graham (1980) were<br />
used <strong>to</strong> evaluate cl<strong>in</strong>ician prognosis. Items <strong>in</strong>cluded likelihood of cl<strong>in</strong>ician<br />
selection for their therapy caseload, and patient likelihood of mak<strong>in</strong>g substantial<br />
progress measured on a 5-po<strong>in</strong>t Likert scale with 0 be<strong>in</strong>g least likely and 5 most
134<br />
likely. Additional items measured severity of impairment, motivation for change,<br />
capacity for <strong>in</strong>sight, expectations about cont<strong>in</strong>uation of treatment, and likelihood<br />
of mak<strong>in</strong>g substantial progress, also measured on a 5-po<strong>in</strong>t Likert scale with<br />
poorest predictions rated 0 and best predictions rated 5 for each item. There<br />
were no published psychometric properties found for this assessment. One could<br />
argue that the scale has good face validity; however, actual psychometric data<br />
are lack<strong>in</strong>g. As this study utilized a with<strong>in</strong>-subject design, differences between<br />
scores on similar vignettes were believed <strong>to</strong> be representative of difference <strong>in</strong> the<br />
cl<strong>in</strong>ical judgment of prognosis of hypothetical patients <strong>in</strong> those vignettes.<br />
Religious Attitude Scale<br />
The Religious Attitude Scale (RAS; Armstrong, Larsen, & Mourer, 1962),<br />
was used <strong>to</strong> measure participant attitudes <strong>to</strong>ward specific Christian beliefs. The<br />
scale identifies 16 core Christian religious concepts which are followed by three<br />
def<strong>in</strong>itions of each concept. Each def<strong>in</strong>ition represents an orthodox, conservative,<br />
or a liberal position <strong>in</strong> relation <strong>to</strong> those beliefs. Scores on each of the dimensions<br />
are converted <strong>in</strong><strong>to</strong> one cont<strong>in</strong>uous score rang<strong>in</strong>g from most orthodox <strong>to</strong> most<br />
liberal. RAS authors discuss that they conceptualize these positions <strong>in</strong> a<br />
cont<strong>in</strong>uous, rather than categorical manner, although they do not use empirical<br />
support for this position. This conceptualization is consistent with the goal <strong>in</strong> this<br />
study of assess<strong>in</strong>g potential bias <strong>in</strong> a group most divergent (<strong>in</strong> this case most<br />
liberal) from the Evangelical Christian patient.
135<br />
Participants were <strong>in</strong>structed <strong>to</strong> select the descriptive phrase for the term<br />
that best describes his or her attitude or behavior <strong>in</strong> relation <strong>to</strong> the term. A<br />
sample item <strong>in</strong>cludes the Virg<strong>in</strong> Mary as def<strong>in</strong>ed by: a.) Mother of Jesus (C), b)<br />
supposedly the mother of a prophet (L), or c) blessed mother of God (O).<br />
Authors of the scale unders<strong>to</strong>od each position <strong>to</strong> characterize Catholic,<br />
Protestant, and Unitarian positions respectively and standardization was done on<br />
participants who self-identified with those denom<strong>in</strong>ational l<strong>in</strong>ks. Although some<br />
persons <strong>in</strong> the sample from each of the identified groups reported not agree<strong>in</strong>g<br />
with some def<strong>in</strong>itions with<strong>in</strong> their category, authors believe this <strong>to</strong> be an expected<br />
occurrence due <strong>to</strong> some diversity <strong>in</strong> religious concepts among groups. However,<br />
<strong>in</strong> terms of scale validity, authors argue that the dist<strong>in</strong>ction between group scores<br />
<strong>in</strong>dicates discrete differences between the groups’ def<strong>in</strong>itions of Christian<br />
concepts.<br />
Test-retest reliability for the scale <strong>in</strong> a group of 71 nonpsychiatric<br />
participants was .98. The test was normed on 121 participants with mean scores<br />
for the orthodox position 139.50, the conservative position 105.95, and the liberal<br />
position 13.48. Test-retest reliability for concepts with<strong>in</strong> religious groups was .73<br />
for the group of 27 Catholics, .67 among 25 Protestants, and .48 among the 19<br />
Unitarians. Inter-test reliability was .66 among Catholics, .61 among Protestants,<br />
and .72 among Unitarians. Because high scores on the RAS <strong>in</strong>dicate higher<br />
levels of conservatism or orthodoxy and positive correlations were predicted<br />
between more religiously liberal attitudes and bias, all items were reverse scored.
136<br />
<strong>Implicit</strong> Association Test<br />
The <strong>Implicit</strong> Association Test (IAT) was used <strong>to</strong> assess the strength of<br />
implicit associations that <strong>in</strong>dicate exist<strong>in</strong>g stereotypic evaluations of the group of<br />
ECs. Specifically, it assessed the strength of participants’ au<strong>to</strong>matic associations<br />
of “Evangelical Christian” (EC) or “Secular or No Religion” (SNR) with words<br />
clearly valenced <strong>in</strong> terms of pleasantness or unpleasantness, and stimulus<br />
concepts which are presumed <strong>to</strong> be associated with either group. SNR was<br />
chosen as study vignettes specifically do not mention religion of patients other<br />
than the EC, and the purpose of the study was not <strong>to</strong> assess attitudes relative <strong>to</strong><br />
other religions.<br />
The adm<strong>in</strong>istration of the IAT <strong>in</strong> this study, utilized guidel<strong>in</strong>es <strong>in</strong> the<br />
literature that were established follow<strong>in</strong>g the <strong>in</strong>vestigation of the effects of<br />
variability <strong>in</strong> the usage and adm<strong>in</strong>istration of the IAT <strong>in</strong> over 120 studies (Nosek,<br />
Greenwald, & Banaji, 2005). Positively valenced terms <strong>in</strong>cluded Marvelous,<br />
Peace, Pleasure, Beautiful, Joyful, Laughter, Lovely, and Wonderful and Happy,<br />
and negatively valenced terms <strong>in</strong>cluded Tragic, Failure, Agony, Pa<strong>in</strong>ful, Terrible,<br />
Awful, Hurt, and Nasty. Associations between concepts that may commonly be<br />
associated with EC versus SNR were used <strong>in</strong> the practice trial blocks for the<br />
purposes of learn<strong>in</strong>g the concept dimension. EC concepts <strong>in</strong>cluded Evangelist,<br />
Religious, Conservative, Traditional, Clergy, M<strong>in</strong>ister, Christ, and SNR concepts<br />
<strong>in</strong>cluded Activist, Liberal, Atheist, Progressive, Scientist, Agnostic, and Humanist.
137<br />
Procedures and <strong>in</strong>structions followed Nosek et al.’s (2005) IAT<br />
recommended procedures. Participants proceeded through five blocks of<br />
respond<strong>in</strong>g <strong>to</strong> provide data. Participants were <strong>in</strong>structed <strong>to</strong> respond as quickly as<br />
possible while attempt<strong>in</strong>g <strong>to</strong> m<strong>in</strong>imize errors. In the first step, participants<br />
practiced sort<strong>in</strong>g items from the different concepts <strong>in</strong><strong>to</strong> superord<strong>in</strong>ate categories,<br />
(e.g., clergy for the EC category and scientist for the SNR category) by us<strong>in</strong>g key<br />
presses, either “E” or “I” with left or right middle f<strong>in</strong>ger respectively on computer<br />
keyboards. In step 2, the participants learned how <strong>to</strong> sort the valenced words<br />
accord<strong>in</strong>g <strong>to</strong> “Good” or “Bad” categories (e.g., joy for Good and horrible for Bad)<br />
us<strong>in</strong>g the same keys. In step 3, sort<strong>in</strong>g tasks were comb<strong>in</strong>ed so that participants<br />
were alternately categoriz<strong>in</strong>g either a stimulus concept or valenced word <strong>to</strong> either<br />
the EC or Good group or the SNR and Bad group. Dur<strong>in</strong>g this trial for example,<br />
one key was the correct response for EC and Good words, and one key was the<br />
correct response for SNR and Bad words. The order of presentation of learn<strong>in</strong>g<br />
blocks was varied by participant order such that one participant was presented<br />
with a learn<strong>in</strong>g block that was configured with EC /Good categories comb<strong>in</strong>ed<br />
first, and the next participant practiced the SNR/Good categories first.<br />
A practice block of 20 trials was completed followed by a brief pause, and<br />
then a second block of 40 trials, referred <strong>to</strong> as the critical block, was presented.<br />
In step 4, the key assignment was reversed and only stimulus concepts were<br />
sorted <strong>in</strong><strong>to</strong> the two target categories (e.g., M<strong>in</strong>ister for EC, Scientist for SNR). In<br />
step 5, the participants sorted valenced word items and stimulus concepts aga<strong>in</strong>,<br />
but <strong>to</strong> a reverse comb<strong>in</strong>ation of target groups (EC and Bad group, or SNR and
138<br />
Good group). Participants aga<strong>in</strong> sorted items <strong>in</strong><strong>to</strong> appropriate categories for 20<br />
practice trials and then 40 critical trials. The latencies <strong>in</strong> the IAT are measured by<br />
calculat<strong>in</strong>g the average latency <strong>in</strong> respond<strong>in</strong>g between the two sort<strong>in</strong>g conditions<br />
(steps 3 and 5).<br />
Reviews of the IAT <strong>in</strong>dicate there is good evidence for convergent and<br />
discrim<strong>in</strong>ant validity (Nosek, Greenwald, & Banaji, 2005; Greenwald & Nosek,<br />
2001) as well as large effect sizes (Greenwald & Nosek, 2001). Frequent weak<br />
correlations with self-report measures (Greenwald et al., 1998) <strong>in</strong>dicate that the<br />
IAT assesses constructs that are often, but not always (Fazio & Olson, 2003),<br />
dist<strong>in</strong>ctive from those assessed <strong>in</strong> explicit self-report measures. Greenwald and<br />
Nosek (2001) reports test-retest reliability of the IAT averages > .6 and an<br />
<strong>in</strong>ternal consistency average of α > .80 (see Greenwald & Nosek, 2001 for<br />
review).<br />
Motivation <strong>to</strong> Control Prejudice Reactions Scale<br />
Dun<strong>to</strong>n and Fazio’s (Dun<strong>to</strong>n & Fazio, 1997) Motivation <strong>to</strong> Control<br />
Prejudiced Reactions (MCPR) subscale of Concern With Act<strong>in</strong>g Prejudiced, the<br />
subscale which has demonstrated moderat<strong>in</strong>g effects of racial prejudice follow<strong>in</strong>g<br />
a prim<strong>in</strong>g technique (Dun<strong>to</strong>n & Fazio, 1997) was modified for use with religious<br />
patients. The subscale is a n<strong>in</strong>e-item scale that asks participants <strong>to</strong> <strong>in</strong>dicate the<br />
extent <strong>to</strong> which they agree or disagree with statements about concern with act<strong>in</strong>g<br />
prejudiced. Participant responses are <strong>in</strong>dicated on a 7- po<strong>in</strong>t Likert scale, rang<strong>in</strong>g
139<br />
from -3 (strongly disagree) <strong>to</strong> +3 (strongly agree). Fazio et al. (1995) found that<br />
the measure predicted scores on the Modern Racism Scale and Dun<strong>to</strong>n and<br />
Fazio (1997) reported further evidence for validity by predict<strong>in</strong>g self-reported<br />
negative attitudes when motivation <strong>to</strong> control prejudiced reactions was low. High<br />
scores on Dun<strong>to</strong>n and Fazio’s MCPR Scale (1997) <strong>in</strong>dicate higher levels of<br />
MCPR. While the scale measures both external and <strong>in</strong>ternal reasons <strong>to</strong> respond<br />
without prejudice, the current <strong>in</strong>terest is <strong>in</strong> how much motivation one has as a<br />
modera<strong>to</strong>r <strong>to</strong> INA, not the orig<strong>in</strong> of that motivation.<br />
Marlowe Crowne Social Desirability Scale-Short Form<br />
The Marlowe Crowne Social Desirability Scale (MCSDS; Crowne &<br />
Marlowe, 1960) has proven useful <strong>in</strong> controll<strong>in</strong>g for social desirability <strong>in</strong> research<br />
us<strong>in</strong>g self-report measures with cl<strong>in</strong>icians (Constant<strong>in</strong>e & Ladany, 2000; Fuertes<br />
& Brobst, 2002). The MCSDS (Crowne & Marlowe, 1960) is a 33-item true-false<br />
measure which has been used extensively <strong>in</strong> the literature and is a primary social<br />
desirability measure used at this time. The Marlowe Crowne Social Desirabilityshort<br />
form, or the MC-Form C (Reynolds, 1982) was used <strong>to</strong> measure tendencies<br />
<strong>to</strong> respond <strong>in</strong> a socially desirable manner. The MC-Form C developed by<br />
Reynolds (1982) is a 13-item form with a reliability level of .76 which compares<br />
favorably with the reliability of the standard form. The short form validity is<br />
demonstrated <strong>in</strong> item fac<strong>to</strong>r load<strong>in</strong>g, concurrent validation with the Edwards<br />
Social Desirability Scale and <strong>to</strong>tal score correlations with the standard MCSDS.
