Journal of Religion and Health, Vol. 13, No. 2, 1974
Mental Health Consultation With Religious Leaders THOMAS S. HULME A s tatemen t attributed to Adolf Meyer in his presidential address at the 84th anniversary meeting of the American Psychiatric Association is that " o n e o f the most i m p o r t a n t lessons of m o d e r n psychiatry is the absolute necessity o f reaching b e y o n d asylum walls and working where things have their beginnings. ''1 U n f o r t u n a t e l y , a careful reading of Dr. Meyer's address fails to uncover the presence o f this felicitous phrase, although it is true to his t h o u g h t t hat psychiatry must b e c o m e extramural, moving b e y o n d the institutions and offices of his day. To work " w h e r e things have their beginnings" is to me b o t h the challenge and the o p p o r t u n i t y for consultation by mental health caregivers who feel th at assistance must be made available to children and their families as early as possible. We need to reach b e y o n d the p r o t e c t e d walls of our hospitals, clinicg, and offices with our 8-to-5, 40-hour weeks, into the c o m m u n i t y - - t o the YM and YWCAs, to the nei ghbor h ood houses, to the schools, to the homes, and to the churches and synagogues. Unless we do so, how shall we reach to " wh er e things have their beginnings," to the children of this land? It is my purpose to set f or t h some specific suggestions for knowledgeable and effective consultation by mental health professionals with Christian clergymen and Jewish rabbis, who are the single most i m p o r t a n t group of c o m m u n i t y caregivers in this count r y. I shall n o t consider in detail the work of the rabbi and the synagogue, since I have no expert knowledge in this area. In general, whatever is true of effective consultation with Christian clergymen, their training, and their willingness to be of assistance to their fellow-men is equally true of their Jewish counterparts.
The opportunity for consultation with religious leaders The J o in t Commission on Mental Illness and Health r e p o r t e d that 42% of persons with a wide range of personal, marital, and parent-child problems who turn to others f or help do so to the clergy, while 29% turn to physicians, 18% to psychiatrists or psychologists, and 10% to social agencies. 2 There are few statistics available t o suggest any significant changes The Rev. Thomas S. Hulme, A.C.S.W., an ordained Episcopal priest, is now Director of Field Services, Iowa State Services for Crippled Children. He was a psychiatric social worker in the child psychiatry service, Department of Psychiatry, University of Iowa, Iowa City. 114
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in these figures for the decade since then. Further, these same religious leaders are in a position to identify, assist, or refer m a n y more, since some 100 million persons belong to churches or synagogues and 170 million profess a belief in God. With the important exceptions of the fundamentalist and Pentecostal church groups and the recent entry of the Roman Catholic Church into the mental health field, old-line American churches have long been active and concerned with mental health especially in the provision of training for the ordained ministry. Pastoral counseling has been the focus of such training since the mid-1940s. The need is n o t normally to "sell" the clergy on the significance of their opportunity, but how to train them to do their job better. They especially need training in study and assessment of problems of living and relationships and in crisis intervention. It is m y opinion t h a t normally long-term depth counseling should not be a t t e m p t e d in a parish situation if other resources are available, because of lack of specialized training of the clergy, a variety of other relationships with the person, and other demands on the cleric's time. The mental health consultant can be of great assistance to the clergy, working with them as a consultant and in the provision of ongoing in-service training programs. To be effective, the consultant must be aware of and sensitive to the spiritual resources of the churches in the total healing process. It is not his role to make "psychiatrists" of the clergy, but to strengthen them in their professional roles. In January of 1971, one of the resident psychiatrists of our hospital and I met with a large group of Episcopal clergymen. The subject was "Behavior Disorders of Childhood--The Overanxious Child and the Hyperkinetic Child." Our presentation included some historical background on this conceptual framework and some of the s y m p t o m a t o l o g y t h a t the clergymen might observe in their role as parish priests. Ways in which the resources of the parish church could be used effectively to help such children, their parents and families, were suggested, as were the circumstances under which referral should be made. The response by these clergymen was immediate and enthusiastic. The conceptual model of behavior disorders of childhood was one t h a t could be transposed immediately into their mental framework w i t h o u t a long preparation in the terminology of classical psychoanalysis, and, more important, "it made sense." Second, the clergymen could use the s y m p t o m a t o l o g y as a clue to ways in which t h e y could provide preventive help to their families and children, where "things have their beginnings." A request for more such conferences was made immediately by these clergymen. Special opportunities o f the clergy
The mental health professional should consider carefully the special opportunities that the trained and observant cleric has readily available to
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assist in assessing, referring, or helping children and their families, for he has an entr6e into the lives of his flock at almost every important turning point. In addition, the pastor has the chance to observe them on a daily or weekly basis. For example, the cleric can observe the hyperkinetic child and the parenting patterns in the home as he makes his pastoral visits; he can observe the same child creating havoc in his nursery school, or squirming over and under the pews during church services. The overanxious child or the withdrawing child can similarly be observed standing on the fringe of activities during vacation church school or clutching desperately the hand of his equally overanxious mother. The parish pastor soon hears of the deeds of the unsocialized, aggressive youngster in the parish or in the neighborhood, and he can also accompany the family of the group delinquent to court. Not only does the easy entr6e of the cleric into the daily life of his parishioners provide him with a unique vantage point for observation, study, and assessment, but he has a special authority with his people. This authority may be based, on personal ability, charisma, goodwill, or the "magic" influence that is ascribed to the results of ordination, prayer, and sacraments. Whatever the source, the ordained minister, priest, or rabbi has a great deal of formal or informal authority that he can use when a referral to a clinic or hospital is needed. His words of guidance and reassurance that the parents are indeed doing the "right thing" can be of great assistance in facilitating a family's early referral and their willing co-operation with the recommendations made by the mental health professionals. Clergy with parochial responsibilities are continuously engaged, both formally and informally, in treatment through their pastoral counseling. Such counseling can have a high degree of mental health expertise. It can occur before marriage, at the birth or baptism of a child or at his confirmation, at times of sickness--either mental or physical--at death and times of bereavement, and in the continual round of crisis situations that make up the daily lives of people. The impact and therapeutic possibilities of the weekly sermon, the parish coffee hour, and the various organizations should never be overlooked. For better or worse, the clergy are doing counseling with far larger numbers of persons than ever appear on the case loads or waiting lists of mental health clinics and hospitals. The parish clergy are, in one sense, the last of the general practitioners: trained professionals with a reasonable degree of competence in many areas. It is the opportunity of the mental health professional with a high degree of skill in particular areas to aid the parish clergy in their study, assessment, and t r e a t m e n t of their people, to guide them when referrals are needed, and to enlist their knowledgeable assistance for follow-up counseling. This opportunity can best occur through consultation. Consultation definitions
The consultation process as defined by Caplan 3 and Gorman 4 and others involves an interaction of role, process, and function. All are related to some
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" p r o b l e m " to be "solved." Each needs to be clarified and u n d e r s t o o d by b o t h the consultant and the consultee. Such consultation can take place in m a n y ways. The following is one classification. First is case insight, in which increased understanding is given to the consultee in p r o p o r t i o n to his increased professional need. Such understanding may be in m a ny areas. If it is t h a t of psychological functioning, for example, the purpose is to assist the caregiver in understanding more clearly the dynamics o f the client so that he can bet t er use his own skills and training in aiding the client. This m a y include joint observation or an interview for assessment by t h e consultant, with discussion and planning afterward. Second is action-help. In this situation the consultant brings his knowledge o f facilities and c o m m u n i t y resources to aid the consultee in making plans for a client. The consultant's role is also to be a support er and clarifier for the consultee as he works out what is appropriate or possible within his institutional setting. It is n o t the mental health consultant's role to impose his mental health plans. Third is consultee crisis. In this situation, the consultee himself needs assistance, for the client's problems have p r o d u c e d in him distortions of perception, the use of stereotypes, or projections of old difficulties. The result is that the consultee's effectiveness has been impaired by his own unresolved problems or "sore spots." The consultant's role is n o t t hat of providing p s y c h o t h e r a p y to the consultee, b u t of assisting him t o work through th e problems of the client with a sensitive awareness t hat the consultee is working through his own problems in the process. The focus is still on the client, but there is a great need for warmth and support for the consultee. F o u r t h is direct administrative consultation. Here the focus is on social systems o f a c o m m u n i t y or an institution or agency and their policies and programs. In this f or m various leaders, professionals in m any fields, consult t o g e t h e r ab o ut the best procedures to use to alleviate the problems. The primary goal is prevention. In all o f these modes of consultation, the basic purpose is to bring fort h the latent possibilities in various situations and f r o m all kinds of people; to stimulate th e m to take responsibility for themselves; to enable t h e m t o f u n c t i o n more securely and i n d e p e n d e n t l y ; to internalize adaptive skills of a more flexible and creative nature. Consultation should be distinguished f r o m direct clinical service. The goal is to aid the c o m m u n i t y caregiver in providing professional assistance to his client or agency. Thus, in an ever-widening circle, more persons are trained and assisted in the care of persons. Clergy practices and attitudes toward mental health problems As Charlie, in Meredith Willson's The Music Man, says to the traveling salesman with the handlebar moustache, it is n o t t h a t things have changed,
