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Chapter One
Introduction
Significance of the Clergy in the Treatment of Emotional Distress
The importance of the clergy, church, and religion in the treatment of emotional distress cannot be overestimated. Their therapeutic impact on mental health over the ages has assumed three basic forms. The first is an individual form as demonstrated by the clergy. This includes the traditional pastoral care rendered by pastors to aid troubled parishioners, as well as the various kinds of pastoral counseling techniques which have evolved during the twentieth century. The second is an organizational form, as taken by the church. The relevant ministry work includes intra-church support groups, as well as the mental health-promoting aspects of church functions such as the sermon, readings, prayer, and others as delineated so well by Clinebell (1972). Mission relates to the efforts of the church to give personnel and financial aid to mental health projects and to establish outreach programs for the emotionally troubled. The third is an ideological form, manifested by religion through the supportive aspect of religion per se.
That the clergy are valued members of the mental health care team is dramatically illustrated by the final report of the Joint Commission on Mental Illness and Health, published in 1961 (Joint Commission on Mental Illness and Health, 1961). The commission found that nearly half (42 percent) of persons seeking help for emotional distress first sought the assistance of the clergy. Remarkably similar results were reported by Kulka et al. about fifteen years later in 1979 (Kulka et al., 1979). They found that in response to the question: "When you had a problem and needed to seek professional help, to whom did you turn?", proportionately more people still indicated they turned to the clergy than to any other profession. Nearly 40 percent (39 percent) stated they turned to the clergy, a figure more than 18 percent over the next closest group, physicians. Thus there is good evidence that the clergy are serving a crucial function in mental health care in this country. Furthermore, this is not just a transitory trend but rather a phenomenon which has been documented with striking consistency over the past two decades. These findings (Joint Commission on Mental Illness and Health, 1961; Kulka et al., 1979) reflect both the overwhelming responsibility and the opportunity for the clergy in working with emotionally distressed persons.
Two trends, perhaps related, are noteworthy within this context. One is the marked increase in pastoral counseling programs for the clergy of the Protestant, Catholic, and Jewish faiths. There has been a rising emphasis on pastoral counseling at the basic levels of training, as well as greater opportunity for advanced training and specialization in this area. The second trend relates to the increased understanding of mental distress. Our knowledge of psychoses, both the functional psychoses (e.g., schizophrenia and manic-depressive illness) and those caused by organic illnesses (e.g., brain tumor or thyroid dysfunction), has benefited from important recent advances in neurophysiology, pharmacology, genetics, and the diagnostic procedures. Treatment of the functional psychoses has changed dramatically over the past fifteen years with the use of antipsychotic and antidepressant medications and improvement in the use of psychotherapy. Treatment of the psychoses associated with organic brain syndromes has advanced with increased diagnostic accuracy and improvement in the care of various mental disorders. Understanding of the neuroses, character disorders, and problems of daily living has also been enhanced recently, primarily through advances in psychotherapeutic, psychoanalytic, and various counseling techniques.
Pastoral Counseling Roles
In the pastoral counseling literature, the counseling role of the pastor has generally been conceptualized and defined in three ways. The first is the traditional pastoral role, which involves visiting shut-ins and hospitalized parishioners, consoling and working through the loss with family members in times of tragedy and grief, and so on. The other two conceptualizations relate to the newer, specialized counseling roles. These include counseling which deals primarily with the problems of daily living, and counseling which focuses on neuroses and character disorders. The problems of daily living refer to marital and family difficulties, minor stress-related depressions, situational problems, and so forth. Distinct from both the traditional pastoral issues and the problems of daily living are severe neuroses and character disorders. Neuroses are characterized chiefly by anxiety (for example, an obsessive-compulsive neurosis), and character disorders by life-long maladaptive patterns of behavior. In some centers, pastoral counseling specialists, pastors whose primary vocation is counseling, treat persons suffering from severe neuroses and character disorders. These latter two conceptualizations of specialized counseling roles involve a wide range of treatment techniques, including individual treatment, marriage and family counseling, traditional groups, and encounter groups.
Curiously, the roles of the clergy in counseling are often delineated in a condescending manner. The pastor has been urged to stick to the traditional pastor's role, the rationale being that in this role, he has his greatest latitude and respect. It has also been suggested that he limit his counseling to the problems of daily living. Finally, it has been noted that while the clergy can feasibly expand their expertise to effectively counsel those with neuroses and character disorders, more severely disturbed parishioners always should be referred elsewhere.
The role of the clergy and church in aiding the severely depressed has been discussed from a variety of perspectives. The conceptualization of the minister as diagnostician has been proposed (Draper, 1965); Pruyser, 1976). Some authors have directly addressed the issue of the clergy's role with psychotic patients (Clinebell, 1972; Joint Commission on Mental Illness and Health, 1961; Kulka et al., 1979; Autton, 1963). The rationale for, and process of, referral in such cases has also been delineated (Clinebell, 1972; Oglesby, 1968).
Yet throughout the pastoral counseling literature, there is a paucity of attempts to define a conceptual framework within which to understand the severely disturbed and the problems faced by the pastor and church in helping them. Both the individual aspects (conceptualization of severe individual psychopathology and the pastor's role in treatment) and the organizational aspects (conceptualization of the church's role) of this subject warrant serious consideration. This book represents an attempt to provide a conceptual framework of the severe clinical problems (i.e., the major psychiatric syndromes termed psychoses) faced by the clergy and to delineate the potential individual and organizational roles of the pastor and church resulting from such a conceptualization. Some technical terms and nomenclature are retained to foster communication between the professions and to make current mental health nomenclature understandable, rather than introducing another new, perhaps less accurate, classification.