140<br />
Social Desirability was measured us<strong>in</strong>g the MC-Form C for the purposes of<br />
detect<strong>in</strong>g its effect on explicit respond<strong>in</strong>g <strong>in</strong> this study.<br />
Religious Conservatism Scale<br />
Lastly, religious conservatism (RC) was measured us<strong>in</strong>g three Likert scale<br />
items that assess degree of devoutness about religious beliefs, follow<strong>in</strong>g<br />
religious traditions or practices, and attempts <strong>to</strong> live one’s life accord<strong>in</strong>g <strong>to</strong><br />
religious scriptures or teach<strong>in</strong>gs. It was hypothesized that conservative persons<br />
of religions other than Christianity may not exhibit bias <strong>to</strong>ward conservative<br />
Christians due <strong>to</strong> the commonality of their conservative approach <strong>to</strong> their religion,<br />
such that they may not be considered an out-group. This scale was author<br />
generated and as such, no psychometric properties for this measure are<br />
available. Items required that participants respond <strong>to</strong> <strong>in</strong>quiries about their degree<br />
of devoutness <strong>in</strong> each of three doma<strong>in</strong>s: religious beliefs, follow<strong>in</strong>g religious<br />
traditions or practices, and attempts <strong>to</strong> live life accord<strong>in</strong>g <strong>to</strong> religious scriptures or<br />
teach<strong>in</strong>gs. As the items asked participants <strong>to</strong> respond directly <strong>to</strong> items about their<br />
adherence <strong>to</strong> traditional beliefs and behaviors, the measure was presumed <strong>to</strong><br />
have face validity.<br />
Procedure
141<br />
Materials that were distributed <strong>to</strong> psychologists <strong>in</strong>clud<strong>in</strong>g the vignettes and<br />
measures for those who chose <strong>to</strong> participate, are conta<strong>in</strong>ed <strong>in</strong> Appendix A.<br />
<strong>Psychologist</strong>s were first emailed an <strong>in</strong>vitation <strong>to</strong> participate <strong>in</strong> the study, which<br />
was described as a study <strong>in</strong>vestigat<strong>in</strong>g cl<strong>in</strong>ical judgments. Participants were<br />
offered chances <strong>to</strong> w<strong>in</strong> a $50 or a $100 donation <strong>to</strong> the American Red Cross’s<br />
Hurricane Recovery Program, a charitable organization of their choice, or cash<br />
prizes <strong>in</strong> those amounts, with w<strong>in</strong>ners selected <strong>in</strong> a draw<strong>in</strong>g of all participants at<br />
the study’s end. A timed trial of the study revealed the time needed <strong>to</strong> participate<br />
<strong>in</strong> the study is approximately 25 m<strong>in</strong>utes, which was disclosed <strong>to</strong> participants <strong>in</strong><br />
the <strong>in</strong>formed consent.<br />
Those who chose <strong>to</strong> participate <strong>in</strong> the study were <strong>in</strong>structed <strong>to</strong> click on a<br />
website l<strong>in</strong>k <strong>to</strong> Survey Monkey, the first of two data collection websites that was<br />
provided <strong>in</strong> the <strong>in</strong>vitation email. The l<strong>in</strong>k <strong>to</strong>ok each participant <strong>to</strong> the front page of<br />
the study which consisted of an electronic <strong>in</strong>formed consent page. Follow<strong>in</strong>g<br />
participant agreement <strong>to</strong> consent terms, <strong>in</strong>clud<strong>in</strong>g the requirement that they use a<br />
W<strong>in</strong>dows Operat<strong>in</strong>g System <strong>to</strong> complete the last portion of the study, he or she<br />
then entered the study by click<strong>in</strong>g on another l<strong>in</strong>k.<br />
The first task was vignette evaluation. Participants were given <strong>in</strong>structions<br />
that “It is unders<strong>to</strong>od that some of the <strong>in</strong>formation presented <strong>in</strong> the vignettes is<br />
ambiguous, and <strong>in</strong>formation required for accurate cl<strong>in</strong>ical judgment is lack<strong>in</strong>g.<br />
Due <strong>to</strong> the fact that this study requires the use of brief vignettes, it is acceptable<br />
and expected that you project a hypothesis about each patient based on all<br />
pieces of <strong>in</strong>formation given, ambiguous or otherwise.” Participants were then
142<br />
asked <strong>to</strong> read two brief vignettes of patients present<strong>in</strong>g with the same number of<br />
anxiety symp<strong>to</strong>ms of Generalized Anxiety Disorder. In one of these vignettes, the<br />
patient was described as an Evangelical Christian with some discussion of the<br />
salience of his participation <strong>in</strong> religious activities. In the second vignette, the<br />
patient’s volunteer activities were described, with some follow-up discussion of<br />
the salience of those activities that were comparable <strong>to</strong> those described for the<br />
Evangelical Christian vignette patient. Order effects for the presentation of each<br />
vignette were controlled by alternat<strong>in</strong>g the order of presentation midway through<br />
the study. Conditions were counterbalanced for the relevant conditions only, with<br />
symp<strong>to</strong>ms rema<strong>in</strong><strong>in</strong>g constant across each condition.<br />
Participants then responded <strong>to</strong> empathy and prognostic measures for<br />
each vignette. Then the religious beliefs and attitudes, social desirability,<br />
motivation <strong>to</strong> control prejudiced reactions, and devoutness measures were<br />
adm<strong>in</strong>istered. After complet<strong>in</strong>g these tasks, respondents were asked background<br />
questions <strong>in</strong>clud<strong>in</strong>g sex, age, education, geographic region, professional degree,<br />
years <strong>in</strong> cl<strong>in</strong>ical practice, and religious affiliation. F<strong>in</strong>ally, participants were then<br />
directed <strong>to</strong> the IAT.<br />
Results<br />
Descriptive Statistics
143<br />
Prior <strong>to</strong> exam<strong>in</strong><strong>in</strong>g my data, I prepared it for analysis by creat<strong>in</strong>g a code<br />
book, and explor<strong>in</strong>g and clean<strong>in</strong>g the data. The study did not accept miss<strong>in</strong>g<br />
responses, so miss<strong>in</strong>g values were not present. Table 1 shows descriptive<br />
statistics for the sample background and demographic characteristics.<br />
The majority of the respondents (60.5%) were female. The respondents had a<br />
broad range of ages, with the 51- <strong>to</strong> 55- year old group (21.7%) and the 56- <strong>to</strong><br />
60- year old group (19.1%) be<strong>in</strong>g the largest. Over three-quarters of the<br />
respondents (78.0%) had obta<strong>in</strong>ed a doc<strong>to</strong>rate <strong>in</strong> cl<strong>in</strong>ical psychology, with an<br />
additional 12.6% hav<strong>in</strong>g a doc<strong>to</strong>rate <strong>in</strong> counsel<strong>in</strong>g psychology. The West (32.2%)<br />
and the Northeast (29.8%) were the most common of the eight geographic<br />
regions, and most of the respondents (81.7%) came from urban locations. The<br />
respondents had a broad range of years of cl<strong>in</strong>ical experience, with 21-30 years<br />
(25.7%) and 16-20 years (15.7%) as the most common levels of experience.<br />
Only 3.1% of the respondents had fewer than three years of experience, and only<br />
2.6% had 40 or more years of experience. The most common religious affiliations<br />
were Protestant (non-Evangelical; 25.4%), followed by Jewish (18.6%), and<br />
Catholic (14.1%). A substantial percentage of respondents (20.9%) <strong>in</strong>dicated that<br />
they had no religious affiliation (none/Atheist/Agnostic), and 10.7% <strong>in</strong>dicated that<br />
they had a religious affiliation not listed among the seven specific choices.<br />
Table 1<br />
Sample Demographic and Background Characteristics (N=382)<br />
Frequency<br />
Percentage
144<br />
Gender<br />
Male 151 39.5<br />
Female 231 60.5<br />
Age<br />
20-29 10 2.6<br />
30-35 24 6.3<br />
36-40 33 8.6<br />
41-45 42 11.0<br />
46-50 50 13.1<br />
51-55 83 21.7<br />
56-60 73 19.1<br />
61-65 43 11.3<br />
66+ 24 6.3<br />
Education<br />
Doc<strong>to</strong>rate Cl<strong>in</strong>ical Psychology 298 78.0<br />
Doc<strong>to</strong>rate Counsel<strong>in</strong>g Psychology 48 12.6<br />
Doc<strong>to</strong>rate Education or Related 10 2.6<br />
Other 26 6.8<br />
Geographic Region<br />
Northeast 114 29.8<br />
Southeast 22 5.8<br />
North 0 0.0
145<br />
Frequency<br />
Percentage<br />
Midwest 45 11.8<br />
South 22 5.8<br />
Northwest 9 2.4<br />
Southwest 47 12.3<br />
West 123 32.2<br />
Primary Location<br />
Rural 70 18.3<br />
Urban 312 81.7<br />
Years <strong>in</strong> Cl<strong>in</strong>ical Practice<br />
1-2 12 3.1<br />
3-5 38 9.9<br />
6-10 57 14.9<br />
11-15 57 14.9<br />
16-20 60 15.7<br />
21-30 98 25.7<br />
31-40 50 13.1<br />
40+ 10 2.6<br />
Religious Affiliation<br />
Buddhist 17 4.5<br />
Catholic 54 14.1<br />
Evangelical 20 5.2
146<br />
Frequency<br />
Percentage<br />
Protestant (non-Evangelical) 97 25.4<br />
H<strong>in</strong>du 0 0.0<br />
Jewish 71 18.6<br />
Muslim 2 .5<br />
None/Atheist/Agnostic 80 20.9<br />
Other 41 10.7<br />
Table 2 provides descriptive statistics for the measures used. Of primary<br />
<strong>in</strong>terest <strong>in</strong> this table are the reliability coefficients. The affective empathy scores<br />
(from the Batson scale) had high reliability, with values of .90 for both Evangelical<br />
Christian (EC) and No Mention of Religion (NMR) vignette patients. For the<br />
cognitive empathy scores (from the Interpersonal Reactivity Index), the<br />
reliabilities were lower but still adequate at .73 for both EC and NMR. Initially, the<br />
reliability of the prognosis scales was only .52 (for EC) and .50 (for NMR).<br />
Further exam<strong>in</strong>ation revealed that Item 7 <strong>in</strong> the scale lowered reliability. There<br />
was a strong negative correlation (-.50) between Item 7 (which is reverse<br />
scored), and Item 8. When Item 7 is removed, the reliability coefficients<br />
<strong>in</strong>creased <strong>to</strong> .64 (for EC) and .58 (for NMR). Exam<strong>in</strong><strong>in</strong>g Item 7 <strong>in</strong>dicates that<br />
respondents may not have <strong>in</strong>terpreted this question <strong>in</strong> the <strong>in</strong>tended manner as<br />
will be explored <strong>in</strong> the discussion section of this study. While the coefficients of<br />
.64 and .58 are still lower than would be desired, they were deemed adequate <strong>to</strong>
147<br />
<strong>in</strong>clude the prognosis scales <strong>in</strong> the hypothesis tests. For the motivation <strong>to</strong> control<br />
prejudice reactions scale, the reliability was .73 and for social desirability scores<br />
(from the MAC-Form C) the reliability was .76. The religiously liberal attitudes <strong>in</strong><br />
relation <strong>to</strong> Christian beliefs (.91) and the religious conservatism scale (.93) both<br />
had high reliability coefficients.
148<br />
Table 2<br />
Descriptive Statistics for Composite Measures (N=382)<br />
M<strong>in</strong>. Max. M SD Α<br />
Affective Empathy EC 6 42 24.62 6.91 .90<br />
Affective Empathy NMR 6 42 25.01 6.84 .90<br />
Cognitive Empathy EC 7 20 15.78 3.34 .73<br />
Cognitive Empathy NMR 8 20 16.20 3.08 .73<br />
Prognosis Vignette EC 1 14 32 25.15 3.45 .64<br />
Prognosis Vignette NMR 1 15 33 25.86 3.02 .58<br />
Motivation <strong>to</strong> Control Prejudice<br />
Reactions<br />
34 89 58.60 10.40 .73<br />
Social Desirability 0 13 4.49 2.95 .76<br />
RLACB 0 31 18.25 7.99 .91<br />
Religious Conservatism 3 12 7.21 3.09 .93<br />
Compatible Test 161 3193 1242.21 402.76<br />
Incompatible Test 572 2218 1170.28 315.48<br />
Implicate Negative Association -1240 2213 71.93 430.76<br />
1 Without Item 7 as discussed <strong>in</strong> the text.<br />
Prelim<strong>in</strong>ary Analyses<br />
Several prelim<strong>in</strong>ary analyses were run prior <strong>to</strong> exam<strong>in</strong><strong>in</strong>g the hypotheses.<br />
Distributions were checked <strong>to</strong> make sure that the data conformed <strong>to</strong> normality
149<br />
assumptions of the test. Figures A1 through A8 <strong>in</strong> Appendix B display the<br />
frequency distributions with superimposed normal distributions for social<br />
desirability, religious conservatism, religiously liberal attitudes <strong>to</strong>ward Christian<br />
beliefs, NMR-EC affective empathy, NMR-EC cognitive empathy, NMR-EC<br />
prognosis, implicit negative associations, and motivation <strong>to</strong> control prejudice<br />
scores. No outliers were found.<br />
Table 3 conta<strong>in</strong>s the normality statistics of each measure. Religious<br />
conservatism and religiously liberal attitudes <strong>in</strong> relation <strong>to</strong> Christian beliefs<br />
(RLACB) scores were somewhat negatively kur<strong>to</strong>tic, and NMR-EC affective<br />
empathy scores were somewhat positively kur<strong>to</strong>tic. However, no transformations<br />
were performed because the sample size is large (N=382), provid<strong>in</strong>g robustness<br />
aga<strong>in</strong>st violations of normality assumptions. Also, skewness is generally<br />
considered more problematic than kur<strong>to</strong>sis (Tabachnick & Fidel, 1996).<br />
Additionally, while the skewness value for several variables was statistically<br />
significant (i.e., when divided by the standard error of skewness exceeds 2), this<br />
is primarily due <strong>to</strong> the large sample size <strong>in</strong> the current study (and therefore the<br />
small standard errors). The largest value of skewness is .48, and values <strong>in</strong> this<br />
range do not pose a problem for the statistical methods employed <strong>in</strong> this study,<br />
particularly given the large sample size.
150<br />
Table 3<br />
Normality Statistics for Variables Used <strong>in</strong> Hypothesis Tests (N=382)<br />
Skewness SE Skewness Kur<strong>to</strong>sis SE Kur<strong>to</strong>sis<br />
Social Desirability .48 .12 -.49 .25<br />
Religious Conservatism -.03 .12 -1.28 .25<br />
RLACB -.48 .12 -1.01 .25<br />
NMR-EC Affective Empathy<br />
Difference<br />
NMR-EC Cognitive Empathy<br />
Difference<br />
.44 .12 4.61 .25<br />
.11 .12 -.21 .25<br />
NMR-EC Prognosis Difference .07 .12 2.06 .25<br />
<strong>Implicit</strong> Negative Association .43 .12 2.37 .25<br />
Motivation <strong>to</strong> Control Prejudice<br />
Reactions<br />
.18 .12 -.39 .25<br />
Regression assumptions of homoscedasticity and the normality of<br />
residuals with<strong>in</strong> each regression were exam<strong>in</strong>ed and are conta<strong>in</strong>ed <strong>in</strong> Appendix<br />
C which shows residual his<strong>to</strong>grams (designed <strong>to</strong> test the assumption of the<br />
normality of residuals) and residual equality scatterplots (designed <strong>to</strong> test the<br />
assumption of homoscedasticity). In each figure, the regression residuals were<br />
normally distributed and the assumption of homoscedasticity was approximated.<br />
It was determ<strong>in</strong>ed that the untransformed scores were adequate.<br />
Table 4 conta<strong>in</strong>s the correlations among the eight key variables <strong>in</strong> this<br />
study. Some of these correlations will be discussed <strong>in</strong> relation <strong>to</strong> specific
151<br />
hypothesis tests; however, several will also be discussed here. First, the first<br />
column of Table 4 shows that social desirability scores were not significantly<br />
correlated with any of the other variables <strong>in</strong> the study. Therefore, social<br />
desirability will be excluded as a covariate from all subsequent analyses.<br />
Second, the correlation between religiously liberal attitudes <strong>in</strong> relation <strong>to</strong><br />
Christian beliefs and religious conservatism was very high (r=-.66, p
152<br />
Table 4<br />
Correlations among Variables Used <strong>in</strong> Hypothesis Tests (N=382)<br />
1. 2. 3. 4. 5. 6. 7. 8.<br />
1. Social<br />
Desirability<br />
2. Religious<br />
Conservatism<br />
1.00<br />
.05 1.00<br />
3. RLACB .03 -<br />
.66***<br />
1.00<br />
4. NMR-EC<br />
Affective Empathy<br />
Difference<br />
.04 -<br />
.18***<br />
.19*** 1.00<br />
5. NMR-EC<br />
Cognitive<br />
Empathy<br />
Difference<br />
6. NMR-EC<br />
Prognosis<br />
Difference<br />
.02 -.16** .18*** .33*** 1.00<br />
.03 -.13** .18*** .37*** .20*** 1.00<br />
7. <strong>Implicit</strong><br />
Negative<br />
Association<br />
-.02 -<br />
.35***<br />
.51*** .06 .09 .12* 1.00<br />
8. Motivation <strong>to</strong><br />
Control Prejudice<br />
Reactions<br />
-.05 .12* -.06 .07 .01 .06 -.04 1.00<br />
*p
153<br />
NMR vignette first and 142 viewed the EC vignette first, and if the order of<br />
presentation resulted <strong>in</strong> differences <strong>in</strong> scores, controll<strong>in</strong>g for order of presentation<br />
would be necessary. Six <strong>in</strong>dependent samples t-tests were performed <strong>to</strong><br />
compare the two groups. Results showed no statistically significant difference for<br />
RLACB (t(380)=-.72, p=.474), NMR-EC affective empathy differences (t(380)=-<br />
1.45, p=.149), NMR-EC cognitive empathy differences (t(380)=-1.42, p=.156),<br />
NMR-EC prognosis differences (t(380)=1.36, p=.176), <strong>Implicit</strong> Negative<br />
Association (INA) scores (t(380)=-.15, p=.882), or Motivation <strong>to</strong> Control Prejudice<br />
Reactions (MCPR) scores (t(380)=-1.08, p=.282). Therefore, there was no need<br />
<strong>to</strong> control for order of presentation <strong>in</strong> the hypothesis tests.<br />
Hypotheses Analyses<br />
In the first hypothesis, the <strong>in</strong>dependent variable was <strong>Religiously</strong> Liberal<br />
Attitudes <strong>in</strong> relation <strong>to</strong> Christian Beliefs (RLACB) as measured by the RAS, and<br />
the dependent variable was Empathy. Empathy was measured by both the<br />
Perspective-Tak<strong>in</strong>g (PT) subscale of the Interpersonal Reactivity Index (IRI) and<br />
Batson’s empathy adjectives for each vignette, where difference refers <strong>to</strong> EC<br />
empathy scores subtracted from NMR empathy scores. Therefore analyses were<br />
performed separately for the affective empathy difference and the cognitive<br />
empathy difference. The results of the regression analysis with the NMR-EC<br />
affective empathy score as the dependent variable are shown <strong>in</strong> Table 5. Overall,<br />
RLACB scores expla<strong>in</strong>ed 4% of the variance <strong>in</strong> the NMR-EC affective empathy
154<br />
difference score, which was statistically significant, F(1,380)=14.38, p
155<br />
Table 6<br />
Regression of Differences <strong>in</strong> Cognitive Empathy on <strong>Religiously</strong> Liberal Attitudes<br />
<strong>in</strong> relation <strong>to</strong> Christian Beliefs: Hypothesis 1, (N=382)<br />
B SE B β t p<br />
Constant -11.16 .85 -13.20
156<br />
Table 7<br />
Regression of Differences <strong>in</strong> Prognosis on Liberal Attitudes <strong>in</strong> relation <strong>to</strong><br />
Christian Beliefs: Hypothesis 2, (N=382)<br />
B SE B β t P<br />
Constant -.50 .38 -1.32 .187<br />
RLACB .07 .02 .18 3.50
157<br />
Table 8<br />
Regression of Differences <strong>in</strong> INA associated with <strong>Religiously</strong> Liberal Attitudes <strong>in</strong><br />
relation <strong>to</strong> Christian Beliefs: Hypothesis 3 (N=382)<br />
B SE B β t p<br />
Constant -427.29 47.48 -9.00
158<br />
p=.186. This <strong>in</strong>dicates that INA is not related <strong>to</strong> affective empathy expressed<br />
between groups. In Block 2, the change <strong>in</strong> R2 with the addition of the <strong>in</strong>teraction<br />
term was .00, and this was not statistically significant, F(1,378)=.98, p=.322. The<br />
regression <strong>in</strong>dicates that the <strong>in</strong>clusion of the product term <strong>in</strong> Block 2 of the model<br />
did not result <strong>in</strong> an <strong>in</strong>crease <strong>in</strong> prediction, and therefore it is concluded that<br />
MCPR does not moderate the relationship between INA and NMR-EC affective<br />
empathy difference scores.
159<br />
Table 9<br />
Regression of Affective Empathy Differences with NMR-EC with Motivation <strong>to</strong><br />
Control Prejudice Reactions as a modera<strong>to</strong>r on Liberality of Attitudes <strong>in</strong> relation<br />
<strong>to</strong> Christian Beliefs: Hypothesis 4, (N=382)<br />
B SE B Β T p<br />
Block 1<br />
Constant .39 .19 2.09 .038<br />
INA .00 .00 .06 1.16 .248<br />
MCPR .03 .02 .08 1.47 .142<br />
Block 2<br />
Constant .40 .19 2.12 .035<br />
INA .00 .00 .07 1.30 .195<br />
MCPR .03 .02 .08 1.52 .129<br />
INA x MCPR .00 .00 .05 .99 .322<br />
Note. Block 1 R 2 =.01, F(2,379)=1.69, p=.186; Block 2 Change R 2 =.00,<br />
F(1,378)=.98, p=.322.<br />
The results of the regression analysis with NMR-EC cognitive empathy<br />
differences as the dependent variable are shown <strong>in</strong> Table 10. In Block 1, only 1%<br />
of the variance <strong>in</strong> NMR-EC cognitive empathy differences was expla<strong>in</strong>ed, and<br />
this was not statistically significant, F(2,379)=1.64, p=.196, <strong>in</strong>dicat<strong>in</strong>g that<br />
cognitive empathy was not related <strong>to</strong> INA. The addition of the product term <strong>in</strong><br />
Block 2 <strong>in</strong>creased the variance expla<strong>in</strong>ed by 1%, but aga<strong>in</strong> this was not<br />
statistically significant, F(1,378)=3.39, p=.067. Therefore, we can conclude that
160<br />
MCPR does not moderate the relationship between INA and the NMR-EC<br />
cognitive empathy difference scores. It should also be noted that INA did become<br />
statistically significant <strong>in</strong> Block 2 (β=.11, p=.039), <strong>in</strong>dicat<strong>in</strong>g that higher INA<br />
scores were associated with greater NMR-EC cognitive empathy differences (i.e.,<br />
those with implicit negative associations regard<strong>in</strong>g ECs relative <strong>to</strong> NMRs showed<br />
slightly more cognitive empathy <strong>to</strong>ward NMRs relative <strong>to</strong> ECs). The regression<br />
coefficient (.11) was similar <strong>to</strong> the correlation between these measures (.09) <strong>in</strong><br />
Table 4, although the bivariate correlation did not reach the level of statistical<br />
significance.
