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New Directions In Clinical Pastoral Training
ERNEST
E. B R U D E R
T h e passage of the Mental Health Act of 1963 marked the beginning of a new era in the treatment of mental illness in the United States. T h e change from the old state hospital concept to the new emphasis u p o n c o m m u n i t y centered treatment for the mentally ill has n o w been developed to the point where we can begin to see important implications for our o w n w o r k as chaplains. Indeed, the last few years have been a period of radical change in the whole mental health field. T h e r e has been a questioning of psychoanalytic practices. At the same time there has been an increasing emphasis on ego psychology, crisis theory, and crisis intervention, as well as preventive psychiatry. There have also been efforts to include nonprofessionals as mental health workers and the beginnings of attempts to enlist the aid of all members of the c o m m u n i t y in promoting and maintaining the kind of c o m m u n i t y that will foster better mental health. O u t of all this one thing is clear. N e w understanding and skills and new methods of training are going to be required for clergymen w h o will be working in the mental health field. Last year at the annual meeting of the THE REV. ERNESTE. BRVDER,D.D., is Director of Protestant Chaplain Activities, Saint Elizabeths Hospital-Division of Clinical and Community Services, National Center for Mental Health Services, Training and Research, National Institute of Mental Health, Washington, D.C. Material contained in this article does not necessarily reflect the opinion, official policy, or position of the National Institute of Mental Health or of the Department of Health, Education, and Welfare. The paper was delivered at the annual meeting of the Association of Mental Health Chaplains, San Francisco, May 9-15, 1970.
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Association of Mental Health Chaplains, this organization adopted a list of guidelines for clergymen who would be employed or associated with the staffs of community mental health centers. These guidelines made clear that such clergymen need more than to be skilled in work with patients who are being -treated behind the walls of an institution. They also need to be skilled in community liaison work, in offering consultation both to community ministers and to other members of the mental health professions. They need to be well qualified to organize and conduct educational and informational programs in the field of mental health for church and civic groups in the community. In short, they are expected to serve co-operatively with members of a number of disciplines in promoting the kind of community life that will tend to prevent the incidence of so much mental illness and to utilize the resources of religious faith and practice to this end. They must be well enough trained so that their activities can encompass prevention, rehabilitation, and research as well as treatment. I think it is true that clergymen have been among the first of the professions concerned with mental health to realize the interrelatedness of better mental health and spiritual health. Because of the wide diversity of religious faith and practice in this country, the natural suspicions about "bad" religion, and the traditional separation of church and state, psychiatrists and other mental health professionals have been slow to accept the clergyman as a natural co-worker. One of the immediate tasks confronting professional mental health chaplains, therefore, is the education of the medical and paramedical professions about the unique contribution the clergyman can make to better mental health. Even more important, however, those of us who are concerned with training clergymen as mental health workers need to re-examine and redirect our programs of clinical pastoral training. Radical reappraisal does not mean ignoring what has been learned and achieved up to this point. The careful study and assessment of the results of previous methods of training and the different approaches in supervision are a prerequisite to a rational approach toward program planning and development of more effective training procedures. Finding new directions in
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clinical pastoral training that will adequately serve the needs of the present and the foreseeable future is not an easy task. Here I can speak from my personal experience. I have had thirty years of experience in the clinical pastoral training movement. Twenty-six of these years have been spent as the originator and director of the Protestant Chaplain Activities program at Saint Elizabeths Hospital, now a part of the National Center for Mental Health Services, Training, and Research. In this period we have initiated six specific new levels of clinical pastoral training, many of which have served as examples for programs in other parts of the country. In looking back over these twenty-six years of experience, I would differentiate roughly three stages through which our program progressed to reach its present status. I think that it is reasonable to assume that others have passed through these same stages, and I think it is equally correct to state that many of the present programs have yet to achieve a transition to higher stages of development. W e have been fortunate at Saint Elizabeths in having available to us resources of the federal government and the concentration of psychiatrists and psychiatric institutions in the nation's capital. Merely to keep pace with what was going on around us, we were always forced to examine carefully what we were doing and to attempt to correct the m{stakes we saw in our program. I would emphasize, too, that it is often easier to see what is wrong than to find and actually put into practice the means of correcting it. I would not want to give the impression that our progress has been smooth or tranquil, nor that it is yet complete. W e have continued to make some of the mistakes that we have always made, in spite of our best efforts to change. A s I look back at the early and first stage, I see a situation in which the focus in training was primarily on the supervisor-student relationship. Even in this very early stage the intent was to help the trainee in his work with patients. W e made use of "process notes," and there was always some discussion of the trainee-patient relationship. However, the primary focus seemed to be on the personal problems of the trainee. In fact, these personal
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problems were frequently sought out by the supervisor since the initial, though not always conscious, supervisory aim was to change the person of the trainee. W e wanted to help him remove personal "hang-ups," with the assumption that he would then be "free" to be a better pastor. There was very little emphasis upon a formal curriculum, but such curricula as were developed were heavily weighted in psychiatric subjects and usually taught by psychiatrists. Group experiences often approximated group therapy, with much discussion of dreams and early life experiences. T h e y also tended at times to be of the "bull-session" type. In the selection of applicants for our program there was a tendency to accept applicants who had personal problems in order to "save them." Frequently seminaries joined in this conspiracy by sending us students who needed to be "straightened out." T h e y still do so. The second stage more or less coincided with the result of a research study that I conducted at the end of my first ten years of clinical-pastoral training at Saint Hizabeths Hospital.* I was impelled to undertake this study, and the study itself confirmed my impression that our training for many students was not accomplishing the intended pastoral objectives we had in mind. Some of the more mature students in the early 1950's accused me and other supervisors of having a "hidden agenda." One student at that time wrote: "What is the main objective of clinical pastoral training? In other words, are we here primarily to better understand ourselves or are we here primarily to help the patients?" Another student in 1952 said: "It is my impression that the clinical pastoral training program at Saint Elizabeths is oriented to the point of view of accenting personal 'analysis'..." An even more important problem was that at the end of the training programs it was very difficult to assess the extent to which the goals of the training had been met and how much actual pastoral learning had been achieved by trainees. The study also appeared to indicate that few of our students were making use of the mental health resources in their communities, once they assumed charge of their own churches. * Bruder, E. E., with Barb, M. L., "A Survey of Ten Years of Clinical Pastoral Training at Saint Elizabeths Hospital," ]. Pastoral Care, 1956, 10, pp. 86-94.