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but that " y a gotta know the territory." Charlie's advice to the salesman, who insisted that "it's different than it was," is essential for those who meet such c o m m u n i t y caregivers as the clergy, for whom much has changed. Indeed, the consultant has to " k n o w the territory." The consultant who knows the territory will be very conscious of the variable of the clergyman's training and interest. "Begin where the consultee is" is a good rule for consultants, as well as for social workers in relation to their clients. The range of clergy training in mental health areas extends on a continuum from very little to great professional competence. Even the focus of the training must be clarified. All clergymen are trained to handle both emotional problems and problems in living. The content of this training may be in mental health areas or in pastoral counseling techniques or in, strictly speaking, " c h u r c h " methods of prayer, exhortation, advice, support, acceptance, and encouragement. There is a significant difference noted in the responses of clergymen in Memphis, Tennessee, in a study between those who finished seminary prior to 1945 and others who were graduated later. The study, by Sandler, drew these conclusions: 1) Two hundred thirty-two ministers (38.6%) replied to a mailed questionnaire. 2) Training in counseling comes from self-study, seminary, seminars, and postgraduate courses. 3) Self-study was the major means of training in counseling for the pre-1945 group, but the post-1945 group considered the seminary as their major source of training in counseling. 4) The problems most c o m m o n l y brought to ministers for counseling are: a) marital problems; b) drinking; c) lack of faith; d) sexual maladjustment. 5) The problem most c o m m o n l y referred to a psychiatrist is obvious mental disease. 6) With the improved training in psychiatry since 1945, communication between psychiatrists and ministers has improved. The post-1945 group more frequently refer a person with an obvious mental disease to a psychiatrist. They also feel much more at ease in counseling and therefore a t t e m p t much more counseling than do those in the pre-1945 group. 5 A similar study by Wauck of the training being introduced in the Roman Catholic Church supported these findings, especially in the large urban areas such as Chicago. 6 Larson, a sociologist, studied denominational variation in clergymen's attitudes concerning mental health. 7 In two studies, in a New England state and a Western South Central state, three key factors were identified: 1) selective recruiting for the ministry on the part of the religious denomination; 2) the socialization process within the seminary as well as in the secular world; and 3) the demands of the minister's parishioners, especially for pastoral counseling. Data from both New England and the
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Southwest clearly supported the importance of the first two factors in influencing the attitudes of the clergy; the significance of the third factor depended on the socioeconomic backgrounds of the parishioners. In the New England state in 1963, the total population questioned for the study included 949 clergymen, from w h o m there were 422 usable responses, including 191 from the Roman Catholic Church alone. In the West South Central state, in 1965, the total population studied was 5,542, from which came 1,868 usable returns, 124 of them from Roman Catholics. This state is predominantly "Bible Belt" in contrast to the heavily Roman Catholic New England state. Larson indicates that in his study all relationships are significant beyond .01%. (The instrument in both cases was identical except for the addition of one set of questions in 1965 designed to give further specification.) The conclusions were that conventional Protestant clergymen (Episcopal, Disciples of Christ, Lutheran, Presbyterian, Methodist) have significantly more favorable attitudes toward mental health and mental illness and its causes than have conservative Protestants (Baptists and Church of Christ), who were more favorable than were fundamentalist Protestants (Nazarene, Church of God, Freewill Baptists, Assembly of God, and Pentecostals). Religious affiliation was a key variable. In the Western South Central state, Episcopal priests ranked 87% above the median on the "favorable attitude toward mental h e a l t h " scale, the highest for any denomination, with the Pentecostal ministers ranking the lowest, with a 6% favorable response. In the New England state, the order was different, with the United Church of Christ first and the Episcopal clergy second. Age of clergy was found to be a significant factor in both states surveyed. Those under 35 gave a 65% favorable response to questions indicating favorable attitudes to mental health and mental illness; of those over age 45, a favorable attitude was f o u n d in 25% or less of the respondents. Urban pastorates, compared to rural, produced similar results, as did larger congregations. The level of skilled or professional training of one's father was important. Clergymen with professional degrees from a seminary had a 69% favorable response to the mental health questions; those with one to three years of college had a 27% favorable response; and those with a high school education or less responded 13% favorably. Finally, and most important for consultants, this study noted t h a t m a n y clergymen have attitudes and opinions that might readily interfere with psychologically oriented referral policies. For example, in the New England state, due to factors just noted, the Episcopal clergy ranked low on questions designed to test realistic opinions on the causes of mental illness, while in the West South Central state, t h e y ranked first, with an 85% favorable, compared to the Pentecostals' 20%. In the East, the R o m a n Catholic priests had the lowest position on these scores; in the Western South Central state, they were in fourth place.
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Who seeks help from the clergy ? The clergymen considered in this paper are those having definite parochial responsibilities and ties. Not included in this analysis are those in specialized ministries, such as chaplaincies and "worker priests," since the variables are so great as to defy generalizations regarding mental health practices. Those seeking help from the parochial clergy fall into three groups. The consultant who works with a cleric around client problems needs to know into which group the client falls, since this affects the cleric-consultee and his practices and referrals. The first group, and the one most likely to be referred to mental health professionals by the clergymen, are the "walk-in" clients. They are persons w i t h o u t any formal connection with the particular parish or congregation the clergyman serves. The parochial clergyman's position fits no job description; it can, and usually does, consume all the time and energy he feels he can invest. Further, he is trained to be a pastor and shepherd to his " f l o c k , " whom he knows by name; they will follow his voice. The walk-in client does not belong to this identifiable group and so represents an added demand on a working schedule that is already full. The cleric is likely to have little emotional investment in him b e y o n d hearing his problem and determining (one hopes) the best referral source. This pattern is especially true in older, d o w n t o w n urban congregations, where the parish itself is large and surrounded by a large, anonymous, and highly transient population. An exception to this position is the parish (and there are many) t h a t is making a concerted attempt to serve precisely this group of transient outsiders. In this kind of parish, the cleric may have a high degree of investment in his "congregation at large," he may be quite resistant to referral, or if he refers, he will make or demand some follow-up by the mental health professional to w h o m the person is referred. In all cases, it is important to assess clearly the level of investment made by the clergyman and to know what feedback is expected. The second group seeking help from the clergyman is made up of people referred to him by members of his congregation, who have, until it is possibly proved mistaken, a great expectation of their pastor's universal competence. Many clergymen feel that they must accept this belief and try to live up to it. They cannot admit to their people, or to themselves, that they are less able than this unreasonable expectation demands. It is at this point that referral patterns change noticeably. With such a referral, the cleric is far more likely to make a number of appointments before he makes a referral, unless there are obviously severe mental health problems. His training, age, denomination, and the other factors noted in the Larson study will be important elements in his decision whether to refer or whether he can provide the assistance needed. I believe that at this point the mental health consultant can be of immeasurable help to the clergyman in providing group training as well as
