Pastoral Leaders Perceptions of Mental Health and Relational Concerns within Faith Based Organizations

Abstract

The purpose of this study was to explore the attitudes, beliefs, and perspectives of pastoral leaders regarding mental health and relational concerns within Faith-Based Organizations (FBO). As a follow-up to a previous study (Moore et al., 2016), the authors intended to gain insight regarding how pastoral leaders view their role within their organizations related to promoting sound mental health and relational health. Utilizing a qualitative description, authors disseminated a survey to 12 pastoral leaders to complete. Three themes emerged from their responses, which included: (1) Defining mental health; (2) The role of pastoral leaders in mental health; and (3) Mental health needs in pastoral leadership. In the study, investigators discuss clinical implications and provide recommendations regarding how pastoral leaders and Faith- Based Organizations may address the topic of mental health and relational health among its constituents. We believe this research is relevant to the readers of this journal as it contributes to a discussion about pastoral leaders and mental health, as well as how pastoral leaders’ perception of mental health may impact how they discuss this topic within their own organizations. Furthermore, for readers who are clinicians, this study contributes to the body of knowledge about what pastoral leaders and constituents may need, as one considers opportunities for collaboration.

Keywords

Pastoral leaders mental health faith-based organizations

Individuals often refer to faith-based organizations and places of worship (churches, temples, synagogues, mosques) as safe places where individuals, couples, and families can connect with God as well with others who share the same religious or spiritual beliefs (Turner, 2011). These safe spaces often provide education in spiritual practices, instruction about life skills, encouragement, and access to a community (Chaney, 2008). Pastoral leaders, referred to as pastors, clergy, bishops, priests, or chaplains, among other titles, often direct faith-based organizations. While pastoral leaders tend to respond to a calling, selection, appointment, or training (depending on the specific religious doctrine), when a person earns the title of pastoral leader based on adequate preparation, that person typically gains full authority from congregants to lead the church organization or place of worship. While variation exists in how pastoral leaders complete their training regarding spirituality and religious doctrine, including counseling regarding one's walk with God (Jernigan, 2000; Tartaglia et al., 2013), the extent to which they receive training in mental health and couple/family relationships remains an unknown commodity. Given that the church is a microcosm of the world in which individuals may struggle with trauma, anxiety, depression, suicidal ideation, and couple and family conflict, among others, the need to gain insight about pastoral leaders’ epistemology regarding mental health within their faith-based organizations is imperative.

Pastoral leaders often function as first responders in crisis situations, frequently for some type of healing (Blank et al., 2002; Stanford, 2007). Therefore, it may be important to learn what pastoral leaders know about mental health, how they acquire that knowledge (epistemology), and how they view their role in addressing mental health issues (Hankerson & Weissman, 2012). Furthermore, it may be helpful to learn how pastoral leaders manage potential burnout (Chandler, 2009, 2010), vicarious or secondary trauma (Hunsinger, 2011), and their own potential mental health issues. In addition, it may be important to understand how pastoral leaders conceptualize their role in collaborating with mental health professionals, such as licensed marriage and family therapists, who could assist them in addressing mental health and relational concerns.

The purpose of this research study was to explore how pastoral leaders view mental health and relational concerns in their place of worship, particularly how they view their role in addressing issues within their organizations. The overarching research question for the study was “How do pastoral leaders define mental health in their place of worship?” Sub-research questions in the study included: (1) How do pastoral leaders conceptualize mental health and relational concerns (couple and family relationships)? and (2) How do pastoral leaders view their role in terms of addressing these issues in their places of worship? This research is relevant to the readers of this journal as it contributes to a discussion about pastoral leaders and mental health and explores how pastoral leaders’ perception of mental health may impact how they address this topic among constituents. Furthermore, the article informs readers about how mental health professionals may promote collaboration.

Literature Review

In many faith-based organizations, a schism exists between mental health and the church (Koenig, 2012; Pargament & Lomax, 2013). The pastoral leader's perspective on mental health may contribute to this schism. In a review of the literature regarding this topic, three major areas emerged: (1) mental health in the church; (2) the role of pastoral leaders; and (3) pastor burnout.