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The second stage followed this period of evaluation. There was a definite attempt on the part of the supervisor to focus more on patient work and the supervisory aim was to help the trainee learn pastoral skills. But it was not always clear what these skills were. Supervisory discussion often became side-tracked on personal issues initiated by the trainee. In spite of our intended emphasis on the trainee-patient relationship, there was still a strong tendency to deal with personal "hang-ups" that were getting in the way through the supervisory relationship. One of our objectives has always been to develop openness in the student. Ideally by this we meant an openness to new ideas, but in actual practice it often became interpreted as encouraging the student to "ventilate" his personal difficulties and hostilities. We considered the ability to do this a sign of personal progress. To a large degree, problems in learning that occurred during the trainees' work with patients were seen as personal problems, and the attempt to resolve them was by the method of treating the trainee himself as though he were a patient. This was not our goal; we had already seen the fallacy of this, but it is difficult to escape the pull of long-established habits and methods. In the second stage there was a definite realization of the need for a structured curriculum. At this stage, however, the curriculum offered a rather limited conception of the pastoral office. There was a focus on developing skills in "pastoral counseling." But we gradually came to realize that we were not properly distinguishing between pastoral counseling and psychotherapy, and that what we were doing was in effect an imitation of psychotherapy. One of the unfortunate by-products of such an approach, and it has happened to us, too, is that so many of the so-called clinically-trained ministers have abandoned the ministry, and, while attempting to retain their ministerial status, have set themselves up as private therapists called "pastoral counselors." It is rumored that some of them charge quite fancy fees, too. There was also an attempt to structure group experience so that these group experiences would have professional goals. The groups, however, had a permissive leadership that allowed free-floating discussion, fantasy sharing,
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and emotional expression. They approximated what is now called "sensitivity training" where the student "opened up" and gained what we honestly thought and called personal "insight." During this stage we tended to accept applicants with minimal personal problems. They were likely to be persons with low-grade depressions:, obsessive-compulsive (nonsymptomatic), and similar mildly neurotic states. There was an attempt in training to help them become more "human." Final evaluations during this period stressed pastoral learning, but there were always underlying assumptions that difficulties in training were due to psychological factors. There was, for example, a considerable emphasis upon peer relationships in the group and the ability to express hostility and other negative feelings freely. This was taken at face value as a sign of growth. The third stage began approximately in 1967 at the time that Saint Elizabeths Hospital became a part of the National Institute of Mental Health. Perhaps the major factor in the change that took place at this time was the formulation of a really complete and integrated curriculum covering the internship and residency programs. By 1962, we had been offering a thirty-nine months' program divided into an intern year, a fifteen months' period as a Chaplain Resident I, and a one-year period as a Chaplain Resident II. The intern year was the traditional year of training for the hospital chaplain, and the fifteen months' Residency I was intended to train chaplain supervisors. The third year was devoted to training in research methodology and the doing of chaplain studies in the field of religion and psychiatry and clinical pastoral education. Each of these levels had its own curriculum, but all of them tended to be somewhat separate and distinct, rather too generalized, and the content of the various seminars varied widely from year to year. In 1967, the integrated curriculum set forth quite clearly a course of study that was progressive in nature, that sought to develop both psychiatric understanding and ~pastoral skills, and that made a real attempt to integrate psychiatric and ~ perspectives. For the first time, a syllabus covering, in considerable detail, the first twenty-seven months of training, outlining the content to be covered in each of the courses given, and integrating these courses with the clinical experience in the institution was developed.
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I do not want to give the impression, however, that this was some sudden, miraculous change that solved our problems. In fact, at first it seemed rather to increase many of them. For again we were confronted with the very human trait that people tended to continue doing things the same way they had always been doing them, in spite of the fact that new plans, policies, objectives, and methods were developed. However, we were learning rapidly that we were on the right track and that these new methods and procedures were finally bringing about some of the results we desired. In 1968, the National Institute of Mental Health converted Saint Elizabeths Hospital into the National Center for Mental Health Services, Training, and Research. As a part of the National Center, a community mental health center was set up to serve the section of the city of Washington immediately adjacent to Saint Elizabeths Hospital. The objective was to create a national model for the conversion of an old-style mental hospital into a modern community-based treatment facility. The community mental health center program got under way in the spring of 1969; therefore we have now had one full year of experience in this type of community mental health activity. W e had, of course, anticipated this change; this is one of the reasons for the major change in program development that took place in 1967. Our training program begins: each year on July 1, to coincide with the government fiscal year. Thus we had a few months' experience with the community mental health program before we began the present year of training. W e found that our assumptions as to future needs, made in 1967, were fundamentally correct. In planning the changes in 1967, we had decided that supervisory focus should be on the pastoral relationship between the student and patient and the development of pastoral skills. W e took the position that difficulties in pastoral work are to be viewed as learning difficulties and, therefore, dealt with by appropriate measures such as role-playing, didactic instruction, and a supervisory relations:hip based on the concepts described by Gerald Caplan when he discussed consultee-centered case consultation. ~ Instead of working * Caplan, Gerald, Principles of Preventive Psychiatry. New York, Basic Books, 1964.
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directly on the personal "hang-ups" of the student, the supervisor focuses on the student-patient relations and points out alternative ways in which the student chaplain may more effectively function as a pastor. The supervisory aim is to provide opportunities for a trainee to learn to minister more effectively, through acquiring information, developing skills, and gaining a wider perspective on the functions and opportunities of the pastor in the community. There was a decided emphasis on the full range of the pastoral office rather than on a narrow specializing in pastoral counseling. As we have already indicated, the curriculum is highly developed through course outlines and syllabi. Pastoral information is carefully organized (comparable in organization to psychiatric lectures), and a definite emphasis is placed on the pastor's unique function to troubled people in the community. " The program begins with an extremely well-thought-out core curriculum emphasizing the particular concerns of the pastor and pastoral work. This is taught by chaplains. Group experiences in the pastoral program emphasize thinking as contrasted with feelings. The program focuses on clarity of professional identity and discussion of specific work problems. W e do not mean, however, that we have no concern with feelings; we recognize that where feelings are focused on exclusively, chaos inevitably results. For some years, group work training had been available to our students on an interdisciplinary basis. Working in co-operation with other disciplines, we have gradually developed a group work training program that is quite comprehensive in nature. I would emphasize that it is training in group work, not an experience of belonging to a therapy group as a "patient." For this type of program we seek applicants who have a strong commitment to the pastoral ministry and a desire to further their skills as ministers. The trainee comes to the program with the objective of gaining information, developing new skills, and working out a practical integration of his theological understanding with psychiatric and social science perspectives. The new directions in which we are moving in clinical pastoral education are best described by the program we have developed for the intern year. This is in a very real sense our basic program. It is offered over a twelve-month