161<br />
Table 10<br />
Regression of Cognitive Empathy Differences with NMR-EC with Motivation <strong>to</strong><br />
Control Prejudice Reactions as a modera<strong>to</strong>r on Liberality of Attitudes <strong>in</strong> relation<br />
<strong>to</strong> Christian Beliefs: Hypothesis 4, (N=382)<br />
B SE B β t p<br />
Block 1<br />
Constant -8.42 .34 -24.52
162<br />
Table 11 <strong>in</strong>dicate that INA was statistically significant as a predic<strong>to</strong>r of NMR-EC<br />
prognosis differences (β=.12, p=.017), with the positive regression coefficient<br />
<strong>in</strong>dicat<strong>in</strong>g that those with higher INA scores (i.e., those with a positive perception<br />
of NMRs relative <strong>to</strong> ECs) also tended <strong>to</strong> have greater NMR-EC prognosis<br />
differences (i.e., more positive perceptions of the prognosis for NMRs versus<br />
ECs). When the <strong>in</strong>teraction term was entered <strong>in</strong> Block 2, the change <strong>in</strong> variance<br />
expla<strong>in</strong>ed was 0%, which was not statistically significant, F(1,378)=.14, p=.711.<br />
This <strong>in</strong>dicates that MCPR did not moderate the relationship between INA and the<br />
NMR-EC difference score.
163<br />
Table 11<br />
Regression of Prognosis Differences with NMR-EC with Motivation <strong>to</strong> Control<br />
Prejudice Respond<strong>in</strong>g as a modera<strong>to</strong>r on Liberality of Attitudes <strong>in</strong> relation <strong>to</strong><br />
Christian Beliefs: Hypothesis 5, (N=382)<br />
B SE B β t p<br />
Block 1<br />
Constant .71 .15 4.67
164<br />
expressed <strong>in</strong> relation <strong>to</strong> the Evanglical patient relative <strong>to</strong> the patient whose<br />
religion was not mentioned. Us<strong>in</strong>g the IAT, a timed measure designed <strong>to</strong> detect<br />
attitudes of participants without giv<strong>in</strong>g them the opportunity <strong>to</strong> censor biased<br />
respond<strong>in</strong>g, Hypothesis 3 was also supported. Those cl<strong>in</strong>icians with more liberal<br />
attitudes <strong>in</strong> relation <strong>to</strong> Christian beliefs demonstrated stronger negative<br />
associations <strong>to</strong>ward the Evangelical Christian target group than the Secular or<br />
No Religion target on the IAT. Hypotheses 4 and 5 were not supported <strong>in</strong> this<br />
study. Participants’ motivation <strong>to</strong> control prejudice respond<strong>in</strong>g had no moderat<strong>in</strong>g<br />
effect on implicit respond<strong>in</strong>g <strong>to</strong> the Christian target group <strong>in</strong> relation <strong>to</strong> explicit<br />
respond<strong>in</strong>g <strong>to</strong> vignette patients on empathy and prognosis measures.<br />
Discussion<br />
This study exam<strong>in</strong>ed whether cl<strong>in</strong>icians with more religiously liberal<br />
attitudes <strong>in</strong> relation <strong>to</strong> Christian beliefs responded differently <strong>to</strong> an Evangelical<br />
Christian vignette patient than <strong>to</strong> a vignette patient whose religion was not<br />
mentioned, and whether they responded with more negative associations <strong>to</strong><br />
Evangelical Christian targets than <strong>to</strong> Secular or No Religion targets on an implicit<br />
measure. The difference between the religiosity of psychologists and the general<br />
public has been referred <strong>to</strong> as the religiosity gap (Richards & Berg<strong>in</strong>, 2000).<br />
Seventy-six percent of the population endorsed Judeo-Christian affiliations of<br />
Protestant, Catholic, Jewish, Orthodox, and Mormon recently (Gallup, 2006), and<br />
<strong>in</strong> this study, 63.3% of psychologists endorsed Judeo-Christian categories. The
165<br />
difference is notable, but markedly different from previous research <strong>in</strong> which 43%<br />
endorsed these affiliations (Bilgrave & Deluty, 1998). It is likely that this study<br />
yielded a higher percentage of psychologists with Judeo-Christian affiliations as a<br />
result of efforts <strong>to</strong> balance the religious backgrounds of participants by recruit<strong>in</strong>g<br />
participants from organizations like the Christian Association for Psychological<br />
Studies, and the American Psychological Association’s Division of the<br />
Psychology of Religion. Nevertheless, dist<strong>in</strong>ct differences <strong>in</strong> the Evangelical<br />
category are noted <strong>in</strong> that only 5.2% of psychologists endorsed this affiliation <strong>in</strong><br />
this study compared <strong>to</strong> estimates of 22% of the general public (Gallup, 2005).<br />
The results of this study revealed that religiously liberal cl<strong>in</strong>icians’ empathy<br />
for, and prognosis for, patients who are described as Evangelical Christian is<br />
significantly different than for patients whose religion is not mentioned. This<br />
f<strong>in</strong>d<strong>in</strong>g of religious bias extends the cl<strong>in</strong>ical religious bias literature <strong>to</strong> date.<br />
Particularly, it is significant <strong>in</strong> that this study controlled for problematic<br />
methodology and design <strong>in</strong> other research that did not f<strong>in</strong>d bias (e.g., Houts &<br />
Graham, 1986; Lewis & Lewis, 1985; Reed, 1992; Wadsworth & Checketts,<br />
1980). These problems <strong>in</strong>clude the use of dicho<strong>to</strong>mous or categorical religious<br />
group assignments of participants, social desirability effects <strong>in</strong> particular related<br />
<strong>to</strong> the exclusive use of self-report measures of bias, between-subjects design,<br />
small sample sizes, and samples largely derived from rural areas <strong>in</strong> which<br />
religiously conservative persons might not be considered dissimilar, or as<br />
members of an outgroup.
166<br />
First, as discussed <strong>in</strong> the review of religious bias literature, previous<br />
studies that did not f<strong>in</strong>d bias were often conducted <strong>in</strong> rural areas <strong>in</strong> which<br />
religious persons may not be considered an out-group. As we have seen,<br />
stereotyp<strong>in</strong>g has been consistently demonstrated <strong>in</strong> the literature with members<br />
of out-groups. A national population of psychologists from a broad geographic<br />
area was solicited for participation <strong>in</strong> this study <strong>to</strong> control for that potential<br />
problem and <strong>to</strong> <strong>in</strong>crease generalizability of f<strong>in</strong>d<strong>in</strong>gs. This sample consisted of<br />
psychologists from all geographic regions; however, a large portion of<br />
participants <strong>in</strong>dicated they were from urban areas. Stereotyp<strong>in</strong>g of this group<br />
may be more common <strong>in</strong> urban areas, <strong>in</strong> which one might assume religiously<br />
conservative persons might be considered part of a more dist<strong>in</strong>ct out-group.<br />
Also, social desirability and transparency, which may have been<br />
problematic <strong>in</strong> other studies, were addressed <strong>in</strong> this study <strong>in</strong> several ways. First,<br />
social desirability was assessed for potential use as a covariate. However, it did<br />
not correlate with other variables <strong>in</strong> this study and so it was not used as a<br />
covariate. It is <strong>in</strong>terest<strong>in</strong>g that bias was detected without hav<strong>in</strong>g <strong>to</strong> control for<br />
social desirability <strong>in</strong> this study, despite that it is reasonable <strong>to</strong> expect that its<br />
effects may impact results <strong>in</strong> any bias or stereotyp<strong>in</strong>g studies. However, it may<br />
not have been necessary <strong>to</strong> control for social desirability here for several<br />
reasons. First, efforts <strong>to</strong> conceal variables of <strong>in</strong>terest <strong>in</strong> bias research, unless<br />
successfully executed, may <strong>in</strong>advertently contribute <strong>to</strong> an <strong>in</strong>crease <strong>in</strong> socially<br />
desirable respond<strong>in</strong>g. In other words, the implication of covert attempts <strong>to</strong><br />
uncover <strong>in</strong>formation about participants could cue the participant that there may
167<br />
be a variable of <strong>in</strong>terest that some might consider worth conceal<strong>in</strong>g. However,<br />
projections about ambiguous <strong>in</strong>formation, often presented <strong>in</strong> prelim<strong>in</strong>ary<br />
therapeutic work with patients, are likely <strong>to</strong> be common as cl<strong>in</strong>icians form their<br />
<strong>in</strong>itial impressions about new patients with limited <strong>in</strong>formation. In this study,<br />
attempts were made <strong>to</strong> normalize that process prior <strong>to</strong> the presentation of the<br />
vignettes so that evaluations could more closely approximate a natural<br />
therapeutic sett<strong>in</strong>g. So, it may not have been as desirable <strong>to</strong> conceal projections<br />
of expectations about vignette patients <strong>in</strong> this study.<br />
Also, liberality of cl<strong>in</strong>ician religiousness <strong>in</strong> relation <strong>to</strong> Christian beliefs was<br />
the <strong>in</strong>dependent variable <strong>in</strong> this study, rather than self-report of religious<br />
affiliation, or self-designation <strong>to</strong> dicho<strong>to</strong>mous groups such as religious versus<br />
nonreligious, which may not be an adequate method of group assignment s<strong>in</strong>ce<br />
group affiliation does not describe religiosity or religious beliefs or values <strong>in</strong> many<br />
cases. Results <strong>in</strong>dicate that religiously liberal cl<strong>in</strong>icians <strong>in</strong> this sample are biased<br />
aga<strong>in</strong>st religiously conservative Christian groups or group members, and are less<br />
likely <strong>to</strong> conceal their bias due <strong>to</strong> social desirability than those who merely<br />
identify membership or affiliation with a particular religious group.<br />
Further, the IAT was used <strong>to</strong> reduce reactive and censor<strong>in</strong>g elements<br />
employed <strong>in</strong> the expression of bias. A correlation between cl<strong>in</strong>ician religious<br />
liberality and au<strong>to</strong>matic negative associations was found, <strong>in</strong>dicat<strong>in</strong>g that<br />
religiously liberal cl<strong>in</strong>icians have some bias aga<strong>in</strong>st the Evangelical Christian<br />
group. In particular, negative associations about Evangelicals predicted a poorer<br />
prognosis for the Evangelical patient compared <strong>to</strong> the patient whose religion was
168<br />
not mentioned. In light of this f<strong>in</strong>d<strong>in</strong>g, and that differences were found <strong>in</strong> the selfreport<br />
expressed empathy <strong>in</strong> relation <strong>to</strong> the vignettes, it is <strong>in</strong>terest<strong>in</strong>g that<br />
negative associations with the Evangelical target did not predict differences <strong>in</strong><br />
affective empathic respond<strong>in</strong>g <strong>to</strong> the hypothetical Evangelical patient. The reason<br />
for this f<strong>in</strong>d<strong>in</strong>g is unclear. While the stereotyp<strong>in</strong>g literature has exam<strong>in</strong>ed<br />
cognitive evaluations of targets as well as affective respond<strong>in</strong>g <strong>to</strong> targets, a<br />
preponderance of the literature did not yield data about the relationship between<br />
the two variables that would assist <strong>in</strong> clarify<strong>in</strong>g this f<strong>in</strong>d<strong>in</strong>g, nor did it offer any<br />
explanations <strong>in</strong> relation <strong>to</strong> the <strong>in</strong>teraction of affective and cognitive empathy. It<br />
may be that someth<strong>in</strong>g about the ability <strong>to</strong> express affective empathy <strong>to</strong>ward<br />
Evangelical Christian patients is different than the general evaluative valence that<br />
cl<strong>in</strong>icians associate with Evangelical Christians <strong>in</strong> general. It may also be that for<br />
those cl<strong>in</strong>icians whose au<strong>to</strong>matic negative associations were related <strong>to</strong> poorer<br />
prognosis for, and less cognitive affect with, Evangelical patients, there were<br />
some strong negative stereotypic beliefs which are unrelated <strong>to</strong> the ability <strong>to</strong><br />
have affective empathy for the Evangelical patient.<br />
However, it should be noted that it is likely that flawed logic was used <strong>in</strong><br />
the manner <strong>in</strong> which this study attempted <strong>to</strong> control for cl<strong>in</strong>ician religious<br />
conservatism. Because conservatism was so highly correlated with endorsement<br />
of Christian beliefs, remov<strong>in</strong>g the effects of conservatism would also likely have<br />
elim<strong>in</strong>ated the ability of scores on the religious attitude scale <strong>to</strong> expla<strong>in</strong> any<br />
difference <strong>in</strong> either the implicit or the explicit measures. So conservatism was not<br />
controlled <strong>in</strong> this study.
169<br />
Overall, these results have significant implications for patients who are<br />
religiously dissimilar <strong>to</strong> cl<strong>in</strong>icians. If cl<strong>in</strong>icians estimate a poorer prognosis for<br />
patients based on religious group as they did <strong>in</strong> this study, it may be because<br />
they presume that pathology exists that is more severe than would be estimated<br />
for comparable patients from other religious groups, or from those with no<br />
religious affiliation. The literature does not support a correlation between<br />
religiosity and poor mental health. In fact, religiosity is associated with lower<br />
levels of depression (Smith, McCullough, & Poll, 2003), anxiety (Berg<strong>in</strong>, Masters,<br />
& Richards, 1987), positive religious cop<strong>in</strong>g with chronic pa<strong>in</strong> (see Rippentrop,<br />
2005 for review), and rehabilitation efforts (Kilpatrick & McCullough, 1999). A<br />
comprehensive review <strong>in</strong>dicated that those with devout <strong>in</strong>ternally motivated<br />
religiousness and participation <strong>in</strong> religious activities such as prayer, scripture<br />
read<strong>in</strong>g, and attendance at church or synagogue are associated with <strong>in</strong>creased<br />
mental health <strong>in</strong>clud<strong>in</strong>g lower rates of anxiety, depression, suicidality, less death<br />
anxiety, substance abuse, and higher life satisfaction, self-esteem, greater well<br />
be<strong>in</strong>g, happ<strong>in</strong>ess, adjustment, social support, <strong>in</strong>ternal locus of control and marital<br />
adjustment and satisfaction, and quicker recovery from depression (see Koenig,<br />
1997, pp. 101-102).<br />
Cognitive appraisals of religious patients as more mentally ill than their<br />
nonreligious counterparts can affect <strong>in</strong>itial impressions of the patient, lik<strong>in</strong>g of the<br />
patient, the ease with which a patient may feel free <strong>to</strong> express him- or herself,<br />
and the cl<strong>in</strong>ician’s assessment of the patient’s potential for change. There are<br />
several ways this can impact the patient <strong>in</strong>clud<strong>in</strong>g therapist satisfaction with
170<br />
patient progress, perception of patient satisfaction, and type of term<strong>in</strong>ation<br />
(Brown, 1970). Additionally, expectations that are based on stereotyped<br />
<strong>in</strong>formation have been associated with effects on <strong>in</strong>formation process<strong>in</strong>g and<br />
judgments, <strong>in</strong>formation seek<strong>in</strong>g and hypothesis test<strong>in</strong>g, and <strong>in</strong>terpersonal<br />
behavior via self-fulfill<strong>in</strong>g prophecies (Hamil<strong>to</strong>n et al., 1990). Clearly, cl<strong>in</strong>icians<br />
may not be impervious <strong>to</strong> these effects and may adjust their cl<strong>in</strong>ical approaches<br />
accord<strong>in</strong>gly.<br />
Last, if the patient’s religiosity or associated values are determ<strong>in</strong>ed <strong>to</strong> be a<br />
contribu<strong>to</strong>r <strong>to</strong> poorer mental health or an impediment <strong>to</strong> therapeutic progress <strong>in</strong><br />
some way, they may be targeted for change. Target<strong>in</strong>g patient values for change<br />
because they are seen as less favorable than the cl<strong>in</strong>ician’s own values although<br />
they have not been found <strong>to</strong> be pathological, may be problematic for therapists<br />
who strive <strong>to</strong> be culturally sensitive and competent and who value acceptance<br />
and positive regard for the patient as <strong>in</strong>tegral <strong>to</strong> successful treatment, and for<br />
patients whose religiosity and associated values may be disrespected or<br />
otherwise <strong>in</strong>sensitively treated. Additionally, this can present a violation of ethical<br />
mandates that require cl<strong>in</strong>icians <strong>to</strong> respect cultural differences of diverse groups.<br />
It is likely, and at least hoped that such unfounded bias is un<strong>in</strong>tended and<br />
operates outside of the cl<strong>in</strong>ician’s awareness.<br />
Empathy has long been considered a corners<strong>to</strong>ne of an effective<br />
therapeutic relationship <strong>in</strong> which the cl<strong>in</strong>ician seeks <strong>to</strong> understand the patient’s<br />
experience (Ivey et al., 1993; Rogers, 1957). <strong>Bias</strong> <strong>in</strong> empathy has been related <strong>to</strong><br />
the cl<strong>in</strong>ician’s ability <strong>to</strong> conceptualize a patient’s mental health issues from a
171<br />
multicultural perspective when rated by others (Constant<strong>in</strong>e, 2001). Group<br />
member rat<strong>in</strong>gs of general and cultural competence have also been associated<br />
with empathy, and competence as perceived by the patient can have an effect on<br />
the patient’s overall satisfaction with treatment (Fuertes & Brobst, 2002). In<br />
relation <strong>to</strong> exist<strong>in</strong>g cl<strong>in</strong>ician religious bias, it is notable that some religious<br />
persons have expressed fears that therapists will judge them or seek <strong>to</strong> change<br />
their religion or associated values (Richards & Berg<strong>in</strong>, 2000, p. 13), which is<br />
likely <strong>to</strong> be related <strong>to</strong> the religious person’s perception of potential psychologist<br />
preference or bias for his or her values over the patient’s.<br />
The results of this study have implications for cl<strong>in</strong>ician multicultural tra<strong>in</strong><strong>in</strong>g<br />
programs. Given that bias was found <strong>in</strong> this study, it is a concern that cl<strong>in</strong>icians<br />
who experience au<strong>to</strong>matic negative bias aga<strong>in</strong>st such a large portion of the<br />
general population, do not successfully moderate their negative respond<strong>in</strong>g <strong>to</strong><br />
the group when given the opportunity <strong>to</strong> use deliberation <strong>in</strong> do<strong>in</strong>g so. Dev<strong>in</strong>e<br />
(1989) posited the theory that one’s negative au<strong>to</strong>matic associations need not be<br />
determ<strong>in</strong>istic <strong>in</strong> relation <strong>to</strong> one’s behavior, if one is sufficiently motivated not <strong>to</strong><br />
act upon the association. Further, the MODE model of prejudice (Fazio & Olson,<br />
2003) posits that the more sensitive a doma<strong>in</strong> of evaluation, such as social group<br />
evaluation, the more likely motivational fac<strong>to</strong>rs <strong>in</strong> conceal<strong>in</strong>g that bias will be<br />
represented <strong>in</strong> self-report measures.<br />
As cl<strong>in</strong>icians can generally be assumed <strong>to</strong> use thoughtful consideration <strong>in</strong><br />
mak<strong>in</strong>g cl<strong>in</strong>ical judgments, these results suggest that there are beliefs about<br />
religious conservative persons that affect cl<strong>in</strong>ical judgment such that cl<strong>in</strong>icians
172<br />
give a poorer prognosis <strong>to</strong> them, and that they do not believe these beliefs <strong>to</strong> be<br />
<strong>in</strong> need of censorship. As it has not been demonstrated that religious persons are<br />
more pathological than nonreligious persons, and <strong>in</strong> fact that their religiosity is<br />
often associated with better mental health, the nature of cl<strong>in</strong>ician’s beliefs about<br />
this group such that they are believed <strong>to</strong> have a poorer prognosis than their<br />
nonreligious counterparts, is of <strong>in</strong>terest and may be considered a variable for<br />
future research.<br />
Diversity tra<strong>in</strong><strong>in</strong>g is often synonymous with racial and ethnic multicultural<br />
approaches <strong>to</strong> treatment and education. As such, religiosity is an often<br />
overlooked expression of diversity <strong>in</strong> tra<strong>in</strong><strong>in</strong>g programs and the diversity literature<br />
(Yarhouse & Fisher, 2002). If religiosity is <strong>to</strong> be considered from an <strong>in</strong>formed and<br />
sensitive multicultural perspective, it is <strong>in</strong>dicated that tra<strong>in</strong><strong>in</strong>g programs should<br />
undertake <strong>to</strong> educate cl<strong>in</strong>icians about culturally appropriate and competent<br />
treatment of religiously dissimilar patients. Multicultural education and literature<br />
should also endeavor <strong>to</strong> <strong>in</strong>crease awareness about the impact of variables such<br />
as sociopolitical <strong>in</strong>fluence that are often presumed <strong>to</strong> be correlated with<br />
religiosity, and that <strong>in</strong>fluence on bias with religiously dissimilar patients (Fuertes<br />
& Brobst, 2002). This is particularly salient as affective charge has been<br />
<strong>in</strong>creas<strong>in</strong>gly associated with religiosity or religious values <strong>in</strong> the political doma<strong>in</strong><br />
(Wallis, 2005).<br />
The f<strong>in</strong>d<strong>in</strong>gs of this study extend the literature on stereotyp<strong>in</strong>g. Byrne’s<br />
attraction paradigm (1971) posits that those who are similar are more attracted <strong>to</strong><br />
each other and those who are dissimilar will be repulsed by each other.
