In-Depth Continuing Education For Clergy In Mental. Health: Ten Years Of A Large Scale Program. Marvin Wasman, Ph.D., Richard B. Corradi, M.D., and ...
In-Depth Continuing Education For Clergy In Mental Health: Ten Years Of A Large Scale Program Marvin Wasman, Ph.D., Richard B. Corradi, M.D., and Norman A. Clemens, M.D. Case Western Reserve University
A B S T R A C T : This paper describes an interdenominational continuing education program for parish clergy in the mental health dimension of pastoral work. The program is in its eleventh year and has reached a significant proportion of the clergy, representing a wide range of religious, ethnic, and socio-economic groups, within a large urban community. The format utilizes case-oriented, small group discussion focused on the clergy's own pastoral work. It emphasizes preventive educational activities along with the development of basic counseling and mental health skills. Ongoing evaluation indicates that the program constitutes an effective, economical, and flexible tool for continuing education with clergy.
As community mental health programs have looked beyond traditional psychiatric and social agencies for additional resources, there has been increased recognition of the potential contribution of the clergy to a variety of mental health activities. Indeed, the clergy's role may allow for unique opportunities for intervention with individual~ family, and community problems. At the same time the inadequacy of the training of most clergy in the mental health area has been strikingly evident to both the mental health professional and the clergy themselves. In 1967, a community planning group was organized by the local mental health association with the purpose of initiating a program to develop the mental health skills of the clergy from all denominations Dr. Wasman is Assistant Professor of Psychology, Dr. Corradi is Assistant Professor of Psychiatry, and Dr. Clemens is Assistant Clinical Professor of Psychiatry in the Department of Psychiatry, School of Medicine, Case Western Reserve University, Cleveland, Ohio, 44106. This work has been supported in part by the National Institute of Mental Health Grant MHl1929 and by grants from the Cleveland Foundation, The Grant Foundation, Inc., and The Cuyahoga County Board of Mental Health and Retardation. The authors wish to thank Dr. Milton Matz, the current Director of the Pastoral Psychology Service-Institute, Case Western Reserve University, for his advice and cooperation in preparing this article. Pastoral Psychology, Vol. 27(4), Summer 1979 0031-2789/79/1400-0251500.95©1979 Human Sciences Press
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within a large metropolitan area. The program was aimed at parishbased clergy who, by virtue of their role, were forced to cope with a variety of psychological problems and mental health issues in their daily ministerial activities. The program had to be flexible enough to serve the needs of clergy with varying levels of experience and formal training, who represented a variety of religious viewpoints, and to serve inner-city, suburban, and even rural congregations of widely diverse socio-economic, racial, and ethnic composition. From the onset, the planners rejected the usual workshop or weekend seminars dealing with topics such as drug abuse, alcoholism or personal growth. We subsequently found in a survey that the majority of ministers had attended such workshops and were highly dissatisfied with these programs. Their complaints confirmed Scarlett's 1 criticism that such workshopS offered information, but no opportunity to develop skills. It seemed evident that even an extended didactic seminar on topics such as psychopathology, counseling, or child development would involve a similar limitation in providing a bridge between the knowledge of the mental health professions and the clergy's day-to-day problems. The idea of an internship within a hospital or agency was also rejected because it provided practicum experience outside of the context of the parish and the pastoral role. Given the goal of developing the clergy's skills within the context of parish work, a program was developed based upon a modification of the consultation model often used in medical education. This approach utilizes small group discussion and integrates didactic teaching around case material--in this instance, problems encountered in the participants daily counseling and other clerical activities. Caplan 2 has described a somewhat similar consultation model involving small group discussions of issues related to counseling in general parish life within a single denominational setting. Westberg and Draper 3 reported on a program designed to reach all clergy within a single community involving an intensive didactic sequence followed by ongoing group consultation. This paper reports on a program which has remained continuously active for ten years and has survived a variety of changes in funding and administrative structure. It also reveals the assets and limitations of the consultation model within a community program. Evaluation data indicate that the program has been successful and confirm the important and unique role of the clergy as a mental health resource within the community. Our observations on this role in the context of pastoral work has been presented elsewhere. 4
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Overview