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period, for ordained ministers with parish experience, with the goal of preparing clinically-trained pastors. They could serve in parishes, as institutional chaplains, as mental health workers in the mental health centers, or perhaps an effective combination of two or more of these. The program provides a wide variety of opportunities for acquiring information and developing skills appropriate to pastoral care in a community church or mental health setting. Major experiences of learning are, of course, with persons in difficulty, and it is required that the intern trainee begin with fifty per cent of his time devoted to ministry to such persons These activities take place on assigned clinical services of the mental hospital and the community mental health center. There are also required lectures and seminars, assigned readings, group experiences, and participation in a variety of clinical conferences. In the first three months of this training, the trainee engages in an intensive and comprehensive introduction to the general body of knowledge--pastoral and psychiatric--covered in the intern year for clergy. This curriculum is designed to communicate in the first three months of the program the core theoretical and practical understandings that will enable the intern to function adequately as a pastor on the hospital's therapeutic team. During these three months, most of the teaching and all of the supervision are done by staff chaplains. Later on, the program shifts to a heavier psychiatric collaboration in learning. In the following nine months, it is anticipated that the core understandings developed in the first three months will be expanded and developed through interdisciplinary course offerings and continuing seminars related to clinical pastoral concerns. Specifically, the courses offered in the summer pastoral curriculum are in the areas of clinical pastoral interviewing, pastoral counseling, conceptions of mental health and illness, distinctive pastoral resources for mental health ministry, community mental health activities, pastoral group work, supervised clinical visitation, and basic administrative concerns for chaplains. Approximately 140 seminar sessions are devoted to these courses during the first three months. This is a much greater proportion of time than in the follow-
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ing nine months, but the objective here is to present a comprehensive overview of pastoral and psychiatric understandings. In addition to the summer core curriculum, which is didactic in nature, each intern is given a primary assignment to a clinical division in the mental hospital. The intern is responsible for conducting initial pastoral visits and interviews with newly-admitted patients, follow-up ministry, including shortterm pastoral counseling, regular services of worship--all of which is done in collaboration and co-operation with interprofessional staff in the particular clinical divisions. In addition, each intern is responsible for twenty-four-hour coverage approximately one day a week at the National Center's Medical and Surgical Service. Here visits are made to newly-admitted patients, pre- and post-operative patients, and patients whose physical condition is listed as serious or critical. Through all of this work, interns are under the direct supervision of experienced staff chaplains trained in both the clinical pastoral ministry and in supervision. Written reports are required for supervisory conferences usually on a weekly basis. These include process notes on patient visits, religious development history studies, and sermons preached in the mental hospital or community. The goals of this supervision are to identify and clarify what transpires in interpersonal transactions relating to the trainee's work as a minister. It seeks to make clear, in understanding and practice, the resources, methods, and meanings of the Christian faith as these are expressed in pastoral care. In the supervisory relationship, the trainee is constantly confronted with the question as to what is unique and distinctive about his functions as a pastor in ministering to deeply troubled people and how this ministry can be carried out most effectively. During the remaining nine months of the intern year, the trainee expands and develops his pastoral and psychiatric understandings. Beginning with the fall session, the didactic portion of the program is divided into three major sections. The first of these is the interdisciplinary curriculum offered by the Vestermark Division of Intramural Training. It includes courses in clinical psychiatry, human growth and development, mental health delivery systems, and systems theory and dynamics.
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The second division of the didactic or structured program is concerned with the ongoing pastoral work of the trainee. There is a weekly seminar in pastoral concerns that deals with current issues in pastoral care. Here trainees assume a ma ior responsibility for presenting their work with patients. A second weekly seminar, concerned with "pastoral identity," provides an opportunity for trainees to clarify their pastoral identity as ministers. A group-work specialist serves as a consultant. Group discussion focuses on those things in the "here and now" that either hinder or enhance one's professional skills as a pastor. It is assumed that, as problems arise either in training or in ministry, the group will discuss alternatives and options available to the person who has a concern or problem and that there will be a genuine sharing of what each has learned so that all may benefit. It is hoped through this seminar to enable trainees to achieve further clarification of their roles as ministers of the church on the modern scene and especially to learn that the minister's contributions to people who are troubled and ill, while different, are as important and needed as those of the medical and other helping professions. The third division of the didactic program during this nine-month period is concerned with group-work training. Two ongoing seminars are part of the regular structure of the program. One of these, while interdisciplinary in nature in that trainees of other disciplines also participate, is conducted by a member of the chaplains staff. This is a reading seminar designed to acquaint interns with some of the maior theoretical writings in the group work field. The second seminar, also interdisciplinary in nature, is under the leadership of a group-work specialist. Trainees present their experiences in ongoing religious counseling groups and discuss their conceptions of their professional role as group leaders. The interdisciplinary nature of this training gives the chaplain trainee a wide exposure to various types of groups. In the fall session, interns retain their primary clinical assignments, but make appropriate rotations on secondary clinical assignments. The fall session clinical assignments include conducting religious counseling groups. At this time, too, there is an introduction to the work going on in the community mental health center. Each intern is given a limited assignment to a
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treatment team of the center. The assignment consists of doing intake interviews, attending team and general staff meetings, and participating in clinical conferences. The involvement in the work of the community mental health center is progressive throughout the fall, winter, and spring sessions. After the trainee has become familiar with the operations of the community mental health center, he begins to do follow-up counseling with outpatients from the community. The time devoted to his work increases gradually from the first minimal assignment until by the spring session he is spending approximately twenty-four hours a week in the community program. Toward the end of the year, the intern will spend a gradually increasing amount of time in community-related activities, which includes participation in organized clergy groups, consultation with community pastors, and visits to various health and welfare agencies in the community. During the fall session, supervision continues on an individual basis. With the beginning of the winter session, however, there is a substantial and significant change. Individual supervision is still available to the interns on a monthly basis or at the individual request of the trainee. The emphasis now shifts from individual supervision to consultation. Having demonstrated, in the first six months, growing competence and skill in pastoral work, the trainee is ready to assume a greater responsibility for his own ministry of learning. During weekly consultation sessions with a pastoral consultant who is a clinically-trained pastor serving a local church, trainees take the initiative in raising concerns and problems in their pastoral work about which they desire assistance. The purpose is not only to provide consultation, but to provide opportunities to learn how to be a consultant. Through learning how to use the services of a consultant in this manner, the trainees are brought to a realization of the values, the possibilities, and the limitations of a consultant's role. Theoretical aspects of consultation are also a part of the ongoing pastoral concerns seminar. It is our intention to make available to trainees adequate knowledge of how consultation can be effective in work in the