173<br />
Importantly, he hypothesized that similarity and dissimilarity based on values and<br />
attitudes are more important <strong>in</strong> determ<strong>in</strong><strong>in</strong>g attraction or repulsion than are<br />
demographic variables. As has been discussed, religious affiliation does not a<br />
religious person make. Methods of group designation by self-report of religious<br />
affiliation or membership tell little of the effects of that association on one’s<br />
beliefs or attitudes. The f<strong>in</strong>d<strong>in</strong>gs of this study, which assessed attitudes <strong>to</strong>ward<br />
core Christian beliefs rather than endorsement of affiliation or membership with a<br />
religious group, supports Byrne’s theory.<br />
This study also adds <strong>to</strong> the grow<strong>in</strong>g body of literature on negative<br />
au<strong>to</strong>matic associations with social out-groups. Self-report measures of<br />
stereotyp<strong>in</strong>g or bias may compromise research results as prejudice is generally<br />
viewed as socially unacceptable, thereby <strong>in</strong>creas<strong>in</strong>g motivation <strong>to</strong> conceal bias,<br />
stereotyped beliefs, or prejudiced respond<strong>in</strong>g. Negative au<strong>to</strong>matic associations<br />
were associated with the group most religiously diverse from the religiously<br />
conservative target. Recall<strong>in</strong>g that some posit that au<strong>to</strong>matic associations are<br />
demonstrated on the basis of common social knowledge of stereotypes rather<br />
than personally held beliefs (Karp<strong>in</strong>ski & Hil<strong>to</strong>n, 2001), this study <strong>in</strong>dicates that<br />
the participant’s beliefs are a primary fac<strong>to</strong>r <strong>in</strong> determ<strong>in</strong><strong>in</strong>g negative<br />
characterization of the group.<br />
There are several limitations <strong>to</strong> this study. The large representation of<br />
urban cl<strong>in</strong>icians <strong>in</strong> this sample may have contributed <strong>to</strong> the f<strong>in</strong>d<strong>in</strong>gs of bias if<br />
religiously conservative persons are considered an out-group <strong>in</strong> those areas. The<br />
sample also largely consisted of those belong<strong>in</strong>g <strong>to</strong> psychological organizations,
174<br />
which were also presumably <strong>in</strong>ternet savvy s<strong>in</strong>ce the completion of the survey<br />
required <strong>in</strong>ternet use and even that the participants download a plug-<strong>in</strong> for the<br />
<strong>Implicit</strong> Association Test (IAT). It is unknown what differences there may be<br />
between this group and others who differ on these characteristics.<br />
Item 7 from the prognosis measure was deleted due <strong>to</strong> its lack of<br />
correlation <strong>to</strong> other variables. It is not unders<strong>to</strong>od why the item did not correlate<br />
with other variables. A review of both items 7 and 8 revealed that participants<br />
may have <strong>in</strong>terpreted the items <strong>in</strong> much the same way and did not differentiate<br />
between the <strong>in</strong>tention of each. Items 7 and 8 ask participants <strong>to</strong> rate “the number<br />
of therapy sessions required for this patient <strong>to</strong> make substantial progress,” and<br />
“number of sessions you expect that this patient will attend therapy” respectively.<br />
Also, there were considerable technical difficulties <strong>in</strong> the adm<strong>in</strong>istration of<br />
the IAT portion of this study. Many participants who began the study, could not,<br />
or did not, f<strong>in</strong>ish it. Further, as one participant po<strong>in</strong>ted out, there may be<br />
differences between psychologists who used MacIn<strong>to</strong>sh operat<strong>in</strong>g systems, and<br />
those who used W<strong>in</strong>dows Operat<strong>in</strong>g Systems which was required for the IAT<br />
portion of the study. It is not known what differences there may be between the<br />
two groups. Last, while it is difficult <strong>to</strong> estimate a response rate <strong>to</strong> this study due<br />
<strong>to</strong> technical problems, the W<strong>in</strong>dows Operat<strong>in</strong>g System requirement, and a<br />
population which <strong>in</strong>cluded unlicensed psychologists who were excluded from the<br />
study, the response rate overall was low.<br />
The results of this study <strong>in</strong>dicate that more research would be helpful <strong>in</strong><br />
determ<strong>in</strong><strong>in</strong>g which cl<strong>in</strong>ician or patient variables are related <strong>to</strong> religious bias, and
175<br />
how they are related, and cont<strong>in</strong>ued <strong>in</strong>vestigations <strong>in</strong><strong>to</strong> the specific processes<br />
that predict religious bias, the orig<strong>in</strong>s, nature, and application of that bias, and<br />
whether biases are specific <strong>to</strong> certa<strong>in</strong> groups are also of <strong>in</strong>terest. Future research<br />
<strong>in</strong> the area of cl<strong>in</strong>ician religious bias would be of service <strong>to</strong> religiously dissimilar<br />
patients if it were <strong>to</strong> seek data that could better <strong>in</strong>form and assist multicultural<br />
tra<strong>in</strong><strong>in</strong>g programs <strong>in</strong> their efforts <strong>to</strong> provide culturally competent and <strong>in</strong>formed<br />
cl<strong>in</strong>ical services <strong>to</strong> these patients. It is hoped that this and similar research<br />
succeeds <strong>in</strong> facilitat<strong>in</strong>g <strong>in</strong>terest <strong>in</strong> cultural tra<strong>in</strong><strong>in</strong>g and <strong>in</strong> the literature <strong>to</strong> more<br />
adequately address issues related <strong>to</strong> competent, respectful, and sensitive<br />
treatment of religious persons and their religiously <strong>in</strong>formed values.
176<br />
References – Part B<br />
Aiken, L.S., & West, S.G. (1991). Multiple regression: Test<strong>in</strong>g and <strong>in</strong>terpret<strong>in</strong>g<br />
<strong>in</strong>teractions. Thousand Oaks, CA: Sage Publications.<br />
American Psychiatric Association. (1987). The diagnostic and statistical manual<br />
of mental disorders third revision. Wash<strong>in</strong>g<strong>to</strong>n, DC: American Psychiatric<br />
Publishers<br />
American Psychiatric Association. (2000). The diagnostic and statistical manual<br />
of mental disorders fourth edition text revision. Wash<strong>in</strong>g<strong>to</strong>n, DC: Author.<br />
APA. (2002). Ethical pr<strong>in</strong>ciples of psychologists and code of conduct. American<br />
<strong>Psychologist</strong>, 57(12), 1060-1073.<br />
Armstrong, R. G., Larsen, G. L., & Mourer, S.A. (1962). Religious attitudes and<br />
emotional adjustment. Journal of Psychological Studies, 13, 35-47<br />
Ashburn-Nardo, L., Voils, C. I., & Monteith, M. J. (2001). <strong>Implicit</strong> associations as<br />
the seeds of <strong>in</strong>tergroup bias: How easily do they take root? Journal of<br />
Personality and Social Psychology, 81(5), 789-799.<br />
Banaji, M. R., & Greenwald, A. G. (1995). <strong>Implicit</strong> gender stereotyp<strong>in</strong>g <strong>in</strong><br />
judgments of fame. Journal of Personality and Social Psychology, 68(2),<br />
181-198.<br />
Banaji, M. R., Hard<strong>in</strong>, C., & Rothman, A. J. (1993). <strong>Implicit</strong> stereotyp<strong>in</strong>g <strong>in</strong> person<br />
judgment. Journal of Personality and Social Psychology, 65(2), 272-281.
177<br />
Bargh, J. A., Chaiken, S., Govender, R., & Prat<strong>to</strong>, F. (1992). The generality of the<br />
au<strong>to</strong>matic attitude activation effect. Journal of Personality and Social<br />
Psychology, 62(6), 893-912.<br />
Bargh, J. A., & Pietromonaco, P. (1982). Au<strong>to</strong>matic <strong>in</strong>formation process<strong>in</strong>g and<br />
social perception: The <strong>in</strong>fluence of trait <strong>in</strong>formation presented outside of<br />
conscious awareness on impression formation. Journal of Personality and<br />
Social Psychology, 43(3), 432-449.<br />
Baron, R.M., & Kenny, D. A. (1986). The modera<strong>to</strong>r-media<strong>to</strong>r variable dist<strong>in</strong>ction<br />
<strong>in</strong> social psychological research: Conceptual, strategic, and statistical<br />
considerations. Journal of Personality and Social Psychology, 51(6), 1173-<br />
1183.<br />
Batson, D. C. (1987). Prosocial motivation: Is it ever truly altruistic? Advances <strong>in</strong><br />
Experimental Social Psychology, 20, 65-122.<br />
Berg<strong>in</strong>, A. (1980). Psychotherapy and religious values. Journal of Consult<strong>in</strong>g and<br />
Cl<strong>in</strong>ical Psychology, 48(1), 95-105.<br />
Berg<strong>in</strong>, A., & Jensen, J. P. (1990). Religiosity of psychotherapists: A national<br />
survey. Psychotherapy, 27(1), 3-7.<br />
Berg<strong>in</strong>, A. E. (1983). Religiosity and mental health: A critical reevaluation and<br />
meta-analysis. Professional Psychology: Research and Practice, 14(2),<br />
170-184.<br />
Berg<strong>in</strong>, A. E. (1991). Values and religious issues <strong>in</strong> psychotherapy and mental<br />
health. American <strong>Psychologist</strong>, 46(4), 394-403.
178<br />
Berg<strong>in</strong>, A. E., Masters, K. S., & Richards, S. P. (1987). Religiousness and mental<br />
health reconsidered: A study of an <strong>in</strong>tr<strong>in</strong>sically religious sample. Journal of<br />
Counsel<strong>in</strong>g and Cl<strong>in</strong>ical Psychology, 34(2), 197-204.<br />
Berkowitz, L., & LePage, A. (1967). Weapons as aggression-elicit<strong>in</strong>g stimuli.<br />
Journal of Personality and Social Psychology, 7(2), 202-207.<br />
Beutler, L. E., Crago, M., & Arizmendi, T. G. (1986). Therapist variables <strong>in</strong><br />
psychotherapy process and outcome. In S. L. Garfield & A. Berg<strong>in</strong> (Eds.),<br />
Handbook of psychotherapy and behavior change (pp. 257-310). New<br />
York: Wiley & Sons.<br />
Beutler, L.E., Machado, P. P. P., & Neufeldt, S. A. (Eds.). (1994). Therapist<br />
Variables (4th ed.). New York: Wiley & Sons.<br />
Beutler, L. E., & Bergan, J. (1991). Value change <strong>in</strong> counsel<strong>in</strong>g and<br />
psychotherapy: A search for scientific credibility. Journal of Counsel<strong>in</strong>g<br />
Psychology, 38(1), 16-24.<br />
Beutler, L. E., Malik, M. L., Alimohamed, S., Harwood, T. M., Talebi, H., Noble,<br />
S., et al. (2004). Therapist variables. In A. E. Berg<strong>in</strong> & S. L. Garfield<br />
(Eds.), Handbook of psychotherapy and behavior change (5th ed.). New<br />
York: Wiley & Sons.<br />
Biernat, M., & Korbrynowicz, D. (2003). Stereotypes and shift<strong>in</strong>g standards:<br />
Some paradoxical effects of cognitive load. Journal of Applied Social<br />
Psychology, 33(10), 2060-2079.
179<br />
Bilgrave, D. P., & Deluty, R. H. (1998). Religious beliefs and therapeutic<br />
orientations of cl<strong>in</strong>ical and counsel<strong>in</strong>g psychologists. Journal for the<br />
Scientific Study of Religion, 37(2), 329-349.<br />
Bodenhausen, G. V., Kramer, G. P., & Susser, K. (1994). Happ<strong>in</strong>ess and<br />
stereotypic th<strong>in</strong>k<strong>in</strong>g <strong>in</strong> social judgment. Journal of Personality and Social<br />
Psychology, 66(4), 621-632.<br />
Bodenhausen, G. V., & Lichtenste<strong>in</strong>, M. (1987). Social stereotypes and<br />
<strong>in</strong>formation-process<strong>in</strong>g strategies: The impact of task complexity. Journal<br />
of Personality and Social Psychology, 52(5), 871-880.<br />
Brawer, P. A., Handal, P. J., Fabrica<strong>to</strong>re, A. N., Roberts, R., & Wajda-Johns<strong>to</strong>n,<br />
V. A. (2002). Tra<strong>in</strong><strong>in</strong>g and education <strong>in</strong> religion/spirituality with<strong>in</strong> APAaccredited<br />
cl<strong>in</strong>ical psychology programs. Professional Psychology:<br />
Research and Practice, 33(2), 203-206.<br />
Brendl, C. M., Markman, A. B., & Messner, C. (2001). How do <strong>in</strong>direct measures<br />
of evaluation work? Evaluat<strong>in</strong>g the <strong>in</strong>ference of prejudice <strong>in</strong> the <strong>Implicit</strong><br />
Association Test. Journal of Personality and Social Psychology, 81(5),<br />
760-773.<br />
Brewer, M. B., & Gardner, W. (1996). Who is this "we"? Levels of collective<br />
identity and self representations. Journal of Personality and Social<br />
Psychology, 71(1), 83-93.<br />
Brickman, P., & Bulman, R. J. (1977). Pleasure and pa<strong>in</strong> <strong>in</strong> social comparison. In<br />
J. M. Suls & R. L. Miller (Eds.), Social comparison processes: Theoretical<br />
and empirical perspectives (pp. 149-186). Wash<strong>in</strong>g<strong>to</strong>n, DC: Hemisphere.