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case-centered consultation on principles of crisis intervention, how to recognize signs of serious mental illness, and when and how to make referrals. Obviously, few referrals are likely to be made, or made effectively, if the mental health professional remains isolated in his own professional " g h e t t o . " Clergymen take seriously such referrals to them and feel, depending on the problem and their training, that it is better for t h e m to handle the problem than to make a poor referral. "Better the devil you know than the one y o u d o n ' t k n o w . " All most clerics need is several referrals that are poorly handled, where little is done for whatever reason, where no report is made to them, and where even the simplest matters of professional courtesy are ignored, and t h e y will never make another. The third group who come to the clergyman are the members of his congregation. All the factors present in those referred to him are present now, and in an intensified form. Unless he is secure in his role and place with the congregation, with the mental health professional involved, and with mental health as a profession, these are the persons least likely to be referred. Further, the mental health consultant, in working with the clergyman, will need to determine the degree of investment the pastor has in the member. " M e m b e r " covers m a n y categories: the "pillars" of the church, the regulars, the Christmas-and-Easter group, and those only on the record books but otherwise "in the outer darkness." Even these categories do not indicate clearly the depth of Christian faith and c o m m i t m e n t in the member. There is only a rough correlation between faith and c o m m i t m e n t and church attendance and activity. In general, unless the pastor is highly sophisticated in mental health procedures, he is unlikely to refer those in whom he has the greatest investment. Further, he is most likely to need consultation because of his lack of objectivity regarding them. Mental health consultation is indeed vital before such referrals can be made, if t h e y are made at all, and case, or even consultee-centered case, consultation can be of great assistance at this point. Levels o f consultation requested by the clergy
Clergymen who seek consultation do so on three levels that affect the focus of consultation given. First, much consultation will be provided to individual clerics around individual case problems. These will be persons in one of the three groups already assessed: the walk-ins, the referred, and parish members. Usually the cleric is asking for answers, for specific knowledge to aid him. How do I handle this problem? Is it one I can handle? Should it be referred? To w h o m ? The consultant will need to assess carefully whether knowledge alone will be sufficient, the nature and level of the consultee's skills and abilities, and how to strengthen him as a professional clergyman by making information given both understandable in his frame of reference and convertible for
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f u tu r e use. Also, the level of the cleric's involvement and the reasons for it must be examined. Further, the cleric himself is usually in a crisis situation. There is a problem th at he c a nnot handle or he would n o t be seeking a consultant's aid. Why is he unable to handle it? Is it because of lack of knowledge or skill? Transference? Clerical bias? Or some problems due to the church system itself--for example, divorce and remarriage? H ow does the cleric feel about the client and about himself in regard to this problem? What supports does he need? What defenses is he using? Second, and simpler in many ways, will be the consultant-trainer role with informal groups of clergymen. Such groups may be small ones of friends and contemporaries drawn together by c o m m o n needs and concerns regarding mental health and illness. The clergymen may be from one d e n o m i n a t i o n or f r o m several, sharing a similar point o f view. The groups may be small or as large as a citywide ministerial association. Assessment, again, of what is being asked for and what can be given in the informal group is needed. Usually t he crisis element is missing and education and professional training in behavioral dynamics are sought. Consultation in such a setting more nearly resembles t hat given to any public or private agency around case conferences f or learning or program and policy development. Case consultation m a y develop into consultee-centered consultation; it m a y be of great value. In such groups, more a t t e nt i on can be given to strengthening these men in their professional roles and in learning from t h e m some of the churches' resources for caring for people. The church, in b o t h its sacred and secular dimensions, has been caring for people for several thousand years and has built up a considerable b o d y of skill and knowledge of human behavior. Assessment of the level o f these clerics in their professional skills will be needed. Their motivation will be high; t h e y are likely to be relatively young, with considerable training and education and with some knowledge of psychosocial behavior. Resistance need n o t be a problem, depending on the nature and approach of the consultant. It is my conviction t hat consultation given in this form can be a most valuable and rewarding experience for b o t h consultant and consultee. The third clergy group t o w hom consultation is given is likely to be formal denominational structures: synods, conferences, or dioceses. In these the consultant-educator role is par a m ount . The groups involve m any clergymen with all levels of training and interest. Usually the f o r m taken is that of a conference or short course of several days' duration at some church center. Again, the c o n t e n t may be client-centered or c o n c e r n e d with program and policy. Such groups are not h o m o g e n e o u s in any respect, except that t hey are professional clergymen who have responded to a vocation. Resistance is likely to be high; attendance at such conferences is often required or "strongly urged;" there are m a ny distractions possible, bot h external and internal. In any such group there will be m any and varied attitudes toward
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the c o n s u l t a n t and t o w a r d m e n t a l health. S o m e c l e r g y m e n will be o p e n and responsive, s o m e will be passive or b o r e d , and m a n y will see little value in Sigmund F r e u d and in w h a t t h o s e " s h r i n k s " have t o say. " W h a t was g o o d e n o u g h f o r St. Paul is g o o d e n o u g h f o r m e . " This is an o v e r s t a t e m e n t , b u t n o t e x t r e m e l y so f o r some. In such situations, k n o w l e d g e is primarily s o u g h t and the c o m b i n a t i o n o f personal ability, t h e a u t h o r i t y of ideas, and professional c o m p e t e n c e are n e e d e d b y a n y c o n s u l t a n t . Special p r o b l e m s in w o r k i n g with the clergy The first o f t h e special p r o b l e m s o f consulting with t h e clergy centers a b o u t the e n t r a n c e o f the c o n s u l t a n t . T h e c h u r c h , w h e t h e r o n a national, a district, or a local level, is a highly c o m p l e x system, v e r y old and highly organized 9 The c o n s u l t a n t is an a t t a c h m e n t t o this s y s t e m and inevitably affects its equilibrium. T h e e n t r y p r o b l e m t o each o f t h e t h r e e d e f i n e d s i t u a t i o n s - individual clerics, i n f o r m a l groups, and d e n o m i n a t i o n s y s t e m s - - d e m a n d s careful s t u d y and assessment b y b o t h t h e c o n s u l t a n t and the consultee. If the e n t r a n c e has b e e n s o u n d l y m a d e , the t e r m i n a t i o n phase of c o n s u l t a t i o n with t h e c l e r g y m a n does n o t p r e s e n t a n y p r o b l e m s significantly d i f f e r e n t f r o m c o n s u l t a t i o n with o t h e r c o m m u n i t y caregivers or with a n y o t h e r agencies. A c c o r d i n g l y , I shall n o t d i r e c t l y c o n s i d e r this aspect here. T h e e n t r a n c e t o the individual cleric is in o n e sense t h e easiest. T h e c o n s u l t a n t is t h e r e at t h e pastor's request 9 He has b e e n invited t o aid in t h e solution o f s o m e problem 9 Yet, because it is so easy on one hand, it is m o r e dangerous on t h e o t h e r , unless a simple " w h a t " or " h o w t o " answer is all t h a t t h e c o n s u l t e e will take or t h e c o n s u l t a n t wants t o give. In entering, ambivalence o f the cleric will be a k e y f a c t o r . He n e e d s help, y e t h e is also afraid t h a t h e m a y a p p e a r i n c o m p e t e n t . T o avoid d e p e n d e n c e , the cleric m a y erect defenses to d e m o n s t r a t e or m a i n t a i n his i n d e p e n d e n c e . The c o n s u l t a n t will n e e d all his i n t e r v e n t i v e skills and k n o w l e d g e if h e is t o be o f real assistance to the c o n s u l t e e . With the i n f o r m a l clergy g r o u p , t h e c o n s u l t a n t is invited in, y e t t h e r e is n o d e m a n d f o r help a r o u n d a crisis s i t u a t i o n and n o unusual set o f a m b i v a l e n t feelings t o be h a n d l e d . The c o n s u l t a n t s h o u l d be m o r e free t o f o c u s o n t h e g r o u p process as a learning t o o l , and his k n o w l e d g e and skill s h o u l d ease t h e e n t r y difficulties t o the individual c l e r g y m e n as well as t o the g r o u p as a whole. F u r t h e r , t h e y have each o t h e r f o r professional s u p p o r t and e n c o u r a g e m e n t if t o o m u c h stress is created. T h e p r o b l e m s in e n t r y will c e n t e r a r o u n d t h e e x t e n t o f a g r e e m e n t t h e group itself has established in its goals with t h e consultant 9 In s u m m a r y , Glidewell says: 9 it has been suggested that the entry problem can be defined in terms of the goodness of fit (in congruence, complementation, or conflict) between the consultant and the client social system with respect to three principal variables:
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1. Perception of need. 2. Perception of prospective equity of role, resource, and reward distribution. 3. Perception of prospective appropriateness of feeling interchange, with special concern about dependency and counterdependency.8 Third, the e n t r y p r o b l e m s o f the c o n s u l t a n t will be m o s t clear with the s t r u c t u r e d , f o r m a l d e n o m i n a t i o n group o f clergymen. T h e c o n s u l t a n t is perceived as entering i n t o their meeting, on their t e r r i t o r y , to tell t h e m s o m e t h i n g a b o u t their job. F u r t h e r , he is i m p o s e d on t h e m , t h o u g h invited b y their d e n o m i n a t i o n a l c h u r c h a u t h o r i t y . Glidewell states f u r t h e r : The problem of entry of consultant into the consultee system requires careful planning and negotiation since the admission of an outsider into any system, even if welcomed, is apt to cause some system disequilibrium. The preliminary discussions and negotiations should result in a contract, which, whether formal or informal, verbal or written, nonetheless explicitly defines mutual expectations and responsibilities. Further periodic clarification and redefinition may be required to maintain the consultation contract. A t h o r o u g h k n o w l e d g e o f h u m a n d y n a m i c s is useful t o a c o n s u l t a n t w h o is serving as an e d u c a t o r t o the clergy. T h e w h o l e range o f h u m a n d y n a m i c s and i n t e r p e r s o n a l relationships will be present. S o m e o f the clergy group will w e l c o m e him, s o m e will be passive, with a " w a i t and s e e " a t t i t u d e ; others will be resistant. S o m e will seek to impress him and others; some will be o p e n l y hostile. T h e c o n s u l t a n t needs t o be aware o f the forces at w o r k within this g r o u p o f