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community. Our experience so far in the community mental health center program has led us to believe that consultation is one of the key functions for the minister on the staff of the community mental health center. The traditional supervisory role and function, in which the supervisor retains responsibility for what goes on with troubled people, is not appropriate in working with clergymen in the community in the field of mental health or pastoral care. This intern year then forms the core and base of our program and indicates the direction in which further advanced training will go. The summer session introducing the intern year is also the basic course for our summer program. This enables us to provide fairly intensive experience to clergymen on leave from their parishes and senior seminarians. For clergymen it is intended as continuing education in the field of clinical pastoral care. In order to provide clergymen who can effectively serve on the staff of community mental health centers, or who can effectively serve from a parish base as leaders and clinical pastoral teachers in the community mental health program, it is anticipated that the intern would go on for the fifteen months of additional training as a Chaplain Resident I. During the additional fifteen months, he would be trained as a pastoral specialist in the field of mental health. Though it may seem a contradiction in terms, this would entail training him first as a "generalist" in the field of mental health work. His clinical assignment during this residency period would be in the community mental health center itself, and he would apply the basic understandings he has gained to his actual work and experience in the center. As a member of the treatment team, he would be particularly concerned with liaison with the community, the organization of educational programs for church and civic groups and clergy in the community, and especially he would be expected to serve as a consultant to individual pastors. A major thrust in this work would be toward the involvement of the "store-front" clergy, or other clergy serving the lower socioeconomic groups who often have not had professional training. Many in this group are in fact only part-time
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clergymen and hold other jobs in the community as well. In addition, they are the most difficult to reach by the mental health worker because they have the greatest fears of anything associated with mental illness. Those who show a special aptitude for leadership in his field would be encouraged to go on for our third year of training or the Resident II year. This is a year devoted to training in research methodology and the doing of study projects in the general field of religion and health and clinical pastoral education. The courses I have described up to this point are those for which we offer a federal stipend in order to train people who will be active in the national mental health effort. In addition, and in fact as a part of these programs, there are also several levels of training offered for seminarians and clergy on a volunteer basis. These are part-time courses such as our incourse training for seminary students from local seminaries, special courses for clergymen from the area served by the community mental health center, special courses for clergymen from the Washington Metropolitan area, and of course many workshops, seminars, and brief courses for laymen. In conclusion I would like to offer some personal reflections on our present program in view of my twenty-six years of experience at this institution. 1. The purpose of clinical pastoral training, if it is to achieve what the title implies, clinical pastoral training, must focus on the pastoral relationship of trainees with patients. Where the focus is on the person of the trainee or on the relationship of the supervisor and the trainee, this is likely to confuse the basic objectives of professional pastoral training. When such objectives do become confused, there is strong suspicion that the supervisor may be attempting to work out his own personal problems at the expense of the student. 2. Even though training programs, including our own, develop pastoral objectives focused on providing opportunities for trainees to learn pastoral skills, to acquire appropriate theological and psychiatric information, and to develop some integrated perspectives of theological understandings and
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psychiatric information, there is a strong tendency in the actual practice for these goals to be subverted and short-circuited. This is something to which the Association of Mental Health Chaplains, as a professional organization, should give careful and continuing consideration. Much research is needed in the area of what actually transpires in supervisory relationships. We may be startled to discover that what is printed in brochures differs widely from what is practiced in the programs themselves. 3. For many years in our own program we followed what is still generally the practice of offering the initial basic course in clinical pastoral training to seminary students at the end of their first year in seminary. It took us many years to realize that this was a mistake. At the end of their first year of theological study, most seminarians are most upset and least sure of themselves. At this point, they have no real theological base. They have often not come to any real understanding of some of the personal problems that may have led them to study for the ministry. This is undoubtedly why many seminaries have been so eager to send students for clinical pastoral training at the end of their first year, in order to "get them straightened out." However, this is not the proper function of clinical pastoral training. It is the function and responsibility of the seminary itself. It is the seminary's task to provide such opportunities as "sensitivity training" and "therapy groups" in the course of regular seminary studies. "Change" in a student is a prerogative and a responsibility of the seminary and should not be expected of a hospital or government institution. It is, however, necessary for the seminaries to have on their faculties people who can deal competently with these problems, which implies that they themselves would have had adequate clinical pastoral training in addition to other specialized group therapy training. The real contribution that clinical pastoral training can make to the education of the seminary student is in the integration of theological and pastoral understanding and practice with the behavioral and social science disciplines. This is far too important a contribution to be subverted, watered down, or confused by a hidden agenda in which the purpose is to change the person of the student.
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4. It follows from the above that clinical pastoral training is best offered for the average seminarian "in-course," during his middle or senior year. Our experience has led us to believe that eight hours per week for two semesters in a well-worked-out program would give the student an adequate foundation in clinical pastoral experience. We believe that such a one-year course would be more than comparable to the present practice of spending a "quarter" in intensive training during the summer. In fact, it seems that this procedure would offer greater opportunities for a more real integration of theological and pastoral understanding with the clinical experience the seminarian is undergoing. Such a course would markedly reduce the high level of anxiety induced in present summer students, which severely inhibits their pastoral learning and constricts and confuses their pastoral identities. 5. When I re-read some of my early evaluations of students I find that I have been guilty of saying that a student had somehow got "insight" into his problems during the course of training. At the present time we receive evaluations from supervisors all over the country of students who have undergone clinical training in their programs and who are now applying f o r one of our programs. I find that there is still a very frequent emphasis on the student somehow getting "insight" into his personal problems as a result of his supposed clinical training. This is a delusion and a snare. Real "insight" cannot be achieved in any three months of clinical pastoral training, nor indeed even in a year of such training. Psychiatrists with whom I have discussed this have been unanimous in concluding that we are deluding ourselves if we believe that the kind of programs we are offering are conducive to the development of "insight" in any real sense. Granted that there may be flashes of understanding in any human situation, they are apt to be a by-product, and certainly not the result of any planned effort in this direction. It is possible, however, in clinical pastoral training to make the student develop an awareness of how he feels and reacts in relations with other human beings. He may even arrive at an understanding of how his feelings and actions affect others. Insight,
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however, as to the origin of feelings, thoughts, wishes, and acts can seldom be achieved except in deep, intensive analysis, and even then it is a rare accomplishment. Even the most desired goal of awareness and understanding of our feelings and action is achieved in clinical pastoral training only as a by-product of a well-thought-out and well-organized program of clinical pastoral experience in which the minister is able to deal compassionately and realistically with the problems of others. 6. The inevitability of new directions for our work in training as mental health chaplains is clear. Change is very often unpleasant, but it is at the same time challenging. There are already 225 community mental health centers in operation in this country and financial support for about 500 such centers is expected from the federal government by the end of 1970. Changes are going to occur more quickly in certain parts of the country than in others, but the writing on the wall is clear. T h e state hospital as we have known it is on its way out. The most urgent question facing us today is to provide the training necessary for what we know is going to happen in the seventies and beyond. As mental health chaplains we have the opportunity to be in the vanguard or we can become anachronisms. It is equally clear that we must set our own house in order; we must be quite clear about the directions in which we as clergymen desire to go if we are to make our contributions and functions clear to psychiatrists and other mental health professionals. It is also important that these new directions be developed from as broad an ecumenical base as possible. As the only truly ecumenical organization of clergy actively concerned in mental health work, our opportunities and responsibilities are great.