Mental Health in the Church

Research suggests that religious participation enhances one's mental health (Moreira-Almeida et al., 2006; Taylor et al., 1996). For example, religiosity proved effective when confronting mental health-related problems for adults and youth (Breland-Noble et al., 2015) and in decreasing mental health issues among Latin X communities (Moreno & Cardemil, 2018). Similarly, spirituality delivered a positive impact on American Indians (Bear et al., 2018) and Puerto Ricans (Rodríguez-Galán & Falcón, 2018), in addition to other majority and minority groups. A vast body of research suggests that persons involved in religious activities exhibit improved physical and mental health (Hill & Pargament, 2003; Jones et al., 2012; Worthington et al., 1996). In particular, researchers cited an advantage in mental and behavioral health, specifically depressive features and self-respect (Hovey et al., 2014; Regnerus, 2003; Weber & Pargament, 2014) to demonstrate how religion/spirituality can help people live healthy lives. Some FBOs develop institutionally-based spirituality components in their programming. Some spiritually integrative psychotherapists/pastoral counselors work within and also externally for faith-based organizations.

While this research centered on the benefits of church attendance on mental health, one cannot ignore the stories related to hurt, disappointment, and scandal that have occurred at the hands of the religious leaders (McGraw et al., 2019; Stevens et al., 2019). In response to this longstanding schism between the church and mental health as well as other issues in some faith-based organizations, mental health professionals recognized the need to assist pastoral leaders (Williams et al., 2014). However, the relationship between mental health professionals and pastoral leaders is complex with potential differences rooted in philosophy about religion and mental health, lack of shared understanding, competing demands, and different priorities, along with other factors.

The Role of Pastoral Leaders

Lyles (1992) found that African American pastors see themselves as serving the church's mental health needs by preaching, teaching, and counseling. When considering pastoral leaders, it is important to define the term pastor to better understand its meaning. According to Christian scripture, the pastor's appointment comes from God with a goal of equipping the people (Ephesians 4:11–12, KJV) and serving as an example for them (1 Timothy 4:12, KJV). Pastors engage in self-care while also overseeing the people (1 Timothy 5:23, KJV). Pastoral care and pastoral counseling require distinctive qualities and a particular skill set (Nelson et al., 2012). These pastoral skills may include providing spiritual leadership to parishioners, as well as counseling and pastoral care, in conjunction with providing empathy related to issues that impact individuals across the lifespan, such as grief and loss, financial stress, mental health issues, and family issues (Nelson et al., 2012). Pastors often see themselves as ill-equipped to provide specialized counseling, thus making them more comfortable acting as a liaison for mental health professionals and their flock (Nelson et al., 2012).

Pastor Burnout

Because pastoral leaders live in the same community as their congregation pastoral leaders serve, this often sets the stage for compassion fatigue (Abernethy et al., 2016). In addition to this dynamic, an unforgiving workload, lack of control, lack of fairness, unrealistic expectations, and lack of knowing self may lend itself to burnout (Jackson-Jordan, 2013; Scott & Lovell, 2015). Maslach et al. (1996) suggested that pastoral leaders can experience burnout, manifested as mental health issues, exhaustion, depersonalization, and an inability to function in their personal and professional lives. Pastoral leaders may also wrestle with burnout due to the pressure of taking care of their church members, along with trying to keep the church financially viable (Chandler, 2010; Golden et al., 2004; Scott & Lovell, 2015). Responding to crises, such as the COVID-19 pandemic, could contribute to burnout (Bard, 2020). With these concerns in place, pastoral leaders may not feel comfortable asking for help—a factor that may contribute to burnout and a greater potential for suicidal ideation and attempts.