professionals t h a t have little to do with him; he needs t o be secure within his professional c o m p e t e n c e , ability, and knowledge. In a d d i t i o n t o the e n t r y p r o b l e m , t h e r e is an entire range o f o t h e r p r o b l e m s , some o f which will be n o t e d in a n y or all o f the t h r e e consulting situations discussed. First, t h e r e is t h e p r o b l e m o f professionalism, a l t h o u g h this m a y be m o r e o f a p r o b l e m t o the c o n s u l t a n t t h a n t o t h e consultee. T h e o r d a i n e d clergy are a professional group. Most o f those with w h o m a c o n s u l t a n t will w o r k have a high degree of training--three to five years b e y o n d college, plus f u r t h e r s t u d y and training. T h e y are m e m b e r s o f the world's " s e c o n d oldest p r o f e s s i o n , " and in s e m i n a r y a large degree o f socialization i n t o the values, p u r p o s e , sanction, k n o w l e d g e , and m e t h o d s o f the ministry has occurred. T h e y have a d e f i n i t e calling, status, role, and even a u n i f o r m as a sign of their professionalism. F e w are conscious o f this professionalism, which makes it h a r d e r t o deal with. T h e professional role is assumed; s e l d o m is it s p o k e n of or r e f e r r e d to d i r e c t l y in seminary. B y c o n t r a s t , the m e n t a l health professional m a y be very insecure in his professional i d e n t i t y , being a m e m b e r o f a marginal profession. M a n y psychiatrists have been on the defensive as a m i n o r i t y g r o u p on the fringe of the medical profession. Clinical psychologists have had their p r o b l e m s , due t o the c o n f u s i o n with e x p e r i m e n t a l " r a t p s y c h o l o g y , " and social w o r k e r s are o n l y just n o w achieving a sense o f professional status even within t h e i r o w n ranks, even less
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a m o n g others. In such a situation, c o m p o u n d e d b y d i f f e r e n t value systems and professional language, m i s u n d e r s t a n d i n g o f motives, suspicion, and ambivalence or hostility are easily possible. S e c o n d , t h e r e is the p r o b l e m o f t h e m e i n t e r f e r e n c e . McWhiter listed t h e m o s t c o m m o n t y p e s o f p r o b l e m s t h e clergy have in caring f o r t h e i r people: 1. Tendency to become over-involved with the case, feeling overwhelmed with the need to "do something" for the person. 2. Over-concern for the eternal salvation of the person, feeling responsible as a minister of God for saving that person's soul. 3. Rigid application of religious principles and discipline. 4. Deficiency in personal self-esteem, seeing his position as minister as the only source of personal worth--his only identity. 5. Easy tendency to consider himself a failure when his parishioners do not change. 6. Increasing doubt about his own religious views and faith as a result of the current turmoil in religion--a fear of losing his own call to the ministry. 7. Use of the consultation to learn about his own emotional and sexual problems. 9 These are a few o f the m a n y possible t y p e s o f i n t e r f e r e n c e s t h a t p r e v e n t a cleric f r o m dealing m o s t effectively with persons w h o have m e n t a l h e a l t h p r o b l e m s . T h e c o n s u l t a n t needs t o listen c a r e f u l l y t o his clerical c o n s u l t e e , t o i d e n t i f y t h e r e c u r r e n t t h e m e o f t h e p r e s e n t a t i o n , and, w o r k i n g carefully, t o clarify the i n t e r f e r e n c e o r suggest o t h e r ways t h r o u g h which t h e p r o b l e m c o u l d be h a n d l e d . A t h i r d set o f p r o b l e m s is related t o the first and second. These are t h e result o f a d e f e n s e the cleric erects t o safeguard s o m e t h i n g he loves--his c h u r c h and t h e spiritual resources it offers. F o r m a n y c l e r g y m e n , t h e r e is the d e e p - r o o t e d c o n v i c t i o n t h a t t h e Gospel itself, the s a c r a m e n t s of the c h u r c h , and personal faith, are e n o u g h t o h a n d l e m o s t p r o b l e m s in living and o f neurosis, if n o t psychosis as well. If these resources are n o t sufficient, it m u s t be d u e t o s o m e personal failing o f the individual cleric. T h e " J e h o v a h c o m p l e x " is j o k e d a b o u t b y t h e clergy, b u t it is also d e e p l y r o o t e d . As a result, a n t a g o n i s m is easily c r e a t e d b y a n o t h e r , a professional f r o m a n o t h e r " f a i t h , " w h o offers a solution or a w a y o f handling a p r o b l e m w h e n he a n d his c h u r c h have failed. A f o u r t h p r o b l e m is t h e result o f a long-standing i m p r e s s i o n t h a t professional social w o r k is t h e same as public welfare. T h e n t h e r e has b e e n t h e over-reaching c o n d e s c e n s i o n o f some n e o - F r e u d i a n s and the i m p l i c a t i o n b y m a n y psychiatrists t h a t t h e y can solve all h u m a n ills. This has p r o d u c e d a large measure o f skepticism a m o n g the clergy. T h e y k n o w t h a t the p r e t e n s i o n s " j u s t ain't s o . " As a result, m a n y c l e r g y m e n fail t o see t h e relevance o f p s y c h i a t r y and p s y c h o t h e r a p y t o t h e i r w o r k . F u r t h e r , t h e clergy have had t o live with the results o f t h e failures of t h e m e n t a l h e a l t h professionals. When the referral is p o o r l y h a n d l e d , w h e n professional c o u r t e s y is ignored, w h e n t h e p e r s o n w i t h d r a w s f r o m t r e a t m e n t , w h e n t h e entire e x p e r i e n c e is one o f f r u s t r a t i o n and d i s a p p o i n t m e n t , t h e p a s t o r still
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has to live with the results. So, for m a n y reasons, professional clergymen are hesitant to place undue faith in the efficacy of mental health caregivers. Fifth and finally, the clergy are persons who have many emotional needs of their own to be met or guarded against. Congregations have unusually high, and often unrealistic, expectations of their minister-priest. So the cleric has to live with the fear of exposure that he is less than he is expected (and paid) to be, and the humiliation that, if only he tried harder and worked longer hours, he could become what others expect of him. Most clergymen are idealists. Learning to live with the difference between the level of their ideals about themselves, their church, their people, and the reality is a difficult and demanding task. Those who fail leave the parish ministry or remain, but become bitter cynics. Others may become "organization m e n " in national or regional church headquarters. The clergy are often lonely, though outwardly gregarious. They are in need of human support, reassurance, and recognition that is noncompetitive. Finally, due to the rapid changes on the ecumenical scene, even the familiar church landmarks are perceived by m a n y as changed or swept away. The wise and sensitive consultant can do much about each of these five problems. In fact, unless he does so, consultation with these c o m m u n i t y caregivers and those whom they serve will have failed much of its purpose, promise, and potential. Conclusion
One of the issues in child psychiatry, and certainly in all hospitals and clinics where children and their families are being treated, is the proportion of staff time that shall be devoted to direct therapy in relation to consultation. There are large numbers of children and their families who need treatment, and there are limitations imposed by lack of staff and funds. Yet the issue of t r e a t m e n t or consultation is a false one. Direct therapy is one m e t h o d of providing help; consultation with the large numbers of c o m m u n i t y health caregivers is another. Furthermore, it is an effective method, since such caregivers can reach the child and family "where things have their beginnings" long before they come to our hospitals, offices, and clinics. If the mental health professionals are genuinely concerned about meeting as m a n y of the needs of their fellow-men as possible, consultation is a necessity and can be a most rewarding experience. This can be especially true in working with the clergy who have a deep and abiding concern for alleviating the suffering of fellow-human beings. For better or for worse, Christian clergymen have been doing so for two millenia and rabbis and priests for three thousand years. Mental health professionals have much in the way of special skill, knowledge, and ways of understanding human behavior to offer to the clergy. The clergy in turn have much about the meaning of creation and each human life within it to give mental health professionals. Further, the ordained clergy have many resources of
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k n o w l e d g e a n d skill t h a t t h e y also can m a k e available in m e e t i n g h u m a n need. B o t h g r o u p s have m u c h t o o f f e r each o t h e r and t h e p e o p l e t h e y serve. In c o n s u l t a t i o n o f m e n t a l health professionals with t h e clergy, r e s p e c t a n d u n d e r s t a n d i n g o f each o t h e r is basic; belief in c o n s u l t a t i o n b o t h as a r e s o u r c e a n d discipline is vital; and k n o w l e d g e o f t h e t e r r i t o r y is required. With these resources, m e n m a y b e t t e r live as t h e y wish a n d as t h e y were i n t e n e d t o live. I n d e e d , " t h e y m a y have life a n d have it m o r e a b u n d a n t l y , " richer far t h a n in their m e m o r i e s or dreams. Such is t h e challenge a n d o p p o r t u n i t y o f c o n s u l t a t i o n b y m e n t a l health professionals t o c o m m u n i t y caregivers-especially t h e clergy. References
1. Meyer, A., "Thirty-five Years of Psychiatry in the U.S. and Our Present Outlooks." Am. J. Psychiatry, 1928, 8, 1-31. 2. Action for Mental Health. Final Report o f the Joint Commission on Mental Illness and Health. New York, Basic Books, Inc., 1961.
3. Caplan, G., "Concepts of Mental Health Consultation." U.S. Department of Health, Education, and Welfare, Children's Bureau Publication #373. Washington, D. C., 4. Gorman, J. F., "Some Characteristics of Consultation." In Lydia Rapoport, ed., Consultation in Social Work Practice. New York, National Association of Social Workers, 1963, p. 28. 5. Sandler, N. H., "Attitudes of Ministers Toward Psychiatry," J. Religion and Health, 1966, 5, 47-60. 6. Wauck, L., "The Clergy as Marriage Counselors," J. Religion and Health, 1966, 5, 252-259. 7. Larson, R. F., "Denominational Variations of Clergymen's Attitudes Concerning Mental Health," Mental Hygiene, 1967, 51,179-189. 8. Glidewell, J., "The Entry Problem in Consultation," J. Social Issues, 1959, 15, 58-59. 9. McWhiter, D. P., "Consultation with Clergy." In W. M. Mendel and P. Solomon, eds., The Psychiatric Consultation. New York, Grune & Stratton, 1968. See also: Caplan, R. B., Helping the Helpers to Help. New York, Seabury Press, 1972.