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ERNEST
E. B R U D E R
T h e passage of the Mental Health Act of 1963 marked the beginning of a new era in the treatment of mental illness in the United States. T h e change from the old state hospital concept to the new emphasis u p o n c o m m u n i t y centered treatment for the mentally ill has n o w been developed to the point where we can begin to see important implications for our o w n w o r k as chaplains. Indeed, the last few years have been a period of radical change in the whole mental health field. T h e r e has been a questioning of psychoanalytic practices. At the same time there has been an increasing emphasis on ego psychology, crisis theory, and crisis intervention, as well as preventive psychiatry. There have also been efforts to include nonprofessionals as mental health workers and the beginnings of attempts to enlist the aid of all members of the c o m m u n i t y in promoting and maintaining the kind of c o m m u n i t y that will foster better mental health. O u t of all this one thing is clear. N e w understanding and skills and new methods of training are going to be required for clergymen w h o will be working in the mental health field. Last year at the annual meeting of the THE REV. ERNESTE. BRVDER,D.D., is Director of Protestant Chaplain Activities, Saint Elizabeths Hospital-Division of Clinical and Community Services, National Center for Mental Health Services, Training and Research, National Institute of Mental Health, Washington, D.C. Material contained in this article does not necessarily reflect the opinion, official policy, or position of the National Institute of Mental Health or of the Department of Health, Education, and Welfare. The paper was delivered at the annual meeting of the Association of Mental Health Chaplains, San Francisco, May 9-15, 1970.
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Association of Mental Health Chaplains, this organization adopted a list of guidelines for clergymen who would be employed or associated with the staffs of community mental health centers. These guidelines made clear that such clergymen need more than to be skilled in work with patients who are being -treated behind the walls of an institution. They also need to be skilled in community liaison work, in offering consultation both to community ministers and to other members of the mental health professions. They need to be well qualified to organize and conduct educational and informational programs in the field of mental health for church and civic groups in the community. In short, they are expected to serve co-operatively with members of a number of disciplines in promoting the kind of community life that will tend to prevent the incidence of so much mental illness and to utilize the resources of religious faith and practice to this end. They must be well enough trained so that their activities can encompass prevention, rehabilitation, and research as well as treatment. I think it is true that clergymen have been among the first of the professions concerned with mental health to realize the interrelatedness of better mental health and spiritual health. Because of the wide diversity of religious faith and practice in this country, the natural suspicions about "bad" religion, and the traditional separation of church and state, psychiatrists and other mental health professionals have been slow to accept the clergyman as a natural co-worker. One of the immediate tasks confronting professional mental health chaplains, therefore, is the education of the medical and paramedical professions about the unique contribution the clergyman can make to better mental health. Even more important, however, those of us who are concerned with training clergymen as mental health workers need to re-examine and redirect our programs of clinical pastoral training. Radical reappraisal does not mean ignoring what has been learned and achieved up to this point. The careful study and assessment of the results of previous methods of training and the different approaches in supervision are a prerequisite to a rational approach toward program planning and development of more effective training procedures. Finding new directions in
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clinical pastoral training that will adequately serve the needs of the present and the foreseeable future is not an easy task. Here I can speak from my personal experience. I have had thirty years of experience in the clinical pastoral training movement. Twenty-six of these years have been spent as the originator and director of the Protestant Chaplain Activities program at Saint Elizabeths Hospital, now a part of the National Center for Mental Health Services, Training, and Research. In this period we have initiated six specific new levels of clinical pastoral training, many of which have served as examples for programs in other parts of the country. In looking back over these twenty-six years of experience, I would differentiate roughly three stages through which our program progressed to reach its present status. I think that it is reasonable to assume that others have passed through these same stages, and I think it is equally correct to state that many of the present programs have yet to achieve a transition to higher stages of development. W e have been fortunate at Saint Elizabeths in having available to us resources of the federal government and the concentration of psychiatrists and psychiatric institutions in the nation's capital. Merely to keep pace with what was going on around us, we were always forced to examine carefully what we were doing and to attempt to correct the m{stakes we saw in our program. I would emphasize, too, that it is often easier to see what is wrong than to find and actually put into practice the means of correcting it. I would not want to give the impression that our progress has been smooth or tranquil, nor that it is yet complete. W e have continued to make some of the mistakes that we have always made, in spite of our best efforts to change. A s I look back at the early and first stage, I see a situation in which the focus in training was primarily on the supervisor-student relationship. Even in this very early stage the intent was to help the trainee in his work with patients. W e made use of "process notes," and there was always some discussion of the trainee-patient relationship. However, the primary focus seemed to be on the personal problems of the trainee. In fact, these personal
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problems were frequently sought out by the supervisor since the initial, though not always conscious, supervisory aim was to change the person of the trainee. W e wanted to help him remove personal "hang-ups," with the assumption that he would then be "free" to be a better pastor. There was very little emphasis upon a formal curriculum, but such curricula as were developed were heavily weighted in psychiatric subjects and usually taught by psychiatrists. Group experiences often approximated group therapy, with much discussion of dreams and early life experiences. T h e y also tended at times to be of the "bull-session" type. In the selection of applicants for our program there was a tendency to accept applicants who had personal problems in order to "save them." Frequently seminaries joined in this conspiracy by sending us students who needed to be "straightened out." T h e y still do so. The second stage more or less coincided with the result of a research study that I conducted at the end of my first ten years of clinical-pastoral training at Saint Hizabeths Hospital.* I was impelled to undertake this study, and the study itself confirmed my impression that our training for many students was not accomplishing the intended pastoral objectives we had in mind. Some of the more mature students in the early 1950's accused me and other supervisors of having a "hidden agenda." One student at that time wrote: "What is the main objective of clinical pastoral training? In other words, are we here primarily to better understand ourselves or are we here primarily to help the patients?" Another student in 1952 said: "It is my impression that the clinical pastoral training program at Saint Elizabeths is oriented to the point of view of accenting personal 'analysis'..." An even more important problem was that at the end of the training programs it was very difficult to assess the extent to which the goals of the training had been met and how much actual pastoral learning had been achieved by trainees. The study also appeared to indicate that few of our students were making use of the mental health resources in their communities, once they assumed charge of their own churches. * Bruder, E. E., with Barb, M. L., "A Survey of Ten Years of Clinical Pastoral Training at Saint Elizabeths Hospital," ]. Pastoral Care, 1956, 10, pp. 86-94.
