Clergymen as Psychotherapists: Problems in Interrole Communication Carroll M. Brodsky, Ph.D., M.D.

ABSTRACT: Training clergymen to become psyehotherapeuticalIy adept in !heir counseling requires more than technical indoctrination. Psychiatry is a subculture with its own values and beliefs that must be translated before they can be adopted by the clergyman's subculture. The familiarity and personal warmth customary in pastoral relationships are consistent with good psychotherapy as long as the clergyman's behavior preserves those elements of the therapist's role that are essential to insuring the counselee's autonomy. Brief as the training programs might be, demonstrable changes occur in the student-pastors' counseling and personal lives. Several private and public agencies have recently begun to initiate efforts to relieve a generally recognized shortage of mental health personnel by training nonprofessional individuals to become psychotherapists. Included in this group are such nonprofessionals as housewives, union shop stewards, and paramedical personnel. In addition, clergymen of all faiths have 'also begun to show interest in these training programs. But the teaching psychiatrist who undertakes such programs faces many problems as he seeks to interpret his field to those unfamiliar with it. No matter what label the course might have, he soon realizes that his experience as a practicing psychiatrist or teacher of psychiatry for medical students has not adequately prepared him for this new task. If he structures the course in a way that permits feedback, he soon learns that he and his students are operating out of differing systems of perception and value. Where the groups might already have a professional homogeneity--as in the case of clergymen --the teacher might well come to see that he is facing a subculture distinctly different from his own. Under the circumstances, the transmission of the psychiatric "world view" is as important as the training in new terminology and technique. Within the past eight years, the author of this report, a psychiatrist and anthropologist, has taught psychiatry to numerous groups of clergymen of various levels of sophistication. Initiative for setting up these training groups Dr. Brodsky is Associate Clinical Professor of Psychiatry, University of California School of Medicine, San Francisco, California, and Director, Adult Psychiatry Clinic, University of California Medical Center, San Francisco, California. Community Mental Health Journal, Vol. 4 (6), 1968

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came from several sources, including departments of continuing education, training programs for hospital chaplains, and seminaries. In consequence, these contacts have been both brief and prolonged (in one case over three years). These many exchanges form the basis of the observations and recommendations reported here. REASONS FOR TRAINING CLERGYMEN In a recent national survey of 2,46o subjects, Gurin, et al. (2960) learned that 24 percent had sought help for psychological difficulties at some time in their lives, and, of these, 42 percent had gone to a clergyman first for this help. This finding emphasizes the key position the clergyman already occupies in the treatment and referral of disturbed people in the community. Perhaps, because of this (and because psychiatry has gained wider influence and acceptance in modern life), clergymen have sought to improve their pastoral counseling by becoming more psychiatrically informed. Many texts and courses in seminaries now show a strong orientation to modem psychiatric concepts and principles and, increasingly, consulting psychiatrists have been invited to participate in institutes and conferences for the counseling clergy. This professional group, therefore, not only offers ideal candidates for the new training programs to increase the ranks of those working for mental health, they are in fact already in such service and desire to improve. There are several advantages to the clergyman's unique position in society that he does not share with the traditional mental health worker. For one, the clergyman is involved with his troubled parishioners in a distinctively intimate, organic sense: he not only knows them well as individuals, he is also familiar with their family members, friends, and the specific cultural milieus from which they come. This wealth of data (which would take many hours for workers in a mental health center to collect) the clergyman already knows at the time of crisis. Then, too, he can offer therapy to those who need help but who fear that the stigma of being cared for by mental health professionals would be intolerable. Finally, since the early identification and treatment of many patients lies in the clergyman's hands, it is important that he feel comfortable in sending those who need more specialized help to psychiatrists. He can do this best when he has gained firsthand knowledge of the discipline and practice of psychiatry. METHODS OF TRAINING Brief note might be taken of the several teaching techniques used in these programs. Didactic lectures were utilized but never as the major (or only) means of instruction. Seminars and informal dialogues were used as better ways of inculcating bodies of concrete information. Actual cases were often presented for observation and class discussion. Demonstration interviews weither actual or on film helped to dramatize for the students the principles of good data-gathering and counseling. Group-dynamics sessions afforded the teacher a chance to illustrate technique and to give the students an opportunity