180<br />
Brown, R. D. (1970). Experienced and <strong>in</strong>experienced counselors' first<br />
impressions of client and case outcomes: Are first impressions last<strong>in</strong>g?<br />
Journal of Counsel<strong>in</strong>g Psychology, 17(6), 550-558.<br />
Byrne, D. (1971). The attraction paradigm. New York: Academic Press.<br />
Cheatham, H. E., Ivey, A. E., Ivey, M. B., & Simek-Morgan, L. (1980).<br />
Multicultural counsel<strong>in</strong>g and therapy: Chang<strong>in</strong>g the foundations of the<br />
field. In A. E. Ivey, M. B. Ivey, & L. Simek-Morgan (Eds.), Counsel<strong>in</strong>g and<br />
psychotherapy: A multicultural perspective (3rd ed., p. 94). Needham<br />
Heights, MA: Allyn & Bacon.<br />
Chen, F. F., & Kenrick, D. T. (2002). Repulsion or attraction? Group membership<br />
and assumed attitude similarity. Journal of Personality and Social<br />
Psychology, 83(1), 111-125.<br />
Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.).<br />
Hillsdale, NJ: Lawrence Erlbaum.<br />
Constant<strong>in</strong>e, M. G., & Ladany, N. (2000). Self-report multicultural counsel<strong>in</strong>g<br />
competence scales: Their relation <strong>to</strong> social desirability attitudes and<br />
multicultural case conceptualization ability. Journal of Counsel<strong>in</strong>g<br />
Psychology, 47(2), 155.<br />
Constant<strong>in</strong>e, M. G. (2001). Multicultural tra<strong>in</strong><strong>in</strong>g, theoretical orientation, empathy,<br />
and multicultural case conceptualization ability <strong>in</strong> counselors. Journal of<br />
Mental Health Counsel<strong>in</strong>g, 23(4), 357-372.<br />
Crawford, M., T., & Skowronski, J. J. (1998). When motivated thought leads <strong>to</strong><br />
heightened bias: High need for cognition can enhance the impact of
181<br />
stereotypes on memory. Society for Personality and Social Psychology<br />
Inc, 24(10), 1075-1088.<br />
Crocker, J., & Luhtanen, R. (1990). Collective self-esteem and <strong>in</strong>group bias.<br />
Journal of Personality and Social Psychology, 58(1), 60-67.<br />
Crocker, J., McGraw, K. M., Thompson, L. L., & Ingerman, C. (1987). Downward<br />
comparison, prejudice, and evaluation of others: Effects of self esteem<br />
and threat. Journal of Personality and Social Psychology, 52(5), 907-916.<br />
Crowne, D. P., & Marlowe, D. (1960). A new scale of desirability <strong>in</strong>dependent of<br />
psychopathology. Journal of Consult<strong>in</strong>g Psychology, 24, 349-354.<br />
Davis, M. H. (1983). Measur<strong>in</strong>g <strong>in</strong>dividual differences <strong>in</strong> empathy: Evidence for a<br />
multidimensional approach. Journal of Personality and Social Psychology,<br />
44(1), 113-126.<br />
Davis, M. H. (1994). Empathy: A social psychological approach. Madison, WI:<br />
Brown & Benchmark.<br />
Davis, M. H., & Kraus, L. A. (1997). Personality and empathic accuracy. In W.<br />
Ickes (Eds), Empathic accuracy (pp. 145-167). New York: Guilford Press.<br />
Dev<strong>in</strong>e, P., Plant, E. A., Amodio, D. M., Harmon-Jones, E., & Vance, S. L.<br />
(2002). The regulation of explicit and implicit race bias: The role of<br />
motivations <strong>to</strong> respond without prejudice. Journal of Personality and Social<br />
Psychology, 82(5), 835-848.<br />
Dev<strong>in</strong>e, P. G. (1989). Stereotypes and prejudice: Their au<strong>to</strong>matic and controlled<br />
components. Journal of Personality and Social Psychology, 56(1), 5-18.
182<br />
Dovidio, J. F., Evans, N., & Tyler, R. B. (1986). Racial stereotypes: The content<br />
of their cognitive representations. Journal of Experimental Social<br />
Psychology, 22, 22-37.<br />
Dovidio, J. F., Kawakami, K., Johnson, C., Johnson, B., & Howard, A. (1997). On<br />
the nature of prejudice: Au<strong>to</strong>matic and controlled processes. Journal of<br />
Experimental Social Psychology, 33, 510-540.<br />
Dra<strong>in</strong>e, S. (2006). Inquisit 2.0.61004.5., www.millisecond.com.[Computer<br />
Software]. Seattle, WA: Millisecond Software LLC.<br />
Dun<strong>to</strong>n, B. C., & Fazio, R. H. (1997). An <strong>in</strong>dividual difference measure of<br />
motivation <strong>to</strong> control prejudice reactions. Society for Personality and<br />
Social Psychology Inc, 23(3), 316-326.<br />
Ellis, A. (1980a). The case aga<strong>in</strong>st religion: A psychotherapist's view and the<br />
case aga<strong>in</strong>st religiosity. Aust<strong>in</strong>, TX: American Atheist Press.<br />
Ellis, A. (1980b). Psychotherapy and atheistic values: A response <strong>to</strong> A.E.Berg<strong>in</strong>'s<br />
"Psychotherapy and Religious Values.” Journal of Consult<strong>in</strong>g and Cl<strong>in</strong>ical<br />
Psychology, 48(5), 635-639.<br />
Ellis, A. (2000). Can rational-emotive behavior therapy (REBT) be effectively<br />
used with people who have devout beliefs <strong>in</strong> God and religion?<br />
Professional Psychology: Research and Practice, 31(1), 29-33.<br />
Erlich, H. J. (1973). The social psychology of prejudice. New York: Wiley.<br />
Fazio, R. H. (1990). Multiple processes by which attitude guides behavior: The<br />
MODE model as an <strong>in</strong>tegrative framework. In M. P. Zanna (Ed.),
183<br />
Advances <strong>in</strong> experimental social psychology (pp. 75-109). New York:<br />
Academic Press.<br />
Fazio, R. H., Jackson, J. R., Dun<strong>to</strong>n, B. C., & Williams, C. J. (1995). Variability <strong>in</strong><br />
au<strong>to</strong>matic activation as an unobtrusive measure of racial attitudes: A bona<br />
fide pipel<strong>in</strong>e? Journal of Personality and Social Psychology, 69, 1013-<br />
1027.<br />
Fazio, R. H., & Olson, M. A. (2003). <strong>Implicit</strong> measures <strong>in</strong> social cognition<br />
research: Their mean<strong>in</strong>g and use. Annual Review of Psychology, 54, 297-<br />
327.<br />
Fazio, R. H., Sanbonmatsu, D. M., Powell, M. C., & Kardes, F. R. (1986). On the<br />
au<strong>to</strong>matic activation of attitudes. Journal of Personality and Social<br />
Psychology, 50(2), 229-238.<br />
Fest<strong>in</strong>ger, L. (1954). A theory of social comparison processes. Human Relations,<br />
7, 117-140.<br />
F<strong>in</strong>lay, R. (2007). SurveyMonkey.com [onl<strong>in</strong>e data collection website]. Portland,<br />
OR.<br />
Francis, L. J., & Peter, K. (2002). The relationship between psychological wellbe<strong>in</strong>g<br />
and Christian faith and practice <strong>in</strong> an Australian population sample.<br />
Journal for the Scientific Study of Religion, 41(1), 179-184.<br />
Freud, S. (2000). Totem and taboo. In Totem and taboo: Resemblances between<br />
the psychic lives of savages and neurotics. (A. A. Brill, Trans.). Amherst,<br />
NY: Prometheus Books. (Orig<strong>in</strong>al work published 1913).
184<br />
Freud, S. (1964). A Weltanschauung? In J. Strachey (Ed.), The standard edition<br />
of the complete psychological works of Sigmund Freud (pp. 158-182).<br />
London: Hogarth Press. (Orig<strong>in</strong>al work published 1933).<br />
Fuertes, J. N., & Brobst, K. (2002). Client's rat<strong>in</strong>gs of counselor multicultural<br />
competency. Cultural Diversity and Ethnic M<strong>in</strong>ority Psychology, 8(3), 214-<br />
223.<br />
Gaertner, L., & Insko, C. A. (2000). Intergroup discrim<strong>in</strong>ation <strong>in</strong> the m<strong>in</strong>imal group<br />
paradigm: Categorization, reciprocation, or fear? Journal of Personality<br />
and Social Psychology, 79(77-94), 77-94.<br />
The Gallup poll: Public op<strong>in</strong>ion <strong>in</strong> 1996. (1996). Wilm<strong>in</strong>g<strong>to</strong>n, DE: Scholarly<br />
Resources.<br />
The Gallup Poll. (2005). Retrieved August 1, 2006, from<br />
http://poll.gallup.com/content/default.aspx?ci=16519<br />
The Gallup Poll. (2006). Retrieved August 1, 2006, from<br />
http://bra<strong>in</strong>.gallup.com/documents/question.aspx?question=72715&Advan<br />
ced=0&SearchConType=1&SearchTypeAll=Universal%20spirit<br />
Gartner, J. (1986). Antireligious prejudice <strong>in</strong> admissions <strong>to</strong> doc<strong>to</strong>ral programs <strong>in</strong><br />
cl<strong>in</strong>ical psychology. Professional Psychology: Research and Practice,<br />
17(5), 473-475.<br />
Gartner, J. (1990). The effect of client and counselor values on cl<strong>in</strong>ical judgment.<br />
Counsel<strong>in</strong>g & Values, 35(1), 58-63.
185<br />
Gartner, J., Hohmann, A., Harmatz, M., & Larson, D. (1990). The effect of patient<br />
and cl<strong>in</strong>ician ideology on cl<strong>in</strong>ical judgment: A study of ideological<br />
countertransference. Psychotherapy, 27, 98-106.<br />
Gartner, J., Larson, D. B., & Allen, G. D. (1991). Religious commitment and<br />
mental health: A review of the empirical literature. Journal of Psychology<br />
and Theology, 19(1), 6-25.<br />
Gilbert, D. T., & Hixon, J. G. (1991). The trouble of th<strong>in</strong>k<strong>in</strong>g: Activation and<br />
application of stereotypic beliefs. Journal of Personality and Social<br />
Psychology, 60(4), 509-517.<br />
Graham, S. A. (1980). Psychotherapists' attitudes <strong>to</strong>ward offender clients.<br />
Journal of Consult<strong>in</strong>g and Cl<strong>in</strong>ical Psychology, 48(6), 796-797.<br />
Graham, T., & Ickes, W. (1997). When women's <strong>in</strong>tuition isn't greater than men's.<br />
In W. Ickes (Ed.), Empathic accuracy. New York: Guilford Press.<br />
Greenwald, A. G., & Banaji, M. R. (1995). <strong>Implicit</strong> social cognition: Attitudes, selfesteem,<br />
and stereotypes. Psychological Review, 102(1), 4-27.<br />
Greenwald, A. G., McGhee, D. E., & Schwartz, J. L. K. (1998). Measur<strong>in</strong>g<br />
<strong>in</strong>dividual differences <strong>in</strong> implicit cognition: The <strong>Implicit</strong> Association Test.<br />
Journal of Personality and Social Psychology, 74(6), 1464-1480.<br />
Greenwald, A. G., & Nosek, B. A. (2001). Health of the <strong>Implicit</strong> Association Test<br />
at age 3. Zeitschrift fur Experimentelle Psychologie, 48(2), 85-93.<br />
Guimond, S., Dambrun, M., Mich<strong>in</strong>ov, N., & Duarte, S. (2003). Does social<br />
dom<strong>in</strong>ance generate prejudice: Integrat<strong>in</strong>g <strong>in</strong>dividual and contextual
186<br />
determ<strong>in</strong>ants of <strong>in</strong>tergroup cognitions. Journal of Personality and Social<br />
Psychology, 84(4), 697-721.<br />
Hamil<strong>to</strong>n, D. L., Sherman, J. W., & Ruvolo, C. M. (1990). Stereotyped-based<br />
expectancies: Effects on <strong>in</strong>formation process<strong>in</strong>g and social behavior.<br />
Journal of Social Issues, 46(2), 35-60.<br />
Hamil<strong>to</strong>n, D. L., & Trolier, T. K. (1986). Stereotypes and stereotyp<strong>in</strong>g: An<br />
Overview of the cognitive approach. In J. F. Dovidio & S. L. Gaertner<br />
(Eds.), Prejudice, discrim<strong>in</strong>ation, and racism (pp. 127-163). Orlando, FL:<br />
Academic Press.<br />
Hense, R. L., Penner, L. A., & Nelson, D. L. (1995). <strong>Implicit</strong> memory for age<br />
stereotypes. Social Cognition, 13(4), 339-415.<br />
Hill, P. C., Pargament, K. I., Hood, R. W., McCullough, M. E., Swyers, J. P.,<br />
Larson, D. B., et al. (2000). Conceptualiz<strong>in</strong>g religion and spirituality: Po<strong>in</strong>ts<br />
of commonality, po<strong>in</strong>ts of departure. Journal for the Theory of Social<br />
Behavior, 30, 51-77.<br />
Hillowe, B. V. (1986). Effects of religiosity of therapist and patient on cl<strong>in</strong>ical<br />
judgment (Paper). 94th Annual Convention of the American Psychological<br />
Association, Wash<strong>in</strong>g<strong>to</strong>n D.C.<br />
Hil<strong>to</strong>n, J. L., & Hippel, W. v. (1996). Stereotypes. Annual Review of Psychology,<br />
47, 237-271.<br />
Houts, A. C., & Graham, K. (1986). Can religion make you crazy? Impact of client<br />
and therapist religious values on cl<strong>in</strong>ical judgments. Journal of Consult<strong>in</strong>g<br />
and Cl<strong>in</strong>ical Psychology, 54(2), 267-271.
187<br />
Ickes, W., Marangoni, C., & Garcia, S. (1997). Study<strong>in</strong>g empathic accuracy <strong>in</strong> a<br />
cl<strong>in</strong>ically relevant context. New York: Guilford Press.<br />
Ivey, A. E., Ivey, M. B., & Simek-Morgan, L. (Eds.). (1993). Counsel<strong>in</strong>g and<br />
psychotherapy: A multicultural perspective. Needham Heights, MA: Simon<br />
& Shuster.<br />
Jackson, L. A., & Sullivan, L. A. (2001). Cognition and affect <strong>in</strong> evaluations of<br />
stereotyped group members. The Journal of Social Psychology, 129(5),<br />
659-672.<br />
Jones, S.L. (1994). A constructive relationship for religion with the science and<br />
profession of psychology perhaps the boldest model yet. American<br />
<strong>Psychologist</strong>, 49(3), 184-199<br />
Jussim, L., Manis, M., Nelson, T. E., & Soff<strong>in</strong>, S. (1995). Prejudice, stereotypes,<br />
and label<strong>in</strong>g effects: Sources of bias <strong>in</strong> person perception. Journal of<br />
Personality and Social Psychology, 68(2), 228-246.<br />
Karp<strong>in</strong>ski, A., & Hil<strong>to</strong>n, J. L. (2001). Attitudes and the <strong>Implicit</strong> Association Test.<br />
Journal of Personality and Social Psychology, 81(5), 774-788.<br />
Kelly, T. A. (1990). The role of values <strong>in</strong> psychotherapy: Review and<br />
methodological critique. Cl<strong>in</strong>ical Psychology Review, 10, 171-186.<br />
Kilpatrick, S. D., & McCullough, M. E. (1999). Religion and spirituality <strong>in</strong><br />
rehabilitation psychology. Rehabilitation Psychology, 44(4), 388-402.<br />
Kim, B. S. K., Gladys, F. N., & Ahn, A. J. (2005). Effect of client expectation for<br />
counsel<strong>in</strong>g success, client-counselor worldview match, and client<br />
adherence <strong>to</strong> Asian and European American cultural values on counsel<strong>in</strong>g
188<br />
process with Asian Americans. Journal of Counsel<strong>in</strong>g Psychology, 52(1),<br />
67-76.<br />
Koenig, F.W., & K<strong>in</strong>g, M. B., Jr. (1964). Cognitive simplicity and out-group<br />
stereotypes. Social Forces, 42(3), 324-327.<br />
Koenig, F. W. (1997). Is religion good for your health? The effects of religion on<br />
physical and mental health. New York: Haworth Press.<br />
Korten, F. F. (1973). The stereotype as a cognitive construct. The Journal of<br />
Social Psychology, 90, 29-39.<br />
Lewis-Hall, E., Gorsuch, R., Malony, H. N., Narramore, S. B., & Stewart Van<br />
Leeuwam, M. (2006). Dialogue, embodiment, and the unity of faith and<br />
learn<strong>in</strong>g: A conversation on <strong>in</strong>tegration <strong>in</strong> a postmodern age. Journal of<br />
Psychology and Christianity, 25(4), 331-338.<br />
Lewis, K. N., & Lewis, D. A. (1985). Impact of religious affiliation on therapists'<br />
judgments of patients. Journal of Counsel<strong>in</strong>g and Cl<strong>in</strong>ical Psychology,<br />
53(6), 926-932.<br />
Long, E. L. (1971). Religious beliefs of American scientists. Westport, CT:<br />
Greenwood Press.<br />
Macrae, N. C., Bodenhausen, G. V., Milne, A. B., & Jetten, J. (1994). Out of m<strong>in</strong>d<br />
but back <strong>in</strong> sight: Stereotypes on the rebound. Journal of Personality and<br />
Social Psychology, 67(5), 808-817.<br />
Macrae, N. C., & Milne, A. B. (1994). Stereotypes as energy-sav<strong>in</strong>g devices: A<br />
peek <strong>in</strong>side the cognitive <strong>to</strong>olbox. Journal of Personality and Social<br />
Psychology, 66(1), 37-47.
189<br />
McKenzie-Mohr, D., & Zanna, M. P. (1990). Treat<strong>in</strong>g women as sexual objects:<br />
Look <strong>to</strong> the (gender schematic) male who has viewed pornography.<br />
Merriam-Webster's On L<strong>in</strong>e Dictionary (2003). Retrieved Oc<strong>to</strong>ber 12, 2006, from<br />
http://www.m-w.com/dictionary/culture<br />
Personality and Social Psychology Bullet<strong>in</strong>, 16(2), 296-308.<br />
Murray, E. J. (1956). A content-analysis method for study<strong>in</strong>g psychotherapy.<br />
Psychological Monographs, 70(13).<br />
National Academy of Sciences. (1984). Science and creationism: A view from the<br />
National Academy of Sciences. Wash<strong>in</strong>g<strong>to</strong>n, DC: National Academy Press<br />
NewPort, F. (2004). A look at Americans and religion <strong>to</strong>day. Retrieved March 28,<br />
2006, from<br />
http://speak<strong>in</strong>goffaith.publicradio.org/programs/godsofbus<strong>in</strong>ess/galluppoll.<br />
shtm<br />
Nosek, B. A., Banaji, M. R., & Greenwald, A. G. (2002). Harvest<strong>in</strong>g implicit group<br />
attitudes and beliefs from a demonstration web site. Group Dynamics:<br />
Theory, Research, and Practice, 6(1), 101-115.<br />
Nosek, B. A., Greenwald, A. G., & Banaji, M. R. (2005). Understand<strong>in</strong>g and us<strong>in</strong>g<br />
the <strong>Implicit</strong> Association Test: Method variables and construct validity.<br />
Personality and Social Psychology Bullet<strong>in</strong>, 31(2), 166-180.<br />
O'Connor, S., & Vandenberg, B. (2005). Psychosis or faith? Cl<strong>in</strong>icians'<br />
assessment of religious beliefs. Journal of Consult<strong>in</strong>g and Cl<strong>in</strong>ical<br />
Psychology, 73(4), 610-616.