Mental Health Consultation With Religious Leaders THOMAS S. HULME A s tatemen t attributed to Adolf Meyer in his presidential address at the 84th anniversary meeting of the American Psychiatric Association is that " o n e o f the most i m p o r t a n t lessons of m o d e r n psychiatry is the absolute necessity o f reaching b e y o n d asylum walls and working where things have their beginnings. ''1 U n f o r t u n a t e l y , a careful reading of Dr. Meyer's address fails to uncover the presence o f this felicitous phrase, although it is true to his t h o u g h t t hat psychiatry must b e c o m e extramural, moving b e y o n d the institutions and offices of his day. To work " w h e r e things have their beginnings" is to me b o t h the challenge and the o p p o r t u n i t y for consultation by mental health caregivers who feel th at assistance must be made available to children and their families as early as possible. We need to reach b e y o n d the p r o t e c t e d walls of our hospitals, clinicg, and offices with our 8-to-5, 40-hour weeks, into the c o m m u n i t y - - t o the YM and YWCAs, to the nei ghbor h ood houses, to the schools, to the homes, and to the churches and synagogues. Unless we do so, how shall we reach to " wh er e things have their beginnings," to the children of this land? It is my purpose to set f or t h some specific suggestions for knowledgeable and effective consultation by mental health professionals with Christian clergymen and Jewish rabbis, who are the single most i m p o r t a n t group of c o m m u n i t y caregivers in this count r y. I shall n o t consider in detail the work of the rabbi and the synagogue, since I have no expert knowledge in this area. In general, whatever is true of effective consultation with Christian clergymen, their training, and their willingness to be of assistance to their fellow-men is equally true of their Jewish counterparts.
The opportunity for consultation with religious leaders The J o in t Commission on Mental Illness and Health r e p o r t e d that 42% of persons with a wide range of personal, marital, and parent-child problems who turn to others f or help do so to the clergy, while 29% turn to physicians, 18% to psychiatrists or psychologists, and 10% to social agencies. 2 There are few statistics available t o suggest any significant changes The Rev. Thomas S. Hulme, A.C.S.W., an ordained Episcopal priest, is now Director of Field Services, Iowa State Services for Crippled Children. He was a psychiatric social worker in the child psychiatry service, Department of Psychiatry, University of Iowa, Iowa City. 114
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in these figures for the decade since then. Further, these same religious leaders are in a position to identify, assist, or refer m a n y more, since some 100 million persons belong to churches or synagogues and 170 million profess a belief in God. With the important exceptions of the fundamentalist and Pentecostal church groups and the recent entry of the Roman Catholic Church into the mental health field, old-line American churches have long been active and concerned with mental health especially in the provision of training for the ordained ministry. Pastoral counseling has been the focus of such training since the mid-1940s. The need is n o t normally to "sell" the clergy on the significance of their opportunity, but how to train them to do their job better. They especially need training in study and assessment of problems of living and relationships and in crisis intervention. It is m y opinion t h a t normally long-term depth counseling should not be a t t e m p t e d in a parish situation if other resources are available, because of lack of specialized training of the clergy, a variety of other relationships with the person, and other demands on the cleric's time. The mental health consultant can be of great assistance to the clergy, working with them as a consultant and in the provision of ongoing in-service training programs. To be effective, the consultant must be aware of and sensitive to the spiritual resources of the churches in the total healing process. It is not his role to make "psychiatrists" of the clergy, but to strengthen them in their professional roles. In January of 1971, one of the resident psychiatrists of our hospital and I met with a large group of Episcopal clergymen. The subject was "Behavior Disorders of Childhood--The Overanxious Child and the Hyperkinetic Child." Our presentation included some historical background on this conceptual framework and some of the s y m p t o m a t o l o g y t h a t the clergymen might observe in their role as parish priests. Ways in which the resources of the parish church could be used effectively to help such children, their parents and families, were suggested, as were the circumstances under which referral should be made. The response by these clergymen was immediate and enthusiastic. The conceptual model of behavior disorders of childhood was one t h a t could be transposed immediately into their mental framework w i t h o u t a long preparation in the terminology of classical psychoanalysis, and, more important, "it made sense." Second, the clergymen could use the s y m p t o m a t o l o g y as a clue to ways in which t h e y could provide preventive help to their families and children, where "things have their beginnings." A request for more such conferences was made immediately by these clergymen. Special opportunities o f the clergy
The mental health professional should consider carefully the special opportunities that the trained and observant cleric has readily available to
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assist in assessing, referring, or helping children and their families, for he has an entr6e into the lives of his flock at almost every important turning point. In addition, the pastor has the chance to observe them on a daily or weekly basis. For example, the cleric can observe the hyperkinetic child and the parenting patterns in the home as he makes his pastoral visits; he can observe the same child creating havoc in his nursery school, or squirming over and under the pews during church services. The overanxious child or the withdrawing child can similarly be observed standing on the fringe of activities during vacation church school or clutching desperately the hand of his equally overanxious mother. The parish pastor soon hears of the deeds of the unsocialized, aggressive youngster in the parish or in the neighborhood, and he can also accompany the family of the group delinquent to court. Not only does the easy entr6e of the cleric into the daily life of his parishioners provide him with a unique vantage point for observation, study, and assessment, but he has a special authority with his people. This authority may be based, on personal ability, charisma, goodwill, or the "magic" influence that is ascribed to the results of ordination, prayer, and sacraments. Whatever the source, the ordained minister, priest, or rabbi has a great deal of formal or informal authority that he can use when a referral to a clinic or hospital is needed. His words of guidance and reassurance that the parents are indeed doing the "right thing" can be of great assistance in facilitating a family's early referral and their willing co-operation with the recommendations made by the mental health professionals. Clergy with parochial responsibilities are continuously engaged, both formally and informally, in treatment through their pastoral counseling. Such counseling can have a high degree of mental health expertise. It can occur before marriage, at the birth or baptism of a child or at his confirmation, at times of sickness--either mental or physical--at death and times of bereavement, and in the continual round of crisis situations that make up the daily lives of people. The impact and therapeutic possibilities of the weekly sermon, the parish coffee hour, and the various organizations should never be overlooked. For better or worse, the clergy are doing counseling with far larger numbers of persons than ever appear on the case loads or waiting lists of mental health clinics and hospitals. The parish clergy are, in one sense, the last of the general practitioners: trained professionals with a reasonable degree of competence in many areas. It is the opportunity of the mental health professional with a high degree of skill in particular areas to aid the parish clergy in their study, assessment, and t r e a t m e n t of their people, to guide them when referrals are needed, and to enlist their knowledgeable assistance for follow-up counseling. This opportunity can best occur through consultation. Consultation definitions
The consultation process as defined by Caplan 3 and Gorman 4 and others involves an interaction of role, process, and function. All are related to some
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" p r o b l e m " to be "solved." Each needs to be clarified and u n d e r s t o o d by b o t h the consultant and the consultee. Such consultation can take place in m a n y ways. The following is one classification. First is case insight, in which increased understanding is given to the consultee in p r o p o r t i o n to his increased professional need. Such understanding may be in m a ny areas. If it is t h a t of psychological functioning, for example, the purpose is to assist the caregiver in understanding more clearly the dynamics o f the client so that he can bet t er use his own skills and training in aiding the client. This m a y include joint observation or an interview for assessment by t h e consultant, with discussion and planning afterward. Second is action-help. In this situation the consultant brings his knowledge o f facilities and c o m m u n i t y resources to aid the consultee in making plans for a client. The consultant's role is also to be a support er and clarifier for the consultee as he works out what is appropriate or possible within his institutional setting. It is n o t the mental health consultant's role to impose his mental health plans. Third is consultee crisis. In this situation, the consultee himself needs assistance, for the client's problems have p r o d u c e d in him distortions of perception, the use of stereotypes, or projections of old difficulties. The result is that the consultee's effectiveness has been impaired by his own unresolved problems or "sore spots." The consultant's role is n o t t hat of providing p s y c h o t h e r a p y to the consultee, b u t of assisting him t o work through th e problems of the client with a sensitive awareness t hat the consultee is working through his own problems in the process. The focus is still on the client, but there is a great need for warmth and support for the consultee. F o u r t h is direct administrative consultation. Here the focus is on social systems o f a c o m m u n i t y or an institution or agency and their policies and programs. In this f or m various leaders, professionals in m any fields, consult t o g e t h e r ab o ut the best procedures to use to alleviate the problems. The primary goal is prevention. In all o f these modes of consultation, the basic purpose is to bring fort h the latent possibilities in various situations and f r o m all kinds of people; to stimulate th e m to take responsibility for themselves; to enable t h e m t o f u n c t i o n more securely and i n d e p e n d e n t l y ; to internalize adaptive skills of a more flexible and creative nature. Consultation should be distinguished f r o m direct clinical service. The goal is to aid the c o m m u n i t y caregiver in providing professional assistance to his client or agency. Thus, in an ever-widening circle, more persons are trained and assisted in the care of persons. Clergy practices and attitudes toward mental health problems As Charlie, in Meredith Willson's The Music Man, says to the traveling salesman with the handlebar moustache, it is n o t t h a t things have changed,