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for self-examination where they explored the depth and complexity of their own feelings. Under the supervision of the teacher, the clergymen themselves conducted psychotherapy and, finally, in private sessions with the teacher, those who wished it were afforded an opportunity to examine the conflicts or resistances they might have had to psychiatry and its approaches. PROBLEMS IN TRAINING A typical clergyman's entrance into the world of psychiatry can result in what anthropologists call "culture shock," a disturbed state of mind that occurs when one is abruptly dropped into a place whose customs and language are totally alien. Even where one might know a great deal about the contrasting core values of the two cultures, one has yet no way of knowing how shocking or painful the actual encounter will be because, in the face-to-face meeting, it is never the contrasting principles themselves that clash but the half-buried assumptions and value judgments derived from these principles that are challenged as never before. In varying degrees, the clergymen in a course of psychiatry are forced to examine the foregone conclusions that undergird their professional lives and, for many, this can be an alarming situation. At the beginning of each course, the teaching psychiatrist may pick up many clues that would indicate an underlying uneasiness among his students: built-in suspicions about unconscious forces; fears that facing these within the self may sabotage motivations for entering and staying in the ministry; an irritated discovery that psychiatry views man as the controller of his own destiny, leaving little room for the interventions of divine aid; a discomfort at being in a subservient position to another professional who considers himself more adept at an art that clergymen perceive to be primarily the "cure of souls." Above all, the hardest task is to overcome old counseling habits of directly advising, cajoling, and perhaps even trying to "inspire" the counselee, This problem, although common among all kinds of trainees in mental health programs, is particularly keen for clergymen--due, perhaps, to their longaccustomed role as guardians of morality. As training progresses to the point where the students are meeting and counseling patients, the discipline of nondirectiveness can become for them frustrating and time-consuming, especially in relation to certain types of disorder. Baute (~965) has found that a sample of priests, after some training in psychotherapy, concluded they were most adequate in their handling of spiritual, marital, or vocational problems and least adequate in treating those behaviors that are least amenable to moral suasion, such as alcoholism, scrupulosity, and homosexuality. Similarly, Bergsma (~962) discusses the church's special difficulty in counseling with the psychopath, and Golf (~964) found the same obstacles in the church's efforts to work with narcotic addicts. Of course, these types of patients are equally resistant to many varieties of psychiatric intervention, but the moral dimensions involved in the treatment of these deviances can present special stumbling blocks for the pastoral counselor.

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To help him in this dilemma, many religious commentators urge a synthesis of psychiatric and spiritual counseling. Generally, these writers agree with the principle of nonjudgmental, nonmanipulative interventions, but they still wish to preserve for the clergyman his traditional role of moral teacher. Thus, they encourage him to make his therapy "redemptive," so that with analytic understanding can also come contrition and atonement. In other words, the troubled parishioner, they admit, must not be made to suffer under any harsh judgments of the pastoral counselor, but he must be helped to know what it means to stand under the judgment of God. [For other samples of this view, see Nishi (596i), Zilboorg (5955), Stern (i955), and Linn and Schwarz (1958)]. SUBCULTURES OF CLERGYMEN AND PSYCHIATRISTS But the difficulties that arise in training the clergy for psychotherapy also spring from issues other than those of differing moral stances and commitment. The very life-styles of pastor and psychiatrist are at many points so divergent that one soon recalls how psychiatric ideologies and techniques have evolved from a highly distinctive "world" and that one cannot transplant that "world" in toto into another, possessing its own characteristic, culturally conditioned shape. The indoctrination--and let us be frank to admit that the teaching discussed here is primarily (and of necessity) just that --must take into account these differences. The psychiatric teacher must not expect to see psychotherapy, as he knows it, replicated whole within the "world" of the clergyman. To begin with, the psychiatrist's "world" has been traditionally urban, and modern psychotherapy, developing within great metropolises, has taken special advantage of this fact. The anonymity afforded by urban life has been incorporated as a special--even "necessary" feature into modern psychiatric practice. In order to promote transference, traditional psychoanalysts have always insisted that patients know next to nothing about the therapist's life beyond the confines of the consulting room. The experiences of psychiatrists who live in small towns (or who, as "society doctors," socialize within the same narrow elite as their patients) provide good supporting evidence for this "necessity" to be neutral or anonymous. In contrast, the world of the average clergyman is his congregation which, even within a large city, is a kind of village where everyone knows everybody, often on intimate terms. The clergyman must be very visible in this "village" and constantly on call for those in need of his help--and this is especially true for ministers and rabbis. Unlike psychiatrists, they cannot schedule a tight interview hour or charge fees for their services because, as servants to their people, they must keep their time open and free to all. Without these strict controls on the psychotherapeutic situation, clergymen might find it difficult to understand the meaning of the transference which develops in the counseling sessions. But the religious counselor is also confronted with the possibility of countertransference because of the many opportunities for socializing with his counselees in the congregation. In both in-