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A clinically-oriented case conference format is the foundation of the program. The clergy meet weekly for two and a half hours, in groups of eight to twelve, for 70 sessions in the two-year core program. They present cases from their current counseling activities with group discussion ranging from case-specific issues to more general topics. With the case material as a starting point, major emphasis is placed on enhancing skills in interviewing, evaluation, referral, supportive counseling, and mental health education. The faculty consists of psychiatrists, psychologists and social workers, m a n y of whom have special interests and considerable experience in working with the clergy. Staff members are assigned to a group for one y e a r and serve roles which include teacher, group leader, and group member. Clergy who have completed the program have, at times, been utilized as co-instructors. The composition of the discussion groups is representative of the community at large; clergy of all the religious faiths, serving both inner-city and suburban congregations and reflecting an ethnic diversity, are assigned to the groups. The participants are exposed to case material and counseling problems which they may not have experienced in their own parochial setting. The most important prerequisite for admission is current activity in pastoral work in a parish setting. By J u n e of 1978, 376 clergy, or approximately 25% of all the clergy in the metropolitan area had participated. A full annual enrollment of 50-70 has been consistently maintained. As local community mental health centers have been established, a group has been set up in each center composed of clergy from its service area. Other groups have utilized churches or local facilities to help establish community ties and a more integrated support system within a neighborhood. While no academic credit is given for the course, graduate students from a nearby seminary have also enrolled in the program as part of their degree work in pastoral counseling. The program has been supported by a combination of private, county, and federal funds supplemented by tuition charges. An advisory board of participants, alumni, and interested clerical and lay persons was established and has been an important factor in obtaining community support. Sources of funding have changed as the program has evolved and become part of the community's ongoing mental health effort. The program was initially funded by the local mental
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health association and private foundations. It was later incorporated as part of a university sponsored continuing education program and supported by a grant from the National Institute of Mental Health. This academic base has been important in contributing to the stability of the program and to its acceptance in the community. Current support is also provided by the county board of mental health and retardation. Tuition charges, ranging from $120-$300 per year have helped defray costs. Liberal scholarships have been utilized by about 20% of the participants. Evaluation has been built into the program from its inception. Independent evaluators undertook formative evaluation by observing the ongoing groups and eliciting comments from the participants and instructors. Summative evaluation provided data on the effectiveness of the program in increasing skills. These procedures included: (1) questionnaires administered at the beginning of the program concerning the participants' own perceptions of their counseling skills and their responses to some common counseling situations; (2) tests administered at the end of the first and second years assessing their response to a sample of counseling problems; (3) observations and evaluation of progress by the instructors; and (4) a follow-up questionnaire concerning the reactions of the clergy to the program and their current counseling activities one year or more after completion of the course. Evaluation results were fed back to the teaching faculty to assess the extent to which curricular goals were being met. This process resulted in several modifications of the program, especially in its early stages.
Background Of The Clergy A total of 226 clergy have completed the two-year core program in ten years. An additional 68 completed one year of the program only. Dropouts after the first three months were relatively low (a total of 45) and primarily resulted from scheduling conflicts and transfers to other geographical areas. Representation by religious affiliation has corresponded to the distribution of clery listed in church organizational directories for the county. About 75% of the participants described their congregations as predominantly middle class. In recent years there has been a marked increase of clergy from black, low-income, and/or inner city churches as a result of active recruiting efforts by personal contact rather than relying on announcements in denominational newsletters. The participants have had considerable experience in the ministry; about 75% have had five years or more of pastoral experience. They
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reported initially an average of eight hours per week spent in counseling activities. During the program many found that they had underestimated, to a considerable degree, the time actually devoted to counseling. Contacts tended to be brief (less than five sessions), and less than ten percent of the participants engaged in long-term colmseling. Eighty-five percent reported that family problems, including marital conflicts and problems with adolescent children, were encountered most frequently and were the most difficult to handle. Other surveys of clergy (e.g., Kaseman and Anderson)5 report a similar emphasis on marital and family problems along with strong feelings of inadequacy in coping with this area. The clergy in our study rated bereavement as the next most important area of their counseling work, but felt far more comfortable in handling bereavement than other problems, such as alcoholism, drug abuse, and serious psychiatric illness. The most frequently utilized resource for consultation was, not surprisingly, another pastor rather than a mental health professional. T e a c h i n g Specific Skills Virtually all of the clergy began the program with no formal training and limited skills in interviewing. They were uncertain as to how to begin and end an interview; they generally lacked any plan as to the sequence of topics to be covered; they were unfamiliar with the use of open-ended questions; and they felt particularly ill-at-ease in bringing up problems which were sensitive or stressful to the congregant. They