190<br />
Perdue, C. W., & Gurtman, M. B. (1990). Evidence for the au<strong>to</strong>maticity of<br />
ageism. Journal of Experimental Social Psychology, 26, 199-216.<br />
Plant, E. A., & Dev<strong>in</strong>e, P. G. (1998). Internal and external motivation <strong>to</strong> respond<br />
without prejudice. Journal of Personality and Social Psychology, 75(3),<br />
811-832.<br />
Ragan, C., Malony, H. N., & Beit-Hallahmi, B. (1980). <strong>Psychologist</strong>s and religion:<br />
Professional fac<strong>to</strong>rs and personal belief. Review of Religious Research,<br />
21, 208-127.<br />
Redd<strong>in</strong>g, R. E. (2002). Grappl<strong>in</strong>g with a diverse conception of diversity. American<br />
<strong>Psychologist</strong>, 57(4), 300-301.<br />
Reed, P. R. (1992). <strong>Psychologist</strong>s' views of a patient's religiousness.<br />
Psychological Reports, 70, 1031-1036.<br />
Reynolds, W. M. (1982). Development of reliable and valid short forms of the<br />
Marlowe-Crowne Social Desirability Scale. Journal of Cl<strong>in</strong>ical Psychology,<br />
38(1), 119-125.<br />
Richards, S. P., & Berg<strong>in</strong>, A. (2000). Handbook of psychotherapy and religious<br />
diversity. Wash<strong>in</strong>g<strong>to</strong>n, DC: American Psychological Association.<br />
Rippentrop, A. E. (2005). A review of the role of religion and spirituality <strong>in</strong> chronic<br />
pa<strong>in</strong> populations. Rehabilitation Psychology, 50(3), 278-284.<br />
Rogers, C. (1957). The necessary and sufficient conditions of therapeutic<br />
personality change. Journal of Consult<strong>in</strong>g Psychology, 21, 95-103.
191<br />
Rosenbaum, M. E. (1986). The repulsion hypothesis: On the nondevelopment of<br />
relationships. Journal of Personality and Social Psychology, 51(6), 1156-<br />
1166.<br />
Rudman, L. A., Greenwald, A. G., Mellott, D. S., & Schwartz, J. L. K. (1999).<br />
Measur<strong>in</strong>g the au<strong>to</strong>matic components of prejudice: Flexibility and<br />
generality of the <strong>Implicit</strong> Association Test. Social Cognition, 17(4), 437-<br />
465.<br />
Sears, G. J., & Rowe, P. M. (2003). A personality-based similar-<strong>to</strong>-me effect <strong>in</strong><br />
the employment <strong>in</strong>terview: Conscientiousness, affect versus competencemediated<br />
<strong>in</strong>terpretations, and the role of job relevance. Canadian Journal<br />
of Behavioural Science, 35(1), 13-24.<br />
Sekaquaptewa, D., Esp<strong>in</strong>oza, P., Thompson, M., Vargas, P., & von Hippel, W.<br />
(2003). Stereotypic explana<strong>to</strong>ry bias: <strong>Implicit</strong> stereotyp<strong>in</strong>g as a predic<strong>to</strong>r of<br />
discrim<strong>in</strong>ation. Journal of Experimental Social Psychology, 39, 75-82.<br />
Seyle, D. C., & Newman, M. L. (2006). A house divided?: The psychology of Red<br />
and Blue America. American <strong>Psychologist</strong>, 61(6), 571-580.<br />
Shafranske, E. D. (1996). Religion and the cl<strong>in</strong>ical practice of psychology.<br />
Wash<strong>in</strong>g<strong>to</strong>n, DC: American Psychological Association.<br />
Shafranske, E. P. (1990). Cl<strong>in</strong>ical psychologists' religious and spiritual<br />
orientations and their practice of psychotherapy. Psychotherapy, 27, 72-<br />
78.
192<br />
Shafranske, E. P. (2000). Religious <strong>in</strong>volvement and professional practices of<br />
psychiatrists and other mental health professionals. Psychiatric Annals,<br />
30(8), 525-532.<br />
Sarason, S. (1993). American psychology, and the needs for transcendence and<br />
community. American Journal of Community Psychology, 21(2).<br />
Sherman, J. (2005). Au<strong>to</strong>matic and controlled components of implicit<br />
stereotyp<strong>in</strong>g and prejudice. APA Onl<strong>in</strong>e Psychological Science Agenda<br />
19, 3. Retrieved March 18, 2005, from http://www.apa.org/science/psa/sbshermanprt.html<br />
Sherman, J. W., Conrey, F. R., Stroessner, S. J., & Azam, O. A. (2005).<br />
Prejudice and stereotype ma<strong>in</strong>tenance processes: Attention, attribution,<br />
and <strong>in</strong>dividuation. Journal of Personality and Social Psychology, 89(4),<br />
607-622.<br />
Sherman, S. J., Mackie, D. M., & Driscoll, D. M. (1990). Prim<strong>in</strong>g and the<br />
differential use of dimensions <strong>in</strong> evaluation. Personality and Social<br />
Psychology Bullet<strong>in</strong>, 16(3), 405-418.<br />
S<strong>in</strong>clair, L., & Kunda, Z. (1999). Reactions <strong>to</strong> a Black professional: Motivated<br />
<strong>in</strong>hibition and activation of conflict<strong>in</strong>g stereotypes. Journal of Personality<br />
and Social Psychology, 77(5), 885-904.<br />
Smith, T. B., McCullough, M. E., & Poll, J. (2003). Religiousness and depression:<br />
Evidence for a ma<strong>in</strong> effect and the moderat<strong>in</strong>g <strong>in</strong>fluence of stressful life<br />
events. Psychological Bullet<strong>in</strong>, 129(4), 614-636.
193<br />
Tabachnick, B.G., & Fidel, L.S. (1996). Us<strong>in</strong>g multivariate statistics. New York:<br />
Harper Coll<strong>in</strong>s.<br />
Tajfel, H., & Turner, J. C. (1979). An <strong>in</strong>tegrative theory of <strong>in</strong>tergroup conflict. In<br />
W. G. Aust<strong>in</strong> & S. Worchel (Eds.), The social psychology of <strong>in</strong>tergroup<br />
relations (pp. 33-47). Monterey, CA: Brooks Cole.<br />
Taylor, S.E. & Lobel, M. (1989). Social comparison activity under threat:<br />
Downward evaluation and upward contacts. Psychological Review, 96(4),<br />
569-575.<br />
Truax, C. B. (1966). Re<strong>in</strong>forcement and nonre<strong>in</strong>forcement <strong>in</strong> Rogerian<br />
psychotherapy. Journal of Abnormal Psychology, 71, 1-9.<br />
V<strong>in</strong>ey, W., & K<strong>in</strong>g, D. B. (1998). A his<strong>to</strong>ry of psychology: Ideas and content (2nd<br />
ed.). Bos<strong>to</strong>n: Allyn & Bacon.<br />
Wadsworth, R. D., & Checketts, K. T. (1980). Influence of religious affiliation on<br />
psychodiagnosis. Journal of Consult<strong>in</strong>g and Cl<strong>in</strong>ical Psychology, 48, 234-<br />
240.<br />
Wallis, J. (2005). God's politics: Why the right gets it wrong and the left doesn't<br />
get it. San Francisco: Harper Coll<strong>in</strong>s.<br />
Watters, W. W. (1992). Deadly doctr<strong>in</strong>e: Health, illness, and Christian God talk.<br />
Buffalo, NY: Prometheus Books.<br />
Wester, S. R., & Vogel, D. L. (2002). The emperor's new clothes: Sociopolitical<br />
diversity <strong>in</strong> psychology. American <strong>Psychologist</strong>, 57(4), 295.
194<br />
Worth<strong>in</strong>g<strong>to</strong>n, E. L. (1988). Understand<strong>in</strong>g the values of religious clients: A model<br />
and its application <strong>to</strong> counsel<strong>in</strong>g. Journal of Counsel<strong>in</strong>g Psychology, 35(2),<br />
166-174.<br />
Worth<strong>in</strong>g<strong>to</strong>n, E. L. (1996). Empirical research on religion and psychotherapeutic<br />
processes and outcomes: A 10-year review and research prospectus.<br />
Psychological Bullet<strong>in</strong>, 119(3), 448-487.<br />
Worth<strong>in</strong>g<strong>to</strong>n, R., Mobley, M., Franks, R. P., & Andreas Tan, J. (2000).<br />
Multicultural counsel<strong>in</strong>g competencies: Verbal content, counselor<br />
attributions, and social desirability. Journal of Counsel<strong>in</strong>g Psychology,<br />
47(4), 460-468.<br />
Yangarber-Hicks, N., Behenskyh, C., Cann<strong>in</strong>g, S., Flanagan, K., Gibson, N.,<br />
Hicks, M., Kimball, C., Pak, J., Plante, T. ,Porter, S. (2006). Invitation <strong>to</strong><br />
the table conversation: A few diverse perspectives on <strong>in</strong>tegration. Journal<br />
of Psychology and Christianity, 25(4), 338-353<br />
Yarhouse, M. A., & Fisher, W. (2002). Levels of tra<strong>in</strong><strong>in</strong>g <strong>to</strong> address religion <strong>in</strong><br />
cl<strong>in</strong>ical practice. Psychotherapy: Theory, Research, Practice, Tra<strong>in</strong><strong>in</strong>g,<br />
39(2), 171-176.<br />
Yzerbyt, V. Y., & Coull, A. (1999). Fenc<strong>in</strong>g off the deviant: The role of cognitive<br />
resources <strong>in</strong> the ma<strong>in</strong>tenance of stereotypes. Journal of Personality and<br />
Social Psychology, 77(3), 449-462.<br />
Zajonc, R. B. (1968). Attitud<strong>in</strong>al effects of mere exposure. Journal of Personality<br />
and Social Psychology, 9(2), 1-27
195<br />
Appendix A:<br />
Materials Provided <strong>to</strong> Participants<br />
Invitation <strong>to</strong> Participate <strong>in</strong> Research Study<br />
Dear Licensed <strong>Psychologist</strong>,<br />
I am writ<strong>in</strong>g <strong>to</strong> request your participation <strong>in</strong> an onl<strong>in</strong>e research study. This study<br />
exam<strong>in</strong>es fac<strong>to</strong>rs and processes associated with cl<strong>in</strong>ical judgment which <strong>in</strong>cludes<br />
a unique measure that I hope you enjoy. This research is <strong>in</strong>tended <strong>to</strong> complete<br />
my requirements for the doc<strong>to</strong>ral dissertation at the Anonymous University <strong>in</strong><br />
fulfillment of the PhD <strong>in</strong> Cl<strong>in</strong>ical Psychology under the supervision of Anonymous,<br />
Ph.D. The requirement for participants is that they must be licensed<br />
psychologists. Please note that unfortunately this study is not MAC compatible at<br />
this time.<br />
I understand that your time is valuable, and as such, your participation is greatly<br />
appreciated. At the study’s end, there will be an opportunity <strong>to</strong> enter two<br />
draw<strong>in</strong>gs, one each for $100 and $50 prizes of either a contribution <strong>in</strong> your name<br />
<strong>to</strong> the American Red Cross’s Hurricane Recovery Program that serves victims<br />
affected by Hurricanes Katr<strong>in</strong>a, Rita and Wilma, or a cash prize <strong>in</strong> either amount.<br />
The anticipated length of time <strong>to</strong> take this study is approximately 25 m<strong>in</strong>utes.<br />
Aga<strong>in</strong>, as data collected <strong>in</strong> this study is part of my doc<strong>to</strong>ral dissertation, your time<br />
and effort is most s<strong>in</strong>cerely appreciated.<br />
I hope you f<strong>in</strong>d the study <strong>in</strong>terest<strong>in</strong>g!<br />
Here is the l<strong>in</strong>k <strong>to</strong> the <strong>in</strong>formed consent and the survey:<br />
S<strong>in</strong>cerely,<br />
Anonymous
196<br />
Informed Consent Form<br />
Please note that this study is not MAC compatible<br />
Fac<strong>to</strong>rs Associated with <strong>Psychologist</strong>s’ Cl<strong>in</strong>ical Judgment<br />
You have been asked <strong>to</strong> participate <strong>in</strong> a dissertation research study conducted<br />
by Anonymous, a doc<strong>to</strong>ral student <strong>in</strong> the School of Cl<strong>in</strong>ical Psychology at<br />
Anonymous. Participation <strong>in</strong> this research is voluntary. As such, the results of this<br />
research will be published <strong>in</strong> Anonymous’s doc<strong>to</strong>ral dissertation and possibly <strong>in</strong><br />
journals, books, or presentations. It <strong>in</strong>volves the exam<strong>in</strong>ation of various fac<strong>to</strong>rs<br />
that relate <strong>to</strong> psychologists’ cl<strong>in</strong>ical judgment and is expected <strong>to</strong> contribute <strong>to</strong><br />
psychology by provid<strong>in</strong>g a more thorough understand<strong>in</strong>g of how those fac<strong>to</strong>rs<br />
affect cl<strong>in</strong>ical practice, and essentially <strong>in</strong>crease patient retention and maximize<br />
outcomes.<br />
This study <strong>in</strong>volves several survey <strong>in</strong>struments. You will be directed <strong>to</strong> a page<br />
that will request that you download a program that is necessary <strong>to</strong> accept and<br />
s<strong>to</strong>re your responses, which will then be transmitted <strong>to</strong> the website host for data<br />
analysis at the conclusion of your participation. Please note the specific security<br />
measures that will be taken <strong>to</strong> ensure that your <strong>in</strong>formation is protected and that<br />
the downloaded program is used solely for data collection purposes, found later<br />
<strong>in</strong> this consent form. You will first be asked <strong>to</strong> read and respond <strong>to</strong> questions<br />
about two cl<strong>in</strong>ical vignettes. Several other brief <strong>in</strong>struments will follow, <strong>in</strong> which<br />
you will be asked <strong>to</strong> respond <strong>to</strong> items that measure various attitudes that may<br />
play a role <strong>in</strong> explicit processes utilized <strong>in</strong> mak<strong>in</strong>g cl<strong>in</strong>ical judgments. Last, you<br />
will be asked <strong>to</strong> complete a timed measure that assesses implicit processes also<br />
believed <strong>to</strong> be a contribut<strong>in</strong>g fac<strong>to</strong>r <strong>in</strong> mak<strong>in</strong>g cl<strong>in</strong>ical judgments.<br />
With the understand<strong>in</strong>g that your time is valuable, a draw<strong>in</strong>g will be held at the<br />
study’s end for the chance <strong>to</strong> w<strong>in</strong> one of two prizes; either a $100 or $50<br />
donation <strong>in</strong> your name <strong>to</strong> either the American Red Cross’s Hurricane Recovery<br />
Program that serves victims affected by Hurricanes Katr<strong>in</strong>a, Rita and Wilma and<br />
others, the charitable organization of your choice, or the option of cash <strong>in</strong> those<br />
amounts. Participation <strong>in</strong> this study is expected <strong>to</strong> take approximately 25<br />
m<strong>in</strong>utes.<br />
Your responses <strong>in</strong> this study are kept anonymous and <strong>in</strong>formation gathered is<br />
used solely for the purposes of this research. Data is transmitted <strong>to</strong> the host<br />
server us<strong>in</strong>g SSL, which is standard data encryption technology for secure data<br />
transmission on the web. You will not be asked <strong>to</strong> provide any identify<strong>in</strong>g data,<br />
unless you choose <strong>to</strong> enter the draw<strong>in</strong>g at the study’s end. Personally identify<strong>in</strong>g
197<br />
data entered <strong>in</strong><strong>to</strong> the draw<strong>in</strong>gs will be separated from the study response data,<br />
prior <strong>to</strong> any review or analysis and discarded immediately follow<strong>in</strong>g the<br />
conclusion of the draw<strong>in</strong>g. All data will be accessible <strong>to</strong> only the researcher and<br />
her committee, and a research assistant who has signed a Confidential<br />
Assistance Agreement.<br />
There are no known or suspected risks associated with participation <strong>in</strong> this study.<br />
However, should you f<strong>in</strong>d anyth<strong>in</strong>g disturb<strong>in</strong>g about the study, please feel free <strong>to</strong><br />
exit it at any time. Only data from completed studies will be saved, and if you<br />
choose <strong>to</strong> exit or refuse participation <strong>in</strong> the study you may do so without penalty.<br />
If you would like a summary of the results of this study, or if you have any<br />
questions about this research, please feel free <strong>to</strong> email Anonymous at<br />
Anonymous or call (818) 634-9022. An electronic summary of results can be<br />
emailed <strong>to</strong> you at the conclusion of the study at your request. For questions, you<br />
may also contact the dissertation committee’s chair, Anonymous, PhD., at<br />
Anonymous University.<br />
The Institutional Review Board at Anonymous reta<strong>in</strong>s access <strong>to</strong> signed consent<br />
forms. As this is an onl<strong>in</strong>e study, click<strong>in</strong>g the SUBMIT but<strong>to</strong>n below serves as<br />
your electronic signature on your agreement <strong>to</strong> the <strong>in</strong>formed consent terms. You<br />
may pr<strong>in</strong>t and keep a copy of this agreement for your records. Please click the<br />
SUBMIT but<strong>to</strong>n <strong>to</strong> signify your <strong>in</strong>formed consent and <strong>to</strong> be taken <strong>to</strong> the study.
198<br />
Introduction <strong>to</strong> Vignettes<br />
It is unders<strong>to</strong>od that some of the <strong>in</strong>formation presented <strong>in</strong> vignette studies is<br />
ambiguous, and <strong>in</strong>formation required for carefully considered cl<strong>in</strong>ical judgment is<br />
lack<strong>in</strong>g. Due <strong>to</strong> the fact that this study requires the use of brief vignettes, it is<br />
acceptable and expected that you project a hypothesis about each patient based on<br />
any and all pieces of <strong>in</strong>formation given, ambiguous or otherwise. Please read the two<br />
follow<strong>in</strong>g vignettes. Follow<strong>in</strong>g each, you will be asked <strong>to</strong> make some cl<strong>in</strong>ical<br />
judgments based on the <strong>in</strong>formation given.