Research Methodology

Qualitative Research

These researchers employed a qualitative questionnaire consisting of open-ended questions in which participants articulated how they perceived mental health, how they defined mental health, and how they understood their role in addressing mental health issues. A Qualitative questionnaire (also referred to as a qualitative survey) is an instrument comprised of open-ended questions and used to obtain information (Braun et al., 2013; Daniels et al., 2020). Researchers distributed the questionnaire ahead of time and did not restrict word count to allow participants to review questions in advance and provide more in-depth responses. In the past, researchers relied on qualitative questionnaires and survey designs to gather information related to religion and spirituality (Canda et al., 2004). For this study, the research team integrated qualitative description, a method of research inquiry widely utilized in health and mental health research, as part of the design approach (Bradshaw et al., 2017; Sandelowski, 2010). According to Neergaard et al. (2009), “Qualitative description follows the tradition of qualitative research, i.e., an empirical method of investigation aiming to describe the informant's perception and experience of the world and its phenomena,” (p. 3). In addition, Neergaard et al. (2009) suggest that “The aim of qualitative description is neither thick description (ethnography), theory development (grounded theory) nor interpretative meaning of an experience (phenomenology), but a rich, straight description of an experience or an event,” (p. 3). Furthermore, Sandelowski (2000) suggested that qualitative descriptive studies offer a comprehensive summary of an event in the everyday terms of those events (p. 336). Also, in qualitative description, researchers stay close to the data and focus on analysis of the words—as written (Sandelowski, 2000).

Recruitment

The first author's academic institution approved this study. After receiving approval, the first author posted a flier with recruitment information on popular social media sites, such as Facebook. In particular, the flier featured information about the study which the researchers posted on social media. In this step of the process, the author sought out specific social media pages that targeted faith-based organizations and pastoral leaders. Additionally, the research team sent the flier via email to faith-based organizations utilizing nowball sampling (Sadler et al., 2010). Potential respondents received the contact information of the principal investigator in order to ask questions about the study's purpose. Participants also received information about the scope of the study, informed consent, and details about risks and benefits of the study, in addition to information about confidentiality and remuneration, to assist them in making the decision of whether or not to participate in the study.

Analysis

The analysis process consisted of a three-pronged approach which included the first and third author working independently to review questionnaire responses. Each of the two authors read through each question and its narrative responses. Each author took notes regarding initial thoughts that the respondents shared. After reading all of the participants’ responses on the questionnaires, the authors isolated each question and compared the respondents’ answers. The researchers then used open coding to review the survey questions. This included decontextualization or separating data from the original context of cases (Starks & Brown Trinidad, 2007). This also consisted of the two authors conducting a line-by-line text analysis to highlight key words, sentences, and concepts (Linneberg & Korsgaard, 2019). The second part of the analysis of the research consisted of the authors engaging in a debriefing session to review their notes and perceptions regarding the initial coding process. Authors discussed noted differences and agreed upon final codes for the study. In the third part of the analysis process, the authors reviewed the questionnaires and appied the final codes. After coding the questionnaires, the researchers met to discuss recontextualization, which included collapsing the codes into categories and designating themes across the participants’ responses (Coates et al., 2021; Starks & Brown Trinidad, 2007; St. Pierre & Jackson, 2014). The two authors also reviewed the questionnaires for exemplars that represented emergent themes.

Reliability

To bolster the reliability for the study, the authors enhanced the confirmability and dependability in their work by maintaining an audit trail of the overall research process. In addition, the researchers used multiple coders (triangulation) during the research process to increase inter-rater reliability and consistency when interpreting the data (Flick, 2004). The authors also employed member checking after the final themes emerged to ensure the researchers’ accuracy in understanding and interpreting the data (Morse, 2015). The researchers also considered negative cases and outliers to strengthen the research's authenticity (Onwuegbuzie & Leech, 2007). The authors also too into account trustworthiness and transferability (Curtin & Fossey, 2007). After deriving research questions from the literature, the researchers interpreted the responses in light of potential applications to other groups. Likewise, the authors integrated the results into the literature in an effort to expand the literature and fill existing gaps. The researchers were also engaged in reflexivity exercises throughout the research process (Berger, 2015; Mauthner & Doucet, 2003). Prior to and throughout the study, the authors explored their positionality, previous background, and biases, as well as beliefs about the research topic. All three authors work as mental health professionals and have experience working with populations that attend faith-based organizations. One author is a professor who has worked with pastoral leaders within higher education. Another author is a Pastor's Kid (PK) and a leader in his church.