tended to ignore the impact of their own nonverbal communications. Frequently their behavior in interviews was more appropriate to other pastoral settings although they were unaware of the incongruity. Interview skills were taught in a variety of ways throughout the two years of the program. The instructors encouraged the presentation of detailed interview material in the discussions of counseling cases and provided comments and suggestions wherever appropriate. During the first year instructors provided a model by interviewing hospital patients or congregants in front of the group. Later in the program the clergy themselves sometimes conducted interviews in front of the group, and the interview was then analyzed in detail. Role playing and recordings were also utilized to review specific techniques and problems. However, the pastor's interviews in the context of his own counseling activities remained the major focus of the seminar. The evaluation skills of most clergy were initially poor. Even some clergy with years of counseling experience did not utilize the concept of evaluating and defining a problem before making a referral or enter-
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ing into a counseling relationship. They were unable to formulate major issues, discriminate between acute and long-term aspects of a situation, weigh the resources and weaknesses of either an individual or a family, or establish hypotheses regarding aspects of the problem which were not immediately evident. They often felt under pressure to act or provide some kind of advice before they had sufficient information upon which to base their recommendation or course of action. The instructors stressed the importance of obtaining information and conceptualizing the problem as a necessary step prior to intervention. At the same time they avoided imposing a formal psychiatric framework in formulating a problem. Most groups evolved a mixture of psychological, social, and religious concepts which seemed appropriate to the role of the clergy. Initially the clergy were unfamiliar with public and private mental health resources with the exception of a few social agencies. They did not view themselves as part of the mental health resources within the community, and were uncomfortable in discussing issues of referral, both with mental health professionals and with their congregants. Referral skills are, of course, closely related to evaluation skills since evaluation of the problem essentially dictates its disposition. As the program proceeded, especially within the second year, improvement in referral skills paralleled increased effectiveness in evaluation. The clergy also became more comfortable in presenting and discussing these issues within their own counseling situations. The program has primarily emphasized the development of supportive short-term counseling skills which focus on current reality-oriented problems. This approach seems most readily incorporated within the clergy's role. For example, the clergy report that marital and family crises constitute the problem area with which they are most frequently confronted. We have emphasized the pastor's unique relationship with the family which provides opportunities for intervention not available to mental health professionals. The case discussions often served as a basis for considering broader issues involving structure, role, and interaction patterns of the family. At the end of the core program the clergy, as a group, acknowledged that their marital and family counseling skills had improved, but felt that they still had difficulties in dealing with the complexities of these problems. Supportive counseling and crisis intervention were also discussed in relation to developmental landmarks such as marriage, birth, illness and death. Other work focused on less clearly defined neurotic and character problems, often involving symptoms of depression which are frequently seen in a variety of pastoral and medical settings. Individu-
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als whose psychopathology includes an intense attraction toward church settings and religious figures represent a special problem for the clergy. These religious preoccupations result from a wide range of severity of disturbance and require carefully individualized intervention. Technical aspects of psychotherapeutic work were considered outside of the scope of supportive counseling; however, the importance of recognizing the sources of the congregant's feelings about the counseling relationship was actively stressed. Discussion also focused on special problems arising from the pastor's position as a religious figure, which may stimulate and encourage fantasies pertaining to authority, omnipotence, and magical powers. Throughout the program we stressed the unique potential for preventive mental health intervention inherent in the educational and liturgical functions of the religious institution. Haugk s has described the manner in which the church school, educational groups, social groups, and even Sunday sermons all represent settings which deal with human problems and psychological issues. They provide a unique educational opportunity to promote healthy personality development: Some participants successfully initiated groups to discuss and confront issues such as death and dying and parent-child relationships. By the sixth year of the program, a sizeable group of core graduates requested an in-depth consideration of the three major problem areas brought to clergy--marital conflict, terminal illness and bereavement, and parent-child crises. Three advanced one-year training sequences were developed to increase selected clinical skills in each of these areas. The preventive mental health aspects of liturgical and educational functions were further explored. The course on death, dying, and loss has been described in a paper by Clemens. 7 E v a l u a t i o n Of The T e a c h i n g F o r m a t