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but that " y a gotta know the territory." Charlie's advice to the salesman, who insisted that "it's different than it was," is essential for those who meet such c o m m u n i t y caregivers as the clergy, for whom much has changed. Indeed, the consultant has to " k n o w the territory." The consultant who knows the territory will be very conscious of the variable of the clergyman's training and interest. "Begin where the consultee is" is a good rule for consultants, as well as for social workers in relation to their clients. The range of clergy training in mental health areas extends on a continuum from very little to great professional competence. Even the focus of the training must be clarified. All clergymen are trained to handle both emotional problems and problems in living. The content of this training may be in mental health areas or in pastoral counseling techniques or in, strictly speaking, " c h u r c h " methods of prayer, exhortation, advice, support, acceptance, and encouragement. There is a significant difference noted in the responses of clergymen in Memphis, Tennessee, in a study between those who finished seminary prior to 1945 and others who were graduated later. The study, by Sandler, drew these conclusions: 1) Two hundred thirty-two ministers (38.6%) replied to a mailed questionnaire. 2) Training in counseling comes from self-study, seminary, seminars, and postgraduate courses. 3) Self-study was the major means of training in counseling for the pre-1945 group, but the post-1945 group considered the seminary as their major source of training in counseling. 4) The problems most c o m m o n l y brought to ministers for counseling are: a) marital problems; b) drinking; c) lack of faith; d) sexual maladjustment. 5) The problem most c o m m o n l y referred to a psychiatrist is obvious mental disease. 6) With the improved training in psychiatry since 1945, communication between psychiatrists and ministers has improved. The post-1945 group more frequently refer a person with an obvious mental disease to a psychiatrist. They also feel much more at ease in counseling and therefore a t t e m p t much more counseling than do those in the pre-1945 group. 5 A similar study by Wauck of the training being introduced in the Roman Catholic Church supported these findings, especially in the large urban areas such as Chicago. 6 Larson, a sociologist, studied denominational variation in clergymen's attitudes concerning mental health. 7 In two studies, in a New England state and a Western South Central state, three key factors were identified: 1) selective recruiting for the ministry on the part of the religious denomination; 2) the socialization process within the seminary as well as in the secular world; and 3) the demands of the minister's parishioners, especially for pastoral counseling. Data from both New England and the
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Southwest clearly supported the importance of the first two factors in influencing the attitudes of the clergy; the significance of the third factor depended on the socioeconomic backgrounds of the parishioners. In the New England state in 1963, the total population questioned for the study included 949 clergymen, from w h o m there were 422 usable responses, including 191 from the Roman Catholic Church alone. In the West South Central state, in 1965, the total population studied was 5,542, from which came 1,868 usable returns, 124 of them from Roman Catholics. This state is predominantly "Bible Belt" in contrast to the heavily Roman Catholic New England state. Larson indicates that in his study all relationships are significant beyond .01%. (The instrument in both cases was identical except for the addition of one set of questions in 1965 designed to give further specification.) The conclusions were that conventional Protestant clergymen (Episcopal, Disciples of Christ, Lutheran, Presbyterian, Methodist) have significantly more favorable attitudes toward mental health and mental illness and its causes than have conservative Protestants (Baptists and Church of Christ), who were more favorable than were fundamentalist Protestants (Nazarene, Church of God, Freewill Baptists, Assembly of God, and Pentecostals). Religious affiliation was a key variable. In the Western South Central state, Episcopal priests ranked 87% above the median on the "favorable attitude toward mental h e a l t h " scale, the highest for any denomination, with the Pentecostal ministers ranking the lowest, with a 6% favorable response. In the New England state, the order was different, with the United Church of Christ first and the Episcopal clergy second. Age of clergy was found to be a significant factor in both states surveyed. Those under 35 gave a 65% favorable response to questions indicating favorable attitudes to mental health and mental illness; of those over age 45, a favorable attitude was f o u n d in 25% or less of the respondents. Urban pastorates, compared to rural, produced similar results, as did larger congregations. The level of skilled or professional training of one's father was important. Clergymen with professional degrees from a seminary had a 69% favorable response to the mental health questions; those with one to three years of college had a 27% favorable response; and those with a high school education or less responded 13% favorably. Finally, and most important for consultants, this study noted t h a t m a n y clergymen have attitudes and opinions that might readily interfere with psychologically oriented referral policies. For example, in the New England state, due to factors just noted, the Episcopal clergy ranked low on questions designed to test realistic opinions on the causes of mental illness, while in the West South Central state, t h e y ranked first, with an 85% favorable, compared to the Pentecostals' 20%. In the East, the R o m a n Catholic priests had the lowest position on these scores; in the Western South Central state, they were in fourth place.
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Who seeks help from the clergy ? The clergymen considered in this paper are those having definite parochial responsibilities and ties. Not included in this analysis are those in specialized ministries, such as chaplaincies and "worker priests," since the variables are so great as to defy generalizations regarding mental health practices. Those seeking help from the parochial clergy fall into three groups. The consultant who works with a cleric around client problems needs to know into which group the client falls, since this affects the cleric-consultee and his practices and referrals. The first group, and the one most likely to be referred to mental health professionals by the clergymen, are the "walk-in" clients. They are persons w i t h o u t any formal connection with the particular parish or congregation the clergyman serves. The parochial clergyman's position fits no job description; it can, and usually does, consume all the time and energy he feels he can invest. Further, he is trained to be a pastor and shepherd to his " f l o c k , " whom he knows by name; they will follow his voice. The walk-in client does not belong to this identifiable group and so represents an added demand on a working schedule that is already full. The cleric is likely to have little emotional investment in him b e y o n d hearing his problem and determining (one hopes) the best referral source. This pattern is especially true in older, d o w n t o w n urban congregations, where the parish itself is large and surrounded by a large, anonymous, and highly transient population. An exception to this position is the parish (and there are many) t h a t is making a concerted attempt to serve precisely this group of transient outsiders. In this kind of parish, the cleric may have a high degree of investment in his "congregation at large," he may be quite resistant to referral, or if he refers, he will make or demand some follow-up by the mental health professional to w h o m the person is referred. In all cases, it is important to assess clearly the level of investment made by the clergyman and to know what feedback is expected. The second group seeking help from the clergyman is made up of people referred to him by members of his congregation, who have, until it is possibly proved mistaken, a great expectation of their pastor's universal competence. Many clergymen feel that they must accept this belief and try to live up to it. They cannot admit to their people, or to themselves, that they are less able than this unreasonable expectation demands. It is at this point that referral patterns change noticeably. With such a referral, the cleric is far more likely to make a number of appointments before he makes a referral, unless there are obviously severe mental health problems. His training, age, denomination, and the other factors noted in the Larson study will be important elements in his decision whether to refer or whether he can provide the assistance needed. I believe that at this point the mental health consultant can be of immeasurable help to the clergyman in providing group training as well as