199<br />
Condition I: Vignette #1<br />
Mr. Dean, a 35 year old married Caucasian male, presents <strong>to</strong> treatment with multiple<br />
symp<strong>to</strong>ms. He reports that he suffers from dizz<strong>in</strong>ess, sweaty palms, and tension <strong>in</strong><br />
his chest. He often feels edgy and irritable, and he has been hav<strong>in</strong>g difficulty focus<strong>in</strong>g<br />
at work, where he is a sales manager at a local telecommunications company. He<br />
notices that he often has worrisome thoughts that are <strong>in</strong>trusive and distract<strong>in</strong>g and he<br />
has left work on several occasions when they have become <strong>in</strong><strong>to</strong>lerable.<br />
Mr. Dean formerly spent some time socializ<strong>in</strong>g with coworkers on occasional<br />
weekends, enterta<strong>in</strong><strong>in</strong>g at his home or watch<strong>in</strong>g sports events with them. He also<br />
states that he is an Evangelical Christian who was an active member of the<br />
Evangelical Free Church until the last year and a half. He was also politically active <strong>in</strong><br />
advocat<strong>in</strong>g for causes related <strong>to</strong> his faith and derived satisfaction from participat<strong>in</strong>g <strong>in</strong><br />
activities that he believed represented his faith and God’s will. He compla<strong>in</strong>s that he<br />
misses social activities with coworkers and religious and political activities. While he<br />
is still capable of enjoy<strong>in</strong>g these activities, he has often had <strong>to</strong> leave events when his<br />
symp<strong>to</strong>ms became “<strong>in</strong><strong>to</strong>lerable”. He has s<strong>in</strong>ce reduced his out<strong>in</strong>gs significantly.<br />
He has fears of fail<strong>in</strong>g <strong>in</strong> his job despite hav<strong>in</strong>g a his<strong>to</strong>ry of reasonable career<br />
success, fears that his wife will leave him, although there is no evidence that she is<br />
unhappy, and fears that he is fall<strong>in</strong>g short of the expectations of his faith, though he<br />
cannot po<strong>in</strong>t <strong>to</strong> evidence that supports these fears. Recently he has become<br />
discouraged about this cont<strong>in</strong>ued pattern and feels that his worry is out of control. He<br />
states that when he returns home at the end of the day, he is irritable and tired but<br />
feels he must appear “normal” <strong>to</strong> his wife and children. He expresses concerns that<br />
he needs <strong>to</strong> be seen as “perfect”.<br />
Hav<strong>in</strong>g consulted with physicians on several occasions regard<strong>in</strong>g dizz<strong>in</strong>ess, sweaty<br />
palms, and muscle tension, Mr. Dean understands that there are no medical causes<br />
for his symp<strong>to</strong>ms. He has no therapy experience <strong>in</strong> his past, and is attend<strong>in</strong>g at the<br />
urg<strong>in</strong>g of a coworker, who has some knowledge of Mr. Dean’s experiences.
200<br />
Condition I: Vignette II<br />
Mr. Bowery is a 32 year old divorced Caucasian man who comes <strong>to</strong> therapy with<br />
several compla<strong>in</strong>ts. Mr. Bowery reports that worries frequently, and that he his worry<br />
has <strong>in</strong>creased <strong>in</strong> the last year. He states that at times he also has <strong>in</strong>creased heart<br />
rate, feels lightheaded, and that his hands shake. He wakens <strong>in</strong> the early morn<strong>in</strong>g<br />
hours, feel<strong>in</strong>g agitated and unable <strong>to</strong> sleep. He is tired dur<strong>in</strong>g the day and f<strong>in</strong>ds it<br />
difficult <strong>to</strong> make decisions at work, where he is a junior architect <strong>in</strong> a successful<br />
company. His<strong>to</strong>rically, his work performance has been marked by achievement and<br />
recognition, however he worries that he will be unable <strong>to</strong> ma<strong>in</strong>ta<strong>in</strong> that success and<br />
move ahead <strong>in</strong> his career. He has recently also become afraid that others will notice<br />
his symp<strong>to</strong>ms or that they will beg<strong>in</strong> <strong>to</strong> effect his work. As Mr. Bowery’s career<br />
advancement is a primary focus of his life, he is considerably distressed by his fears<br />
of failure.<br />
Mr. Bowery has enjoyed an active social life, hav<strong>in</strong>g a circle of good friends with<br />
whom he has enjoyed ski<strong>in</strong>g, snowboard<strong>in</strong>g and other activities. He has been<br />
married once and was divorced when 27 years old. He reports that he has had two<br />
mean<strong>in</strong>gful relationships with women <strong>in</strong> the past 5 years and that someday he would<br />
like <strong>to</strong> be married aga<strong>in</strong>. He reports that he worries that he will not “f<strong>in</strong>d the right one”<br />
and may not marry aga<strong>in</strong>. Mr. Bowery states that he formerly found it reward<strong>in</strong>g <strong>to</strong><br />
volunteer his time as a men<strong>to</strong>r <strong>to</strong> boys <strong>in</strong> a local boys’ foster home. He had also<br />
developed friendships there with other men<strong>to</strong>rs and felt as though his volunteer<br />
activities imparted some special purpose <strong>in</strong> his life. Mr. Bowery reports be<strong>in</strong>g able <strong>to</strong><br />
enjoy these activities still, except that lately his symp<strong>to</strong>ms have left him feel<strong>in</strong>g<br />
fatigued and he has been “unable <strong>to</strong> keep up” with social and volunteer activities<br />
alike. Mr. Bowery also reports that although he used <strong>to</strong> be excited about his work and<br />
his career path, often work<strong>in</strong>g overtime on important projects, he is spend<strong>in</strong>g less<br />
and less time at work.<br />
Mr. Bowery has been cleared of any medical diagnosis that may be contribut<strong>in</strong>g <strong>to</strong><br />
his symp<strong>to</strong>ms. He has been feel<strong>in</strong>g down lately as his symp<strong>to</strong>ms cont<strong>in</strong>ue and is<br />
seek<strong>in</strong>g assistance <strong>in</strong> therapy on the advice of a men<strong>to</strong>r at the boy’s home.
201<br />
Condition II: Vignette I<br />
Mr. Dean, a 35 year old married Caucasian male, presents <strong>to</strong> treatment with multiple<br />
symp<strong>to</strong>ms. He reports that he suffers from dizz<strong>in</strong>ess, sweaty palms, and tension <strong>in</strong><br />
his chest. He often feels edgy and irritable, and he has been hav<strong>in</strong>g difficulty focus<strong>in</strong>g<br />
at work, where he is a sales manager at a local telecommunications company. He<br />
notices that he often has worrisome thoughts that are <strong>in</strong>trusive and distract<strong>in</strong>g and he<br />
has left work on several occasions when they have become <strong>in</strong><strong>to</strong>lerable.<br />
Mr. Dean formerly spent some time socializ<strong>in</strong>g with coworkers on occasional<br />
weekends, enterta<strong>in</strong><strong>in</strong>g at his home or watch<strong>in</strong>g sports events with them. Mr. Dean<br />
states that he formerly found it reward<strong>in</strong>g <strong>to</strong> volunteer his time as a men<strong>to</strong>r <strong>to</strong> boys <strong>in</strong><br />
a local boys’ foster home. He had also developed friendships there with other<br />
men<strong>to</strong>rs and felt as though his volunteer activities imparted some special purpose <strong>in</strong><br />
his life. Mr. Dean reports that he would like <strong>to</strong> participate <strong>in</strong> these activities still,<br />
except that lately his worry and other symp<strong>to</strong>ms have left him feel<strong>in</strong>g fatigued and he<br />
has been “unable <strong>to</strong> keep up” with social and volunteer activities alike. While he is<br />
still capable of enjoy<strong>in</strong>g these activities, he has often had <strong>to</strong> leave events when his<br />
symp<strong>to</strong>ms became “<strong>in</strong><strong>to</strong>lerable”. He has s<strong>in</strong>ce reduced his out<strong>in</strong>gs significantly.<br />
He has fears of fail<strong>in</strong>g <strong>in</strong> his job despite hav<strong>in</strong>g a his<strong>to</strong>ry of reasonable career<br />
success, fears that his wife will leave him although there is no evidence that she is<br />
unhappy, and fears that he is fall<strong>in</strong>g short of the expectations of his faith, though he<br />
cannot po<strong>in</strong>t <strong>to</strong> evidence that supports those fears. Recently he has become<br />
discouraged about this cont<strong>in</strong>ued pattern and feels that his worry is out of control. He<br />
states that when he returns home at the end of the day, he is irritable and tired but<br />
feels he must appear “normal” <strong>to</strong> his wife and children. He expresses concerns that<br />
he needs <strong>to</strong> be seen as “perfect”.<br />
Hav<strong>in</strong>g consulted with physicians on several occasions regard<strong>in</strong>g dizz<strong>in</strong>ess, sweaty<br />
palms, and muscle tension, Mr. Dean understands that there are no medical causes<br />
for his symp<strong>to</strong>ms. He has no therapy experience <strong>in</strong> his past, and is attend<strong>in</strong>g on the<br />
advice of a men<strong>to</strong>r at the boy’s home, who has some knowledge of Mr. Dean’s<br />
experiences.
202<br />
Condition II: Vignette II<br />
Mr. Bowery is a 32 year old divorced Caucasian man who comes <strong>to</strong> therapy with<br />
several compla<strong>in</strong>ts. Mr. Bowery reports that he worries frequently, and that he his<br />
worry has <strong>in</strong>creased <strong>in</strong> the last year. He states that at times he also has <strong>in</strong>creased<br />
heart rate, feels lightheaded, and that his hands shake. He wakens <strong>in</strong> the early<br />
morn<strong>in</strong>g hours, feel<strong>in</strong>g agitated and unable <strong>to</strong> sleep. He is tired dur<strong>in</strong>g the day and<br />
f<strong>in</strong>ds it difficult <strong>to</strong> make decisions at work, where he is a junior architect <strong>in</strong> a<br />
successful company. His<strong>to</strong>rically, his work performance has been marked by<br />
achievement and recognition, however he worries that he will be unable <strong>to</strong> ma<strong>in</strong>ta<strong>in</strong><br />
that success and move ahead <strong>in</strong> his career. He has recently also become afraid that<br />
others will notice his symp<strong>to</strong>ms or that they will beg<strong>in</strong> <strong>to</strong> effect his work. As Mr.<br />
Bowery’s career advancement is a primary focus of his life, he is considerably<br />
distressed by his unfounded fears of failure.<br />
Mr. Bowery has enjoyed an active social life, hav<strong>in</strong>g a circle of good friends with<br />
whom he has enjoyed ski<strong>in</strong>g, snowboard<strong>in</strong>g and other activities. He has been<br />
married once and was divorced when 27 years old. He reports that he has had two<br />
mean<strong>in</strong>gful relationships with women <strong>in</strong> the past 5 years and that someday he would<br />
like <strong>to</strong> be married aga<strong>in</strong>. He reports that he worries that he will not “f<strong>in</strong>d the right one”<br />
and may not marry aga<strong>in</strong>. He also states that he is an Evangelical Christian who was<br />
an active member of the Evangelical Free Church until the last year and a half. He<br />
was also politically active <strong>in</strong> advocat<strong>in</strong>g for causes related <strong>to</strong> his faith and derived<br />
satisfaction from participat<strong>in</strong>g <strong>in</strong> activities that he believed represented his faith and<br />
God’s will. He compla<strong>in</strong>s that he misses social activities with friends and religious and<br />
political activities. Mr. Bowery also reports that although he used <strong>to</strong> be excited about<br />
his work and his career path, often work<strong>in</strong>g overtime on important projects, he is<br />
spend<strong>in</strong>g less and less time at work. He stated that he has left work or volunteer or<br />
social activities due <strong>to</strong> his symp<strong>to</strong>ms.<br />
Mr. Bowery has been cleared of any medical diagnosis that may be contribut<strong>in</strong>g <strong>to</strong><br />
his symp<strong>to</strong>ms. He has been feel<strong>in</strong>g down lately as his symp<strong>to</strong>ms cont<strong>in</strong>ue and is<br />
seek<strong>in</strong>g assistance <strong>in</strong> therapy at the urg<strong>in</strong>g of a coworker.
203<br />
Measures<br />
Empathy<br />
Affective Empathy: Batson’s empathy adjectives<br />
Please <strong>in</strong>dicate on a 7-po<strong>in</strong>t scale from 1 (not at all) – 7 (extremely) how strongly you<br />
feel each emotion when th<strong>in</strong>k<strong>in</strong>g about this patient.<br />
1.) sympathetic 1 2 3 4 5 6 7<br />
2.) moved 1 2 3 4 5 6 7<br />
3.) compassionate 1 2 3 4 5 6 7<br />
4.) tender 1 2 3 4 5 6 7<br />
5.) warm 1 2 3 4 5 6 7<br />
6.) softhearted 1 2 3 4 5 6 7<br />
Cognitive Empathy: The Perspective Tak<strong>in</strong>g Scale of the Interpersonal Reactivity<br />
Index<br />
Please <strong>in</strong>dicate the degree <strong>to</strong> which the items below describe your response <strong>to</strong> this<br />
patient on a five-po<strong>in</strong>t scale runn<strong>in</strong>g from 0 (does not describe me well) <strong>to</strong> 4<br />
(describes me very well).<br />
1. I have a hard time see<strong>in</strong>g th<strong>in</strong>gs from this patient’s po<strong>in</strong>t of view. 0 1 2 3 4<br />
2. I am able <strong>to</strong> look at this patient’s side of th<strong>in</strong>gs when mak<strong>in</strong>g judgments. 0 1 2<br />
3 4<br />
3. I am able <strong>to</strong> understand this patient better by imag<strong>in</strong>g how th<strong>in</strong>gs look from his<br />
perspective. 0 1 2 3 4<br />
4. Before mak<strong>in</strong>g a judgment about this patient, I imag<strong>in</strong>e how it would feel <strong>to</strong> be<br />
<strong>in</strong> his place. 0 1 2 3 4
204<br />
Prognosis<br />
Please rate the patient on each of the follow<strong>in</strong>g items:<br />
1.) Appropriateness for therapy. 0 (least appropriate) – 4 (most appropriate) 0 1 2<br />
3 4<br />
2.) Selection for your caseload. 0 (least likely <strong>to</strong> select) – 4 (most likely <strong>to</strong> select)<br />
0 1 2 3 4<br />
3.) Severity of impairment. 0 (most severely impaired) – 4 (least severely<br />
impaired)* 0 1 2 3 4<br />
4.) Motivation for change. 0 (least motivated) – 4 (most motivated) 0 1 2<br />
3 4<br />
5.) Capacity for <strong>in</strong>sight. 0 (least capacity for <strong>in</strong>sight) – 4 (most capacity for<br />
<strong>in</strong>sight) 0 1 2 3 4<br />
6.) Likelihood of mak<strong>in</strong>g substantial progress. 0 (least likelihood) – 4 (most likelihood<br />
for mak<strong>in</strong>g substantial progress) 0 1 2 3 4<br />
7.) Number of therapy sessions required for this patient <strong>to</strong> make substantial progress.<br />
0.) 1-5 1.) 6-10 2.) 11-15 3.) 16-20 4.) 21+ *<br />
8.) Number of sessions you expect this patient will attend therapy<br />
0.) 1-5 1.) 6-10 2.) 11-15 3.) 16-20 4.) 21+<br />
*Reverse coded
205<br />
Motivation <strong>to</strong> Control Prejudiced Reactions<br />
Please <strong>in</strong>dicate the degree <strong>to</strong> which you agree or disagree with the follow<strong>in</strong>g<br />
statements on a scale rang<strong>in</strong>g from -3 (strongly disagree) <strong>to</strong> +3 (strongly agree)<br />
1. In <strong>to</strong>day’s society it is important that one not be perceived as prejudiced <strong>in</strong> any<br />
manner. -3, -2, -1, 0, +1, +2, +3<br />
2. I always express my thoughts and feel<strong>in</strong>gs, regardless of how controversial<br />
they might be. R* -3, -2, -1, 0, +1, +2, +3<br />
3. I get angry with myself when I have a thought or feel<strong>in</strong>g that might be<br />
considered prejudiced. -3, -2, -1, 0, +1, +2, +3<br />
4. If I were participat<strong>in</strong>g <strong>in</strong> a class discussion and a person of another religion<br />
expressed an op<strong>in</strong>ion with which I disagreed, I would be hesitant <strong>to</strong> express<br />
my viewpo<strong>in</strong>t.<br />
-3, -2, -1, 0, +1, +2, +3<br />
5. Go<strong>in</strong>g through life worry<strong>in</strong>g about whether you might offend someone is just<br />
more trouble than it’s worth. R<br />
-3, -2, -1, 0, +1, +2, +3<br />
6. It’s important <strong>to</strong> me that other people th<strong>in</strong>k I’m not prejudiced.<br />
-3, -2, -1, 0, +1, +2, +3<br />
7. I feel it’s important <strong>to</strong> behave accord<strong>in</strong>g <strong>to</strong> society’s standards.<br />