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stances, the special relationship required in good psychotherapy is inhibited or disrupted by the mutual familiarity. The urban psychiatrist also has an advantage in the neutrality of his demands on the patient. On the one hand, by insisting that his client be prompt at all interviews and with the payment of the fees, the psychiatrist encourages his patient to assume some of the responsibility for his cure (and this is, in fact, a major step he takes toward his recovery). These demands can also quickly set the tone and clearly draw the limits of the roles of therapist and patient and the characteristics of their momentary relationship together. But these requirements do not appear as unreasonable to the patient. They seem "natural" enough to be unthreatening to him or unprovoking of his anger. The clergyman, on the other hand, can only inculcate therapeutic responsibility by insisting that his parishioner abide by the moral injunctions of his church, and these might be so onerous or anxiety-provoking to the counselee that good therapy is impeded. When this occurs, of course, the clergyman would be best advised to refer the case to a psychiatrist, leaving himself to function as an auxiliary in the treatment. The "village world" also forces the clergyman to be not only close to all members of his congregation but to stay on the best of terms with them. His tenure is often dependent on the approval of his parishioners, and this is also especially true for Protestant and Jewish clergymen. In addition, pastors of practically all faiths must answer to superiors for what goes amiss in their congregations. They can, thus, ill afford to alienate anyone. Under these limitations, establishing that very special relationship required in psychotherapy--defined, impartial, and limited to one specific purpose--is next to impossible in the pastor's world which must be kept warm and personal--or at least appear so. Finally, if any parishioner becomes dissatisfied with his religious leader, he can--unlike the patient who becomes angry at his psychiatrist-easily create a negative public opinion against him and wreak havoc in his personal and professional life. Accordingly, whatever psychotherapeutic powers and skills the clergyman might have, or wish to attain, must be carefully translated beyond the training situation. He will have to adapt the techniques he learns to the special resources and limitations of the religious "world" to which he is committed. And he must be mindful, too, of the effect he will produce on his parishioners. Even where he is most enthusiastic about putting into practice all he has learned, his congregation will, upon his return from the training, resist too radical a change in his accustomed ways of interrelating with them. (For an excellent discussion of the techniques for effecting cultural change, see Arensburg and Neihoff, 5964. ) ADAPTING PSYCHOTHERAPY TO PASTORAL COUNSELING Despite these subcultural differences, there are ways of translating the experience of the psychiatrist into that of the clergyman. It is

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futile to expect that clergymen must function in the psychotherapeutic role exactly as the psychiatrist does. Too strong an insistence on this will force the clergyman out of his primary roles of minister and counselor. The closer degree of interaction in pastoral counseling need not in itself impair maximal~ therapeutic effectiveness. Scanning the major levels of psychotherapeufic intervention, we can see that none of them, in principle, is incompatible with the clergyman's role, i.e., providing (5) directions (referring patients to others along the line of treatment), (z) information, such as one could pick up in any "guide for mental health," and (3) psychotherapy. Three general functions characterize the therapy: relieving the patient of his feelings of isolation; providing a relationship that can easily counter his notions that his world is falling apart, or that he is worthless or socially doomed; and exploring with him the alternatives for change available within the framework of his present, actual life. Pastoral counselors, for their part, can perform all three of these therapeutic functions without difficulty, if they keep in mind the rule that they should not try to compel counselees to change in directions they might deem proper or necessary. They need not feel uneasy in the counseling situation, as long as they do not forget the above requisites of the therapeutic task. And most important, they need not feel that the permissiveness and validation of individual selfhood which lie at the core of a psychiatrist's credo will surely give license to patients to engage in all varieties of lawless or sinful behavior. They must remember: by freeing a patient from his fears and by increasing his awareness of himself and of the possibilities he faces, one does not release a moral monster upon the world but rather a more predictable, self-protecting, autonomous human being, one who can assume full responsibility for his conduct in everyday life, and one who is no longer victim of his inner forces but judicious master of them. The neutrality of the psychiatrist's role--as already noted---is impossible to translate directly into pastoral counseling but, once again, examining the principles involved, we can see how this neutrality can be adapted to differing circumstances. The psychiatrist is not open or self-revealing with his patients because he desires above all not to limit in any way their personal explorations of self and its potentials, nor does he want to inhibit the expression of whatever fantasies the patient might wish to entertain about him, for this material reveals much of the character of the patient's inner life. Also, acqfiainting the patient with the personal details of his life would be inappropriate to the therapy, except where the patient might have a right to know--as in inquiring after the therapist's qualifications. But whatever the patient learns, from whatever source, need not affect the psychiatrist's strict adherence to his professional role, if the irrelevant knowledge is frankly faced and excluded from the business of the therapy. The treatment the clergyman offers must be consistent with his life style. Admittedly, he cannot be impersonal or distant, nor can he pretend to be unfamiliar with the families of his counselees. We cannot expect him to dis-