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case-centered consultation on principles of crisis intervention, how to recognize signs of serious mental illness, and when and how to make referrals. Obviously, few referrals are likely to be made, or made effectively, if the mental health professional remains isolated in his own professional " g h e t t o . " Clergymen take seriously such referrals to them and feel, depending on the problem and their training, that it is better for t h e m to handle the problem than to make a poor referral. "Better the devil you know than the one y o u d o n ' t k n o w . " All most clerics need is several referrals that are poorly handled, where little is done for whatever reason, where no report is made to them, and where even the simplest matters of professional courtesy are ignored, and t h e y will never make another. The third group who come to the clergyman are the members of his congregation. All the factors present in those referred to him are present now, and in an intensified form. Unless he is secure in his role and place with the congregation, with the mental health professional involved, and with mental health as a profession, these are the persons least likely to be referred. Further, the mental health consultant, in working with the clergyman, will need to determine the degree of investment the pastor has in the member. " M e m b e r " covers m a n y categories: the "pillars" of the church, the regulars, the Christmas-and-Easter group, and those only on the record books but otherwise "in the outer darkness." Even these categories do not indicate clearly the depth of Christian faith and c o m m i t m e n t in the member. There is only a rough correlation between faith and c o m m i t m e n t and church attendance and activity. In general, unless the pastor is highly sophisticated in mental health procedures, he is unlikely to refer those in whom he has the greatest investment. Further, he is most likely to need consultation because of his lack of objectivity regarding them. Mental health consultation is indeed vital before such referrals can be made, if t h e y are made at all, and case, or even consultee-centered case, consultation can be of great assistance at this point. Levels o f consultation requested by the clergy
Clergymen who seek consultation do so on three levels that affect the focus of consultation given. First, much consultation will be provided to individual clerics around individual case problems. These will be persons in one of the three groups already assessed: the walk-ins, the referred, and parish members. Usually the cleric is asking for answers, for specific knowledge to aid him. How do I handle this problem? Is it one I can handle? Should it be referred? To w h o m ? The consultant will need to assess carefully whether knowledge alone will be sufficient, the nature and level of the consultee's skills and abilities, and how to strengthen him as a professional clergyman by making information given both understandable in his frame of reference and convertible for
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f u tu r e use. Also, the level of the cleric's involvement and the reasons for it must be examined. Further, the cleric himself is usually in a crisis situation. There is a problem th at he c a nnot handle or he would n o t be seeking a consultant's aid. Why is he unable to handle it? Is it because of lack of knowledge or skill? Transference? Clerical bias? Or some problems due to the church system itself--for example, divorce and remarriage? H ow does the cleric feel about the client and about himself in regard to this problem? What supports does he need? What defenses is he using? Second, and simpler in many ways, will be the consultant-trainer role with informal groups of clergymen. Such groups may be small ones of friends and contemporaries drawn together by c o m m o n needs and concerns regarding mental health and illness. The clergymen may be from one d e n o m i n a t i o n or f r o m several, sharing a similar point o f view. The groups may be small or as large as a citywide ministerial association. Assessment, again, of what is being asked for and what can be given in the informal group is needed. Usually t he crisis element is missing and education and professional training in behavioral dynamics are sought. Consultation in such a setting more nearly resembles t hat given to any public or private agency around case conferences f or learning or program and policy development. Case consultation m a y develop into consultee-centered consultation; it m a y be of great value. In such groups, more a t t e nt i on can be given to strengthening these men in their professional roles and in learning from t h e m some of the churches' resources for caring for people. The church, in b o t h its sacred and secular dimensions, has been caring for people for several thousand years and has built up a considerable b o d y of skill and knowledge of human behavior. Assessment of the level o f these clerics in their professional skills will be needed. Their motivation will be high; t h e y are likely to be relatively young, with considerable training and education and with some knowledge of psychosocial behavior. Resistance need n o t be a problem, depending on the nature and approach of the consultant. It is my conviction t hat consultation given in this form can be a most valuable and rewarding experience for b o t h consultant and consultee. The third clergy group t o w hom consultation is given is likely to be formal denominational structures: synods, conferences, or dioceses. In these the consultant-educator role is par a m ount . The groups involve m any clergymen with all levels of training and interest. Usually the f o r m taken is that of a conference or short course of several days' duration at some church center. Again, the c o n t e n t may be client-centered or c o n c e r n e d with program and policy. Such groups are not h o m o g e n e o u s in any respect, except that t hey are professional clergymen who have responded to a vocation. Resistance is likely to be high; attendance at such conferences is often required or "strongly urged;" there are m a ny distractions possible, bot h external and internal. In any such group there will be m any and varied attitudes toward
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the c o n s u l t a n t and t o w a r d m e n t a l health. S o m e c l e r g y m e n will be o p e n and responsive, s o m e will be passive or b o r e d , and m a n y will see little value in Sigmund F r e u d and in w h a t t h o s e " s h r i n k s " have t o say. " W h a t was g o o d e n o u g h f o r St. Paul is g o o d e n o u g h f o r m e . " This is an o v e r s t a t e m e n t , b u t n o t e x t r e m e l y so f o r some. In such situations, k n o w l e d g e is primarily s o u g h t and the c o m b i n a t i o n o f personal ability, t h e a u t h o r i t y of ideas, and professional c o m p e t e n c e are n e e d e d b y a n y c o n s u l t a n t . Special p r o b l e m s in w o r k i n g with the clergy The first o f t h e special p r o b l e m s o f consulting with t h e clergy centers a b o u t the e n t r a n c e o f the c o n s u l t a n t . T h e c h u r c h , w h e t h e r o n a national, a district, or a local level, is a highly c o m p l e x system, v e r y old and highly organized 9 The c o n s u l t a n t is an a t t a c h m e n t t o this s y s t e m and inevitably affects its equilibrium. T h e e n t r y p r o b l e m t o each o f t h e t h r e e d e f i n e d s i t u a t i o n s - individual clerics, i n f o r m a l groups, and d e n o m i n a t i o n s y s t e m s - - d e m a n d s careful s t u d y and assessment b y b o t h t h e c o n s u l t a n t and the consultee. If the e n t r a n c e has b e e n s o u n d l y m a d e , the t e r m i n a t i o n phase of c o n s u l t a t i o n with t h e c l e r g y m a n does n o t p r e s e n t a n y p r o b l e m s significantly d i f f e r e n t f r o m c o n s u l t a t i o n with o t h e r c o m m u n i t y caregivers or with a n y o t h e r agencies. A c c o r d i n g l y , I shall n o t d i r e c t l y c o n s i d e r this aspect here. T h e e n t r a n c e t o the individual cleric is in o n e sense t h e easiest. T h e c o n s u l t a n t is t h e r e at t h e pastor's request 9 He has b e e n invited t o aid in t h e solution o f s o m e problem 9 Yet, because it is so easy on one hand, it is m o r e dangerous on t h e o t h e r , unless a simple " w h a t " or " h o w t o " answer is all t h a t t h e c o n s u l t e e will take or t h e c o n s u l t a n t wants t o give. In entering, ambivalence o f the cleric will be a k e y f a c t o r . He n e e d s help, y e t h e is also afraid t h a t h e m a y a p p e a r i n c o m p e t e n t . T o avoid d e p e n d e n c e , the cleric m a y erect defenses to d e m o n s t r a t e or m a i n t a i n his i n d e p e n d e n c e . The c o n s u l t a n t will n e e d all his i n t e r v e n t i v e skills and k n o w l e d g e if h e is t o be o f real assistance to the c o n s u l t e e . With the i n f o r m a l clergy g r o u p , t h e c o n s u l t a n t is invited in, y e t t h e r e is n o d e m a n d f o r help a r o u n d a crisis s i t u a t i o n and n o unusual set o f a m b i v a l e n t feelings t o be h a n d l e d . The c o n s u l t a n t s h o u l d be m o r e free t o f o c u s o n t h e g r o u p process as a learning t o o l , and his k n o w l e d g e and skill s h o u l d ease t h e e n t r y difficulties t o the individual c l e r g y m e n as well as t o the g r o u p as a whole. F u r t h e r , t h e y have each o t h e r f o r professional s u p p o r t and e n c o u r a g e m e n t if t o o m u c h stress is created. T h e p r o b l e m s in e n t r y will c e n t e r a r o u n d t h e e x t e n t o f a g r e e m e n t t h e group itself has established in its goals with t h e consultant 9 In s u m m a r y , Glidewell says: 9 it has been suggested that the entry problem can be defined in terms of the goodness of fit (in congruence, complementation, or conflict) between the consultant and the client social system with respect to three principal variables:
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1. Perception of need. 2. Perception of prospective equity of role, resource, and reward distribution. 3. Perception of prospective appropriateness of feeling interchange, with special concern about dependency and counterdependency.8 Third, the e n t r y p r o b l e m s o f the c o n s u l t a n t will be m o s t clear with the s t r u c t u r e d , f o r m a l d e n o m i n a t i o n group o f clergymen. T h e c o n s u l t a n t is perceived as entering i n t o their meeting, on their t e r r i t o r y , to tell t h e m s o m e t h i n g a b o u t their job. F u r t h e r , he is i m p o s e d on t h e m , t h o u g h invited b y their d e n o m i n a t i o n a l c h u r c h a u t h o r i t y . Glidewell states f u r t h e r : The problem of entry of consultant into the consultee system requires careful planning and negotiation since the admission of an outsider into any system, even if welcomed, is apt to cause some system disequilibrium. The preliminary discussions and negotiations should result in a contract, which, whether formal or informal, verbal or written, nonetheless explicitly defines mutual expectations and responsibilities. Further periodic clarification and redefinition may be required to maintain the consultation contract. A t h o r o u g h k n o w l e d g e o f h u m a n d y n a m i c s is useful t o a c o n s u l t a n t w h o is serving as an e d u c a t o r t o the clergy. T h e w h o l e range o f h u m a n d y n a m i c s and i n t e r p e r s o n a l relationships will be present. S o m e o f the clergy group will w e l c o m e him, s o m e will be passive, with a " w a i t and s e e " a t t i t u d e ; others will be resistant. S o m e will seek to impress him and others; some will be o p e n l y hostile. T h e c o n s u l t a n t needs t o be aware o f the forces at w o r k within this g r o u p o f professionals t h