Qualitative Research Article Summary

Evangelical Christian Undergraduate Attitudes toward Depression’s Etiology and Treatment: A Qualitative Study

Objective: Little is known about how participation in campus religious organizations affects undergraduates’ willingness to engage mental health services. This study explores evangelical Christian students’ views regarding the etiology and treatment of depression.

Participants: Members of two evangelical Christian organizations at a research university were recruited in January 2014.

Methods: Participants completed semi-structured interviews exploring their views on depression and a modified grounded theory approach was used to analyze interview transcripts.

Results: Participants perceived their fellowships as generally supportive places to discuss mental health concerns. Students expressed eclectic understandings of depression that balanced theological, social, and neurobiological accounts. They often preferred counselors of the same faith and articulated ambivalence about the use of antidepressants.

Conclusions: Evangelical student organizations can provide substantial emotional support for student members. Participants in these organizations conceptualize depression using multiple etiological narratives, often prefer counselors who share their faith, and may be ambivalent about using

antidepressants.

Keywords: mental health, religion, spirituality, depression, college students

Major depressive disorder (MDD) is one of the most common mental health disorders diagnosed in the American population, with an estimated lifetime prevalence of 17.1%.1 Among college students, the rate of depression is even higher: 18.07% of undergraduates participating in the American College Health Association National College Health Assessment II from 2011 to 2013 reported having been diagnosed with depression in their lifetimes. College students suffering from depression often experience academic impairment in the form of decreased class attendance and lower grades.6 Depression can also threaten social relationships and perceived social support: in Daughtry and Kunkel’s7 qualitative exploration of the experience of depression in university students, participants mentioned feeling that they did not belong, like a “nobody” and an “outcast.” 7, p. 320
Because of the negative effects depression can have on students, student health services are eager to identify and support depressed students. Little is known, however, about how college students’ religious affiliations shape the ways they understand and experience depression, and how religious affiliation affects students’ willingness to engage student mental health services. Given that many students on American college campuses turn to campus religious organizations as primary sites of social engagement and support, this question is an important one. Information about the way that participants in campus religious organizations understand mental illness and utilize mental health services is relevant not only to chaplains and administrators charged with oversight of campus religious organizations, but also to student health clinicians and policymakers seeking to meet the needs of students with mental health problems.
In this study, we explore attitudes regarding the etiology and treatment of depression among students involved in evangelical Christian campus organizations, one subset of student religious organizations. Although the American population is increasingly pluralistic with respect to religious belief and affiliation, 22% of adults aged 18-29 self-identified as evangelical Christians (“evangelicals”) on a recent major national survey.8 While the term “evangelical” has no fixed meaning, those who identify as evangelical Christians typically believe that “the final, ultimate authority is the Bible” and “that Christ died for the salvation of all”; they also emphasize being “born again” and evangelizing or sharing their faith.9, p. 3 Self-professed evangelicals often organize on college campuses through student organizations that can serve as primary loci for student social networking and community engagement. Intervarsity Christian Fellowship (“Intervarsity”) and Cru (formerly Campus Crusade for Christ), two of the largest evangelical Christian organizations, counted a combined national membership of over 110,000 active student members in the 2012-2013 school year.10,11 Both organizations’ mission statements demonstrate an emphasis on the Bible as the “inspired Word of God,” an emphasis on being “born again” or “saved,” and a recognition of the importance of seeking the conversion of others.12-14 Other national evangelical campus organizations include the Reformed University Fellowship and the Fellowship of Christian Athletes.
Recent ethnographic research on evangelical campus organizations lays important groundwork for this study.

In an ethnographic study of one evangelical student group at a university in the northeastern United States, Wilkins argued that the group created a strong social pressure to appear happy and to hide negative emotions.15 Students in Wilkins’ study articulated the belief that happiness was a sign of “God’s work in their hearts.”15,p.283 This research suggests that for at least some students in evangelical campus organizations, seeking help for “feeling down” could threaten their sense of group belonging and, possibly, challenge their religious faith as