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regard his values and beliefs--these are already public knowledge anyway. His denial of them or a lack of frankness concerning them will no doubt arouse a suspicion in his parishioner that he might be play-acting or that he is a downright hypocrite. The counselee has, in fact, selected him in part because he is an exponent of a particular faith. The essence of psychotherapy always insists on a singular focus upon the person who comes for help, his problems, conflicts, preconceptions, fears, guilts, and if this focus is assiduously maintained and the therapist clearly demonstrates to his client that his role is not that of a judge or censor but that of a listener and helpmate in the process of self-discovery, then the counselee can know a great deal about the clergyman without any of it interfering with the treatment. In fact, the clergyman can be a fervently orthodox adherent to his faith but still an excellent counselor, once he knows how to sustain that important distinction between his own role and his parishioner's need to have someone help him work through his problems. In brief, psychiatrists who despair of teaching clergymen because they cannot imagine themselves interacting so closely with patients while still maintaining an objective role must not reject the possibility of adapting good psychiatric practice into the pastoral setting. There are some advantages to the closer interaction and these can be positively exploited. The conditions of pastoral counseling do not militate against an autonomous therapist, respecting the autonomy of his counselee. OUTCOMES No formal evaluations of the effectiveness of the several teaching programs have been attempted because well-controlled follow-up studies would require a staff and facilities that are not available. However, through many informal contacts--reciprocal visits through the years, letters, regular therapy sessions--a generalized pattern of outcomes is discernible. For some clergymen, the training programs achieved results far beyond the expectation of the faculty. Others varied in their acquisition and retention of psychiatric knowledge, techniques, and attitudes. Some came away with only a battery of "handy" techniques; and a few left with less respect and greater antipathy for psychiatry than they had felt at the beginning of their training. But these results are no different than what might be expected from training groups of unselected physicians or, for that matter, psychiatric residents. It is unreasonable to expect an equal endowment among all students for the cultivation of those traits making for ideal growth and development as a therapist. Ongoing observations, spanning in some cases five years after a course of training, would warrant the following generalizations on the psychiatric training of clergymen. z. Students achieve levels of proficiency consistent with the goals of the course in direct relationship to its duration, i.e., the longer the period of training, the greater the achievement. But it must be borne in mind that even the

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best training programs for clergymen currently available represent only a fraction of the time devoted to the training of psychiatric residents. 2. Those students who arrive with an open mind, i.e., without any particularly great enthusiasm or antipathy for psychiatry, attain a more solid level of achievement than those who come with the highest hopes or the strongest doubts. Although these extremes do progress toward the mean in time, the erstwhile champions are particularly vulnerable to an embittered disillusionment and rejection of the subject matter. 3. The liberal Protestant minister is most readily acculturated to psychiatry, whereas the fundamentalist Protestant has the greatest difficulty. The Catholic priest, either liberal or conservative, will make use of psychiatric techniques for his own work, but he does not readily incorporate the belief system undergirding the field. There were not a sufficient number of rabbis enrolled in the training programs to justify any generalizations about them. 4- Most graduates make easier and more intelligent referrals than those unexposed to psychiatric training. They have a finer sense of who can or cannot be helped by a psychiatrist. In those cases where they feel obliged to refer patients with a poor prognosis, they are aware of the social pressures motivating the referral. 5- The training enabled many of the clergymen to be more critical of their relationships with congregation members. Compared with untrained clergymen, they are less prone to rationalize an emotional conflict with their counselees. 6. Most trainees felt that their exposure to psychiatry made their counseling easier. Following the training period, they felt less pressured than before to produce striking changes and were better able to shift the major burden of the therapeutic responsibility to their counselees. 7. The effects on their lives as clergymen were varied. Some achieved a successful integration of the ministerial and therapeutic roles with increasing comfort and gratifying progress. A few were led to abandon their religious vocations for that of full-time counselors, but this occurred less frequently than is commonly found among nonpsychiatric physicians undertaking such courses. Most often, those who did make a change in vocation had enrolled in the course with the intention of testing an earlier resolve to do so. Some, finding no answer in psychiatry, became more spiritual in their orientation--or at least more committed than before to their original outlook. Those who came to solve their own psychological problems were most often successful, especially when some personal therapy was possible. Some in this group, of course, failed to resolve their difficulties, and the few unfortunates who became psychotic-sometimes months or even years after the training--returned to their psychiatric teacher for treatment. But even in these cases, we can see reflected some benefit from their exposure to psychiatry--they had at least learned enough to refer themselves for treatment before their disabilities had completely overwhelmed them.