a t have little to do with him; he needs t o be secure within his professional c o m p e t e n c e , ability, and knowledge. In a d d i t i o n t o the e n t r y p r o b l e m , t h e r e is an entire range o f o t h e r p r o b l e m s , some o f which will be n o t e d in a n y or all o f the t h r e e consulting situations discussed. First, t h e r e is t h e p r o b l e m o f professionalism, a l t h o u g h this m a y be m o r e o f a p r o b l e m t o the c o n s u l t a n t t h a n t o t h e consultee. T h e o r d a i n e d clergy are a professional group. Most o f those with w h o m a c o n s u l t a n t will w o r k have a high degree of training--three to five years b e y o n d college, plus f u r t h e r s t u d y and training. T h e y are m e m b e r s o f the world's " s e c o n d oldest p r o f e s s i o n , " and in s e m i n a r y a large degree o f socialization i n t o the values, p u r p o s e , sanction, k n o w l e d g e , and m e t h o d s o f the ministry has occurred. T h e y have a d e f i n i t e calling, status, role, and even a u n i f o r m as a sign of their professionalism. F e w are conscious o f this professionalism, which makes it h a r d e r t o deal with. T h e professional role is assumed; s e l d o m is it s p o k e n of or r e f e r r e d to d i r e c t l y in seminary. B y c o n t r a s t , the m e n t a l health professional m a y be very insecure in his professional i d e n t i t y , being a m e m b e r o f a marginal profession. M a n y psychiatrists have been on the defensive as a m i n o r i t y g r o u p on the fringe of the medical profession. Clinical psychologists have had their p r o b l e m s , due t o the c o n f u s i o n with e x p e r i m e n t a l " r a t p s y c h o l o g y , " and social w o r k e r s are o n l y just n o w achieving a sense o f professional status even within t h e i r o w n ranks, even less
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a m o n g others. In such a situation, c o m p o u n d e d b y d i f f e r e n t value systems and professional language, m i s u n d e r s t a n d i n g o f motives, suspicion, and ambivalence or hostility are easily possible. S e c o n d , t h e r e is the p r o b l e m o f t h e m e i n t e r f e r e n c e . McWhiter listed t h e m o s t c o m m o n t y p e s o f p r o b l e m s t h e clergy have in caring f o r t h e i r people: 1. Tendency to become over-involved with the case, feeling overwhelmed with the need to "do something" for the person. 2. Over-concern for the eternal salvation of the person, feeling responsible as a minister of God for saving that person's soul. 3. Rigid application of religious principles and discipline. 4. Deficiency in personal self-esteem, seeing his position as minister as the only source of personal worth--his only identity. 5. Easy tendency to consider himself a failure when his parishioners do not change. 6. Increasing doubt about his own religious views and faith as a result of the current turmoil in religion--a fear of losing his own call to the ministry. 7. Use of the consultation to learn about his own emotional and sexual problems. 9 These are a few o f the m a n y possible t y p e s o f i n t e r f e r e n c e s t h a t p r e v e n t a cleric f r o m dealing m o s t effectively with persons w h o have m e n t a l h e a l t h p r o b l e m s . T h e c o n s u l t a n t needs t o listen c a r e f u l l y t o his clerical c o n s u l t e e , t o i d e n t i f y t h e r e c u r r e n t t h e m e o f t h e p r e s e n t a t i o n , and, w o r k i n g carefully, t o clarify the i n t e r f e r e n c e o r suggest o t h e r ways t h r o u g h which t h e p r o b l e m c o u l d be h a n d l e d . A t h i r d set o f p r o b l e m s is related t o the first and second. These are t h e result o f a d e f e n s e the cleric erects t o safeguard s o m e t h i n g he loves--his c h u r c h and t h e spiritual resources it offers. F o r m a n y c l e r g y m e n , t h e r e is the d e e p - r o o t e d c o n v i c t i o n t h a t t h e Gospel itself, the s a c r a m e n t s of the c h u r c h , and personal faith, are e n o u g h t o h a n d l e m o s t p r o b l e m s in living and o f neurosis, if n o t psychosis as well. If these resources are n o t sufficient, it m u s t be d u e t o s o m e personal failing o f the individual cleric. T h e " J e h o v a h c o m p l e x " is j o k e d a b o u t b y t h e clergy, b u t it is also d e e p l y r o o t e d . As a result, a n t a g o n i s m is easily c r e a t e d b y a n o t h e r , a professional f r o m a n o t h e r " f a i t h , " w h o offers a solution or a w a y o f handling a p r o b l e m w h e n he a n d his c h u r c h have failed. A f o u r t h p r o b l e m is t h e result o f a long-standing i m p r e s s i o n t h a t professional social w o r k is t h e same as public welfare. T h e n t h e r e has b e e n t h e over-reaching c o n d e s c e n s i o n o f some n e o - F r e u d i a n s and the i m p l i c a t i o n b y m a n y psychiatrists t h a t t h e y can solve all h u m a n ills. This has p r o d u c e d a large measure o f skepticism a m o n g the clergy. T h e y k n o w t h a t the p r e t e n s i o n s " j u s t ain't s o . " As a result, m a n y c l e r g y m e n fail t o see t h e relevance o f p s y c h i a t r y and p s y c h o t h e r a p y t o t h e i r w o r k . F u r t h e r , t h e clergy have had t o live with the results o f t h e failures of t h e m e n t a l h e a l t h professionals. When the referral is p o o r l y h a n d l e d , w h e n professional c o u r t e s y is ignored, w h e n t h e p e r s o n w i t h d r a w s f r o m t r e a t m e n t , w h e n t h e entire e x p e r i e n c e is one o f f r u s t r a t i o n and d i s a p p o i n t m e n t , t h e p a s t o r still
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has to live with the results. So, for m a n y reasons, professional clergymen are hesitant to place undue faith in the efficacy of mental health caregivers. Fifth and finally, the clergy are persons who have many emotional needs of their own to be met or guarded against. Congregations have unusually high, and often unrealistic, expectations of their minister-priest. So the cleric has to live with the fear of exposure that he is less than he is expected (and paid) to be, and the humiliation that, if only he tried harder and worked longer hours, he could become what others expect of him. Most clergymen are idealists. Learning to live with the difference between the level of their ideals about themselves, their church, their people, and the reality is a difficult and demanding task. Those who fail leave the parish ministry or remain, but become bitter cynics. Others may become "organization m e n " in national or regional church headquarters. The clergy are often lonely, though outwardly gregarious. They are in need of human support, reassurance, and recognition that is noncompetitive. Finally, due to the rapid changes on the ecumenical scene, even the familiar church landmarks are perceived by m a n y as changed or swept away. The wise and sensitive consultant can do much about each of these five problems. In fact, unless he does so, consultation with these c o m m u n i t y caregivers and those whom they serve will have failed much of its purpose, promise, and potential. Conclusion
One of the issues in child psychiatry, and certainly in all hospitals and clinics where children and their families are being treated, is the proportion of staff time that shall be devoted to direct therapy in relation to consultation. There are large numbers of children and their families who need treatment, and there are limitations imposed by lack of staff and funds. Yet the issue of t r e a t m e n t or consultation is a false one. Direct therapy is one m e t h o d of providing help; consultation with the large numbers of c o m m u n i t y health caregivers is another. Furthermore, it is an effective method, since such caregivers can reach the child and family "where things have their beginnings" long before they come to our hospitals, offices, and clinics. If the mental health professionals are genuinely concerned about meeting as m a n y of the needs of their fellow-men as possible, consultation is a necessity and can be a most rewarding experience. This can be especially true in working with the clergy who have a deep and abiding concern for alleviating the suffering of fellow-human beings. For better or for worse, Christian clergymen have been doing so for two millenia and rabbis and priests for three thousand years. Mental health professionals have much in the way of special skill, knowledge, and ways of understanding human behavior to offer to the clergy. The clergy in turn have much about the meaning of creation and each human life within it to give mental health professionals. Further, the ordained clergy have many resources of
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k n o w l e d g e a n d skill t h a t t h e y also can m a k e available in m e e t i n g h u m a n need. B o t h g r o u p s have m u c h t o o f f e r each o t h e r and t h e p e o p l e t h e y serve. In c o n s u l t a t i o n o f m e n t a l health professionals with t h e clergy, r e s p e c t a n d u n d e r s t a n d i n g o f each o t h e r is basic; belief in c o n s u l t a t i o n b o t h as a r e s o u r c e a n d discipline is vital; and k n o w l e d g e o f t h e t e r r i t o r y is required. With these resources, m e n m a y b e t t e r live as t h e y wish a n d as t h e y were i n t e n e d t o live. I n d e e d , " t h e y m a y have life a n d have it m o r e a b u n d a n t l y , " richer far t h a n in their m e m o r i e s or dreams. Such is t h e challenge a n d o p p o r t u n i t y o f c o n s u l t a t i o n b y m e n t a l health professionals t o c o m m u n i t y caregivers-especially t h e clergy. References
1. Meyer, A., "Thirty-five Years of Psychiatry in the U.S. and Our Present Outlooks." Am. J. Psychiatry, 1928, 8, 1-31. 2. Action for Mental Health. Final Report o f the Joint Commission on Mental Illness and Health. New York, Basic Books, Inc., 1961.
3. Caplan, G., "Concepts of Mental Health Consultation." U.S. Department of Health, Education, and Welfare, Children's Bureau Publication #373. Washington, D. C., 4. Gorman, J. F., "Some Characteristics of Consultation." In Lydia Rapoport, ed., Consultation in Social Work Practice. New York, National Association of Social Workers, 1963, p. 28. 5. Sandler, N. H., "Attitudes of Ministers Toward Psychiatry," J. Religion and Health, 1966, 5, 47-60. 6. Wauck, L., "The Clergy as Marriage Counselors," J. Religion and Health, 1966, 5, 252-259. 7. Larson, R. F., "Denominational Variations of Clergymen's Attitudes Concerning Mental Health," Mental Hygiene, 1967, 51,179-189. 8. Glidewell, J., "The Entry Problem in Consultation," J. Social Issues, 1959, 15, 58-59. 9. McWhiter, D. P., "Consultation with Clergy." In W. M. Mendel and P. Solomon, eds., The Psychiatric Consultation. New York, Grune & Stratton, 1968. See also: Caplan, R. B., Helping the Helpers to Help. New York, Seabury Press, 1972.