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The second stage followed this period of evaluation. There was a definite attempt on the part of the supervisor to focus more on patient work and the supervisory aim was to help the trainee learn pastoral skills. But it was not always clear what these skills were. Supervisory discussion often became side-tracked on personal issues initiated by the trainee. In spite of our intended emphasis on the trainee-patient relationship, there was still a strong tendency to deal with personal "hang-ups" that were getting in the way through the supervisory relationship. One of our objectives has always been to develop openness in the student. Ideally by this we meant an openness to new ideas, but in actual practice it often became interpreted as encouraging the student to "ventilate" his personal difficulties and hostilities. We considered the ability to do this a sign of personal progress. To a large degree, problems in learning that occurred during the trainees' work with patients were seen as personal problems, and the attempt to resolve them was by the method of treating the trainee himself as though he were a patient. This was not our goal; we had already seen the fallacy of this, but it is difficult to escape the pull of long-established habits and methods. In the second stage there was a definite realization of the need for a structured curriculum. At this stage, however, the curriculum offered a rather limited conception of the pastoral office. There was a focus on developing skills in "pastoral counseling." But we gradually came to realize that we were not properly distinguishing between pastoral counseling and psychotherapy, and that what we were doing was in effect an imitation of psychotherapy. One of the unfortunate by-products of such an approach, and it has happened to us, too, is that so many of the so-called clinically-trained ministers have abandoned the ministry, and, while attempting to retain their ministerial status, have set themselves up as private therapists called "pastoral counselors." It is rumored that some of them charge quite fancy fees, too. There was also an attempt to structure group experience so that these group experiences would have professional goals. The groups, however, had a permissive leadership that allowed free-floating discussion, fantasy sharing,
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and emotional expression. They approximated what is now called "sensitivity training" where the student "opened up" and gained what we honestly thought and called personal "insight." During this stage we tended to accept applicants with minimal personal problems. They were likely to be persons with low-grade depressions:, obsessive-compulsive (nonsymptomatic), and similar mildly neurotic states. There was an attempt in training to help them become more "human." Final evaluations during this period stressed pastoral learning, but there were always underlying assumptions that difficulties in training were due to psychological factors. There was, for example, a considerable emphasis upon peer relationships in the group and the ability to express hostility and other negative feelings freely. This was taken at face value as a sign of growth. The third stage began approximately in 1967 at the time that Saint Elizabeths Hospital became a part of the National Institute of Mental Health. Perhaps the major factor in the change that took place at this time was the formulation of a really complete and integrated curriculum covering the internship and residency programs. By 1962, we had been offering a thirty-nine months' program divided into an intern year, a fifteen months' period as a Chaplain Resident I, and a one-year period as a Chaplain Resident II. The intern year was the traditional year of training for the hospital chaplain, and the fifteen months' Residency I was intended to train chaplain supervisors. The third year was devoted to training in research methodology and the doing of chaplain studies in the field of religion and psychiatry and clinical pastoral education. Each of these levels had its own curriculum, but all of them tended to be somewhat separate and distinct, rather too generalized, and the content of the various seminars varied widely from year to year. In 1967, the integrated curriculum set forth quite clearly a course of study that was progressive in nature, that sought to develop both psychiatric understanding and ~pastoral skills, and that made a real attempt to integrate psychiatric and ~ perspectives. For the first time, a syllabus covering, in considerable detail, the first twenty-seven months of training, outlining the content to be covered in each of the courses given, and integrating these courses with the clinical experience in the institution was developed.
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I do not want to give the impression, however, that this was some sudden, miraculous change that solved our problems. In fact, at first it seemed rather to increase many of them. For again we were confronted with the very human trait that people tended to continue doing things the same way they had always been doing them, in spite of the fact that new plans, policies, objectives, and methods were developed. However, we were learning rapidly that we were on the right track and that these new methods and procedures were finally bringing about some of the results we desired. In 1968, the National Institute of Mental Health converted Saint Elizabeths Hospital into the National Center for Mental Health Services, Training, and Research. As a part of the National Center, a community mental health center was set up to serve the section of the city of Washington immediately adjacent to Saint Elizabeths Hospital. The objective was to create a national model for the conversion of an old-style mental hospital into a modern community-based treatment facility. The community mental health center program got under way in the spring of 1969; therefore we have now had one full year of experience in this type of community mental health activity. W e had, of course, anticipated this change; this is one of the reasons for the major change in program development that took place in 1967. Our training program begins: each year on July 1, to coincide with the government fiscal year. Thus we had a few months' experience with the community mental health program before we began the present year of training. W e found that our assumptions as to future needs, made in 1967, were fundamentally correct. In planning the changes in 1967, we had decided that supervisory focus should be on the pastoral relationship between the student and patient and the development of pastoral skills. W e took the position that difficulties in pastoral work are to be viewed as learning difficulties and, therefore, dealt with by appropriate measures such as role-playing, didactic instruction, and a supervisory relations:hip based on the concepts described by Gerald Caplan when he discussed consultee-centered case consultation. ~ Instead of working * Caplan, Gerald, Principles of Preventive Psychiatry. New York, Basic Books, 1964.
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directly on the personal "hang-ups" of the student, the supervisor focuses on the student-patient relations and points out alternative ways in which the student chaplain may more effectively function as a pastor. The supervisory aim is to provide opportunities for a trainee to learn to minister more effectively, through acquiring information, developing skills, and gaining a wider perspective on the functions and opportunities of the pastor in the community. There was a decided emphasis on the full range of the pastoral office rather than on a narrow specializing in pastoral counseling. As we have already indicated, the curriculum is highly developed through course outlines and syllabi. Pastoral information is carefully organized (comparable in organization to psychiatric lectures), and a definite emphasis is placed on the pastor's unique function to troubled people in the community. " The program begins with an extremely well-thought-out core curriculum emphasizing the particular concerns of the pastor and pastoral work. This is taught by chaplains. Group experiences in the pastoral program emphasize thinking as contrasted with feelings. The program focuses on clarity of professional identity and discussion of specific work problems. W e do not mean, however, that we have no concern with feelings; we recognize that where feelings are focused on exclusively, chaos inevitably results. For some years, group work training had been available to our students on an interdisciplinary basis. Working in co-operation with other disciplines, we have gradually developed a group work training program that is quite comprehensive in nature. I would emphasize that it is training in group work, not an experience of belonging to a therapy group as a "patient." For this type of program we seek applicants who have a strong commitment to the pastoral ministry and a desire to further their skills as ministers. The trainee comes to the program with the objective of gaining information, developing new skills, and working out a practical integration of his theological understanding with psychiatric and social science perspectives. The new directions in which we are moving in clinical pastoral education are best described by the program we have developed for the intern year. This is in a very real sense our basic program. It is offered over a twelve-month