Demographics

Pastoral Leaders

Twelve religious leaders participated in this study, mostly located in the southern United States except for two in midwestern and western states. Four participants in the study identified as female, while the remaining eight identified as male. In the study, the participants’ average age was 47 years, with a range of 31–75 years. In the study, 11 of the pastoral leaders identified as Christian, and one participant identified as Jewish. The represented denominations included: nondenominational (n = 5), Baptist (n = 3), Lutheran (n = 1), Seventh-Day Adventist (n = 1), Latter-Day Saint (n = 1), and Jewish (n = 1). In terms of race, the majority of participants identified as African American (n = 10), with the remaining participants identifying as White (n = 2). Pastoral leaders reponded to questions about their own mental health. In the study, nine participants reported no mental health issues, while three reported having experienced mental health issues (clinical depression, Post-Traumatic Stress Disorder, and depression after divorce). These leaders also responded to questions regarding mental health issues in their family, with six participants reporting affirmatively while six reported no family mental health issues. For the pastoral leaders who mentioned mental health issues in their family, these included Generalized Anxiety Disorder, Adjustment Disorder, Bipolar Disorder, Clinical Depression, and Schizophrenia.

Faith-based Organizations

The represented Faith-Based Organizations ranged in size from 25–4,500 members. In the study, eight individuals reported that their organization consisted of a majority of African American attendees, three individuals reported that their FBO consists primarily of white congregants, and one participant reported an FBO evenly split between African American and White members. Respondents also answered questions about mental health and relational issues in their FBO. In the study, nine participants reported mental health issues, such as “Clinical Depression, Generalized Anxiety Disorder, Bipolar Disorder, Personality Disorders, Post- Traumatic Stress Disorder, Adjustment Disorder, addictions, divorce, family issues/conflict, parent/child conflict, anger issues, marital issues, and lack of communication, among others. All 12 participants reported that they provide pastoral counseling. When asked what types of issues they typically encounter during their counseling, participants mentioned premarital and marital issues, depression, anxiety, difficulties transitioning from prison, financial counseling, spiritual discernment, grief counseling, stress management, managing aging parents, addictions and co-dependency issues, self-esteem issues, and Post-Traumatic Stress Disorder. Interviewees responded to the question of whether they ever refer their members to a licensed mental health professional. During the study, eight participants reported that they actively refer people to licensed professionals. Pastoral leaders also answered a question regarding whether their FBO currently has any official programs that focus on mental health and relational health. In the study, eight participants reported that their organizations have mental health and relational health programs, such as hosting guest speakers to discuss mental health, hosting weekly support groups related to mental illness, having mental health professionals as attendees in the church, and referring clients to external mental health professionals.

Results

Three themes emerged from the data: (1) Defining mental health; (2) the role of pastoral leaders in mental health; and (3) mental health needs in pastoral leadership. Using the overarching research question: “How do pastoral leaders define mental health in their place of worship?” and the sub-research questions: “How do pastoral leaders conceptualize mental health and relational concerns (couple and family relationships)?” and “How do pastoral leaders view their role in terms of addressing these issues in their places of worship?” Researchers described each theme respectively.

Theme 1: Defining Mental Health

“Mental health is relationship health and, from a pastoral perspective, it means having a healthy relationship with self, significant others, family and community. In that healthy relationship, first and foremost, consideration is given to doing no harm, providing safety and security, hope and love, and contributing to the capacity of self and others.” – Participant 10

The first identified theme from the research is defining mental health within the context of faith-based organizations. In describing mental health, participants frequently noted the “emotional, psychological, and social well-being” (Participant 6) of individuals and families as well as “struggling to maintain inner peace of the soul due to life's circumstances or … an imbalance of brain chemistry or hormones” (Participant 2). Participant 3 specified that “a person with mental health [challenges] … is not at fault for their mental illness, but they are responsible for managing it,” with Participant 11 explaining that “Often people think that because you are a believer in Christ that you should not have mental health issues, but that is a false narrative.”

When research participants responded to questions about what mental health issues they encounter in their organizations, the list consisted of happiness, depression, grief, marital conflict, parent-child conflict, in-law conflict, finances, sex, communication, PTSD, anxiety, personality disorders, autism, suicidal ideation, gender issues, anger, adjustment disorders, addiction, and infidelity, among others. Nine participants specifically referenced depression and ranked it as the top issue in their congregation, followed by six participants reporting anxiety, and four participants specifically identifying finances and grief as top mental health-related issues.