-3, -2, -1, 0, +1, +2, +3<br />
8. I’m careful not <strong>to</strong> offend my friends, but I don’t worry about offend<strong>in</strong>g people I<br />
don’t know or don’t like. R<br />
-3, -2, -1, 0, +1, +2, +3<br />
9. I th<strong>in</strong>k it’s important <strong>to</strong> speak one’s m<strong>in</strong>d rather than worry about offend<strong>in</strong>g<br />
someone. R<br />
-3, -2, -1, 0, +1, +2, +3<br />
10. It’s never acceptable <strong>to</strong> express one’s prejudices.<br />
-3, -2, -1, 0, +1, +2, +3<br />
11. I feel guilty when I have a negative thought or feel<strong>in</strong>g about a person of<br />
another religion person.<br />
-3, -2, -1, 0, +1, +2, +3
12. When speak<strong>in</strong>g <strong>to</strong> a person of another religion, it’s important <strong>to</strong> me that he/she<br />
not th<strong>in</strong>k I’m prejudiced.<br />
-3, -2, -1, 0, +1, +2, +3<br />
13. It bothers me a great deal when I th<strong>in</strong>k I’ve offended someone, so I’m always<br />
careful <strong>to</strong> consider other people’s feel<strong>in</strong>gs.<br />
-3, -2, -1, 0, +1, +2, +3<br />
14. If I have a prejudiced thought or feel<strong>in</strong>g, I keep it <strong>to</strong> myself.<br />
-3, -2, -1, 0, +1, +2, +3<br />
15. I would never tell jokes that might offend others.<br />
-3, -2, -1, 0, +1, +2, +3<br />
16. I’m not afraid <strong>to</strong> tell others what I th<strong>in</strong>k, even when I know they disagree with<br />
me. R<br />
-3, -2, -1, 0, +1, +2, +3<br />
*Reverse coded<br />
206
207<br />
Social Desirability: Marlowe Crowne- Form C<br />
Please read and respond <strong>to</strong> each statement as either true (T) or false (F) about your<br />
own behavior, feel<strong>in</strong>gs, or attitude<br />
1. It is sometimes hard for me <strong>to</strong> go on with my work if I am not encouraged. T F<br />
2. I sometimes feel resentful when I don’t get my way. T F<br />
3. On a few occasions, I have given up do<strong>in</strong>g someth<strong>in</strong>g because I thought <strong>to</strong>o<br />
little of my ability. T F<br />
4. There have been times when I felt like rebell<strong>in</strong>g aga<strong>in</strong>st people <strong>in</strong> authority<br />
even though I knew they were right. T F<br />
5. No matter who I’m talk<strong>in</strong>g <strong>to</strong>o, I’m always a good listener.* T F<br />
6. There have been occasions when I <strong>to</strong>ok advantage of someone. T F<br />
7. I’m always will<strong>in</strong>g <strong>to</strong> admit it when I make a mistake.* T F<br />
8. I sometimes try <strong>to</strong> <strong>to</strong> get even rather than forgive and forget. T F<br />
9. I am always courteous, even <strong>to</strong> people who are disagreeable.* T F<br />
10. I have never been irked when people expressed ideas very different from my<br />
own.* T F<br />
11. There have been times when I was quite jealous of the good fortunes of<br />
others. T F<br />
12. I am sometimes irritated by people who ask favors of me. T F<br />
13. I have never deliberately said someth<strong>in</strong>g that hurt someone’s feel<strong>in</strong>gs.* T F<br />
*Reverse coded
208<br />
Religious Attitude Scale<br />
Select and check for each item the one descriptive phrase that would best describe<br />
your attitude. (Scores are <strong>in</strong>dicated <strong>in</strong> parentheses such that 0 = liberal, 1=<br />
conservative, and 2 = orthodox positions)<br />
1. God<br />
a.) spiritual, guid<strong>in</strong>g force (1)<br />
b.) All-powerful crea<strong>to</strong>r of the universe (2)<br />
c.) Man-made explanation of the unknown (0)<br />
2. Jesus<br />
a.) wise prophet and successful crusader (0)<br />
b.) God manifest <strong>in</strong> man (1)<br />
c.) Son of God (2)<br />
3. Holy Ghost<br />
a.) third person of the Blessed Tr<strong>in</strong>ity (2)<br />
b.) God revealed <strong>in</strong> spiritual form (1)<br />
c.) Supposedly a div<strong>in</strong>e be<strong>in</strong>g (0)<br />
4. Virg<strong>in</strong> Mary<br />
a.) mother of Jesus (1)<br />
b.) Supposedly the mother of a prophet (0)<br />
c.) Blessed mother of God (2)<br />
5. Sa<strong>in</strong>ts<br />
a.) agents effect<strong>in</strong>g communication between God and man (2)<br />
b.) good people liv<strong>in</strong>g or hav<strong>in</strong>g lived Christian lives (1)<br />
c.) humans falsely elevated <strong>to</strong> hol<strong>in</strong>ess (0)<br />
6. Angels<br />
a.) heavenly be<strong>in</strong>gs created <strong>in</strong> God’s likeness (2)<br />
b.) revelation of God’s ways (1)<br />
c.) manmade symbols of goodness (0)<br />
7. Devils<br />
a.) manmade symbols of evil (0)<br />
b.) our temptations <strong>to</strong> do evil (1)<br />
c.) fallen angels (2)<br />
8. Heaven<br />
a.) peaceful state of m<strong>in</strong>d (0)<br />
b.) the place of eternal happ<strong>in</strong>ess for only those who are saved (2)<br />
c.) future life <strong>in</strong> the k<strong>in</strong>gdom of God (1)<br />
9. Hell<br />
a.) threat of future punishment for man’s s<strong>in</strong>s (1)
209<br />
b.) our earthly suffer<strong>in</strong>g (0)<br />
c.) place of eternal punishment for the damned (2)<br />
10. Soul<br />
a.) Personality (0)<br />
b.) spiritual part of man, l<strong>in</strong>k<strong>in</strong>g him <strong>to</strong> God (1)<br />
c.) Immortal, immaterial part of man (2)<br />
11. S<strong>in</strong><br />
a.) fall<strong>in</strong>g short of our best and our misdeeds <strong>to</strong>wards others (0)<br />
b.) transgression aga<strong>in</strong>st God’s laws (2)<br />
c.) break<strong>in</strong>g an established moral and religious code (1)<br />
12. Salvation<br />
a.) sav<strong>in</strong>g one’s soul, which is the ultimate end of man’s creation (2)<br />
b.) submitt<strong>in</strong>g <strong>to</strong> God’s will (1)<br />
c.) hav<strong>in</strong>g fulfilled one’s purpose <strong>in</strong> life (0)<br />
13. Miracles<br />
a.) illustrations expla<strong>in</strong><strong>in</strong>g God’s ways (1)<br />
b.) unusual occurrences which do have a logical explanation (0)<br />
c.) unusual acts produced through the power of God (2)<br />
14. Bible<br />
a.) book of his<strong>to</strong>ry and moral behavior (0)<br />
b.) book of reverent religious writ<strong>in</strong>gs (1)<br />
c.) revealed word of God (2)<br />
15. Prayer<br />
a.) attempts at magical wish fulfillment (0)<br />
b.) religious meditation (1)<br />
c.) communication with God (2)<br />
16. Rituals and sacraments<br />
a.) means of achiev<strong>in</strong>g grace (2)<br />
b.) manmade actions for the pleasure of mythical be<strong>in</strong>gs (0)<br />
c.) symbolic actions dur<strong>in</strong>g worship (1)
210<br />
Conservatism Scale<br />
Please assess your degree of devoutness about your own religious beliefs<br />
0 1 2 3<br />
not at all/ slightly devout somewhat very devout<br />
does not apply<br />
devout<br />
Please assess your degree of devoutness <strong>in</strong> follow<strong>in</strong>g your religious traditions or<br />
practices<br />
0 1 2 3<br />
not at all/ slightly devout somewhat very devout<br />
does not apply<br />
devout<br />
Please assess your attempts <strong>to</strong> live your life accord<strong>in</strong>g <strong>to</strong> your religious scriptures or<br />
teach<strong>in</strong>gs<br />
0 1 2 3<br />
don’t attempt attempt attempt attempt very much<br />
at all/ does slightly somewhat<br />
not apply
211<br />
Background Questionnaire<br />
Please respond <strong>to</strong> the follow<strong>in</strong>g background questions:<br />
1. Sex.<br />
A. M<br />
B. F<br />
2. Age.<br />
A. 20-29<br />
B. 30-35<br />
C. 36-40<br />
D. 41-45<br />
E. 46-50<br />
F. 51-55<br />
G. 56-60<br />
H. 61-65<br />
I. 66+<br />
3. Education.<br />
A. Doc<strong>to</strong>rate Cl<strong>in</strong>ical Psychology<br />
B. Doc<strong>to</strong>rate Counsel<strong>in</strong>g Psychology<br />
C. Doc<strong>to</strong>rate Education or related<br />
D. Other<br />
3. Geographic Region<br />
A. Northeast E. South<br />
B. Southeast F. Northwest<br />
C. North G. Southwest<br />
D. Midwest H. West<br />
4. Primary Location as urban or rural<br />
A. Rural B. Urban<br />
5. Years <strong>in</strong> cl<strong>in</strong>ical practice<br />
A. 1-2<br />
B. 3-5<br />
C. 6-10<br />
D. 11-15<br />
E. 16-20<br />
F. 21-30<br />
G. 31-40<br />
H. 40+<br />
6. Religious Affiliation<br />
A. Buddhist<br />
B. Christian-Catholic
212<br />
C. Christian- Evangelical<br />
D. Christian- Protestant (all other denom<strong>in</strong>ations exclud<strong>in</strong>g Evangelical)<br />
E. H<strong>in</strong>du<br />
F. Jewish<br />
G. Muslim<br />
H. None/Atheist/Agnostic<br />
I. Other<br />
This measure will be the last prior <strong>to</strong> the IAT. Follow<strong>in</strong>g this there will be a notice:<br />
“You will now be directed <strong>to</strong> the f<strong>in</strong>al portion of the study, which should take<br />
approximately 5 m<strong>in</strong>utes <strong>to</strong> complete. You will be asked <strong>to</strong> download a small plug-<strong>in</strong><br />
(Active-X) that will allow for responses <strong>to</strong> be time. This plug-<strong>in</strong> cannot and does not<br />
gather any data from your computer other than what is required for data collection. I<br />
hope that you will cont<strong>in</strong>ue on through this last piece as partial data is not usable <strong>in</strong><br />
this study. Thank you for your cont<strong>in</strong>ued participation!”
213<br />
<strong>Implicit</strong> Association Test<br />
The implicit association test is not a measure, but a method of measur<strong>in</strong>g au<strong>to</strong>matic<br />
attitudes. It requires a process of categorization of concepts or words on l<strong>in</strong>e or on a<br />
dedicated computer. Therefore it cannot be replicated here. Demonstrations of the<br />
IAT can be seen at the follow<strong>in</strong>g site:<br />
https://implicit.harvard.edu/implicit/demo/measureyourattitudes.html<br />
That hav<strong>in</strong>g been said, some text is available. After completion of the measure,<br />
participants will be given feedback. An example of this would be:<br />
Below is a summary of your average response time for two different configurations:<br />
When good words were matched with the Evangelical Christian category, your<br />
response time was xxxx milliseconds.<br />
When good words were matched with the Secular/No Religion category, your<br />
response time was xxxx milliseconds.<br />
Did you respond much more quickly <strong>to</strong> one of the configurations than the other? If so,<br />
that configuration may be more consistent with your attitudes about these categories.<br />
Please press ENTER <strong>to</strong> end the study.<br />
On the next page a text box reads:<br />
Thank you for participat<strong>in</strong>g <strong>in</strong> this study. If you would like <strong>to</strong> be entered <strong>in</strong> the draw<strong>in</strong>g<br />
for the $50 and the $100 prizes, please type your email address <strong>in</strong> the box below.<br />
W<strong>in</strong>ners will be notified by email.
214<br />
Appendix B: Distribution of Variable Scores<br />
His<strong>to</strong>grams<br />
60<br />
50<br />
40<br />
Frequency<br />
30<br />
20<br />
10<br />
0<br />
0.00<br />
2.50<br />
5.00<br />
7.50<br />
10.00<br />
12.50<br />
Social Desirability<br />
Figure B1. Distribution of social desirability scores.
215<br />
100<br />
80<br />
Frequency<br />
60<br />
40<br />
20<br />
0<br />
0.00<br />
2.00<br />
4.00<br />
6.00<br />
8.00<br />
10.00<br />
12.00<br />
Religious Conservatism<br />
Figure B2. Distribution of religious conservatism scores.
216<br />
40<br />
30<br />
Frequency<br />
20<br />
10<br />
0<br />
0.00<br />
10.00<br />
20.00<br />
30.00<br />
Liberality of Christian Beliefs<br />
Figure B3. Distribution of religious liberality <strong>in</strong> relation <strong>to</strong> Christian beliefs scores.
217<br />
100<br />
80<br />
Frequency<br />
60<br />
40<br />
20<br />
0<br />
-20.00<br />
-10.00<br />
0.00<br />
10.00<br />
20.00<br />
NMR - EC Affective Empathy Difference<br />
Figure B4. Distribution of NMR – EC affective empathy difference scores.
218<br />
50<br />
40<br />
Frequency<br />
30<br />
20<br />
10<br />
0<br />
-30.00<br />
-20.00<br />
-10.00<br />
0.00<br />
10.00<br />
20.00<br />
NMR - EC Cognitive Empathy Difference<br />
Figure B5. Distribution of NMR – EC cognitive empathy difference scores.
219<br />
80<br />
60<br />
Frequency<br />
40<br />
20<br />
0<br />
-15.00<br />
-10.00<br />
-5.00<br />
0.00<br />
5.00<br />
10.00<br />
15.00<br />
NMR - EC Prognosis Difference<br />
Figure B6. Distribution of NMR – EC prognosis scores.
220<br />
100<br />
80<br />
Frequency<br />
60<br />
40<br />
20<br />
0<br />
-2000.00<br />
-1000.00<br />
0.00<br />
1000.00<br />
2000.00<br />
3000.00<br />
<strong>Implicit</strong> Negative Associations<br />
Figure B7. Distribution of implicit negative association scores.
221<br />
50<br />
40<br />
Frequency<br />
30<br />
20<br />
10<br />
0<br />
30.00<br />
40.00<br />
50.00<br />
60.00<br />
70.00<br />
80.00<br />
90.00<br />
Motivation <strong>to</strong> Control Prejudice Reactions<br />
Figure B8. Distribution of motivation <strong>to</strong> control prejudice reactions scores.
222<br />
Appendix C: Exam<strong>in</strong>ation of Regression Assumptions<br />
100<br />
80<br />
Frequency<br />
60<br />
40<br />
20<br />
0<br />
-5.0<br />
-2.5<br />
0.0<br />
2.5<br />
5.0<br />
Regression Standardized Residual<br />
5.0<br />
Regression Standardized Residual<br />
2.5<br />
0.0<br />
-2.5<br />
-5.0<br />
-3<br />
-2<br />
-1<br />
0<br />
1<br />
Regression Standardized Predicted Value<br />
2<br />
Figure C1. Residual normality his<strong>to</strong>gram and residual equality scatterplot for<br />
regression analysis with NMR-EC affective empathy difference scores as the<br />
dependent variable for hypothesis 1.
223<br />
40<br />
30<br />
Frequency<br />
20<br />
10<br />
0<br />
-2<br />
0<br />
2<br />
4<br />
Regression Standardized Residual<br />
4<br />
Regression Standardized Residual<br />
2<br />
0<br />
-2<br />
-3<br />
-2<br />
-1<br />
0<br />
1<br />
Regression Standardized Predicted Value<br />
2<br />
Figure C2. Residual normality his<strong>to</strong>gram and residual equality scatterplot for<br />
regression analysis with NMR-EC cognitive empathy difference scores as the<br />
dependent variable for hypothesis 1.
224<br />
80<br />
60<br />
Frequency<br />
40<br />
20<br />
0<br />
-4<br />
-2<br />
0<br />
2<br />
4<br />
Regression Standardized Residual<br />
4<br />
Regression Standardized Residual<br />
2<br />
0<br />
-2<br />
-4<br />
-3<br />
-2<br />
-1<br />
0<br />
1<br />
Regression Standardized Predicted Value<br />
2<br />
Figure C3. Residual normality his<strong>to</strong>gram and residual equality scatterplot for<br />
regression analysis with NMR-EC prognosis difference scores as the dependent<br />
variable for hypothesis 2.
225<br />
80<br />
60<br />
Frequency<br />
40<br />
20<br />
0<br />
-4<br />
-2<br />
0<br />
2<br />
4<br />
6<br />
Regression Standardized Residual<br />
6<br />
Regression Standardized Residual<br />
4<br />
2<br />
0<br />
-2<br />
-4<br />
-3<br />
-2<br />
-1<br />
0<br />
1<br />
Regression Standardized Predicted Value<br />
2<br />
Figure C4. Residual normality his<strong>to</strong>gram and residual equality scatterplot for<br />
regression analysis with INA scores as the dependent variable for hypothesis 2.
226<br />
120<br />
100<br />
80<br />
Frequency<br />
60<br />
40<br />
20<br />
0<br />
-5.0<br />
-2.5<br />
0.0<br />
2.5<br />
5.0<br />
Regression Standardized Residual<br />
5.0<br />
Regression Standardized Residual<br />
2.5<br />
0.0<br />
-2.5<br />
-5.0<br />
-4<br />
-2<br />
0<br />
2<br />
4<br />
Regression Standardized Predicted Value<br />
6<br />
Figure C5. Residual normality his<strong>to</strong>gram and residual equality scatterplot for<br />
regression analysis with NMR-EC affective empathy differences as the dependent<br />
variable for hypothesis 4.
227<br />
50<br />
40<br />
Frequency<br />
30<br />
20<br />
10<br />
0<br />
-2<br />
0<br />
2<br />
4<br />
Regression Standardized Residual<br />
4<br />
Regression Standardized Residual<br />
2<br />
0<br />
-2<br />
-5.0<br />
-2.5 0.0<br />
2.5<br />
Regression Standardized Predicted Value<br />
5.0<br />
Figure C6. Residual normality his<strong>to</strong>gram and residual equality scatterplot for<br />
regression analysis with NMR-EC cognitive empathy differences as the dependent<br />
variable for hypothesis 4.
228<br />
80<br />
60<br />
Frequency<br />
40<br />
20<br />
0<br />
-4<br />
-2<br />
0<br />
2<br />
4<br />
Regression Standardized Residual<br />
4<br />
Regression Standardized Residual<br />
2<br />
0<br />
-2<br />
-4<br />
-6<br />
-4<br />
-2<br />
0<br />
2<br />
Regression Standardized Predicted Value<br />
4<br />
Figure C7. Residual normality his<strong>to</strong>gram and residual equality scatterplot for<br />
regression analysis with NMR-EC prognosis differences as the dependent variable<br />
for hypothesis 5