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period, for ordained ministers with parish experience, with the goal of preparing clinically-trained pastors. They could serve in parishes, as institutional chaplains, as mental health workers in the mental health centers, or perhaps an effective combination of two or more of these. The program provides a wide variety of opportunities for acquiring information and developing skills appropriate to pastoral care in a community church or mental health setting. Major experiences of learning are, of course, with persons in difficulty, and it is required that the intern trainee begin with fifty per cent of his time devoted to ministry to such persons These activities take place on assigned clinical services of the mental hospital and the community mental health center. There are also required lectures and seminars, assigned readings, group experiences, and participation in a variety of clinical conferences. In the first three months of this training, the trainee engages in an intensive and comprehensive introduction to the general body of knowledge--pastoral and psychiatric--covered in the intern year for clergy. This curriculum is designed to communicate in the first three months of the program the core theoretical and practical understandings that will enable the intern to function adequately as a pastor on the hospital's therapeutic team. During these three months, most of the teaching and all of the supervision are done by staff chaplains. Later on, the program shifts to a heavier psychiatric collaboration in learning. In the following nine months, it is anticipated that the core understandings developed in the first three months will be expanded and developed through interdisciplinary course offerings and continuing seminars related to clinical pastoral concerns. Specifically, the courses offered in the summer pastoral curriculum are in the areas of clinical pastoral interviewing, pastoral counseling, conceptions of mental health and illness, distinctive pastoral resources for mental health ministry, community mental health activities, pastoral group work, supervised clinical visitation, and basic administrative concerns for chaplains. Approximately 140 seminar sessions are devoted to these courses during the first three months. This is a much greater proportion of time than in the follow-
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ing nine months, but the objective here is to present a comprehensive overview of pastoral and psychiatric understandings. In addition to the summer core curriculum, which is didactic in nature, each intern is given a primary assignment to a clinical division in the mental hospital. The intern is responsible for conducting initial pastoral visits and interviews with newly-admitted patients, follow-up ministry, including shortterm pastoral counseling, regular services of worship--all of which is done in collaboration and co-operation with interprofessional staff in the particular clinical divisions. In addition, each intern is responsible for twenty-four-hour coverage approximately one day a week at the National Center's Medical and Surgical Service. Here visits are made to newly-admitted patients, pre- and post-operative patients, and patients whose physical condition is listed as serious or critical. Through all of this work, interns are under the direct supervision of experienced staff chaplains trained in both the clinical pastoral ministry and in supervision. Written reports are required for supervisory conferences usually on a weekly basis. These include process notes on patient visits, religious development history studies, and sermons preached in the mental hospital or community. The goals of this supervision are to identify and clarify what transpires in interpersonal transactions relating to the trainee's work as a minister. It seeks to make clear, in understanding and practice, the resources, methods, and meanings of the Christian faith as these are expressed in pastoral care. In the supervisory relationship, the trainee is constantly confronted with the question as to what is unique and distinctive about his functions as a pastor in ministering to deeply troubled people and how this ministry can be carried out most effectively. During the remaining nine months of the intern year, the trainee expands and develops his pastoral and psychiatric understandings. Beginning with the fall session, the didactic portion of the program is divided into three major sections. The first of these is the interdisciplinary curriculum offered by the Vestermark Division of Intramural Training. It includes courses in clinical psychiatry, human growth and development, mental health delivery systems, and systems theory and dynamics.
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The second division of the didactic or structured program is concerned with the ongoing pastoral work of the trainee. There is a weekly seminar in pastoral concerns that deals with current issues in pastoral care. Here trainees assume a ma ior responsibility for presenting their work with patients. A second weekly seminar, concerned with "pastoral identity," provides an opportunity for trainees to clarify their pastoral identity as ministers. A group-work specialist serves as a consultant. Group discussion focuses on those things in the "here and now" that either hinder or enhance one's professional skills as a pastor. It is assumed that, as problems arise either in training or in ministry, the group will discuss alternatives and options available to the person who has a concern or problem and that there will be a genuine sharing of what each has learned so that all may benefit. It is hoped through this seminar to enable trainees to achieve further clarification of their roles as ministers of the church on the modern scene and especially to learn that the minister's contributions to people who are troubled and ill, while different, are as important and needed as those of the medical and other helping professions. The third division of the didactic program during this nine-month period is concerned with group-work training. Two ongoing seminars are part of the regular structure of the program. One of these, while interdisciplinary in nature in that trainees of other disciplines also participate, is conducted by a member of the chaplains staff. This is a reading seminar designed to acquaint interns with some of the maior theoretical writings in the group work field. The second seminar, also interdisciplinary in nature, is under the leadership of a group-work specialist. Trainees present their experiences in ongoing religious counseling groups and discuss their conceptions of their professional role as group leaders. The interdisciplinary nature of this training gives the chaplain trainee a wide exposure to various types of groups. In the fall session, interns retain their primary clinical assignments, but make appropriate rotations on secondary clinical assignments. The fall session clinical assignments include conducting religious counseling groups. At this time, too, there is an introduction to the work going on in the community mental health center. Each intern is given a limited assignment to a
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treatment team of the center. The assignment consists of doing intake interviews, attending team and general staff meetings, and participating in clinical conferences. The involvement in the work of the community mental health center is progressive throughout the fall, winter, and spring sessions. After the trainee has become familiar with the operations of the community mental health center, he begins to do follow-up counseling with outpatients from the community. The time devoted to his work increases gradually from the first minimal assignment until by the spring session he is spending approximately twenty-four hours a week in the community program. Toward the end of the year, the intern will spend a gradually increasing amount of time in community-related activities, which includes participation in organized clergy groups, consultation with community pastors, and visits to various health and welfare agencies in the community. During the fall session, supervision continues on an individual basis. With the beginning of the winter session, however, there is a substantial and significant change. Individual supervision is still available to the interns on a monthly basis or at the individual request of the trainee. The emphasis now shifts from individual supervision to consultation. Having demonstrated, in the first six months, growing competence and skill in pastoral work, the trainee is ready to assume a greater responsibility for his own ministry of learning. During weekly consultation sessions with a pastoral consultant who is a clinically-trained pastor serving a local church, trainees take the initiative in raising concerns and problems in their pastoral work about which they desire assistance. The purpose is not only to provide consultation, but to provide opportunities to learn how to be a consultant. Through learning how to use the services of a consultant in this manner, the trainees are brought to a realization of the values, the possibilities, and the limitations of a consultant's role. Theoretical aspects of consultation are also a part of the ongoing pastoral concerns seminar. It is our intention to make available to trainees adequate knowledge of how consultation can be effective in work in the