Based upon our observations of performance within the group setting, limited formal testing and the clergy's own reports, we are satisfied that significant gains in mental health skills have been achieved by most of the participants. One criterion of the program's success is the fact that we have maintained a full enrollment for 11 years despite changes in funding sources, teaching staff, and denominational leadership within the community. We feel that the clinical case model within a small group context constitutes the foundation of the program. This experience appears to contrast sharply with workshops and lectures given from the mental health professional's perspective which is often irrelevant and incomprehensible to the parish clergyman. Instead, the
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focus on pastoral counseling material allows for discussion of mental health concepts in the context of clergy's everyday experience. In addition, the continuity of the program over a two year period allows for feedback regarding the progress of cases and the gradual development of counseling skills. It is important to acknowledge the problems associated with teaching in case-oriented group discussions. Important topics can be omitted if none of the participants presents a relevant case. Sometimes the instructor is required to modify the format by planning a sequence of topics and requesting relevant case samples. In addition, because of the necessity for group interaction and response to the case material, few topics can be covered systematically from a didactic and theoretical standpoint. Individual instructors differ in their orientations, and the absence of a fixed syllabus or course outline further contributes to the variability between groups. However, a basic core of topics, including areas such as family and child development, problems of adolescence, marital problems, bereavement, and serious mental illness is covered with a practical rather than theoretical focus. The utilization of various mental health disciplines, including psychiatry, social work, and psychology, serves to enrich the program. The emphasis in psychiatric teaching on diagnosis and psychopathology has not proved relevant. In many ways an emphasis on interpersonal dynamics, especially in family and marital relationships, appears more useful to the pastoral role. All of the instructors have continuously modified their teaching methods as a result of their interaction with the clergy. Thus, a long-term teaching commitment from the instructional staff appears essential to the success of the program. We believe that the group process constitutes a significant aspect of the program. Although clergy often meet, it is rare for them to discuss pastoral counseling activities. In fact, time pressures, rivalries, and self-doubts appear to discourage such discussions. In the ecumenical, neutral setting of our weekly small group meetings, they seem to find mutual support and a renew6d interest and fulfillment in their ministry. In fact, the group process became so important that early efforts to develop individual supervisory contacts between the instructors and clergy were rarely fruitful. Personal issues are often brought up in the group when they seem relevant to the immediate topic or issue. The instructors are careful to utilize personal experience within appropriate limits, maintaining a teaching focus and avoiding the development of a sensitivity or therapy-oriented group experience. The success of the program with regard to the development of the role of the clergy in primary prevention has been more difficult to
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assess. Some participants have utilized opportunities within the church, helping their parishioners prepare for dealing with psychological issues related to normal crises and developmental landmarks. Other participants appear to feel uncomfortable in working with groups or choose to delegate this responsibility. We hope that, after completion of the program, they will be able to translate some of the skills and experience in working with individual problems into the broader context of preventive work. In the early phase of the program we had the concern that some clergy might begin to identify with the psychotherapist's role to an inappropriate degree or might even leave the pastoral ministry for careers in private practice counseling for which they are unprepared; this outcome has not materialized. To the best of our knowledge the clergy emerge from the program with a realistic view of the limitations in their skills. In fact, they often need support and encouragement to take on problems which are within the range of their experience and ability. We feel that this program constitutes a model for other communities in developing the mental health skills of clergy. Recently, the current director of the program has aided in the development of a similar program in a somewhat smaller city and has served as a consultant to a national religious group concerned with providing such opportunities elsewhere. The program appears to represent an economically feasible approach to teaching large numbers of clergy and appears adaptable to a variety of local circumstances and programmatic growth. Reference Notes 1. W. George Scarlett, ~The Clergyman's role and community mental health," Mental Hygiene, Vol. 54, 1970, pp. 378-381. 2. Ruth B. Caplan, Helping the Helpers (New York: Seabury, 1972). 3. Granger E. Westberg and E. Draper, Community Psychiatry and the Clergyman. (Springfield, Ill.: Charles Thomas, 1966). 4. N. A. Clemens, R. B. Corradi and M. Wasman, ~The Parish Clergy as a Mental Health Resource," Journal of Religion and Health, Vol. 17, 1978, pp. 227-232. 5. Charlotte M. Kaseman and Robert G. Anderson, "Clergy Consultation as a Mental Health Program," Community Mental Health Journal, Vol. 13, 1977, pp. 84-91. 6. Kenneth C. Haugk, ~'Unique contributions of churches and clergy to community mental health," Community Mental Health Journal, Vol. 12, 1976, pp. 20-28. 7. N. A. Clemens, '~An Intensive Course for Clergy on Death, Dying, and Loss," Journal of Religion and Health, Vol. 15, 1976, pp. 223-229.