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DISCUSSION AND CONCLUSIONS The teaching experience summarized in this paper represents more than the simple indoctrination of clergymen with the functioning of the psychiatrist's role. We have seen how the experience has brought two different subcultures into contact. A brief look at the historical development of role theory will show why this is so. The concept of role, as developed by Linton and others, was derived from field studies of primitive societies with a single, unified culture. Within this context, the roles of chief, shaman, or artisan could be described in terms of function alone, because values and beliefs were shared by all members of society, regardless of role. In contrast to primitive groups, our modern, pluralistic society contains many different cultures (or, more properly, subcultures because of their overlapping value systems with other groups). In consequence, modern work roles no longer represent a simple differentiation of function but frequently indude sets of differing values, beliefs, and attitudes that make up the group's subculture. Where these subcultures overlap, interrole communications can be easy and effective, but efforts to communicate where areas do not overlap can be frustrating. The psychiatrist, teaching his principles of psychotherapy to clergymen, is constantly faced with the difficulties of interpreting the value-system of his own subculture to members of another. His communications with nonpsychiatric physicians can be equally fraught with difficulties (Brodsky, 5967), but these will arise from other sets of differing values. These difficulties might not be apparent to the teacher who considers his lectures sufficient means to transmit information and inculcate attitudes cross-culturally. Since psychiatry is presently a high-status field, it manifests many trends of ethnocentrism and this, of course, increases the likelihood of authoritarian teaching in this field, especially when the status of psychiatrist and student is not equal. The clergyman's problem in training might become dearer to the psychiatrist if he imagined himself taking a course on counseling from clergymen who were as unfamiliar with the psychiatrist's values and belief system as he is with the clergymen's. Unless the teaching psychiatrist acquaints himself with the cultural differences of his target group, he will either be seriously frustrated or deceived into believing he has successfully transmitted his messages when, in reality, he has not. His indoctrination of attitudes, values, and techniques will be most effective and least disturbing to his students when the teacher separates the essence from the subcultural accidents of the matter to be taught. REFERENCES Arensberg, C. M., & Niehoff, A. H. Introducing social change: A manual for Americans overseas. Chicago: Aldine, :a964. Baute, P. A report on pastoral counselor training. Chicago Studies, 5965, 4 (a), 58I-2oo. Bergsma, S. The pastor and the psychopath. Christianity Today, I962, 6 (:~8), 877-88o. Brodsky, C. M. A social view of the psychiatric consultation: The medical view and the social view. Psychosomatics, March-April, I967, 8, 61-68.

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Goff, D. H. Background paper on narcotic addiction. Journal of Pastoral Care, x964, z8 (2), 72-76 .

Gurin, G., Veroff, J., & Feld, S. Americans view their mental health. New York: Basic Books, 296o.

Linn, L., & Schwarz, L. W. Psychiatry and religious experience. New York: Random House, 2958. Nishi, S. F. A theological perspective on sexual morality and counseling. Journal of Pastoral Care, 2962, 25 (4), 2o4-226. Stern, K. Some spiritual aspects of psychotherapy. In F. J. Braceland,Faith, reason and modern psychiatry: Sources for a synthesis. New York: P. J. Kenedy & Sons, 2955. Pp. 225-24o. Zilboorg, G. Some denials and assertions of religious faith. In F. J. Braceland, Faith, reason and modern psychiatry: Sources for a synthesis. New York: P. J. Kenedy & Sons, 2955. Pp. 99-22~.

National Conference on Suicide The American Association of Suicidology will hold its annual national conference in New York City, March 29-3o, 2969. The program will include technical papers and a symposium on Emergency Rescue Services. Inquiries may be addressed to Edwin S. Shneidman, Chief, Center for Studies of Suicide Prevention, N.!.M.H., 5454 Wisconsin Ave., Chevy Chase, Md. 2020.3