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community. Our experience so far in the community mental health center program has led us to believe that consultation is one of the key functions for the minister on the staff of the community mental health center. The traditional supervisory role and function, in which the supervisor retains responsibility for what goes on with troubled people, is not appropriate in working with clergymen in the community in the field of mental health or pastoral care. This intern year then forms the core and base of our program and indicates the direction in which further advanced training will go. The summer session introducing the intern year is also the basic course for our summer program. This enables us to provide fairly intensive experience to clergymen on leave from their parishes and senior seminarians. For clergymen it is intended as continuing education in the field of clinical pastoral care. In order to provide clergymen who can effectively serve on the staff of community mental health centers, or who can effectively serve from a parish base as leaders and clinical pastoral teachers in the community mental health program, it is anticipated that the intern would go on for the fifteen months of additional training as a Chaplain Resident I. During the additional fifteen months, he would be trained as a pastoral specialist in the field of mental health. Though it may seem a contradiction in terms, this would entail training him first as a "generalist" in the field of mental health work. His clinical assignment during this residency period would be in the community mental health center itself, and he would apply the basic understandings he has gained to his actual work and experience in the center. As a member of the treatment team, he would be particularly concerned with liaison with the community, the organization of educational programs for church and civic groups and clergy in the community, and especially he would be expected to serve as a consultant to individual pastors. A major thrust in this work would be toward the involvement of the "store-front" clergy, or other clergy serving the lower socioeconomic groups who often have not had professional training. Many in this group are in fact only part-time
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clergymen and hold other jobs in the community as well. In addition, they are the most difficult to reach by the mental health worker because they have the greatest fears of anything associated with mental illness. Those who show a special aptitude for leadership in his field would be encouraged to go on for our third year of training or the Resident II year. This is a year devoted to training in research methodology and the doing of study projects in the general field of religion and health and clinical pastoral education. The courses I have described up to this point are those for which we offer a federal stipend in order to train people who will be active in the national mental health effort. In addition, and in fact as a part of these programs, there are also several levels of training offered for seminarians and clergy on a volunteer basis. These are part-time courses such as our incourse training for seminary students from local seminaries, special courses for clergymen from the area served by the community mental health center, special courses for clergymen from the Washington Metropolitan area, and of course many workshops, seminars, and brief courses for laymen. In conclusion I would like to offer some personal reflections on our present program in view of my twenty-six years of experience at this institution. 1. The purpose of clinical pastoral training, if it is to achieve what the title implies, clinical pastoral training, must focus on the pastoral relationship of trainees with patients. Where the focus is on the person of the trainee or on the relationship of the supervisor and the trainee, this is likely to confuse the basic objectives of professional pastoral training. When such objectives do become confused, there is strong suspicion that the supervisor may be attempting to work out his own personal problems at the expense of the student. 2. Even though training programs, including our own, develop pastoral objectives focused on providing opportunities for trainees to learn pastoral skills, to acquire appropriate theological and psychiatric information, and to develop some integrated perspectives of theological understandings and
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psychiatric information, there is a strong tendency in the actual practice for these goals to be subverted and short-circuited. This is something to which the Association of Mental Health Chaplains, as a professional organization, should give careful and continuing consideration. Much research is needed in the area of what actually transpires in supervisory relationships. We may be startled to discover that what is printed in brochures differs widely from what is practiced in the programs themselves. 3. For many years in our own program we followed what is still generally the practice of offering the initial basic course in clinical pastoral training to seminary students at the end of their first year in seminary. It took us many years to realize that this was a mistake. At the end of their first year of theological study, most seminarians are most upset and least sure of themselves. At this point, they have no real theological base. They have often not come to any real understanding of some of the personal problems that may have led them to study for the ministry. This is undoubtedly why many seminaries have been so eager to send students for clinical pastoral training at the end of their first year, in order to "get them straightened out." However, this is not the proper function of clinical pastoral training. It is the function and responsibility of the seminary itself. It is the seminary's task to provide such opportunities as "sensitivity training" and "therapy groups" in the course of regular seminary studies. "Change" in a student is a prerogative and a responsibility of the seminary and should not be expected of a hospital or government institution. It is, however, necessary for the seminaries to have on their faculties people who can deal competently with these problems, which implies that they themselves would have had adequate clinical pastoral training in addition to other specialized group therapy training. The real contribution that clinical pastoral training can make to the education of the seminary student is in the integration of theological and pastoral understanding and practice with the behavioral and social science disciplines. This is far too important a contribution to be subverted, watered down, or confused by a hidden agenda in which the purpose is to change the person of the student.
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4. It follows from the above that clinical pastoral training is best offered for the average seminarian "in-course," during his middle or senior year. Our experience has led us to believe that eight hours per week for two semesters in a well-worked-out program would give the student an adequate foundation in clinical pastoral experience. We believe that such a one-year course would be more than comparable to the present practice of spending a "quarter" in intensive training during the summer. In fact, it seems that this procedure would offer greater opportunities for a more real integration of theological and pastoral understanding with the clinical experience the seminarian is undergoing. Such a course would markedly reduce the high level of anxiety induced in present summer students, which severely inhibits their pastoral learning and constricts and confuses their pastoral identities. 5. When I re-read some of my early evaluations of students I find that I have been guilty of saying that a student had somehow got "insight" into his problems during the course of training. At the present time we receive evaluations from supervisors all over the country of students who have undergone clinical training in their programs and who are now applying f o r one of our programs. I find that there is still a very frequent emphasis on the student somehow getting "insight" into his personal problems as a result of his supposed clinical training. This is a delusion and a snare. Real "insight" cannot be achieved in any three months of clinical pastoral training, nor indeed even in a year of such training. Psychiatrists with whom I have discussed this have been unanimous in concluding that we are deluding ourselves if we believe that the kind of programs we are offering are conducive to the development of "insight" in any real sense. Granted that there may be flashes of understanding in any human situation, they are apt to be a by-product, and certainly not the result of any planned effort in this direction. It is possible, however, in clinical pastoral training to make the student develop an awareness of how he feels and reacts in relations with other human beings. He may even arrive at an understanding of how his feelings and actions affect others. Insight,
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however, as to the origin of feelings, thoughts, wishes, and acts can seldom be achieved except in deep, intensive analysis, and even then it is a rare accomplishment. Even the most desired goal of awareness and understanding of our feelings and action is achieved in clinical pastoral training only as a by-product of a well-thought-out and well-organized program of clinical pastoral experience in which the minister is able to deal compassionately and realistically with the problems of others. 6. The inevitability of new directions for our work in training as mental health chaplains is clear. Change is very often unpleasant, but it is at the same time challenging. There are already 225 community mental health centers in operation in this country and financial support for about 500 such centers is expected from the federal government by the end of 1970. Changes are going to occur more quickly in certain parts of the country than in others, but the writing on the wall is clear. T h e state hospital as we have known it is on its way out. The most urgent question facing us today is to provide the training necessary for what we know is going to happen in the seventies and beyond. As mental health chaplains we have the opportunity to be in the vanguard or we can become anachronisms. It is equally clear that we must set our own house in order; we must be quite clear about the directions in which we as clergymen desire to go if we are to make our contributions and functions clear to psychiatrists and other mental health professionals. It is also important that these new directions be developed from as broad an ecumenical base as possible. As the only truly ecumenical organization of clergy actively concerned in mental health work, our opportunities and responsibilities are great.