Theme 2: Role of Pastoral Leaders in Mental Health

“My role is to assist the needs of the person who is having an issue. I would not say that leaders are required to address mental health and relational issues. Most people do not come to church seeking to address their mental health issues, they come to be fed spiritually, but I do think that a pastoral leader or ministry leader should be available if someone is seeking assistance for mental health or family relational issues” – Participant 11

After gaining an understanding of the meaning of mental health within FBOs, researchers identified the second theme of what role pastoral leaders experience in addressing mental health needs in their congregations. All but three participants expressed that dealing with mental health and family relational issues was a part of their role as a pastoral leader in their faith-based organization. As stated by Participant 9, “Pastoral counseling and care should be a primary focus of any ministry.” Of the 12 participants, two work as licensed clinicians and one was completing the licensure process. Participant 12 explained that “I address these issues because I am a trained therapist. We have a specific organization in our church that addresses mental health and relational issues,” and described the FBO as “a worldwide agency … where members of the church who are trained therapists and counselors address those issues with church members.” Despite reporting that mental health counseling is a part of their role, 10 participants referenced outsourcing or referring members of their congregation to outside mental health professionals. For example, Participant 9 stated that “My role is to make sure I have the resources/referrals to help others with mental health issues. I believe these issues are outside the pastor scope and role.” When asked how pastoral leaders would utilize access to a Marriage and Family Therapist, nine participants expressed interest in the MFT as a potential resource to address and normalize general mental health, overall health, communication, and relationships, among others.

Theme 3: Mental Health Needs in Pastoral Leadership

“I think we deal with feeling like we have no one to talk to because we’re hiding behind the shroud of perfection. Being on a pedestal (intentional or not intentional) sucks because there comes an expectation that we aren’t supposed to struggle with anything and to tell others that we struggle with something is tantamount to resigning from our posts at some churches. I tell my church all the time that I, too, have problems, and every now and then, I need someone to check on my soul and ask me, “How are you doing?” and actually mean it. Pastors struggle with the same issues everyone else struggles with. We are not immune to any of the struggles of man.” – Participant 2

The third theme that emerged from the research was that pastoral leaders also have mental health needs. Four participants directly reported feeling that pastoral leaders need a personal therapist, and three additional participants articulated a need for personal support and assistance, such as another pastor or mentor, as mentioned by Participant 3. Participant 4 demonstrated this need by expressing, “Every pastor needs a therapist. We need someone that we can trust and talk to regarding issues that we may be experiencing in our lives.”

Eight participants referenced a need for more support for better self-care, such as Participant 12, who explained, “I think pastoral leaders often take on the stresses of their congregants and are not trained in self-care.” Participant 11 stated, “I think depression is a big issue for a lot of pastoral leaders,” with five participants expressing needs specific to experiencing depression. Four participants referenced boundaries as Participant 4 posited, “We take our work home with us … Pastors are not always trained in areas regarding boundaries.” Four participants also cited experiencing isolation and loneliness in their roles. Additionally, respondents mentioned a range of mental health issues, including: anxiety, stress, PTSD, marital fidelity, jealousy, insecurity and intimidation, church hurt, and grief related to the impact of death.

Discussion

A significant contribution of this current study to existing research is identifying the perspectives and needs of pastoral leaders in regards to their own mental health. As addressed in the third theme, the research offers a glimpse into how pastoral leaders conceptualize, experience, and address personal mental health concerns as well as identifying potential mental health needs of pastoral leaders. Thus, the current research offers understanding in connecting the definition of mental health and its perception by FBOs and pastoral leaders and is significant as it may directly impact the individual mental health of pastoral leaders and how they fulfill their roles, as well as assisting their constituents as meeting the needs of their congregants. This novel finding expands the current literature as it connects the perception of pastoral leaders’ mental health and how they address—or dismiss—this matter in faith-based organizations. As one considers the increase of mental health issues in faith-based organizations, along with an uptick in rates of depression, suicidal ideation and suicidal attempts, and actual suicides among pastoral leaders, the findings help to move the conversation beyond “burnout” among pastoral leaders and the need for collaboration and prevention over intervention. This may include a change in training pastoral leaders in the area of mental health, in conjunction with ongoing support offered to them while serving in leadership positions and more instruction on how they address their own mental health needs as well as those of their parishioners (Weaver et al., 2002).