well.
In another qualitative study of an evangelical Christian organization at a large research university, Bryant16 found that there was a strong group pressure to conform to particular social beliefs and norms regarding abortion, sexual practices and belief in the inerrancy of Scripture, even though students held diverse opinions on other moral and political issues. Though not focused on mental health concerns, these studies suggest that evangelical campus organizations maintain strong internal norms, including a “happiness norm” that discourages the display of negative emotion.
Objective
Within the context of two campus Christian organizations at an American university, this study explores the following research questions:
• How do student participants in undergraduate evangelical organizations or “fellowships” understand the causes of depression?
• How, and in what contexts, do these fellowships discuss topics such as sadness and depression?
• When it comes to discussing depressive symptoms, how do members of undergraduate evangelical fellowships characterize the advantages and drawbacks of explicitly religious counselors and counselors who do not self-identify as religious?
• How do evangelical students understand the role of medication in the treatment of depression?
Methods
Sample
Participants were recruited via convenience sampling from two evangelical Christian organizations on the campus of an American research university (“Community Christian Fellowship” [CCF] and “Good News Fellowship” [GNF], both pseudonyms). According to participants, Community Christian Fellowship has a weekly attendance of approximately 100 at their “large group” session and between 8-10 students at each of several weekly “small group” sessions. Good News Fellowship has a weekly attendance of about 45 students at its large group sessions and between 8-15 students in “small group” sessions. Large group sessions vary somewhat in content, but they typically center on a “message,” often delivered by a local Christian pastor, and the singing of worship songs. Small group sessions usually involve discussing a passage in the Bible, prayer, and opportunities for sharing personal concerns, struggles and prayer requests. Participants described Community Christian Fellowship as predominantly composed of white, non-Hispanic students and Good News Fellowship as predominantly composed of Asian students.
Participants were recruited through the use of posted fliers in prominent locations on campus and through Facebook advertisement. Finally, emails sent on fellowship-associated listservs were used to recruit participants. Both groups declined requests to allow official recruitment during large group fellowship meetings, citing organizational policies that prohibit granting researchers access to students for the purpose of scholarly research during official meeting times.
Nine students agreed to participate in the interviews; due to one no-show, 8 interviews were completed. All participants were undergraduate students during the 2013-2014 school year. Of the 8 participants, 7 were female and 1 was male. Four participants were members of Community Christian Fellowship and 5 were members of Good News Fellowship. One participant was a member of both groups. Four of the participants self-identified as white and 4 self-identified as Asian/Asian American. Participant interviews were conducted in January 2014 at [Redacted] University.
Study Procedure
Participants were invited to participate either in fellowship-specific group interviews or in individual interviews. Six participants elected individual interviews and 2 participants were interviewed together. The interviews were conducted using predetermined probes that explored students’ attitudes toward antidepressant medication, their opinions about explicitly religious providers and providers who did not self-identify as religious, and their perceptions of how their fellowship’s culture influenced discussions of depression within the organization. While prepared questions were used, the conversation was also allowed to follow particular interests of the student. The interviews were conducted at a neutral location on the university campus, usually an empty classroom.
Participants completed an oral informed consent procedure. Students were asked to provide information about their gender, race, and fellowship affiliation at the beginning of the interview. Although some students volunteered information regarding their personal mental health histories, we did not ask any participants to disclose this information. All sessions were audio recorded and transcribed by the interviewer. In return for his or her time, each participant was given a $10 gift card to Amazon.com. For participants in the small group interview, refreshments were provided in addition to the gift cards.
This study was approved by the [Redacted] University Institutional Review Board.
Data Analysis
All interviews were transcribed by the interviewer, and participants’ personal and identifying information was redacted. A modified grounded theory approach, using constant comparative analysis of the interview transcripts, was employed.17 The transcripts were coded using an open coding technique, in which codes were allowed to emerge organically from the data.18 Through a process of re-coding, editing, written reflection, diagramming and rearrangement, 8 themes arranged around 4 central topics emerged from the coding process.19 These themes are discussed in the Results section.
Reflexivity also played an important part in the data analysis. Though not acquainted with any of the study participants, the interviewer had once been associated with one of these organizations, and this participation history influenced the guiding questions of the study. For this reason, it was important to recognize the way that this experience influenced the interviewing process. Discussions with fellow researchers and written reflections of reactions to the interviews immediately after they took place aided in this practice.
The second and third authors of this study assisted in the process of triangulation. The third author served as another primary reader of all interview transcripts, identifying salient themes and codes. The second author analyzed three of the transcribed interviews and provided feedback on aggregated codes, categories and themes identified by the interviewer.
Results
Social Support
Students identified both fellowships as having accepting, supportive cultures, but several participants cited concerns about academic stress, “cliques,” and superficiality as internal threats to these supportive cultures.
One student noted that in Community Christian Fellowship, “everyone’s very accepting of each other” and that “we’re going to act as Christ did and accept each other as Christ did.” In a similar vein, another Community Christian Fellowship student observed: “I guess [a welcoming atmosphere] is valued highly at CCF because that’s how Christ was, he welcomed in everybody regardless of their background or what they had done. So that’s the same mindset that you want to take with the Christian ministry.” Other students used the words “open,” and “supportive,” to describe Good News Fellowship and “welcoming” and “accepting” to describe Community Christian Fellowship.
In spite of the welcoming atmosphere students described, a number of concerns also surfaced about potential fractures in group unity. Concerns about “power players,” the students who tended to be the most involved in the fellowships, and “cliques” emerged in several interviews. One student also voiced a concern that students new to Community Christian Fellowship’s large group might initially see students portraying an image of having things “under control” and miss the more vulnerable interactions that occur in other fellowship contexts:
At the same point we all fall into the trap that you know we want to seem perfect, you know we want to seem like we have it under control... And so that’s my fear for someone new coming in is just seeing that and not seeing the reality and the strength of emotions that are under each layer.