The relative lack of participation by the clergy and church in the issues surrounding the recognition and treatment of the psychoses is puzzling and worth examining. Perhaps their exists a fear and abhorrence of such people, with consequent distancing by individuals and organizations. Perhaps an absence of understanding the processes within these people leads to their neglect. Perhaps it is a lack of treatment expertise which keeps the clergy and church from dealing with psychoses. However, these last two possibilities would appear to be rationalizations, for the knowledge is now available. It may well be that emotional resistance has combined with various rationalizations with the result being that psychoses have not been adequately addressed by the clergy and the church. Yet parishioners manifesting psychotic illnesses are severely distressed, and they deserve systematic and meaningful efforts by the clergy and church to help them.
The Current Task
The clergy and church represent the front lines of mental health care, as both the 1961 and 1979 studies confirm (Joint Commission of Mental Illness and Health, 1961; Kulka et al., 1979). Clinical experience indicates that many of those seeking help from pastors manifest psychotic symptoms. The process of aiding the severely distressed is a task rendered to the clergy by the sufferers themselves. Thus to suggest a conceptual framework and potential pastoral roles for aiding those suffering from psychoses is not to introduce a totally new or nonessential model of activity for the clergy. Rather, the important issue now becomes one of defining and clarifying this process so that fears are overcome, responsibilities fulfilled, and opportunities realized. Necessary knowledge of these disorders and methods of treatment are currently available, and it has finally become feasible for the clergy and church to address this topic in a systematic and meaningful way.
This book is directed toward pastors, interested lay people, and the church officials and administrators who have responsibilities for programs in the area. Pastors might be divided into the following, somewhat overlapping, groups with respect to counseling roles: parish pastors, who fulfill the traditional pastoral role as well as doing some work with the problems of daily living, as described above; the pastoral counseling specialists, who with their vocational focus on counseling may work with severe neuroses and character disorders in addition to the traditional role and problems of daily living; and those few pastoral counseling specialists, frequently hospital-based, who have also had training in the treatment of the psychoses. Since parishioners manifesting psychotic symptoms may seek help from any pastor, the assessment, treatment, and organizational principles set forth in this book may be relevant to pastors in all these groups. Because of the emphasis on the recognition and assessment of psychotic symptoms, this book's primary value will be for those hundreds of thousands of parish pastors and pastoral counselors who have had little or no training in dealing with psychoses. However, descriptions also are presented of specific specialized treatment roles which require training in psychotic illnesses, and these are directed towards those pastoral counseling specialists with such advanced training.
The conceptual framework used here is that of clinical psychiatric nomenclature. This clinical framework is based on detailed observation, accurate diagnosis, an attempt at understanding etiology to determine resultant treatment, follow-up, and continual assessment of the degree of individual benefit from the intervention. In this conceptualization, the terms "severely distressed" or "disturbed" refer to those suffering from psychoses. This is done intentionally to highlight the fact that those manifesting psychotic symptoms, whether organic or functional in etiology, do suffer tremendously and deserve our serious attention. Any attempt to romanticize the plight of the schizophrenic or suicidal person is misdirected.
Clinical psychiatric nomenclature is not the only possible framework. For example, Pruyser (1976), while not dealing exclusively with the issue of psychoses, outlined a theological framework for the pastor in the proposed role of diagnostician. Regardless of the specific framework used, it is hoped that such attempts will act as catalysts to bring further attention to the problems of the severely disturbed and to the potential contributions of the clergy and church to their care.
This book consists of three parts. Part I, entitled "A Conceptual Framework," provides the clinical structure. the advantages and disadvantages of utilizing clinical psychiatric nomenclature and the medical model are discussed. The clinical syndromes are delineated, including organic brain syndromes; functional psychoses with disturbances in thinking, such as schizophrenia and paranoia; functional psychoses with disturbances of mood, such as manic-depressive illness and psychotic depressive reactions; neuroses; and character disorders. Medications are described with a discussion of the changes in conceptualization of mental illness which resulted from the emergence of psychotropic drugs. In Part II, "The Pastor's Role in the Clinical Setting," an overview of the potential roles of the clergy in the clinical context is presented. Clinical situations and emergencies involving severely disturbed patients are described; perceptual and cognitive disturbances such as hallucinations and delusions; disorientation; suicide and homicide; depression; mania; suspiciousness and paranoia. These situations are then conceptualized within the framework established in Part I, and therapeutic interventions by the clergy are proposed. Part III, "The Role of Organized Religion," depicts programs through which the church as an organizational system, on both national and local levels, has addressed the issue of major psychiatric illness. Prototypes for aiding the severely emotionally distressed are studied with particular reference to the local church. Included are a variety of models: mental health-promoting aspects of local church functions, pastoral counseling programs of the local church, the Wholistic Health Center Project (WHC), the Community Organization for Personal Enrichment (COPE Program), Christian Action Ministry (CAM), and Prairie View (Mennonite Mental Health Services). Finally, various issues involved in the training of pastors in the assessment or treatment of psychoses are addressed, and training and program recommendations are offered.
Footnotes have been omitted. |
Pastoral Care of Severe Emotional Disorders: Principles of Diagnosis and Treatment