Recommendations

The authors suggest a more in-depth examination of how to address mental health in FBOs, particularly in the methods used to connect members and pastoral leaders to resources. Since the majority of participants reported referring members of their congregations to mental health specialists, this serves as incentive for MFTs and related mental health professionals to explore other applications in their specialties for these communities. A need exists for a deeper investigation into the method of delivery and the extent of mental health training pastoral leaders receive in their education; this could potentially suggest an overlapping component with MFT and other mental health educational curriculums or training programs. Additional clarity in the treatment and resources available for mental health needs within FBOs could increase the level of understanding in terms of how MFTs could benefit members and leaders of these organizations. Identifying the roles of pastoral leaders in the dissemination of mental health counseling, resources and information may provide greater understanding of the connection between mental, physical, and spiritual health and how MFTs and other health professionals can collaborate to address the needs of individuals, couples, and families in FBOs.

Limitations

This study's research focused on exploring the experiences and perceptions of pastoral leaders related to mental health by incorporating a qualitative survey to obtain data from participants. Some researchers might view qualitative research as a limitation due to an inability to generalize its results. However, in the study, researchers viewed the data and considered methods of application to other areas—transferability. One limitation of the study was the small sample size of participants. However, qualitative research lends itself to small sample size with a greater focus on saturation (Saunders et al., 2018). The researchers provided data that could potentially support the development of a larger study with more diversity in terms of types of pastoral leaders and religions. In the study, researchers administered a qualitative survey in an effort to gain insight regarding participants’ experiences, attitudes, and perceptions. However, future research using supplemental qualitative methods such as semi-structure interviews or focus groups could garner additional data. Another limitation of the study related to race/ethnicity since the majority of participants were African Americans, but current experiences facing this sector of the populace related to Black Lives Matter and other experiences of trauma make these individuals important respondents for this research (Watson et al., 2020). Furthermore, the study focused on pastoral leaders and did not include parishioners, which could have provided an alternative perspective regarding mental health within faith-based organizations.

Future Research

Future research may include exploring pastoral leaders’ attitudes, perspectives, and beliefs related to mental health, using both quantitative and qualitative methods. Authors may consider exploring (1) a greater understanding of mental health and relational concerns within the context of spirituality; (2) pastoral leaders’ responses to mental health issues within faith-based organizations; and (3) how pastoral leaders experience and address their own mental health and relational issues. Given that pastoral leaders discussed scenarios experienced within their own families of origin, while shouldering the responsibility of leading their constituents, researchers could further explore potential opportunities for social support and intervention for pastoral leaders as well as their spouses and children (Potts, 2021), who may also experience mental health and relational concerns.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship and/or publication of this article.

ORCID iD

Darren D. Moore

Darren D. Moore, is a core faculty and the Associate Director of Clinical Training and Supervision in the Marriage and Family Therapy program at The Family Institute, Northwestern University. He formerly served as the Program Director of the MFT program at Touro University Worldwide. He is also the owner of I AM MOORE, LLC, a private practice. Dr. Moore directs the MOORE Lab and his research and clinical focus is far reaching which includes, obesity, weight loss, and eating disorders, fatherhood and fatherlessness, men, mental health, and couple/family relationships, and leadership, diversity, equity, inclusion, and sense of belonging in higher education and other workspaces. Dr. Moore obtained his Ph.D from Virginia Tech University and holds a Masters of Arts in Higher and Postsecondary Education, from Teachers College, Columbia University. Dr. Moore can be reached at moore@iammoorellc.com.

Charles Williams, is a Licensed Associate Counselor and a Licensed Associate Marriage & Family Therapist in the state of Arkansas. He works at a treatment facility in central Arkansas and is completing a degree in Theology at Reformed Theological Seminary in Jackson, MS. He is interested in the impact of economic disparities on families, self-image, toxic shame, faith-based organizations, trauma, and utilizing systems theory and other evidenced based practices in his work with in the individuals, couples, and families. Mr. Williams ca be reached at cwcharlesmwilliamsjr@gmail.com.

Clinton E. Cooper, is the owner/operator of a private therapy, coaching, and consulting practice in Scottsdale, AZ, and is licensed in Arizona and Georgia. He serves as a research associate and a senior member of Dr. Moore's research team. Clinton’s research interests includes: exercise, weight, and eating-related disorders; couples issues, health disparities in minority populations, sexuality, gender identity, and elder populations within individual, couple, family, and larger systemic relationships. Mr. Cooper can be reached at cliclint@clintcoopertherapy.com.

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