Pastoral counseling: What is it, and when can it help?
Certified pastoral counselors can be particularly helpful for patients experiencing loss, terminal illness, or conflicts regarding religious beliefs.
Pastoral counselors represent a valuable resource for psychiatric referrals as they are uniquely qualified to address certain mental health issues—including bereavement and coping with terminal illness. Pastoral counselors trained in behavioral sciences can help assess and treat patients who prefer psychotherapy that reflects their spiritual beliefs.
Ministers have been counseling members of their congregations since ancient times. As many psychiatrists may not be aware of the skills and services offered by pastoral counselors, this article:
- describes their background and credentialing
- identifies clinical scenarios in which splitting care with a pastoral counselor may benefit the patient.
Short- or long-term counseling
Pastoral counselors practice in a variety of settings, including pastoral counseling centers, inpatient and outpatient mental health facilities, and in private practice. Individuals generally seek therapy from a pastoral counselor because of their connection with a particular faith, whether Christian, Jewish, Native American, or others. Pastoral counselors— with training in both a religious tradition and the basics of psychology and psychotherapy—can challenge rigid, defensive, or misinformed spiritual beliefs that might contribute to a patient’s psychological distress and dysfunction. 1
PASTORAL COUNSELING’S JUDEO-CHRISTIAN ROOTS
- In the Torah, the word for counsel, etsah, is used 84 times. Its verb, yaatz, is the root of the Hebrew word for counselor.3
- In the Bible, pastoral counseling prototypes include ministers assigned by Moses to guide the Hebrew people in family, community, and religious life; the prophets Samuel, Jeremiah, and Ezekiel; Jesus of Nazareth; and the apostle, Paul.
- In the 6th century, manuals for Christian priests on assigning penance during confessions (the “Penitentials”) were also intended to reconstruct the personality.3
- Sixteenth-century documents detail steps to “growth in holiness” and prayer and meditation for persons aspiring to greater “perfection.”4
- Martin Luther, leader of the Protestant Reformation in the 16th century, emphasized reasoning and individual freedom rather than doctrine in the Christian church.
Some forms of pastoral counseling are short-term and problem-focused, whereas others address long-standing conflicts and require a long-term relationship with the therapist. For this reason, some therapists prefer the term “pastoral psychotherapy,” feeling it better reflects the work and goals of the counseling they do.
Pastoral counseling and psychotherapy are predominantly insight-oriented but include other therapeutic models as well. Clinebell recommends that pastoral counselors be familiar with four types of therapy:
- human potential (e.g., transactional analysis and Gestalt psychology)
- and spiritual growth (e.g., based on theories and practices of Carl Jung).2
Integration of religion and science
Examples of pastoral counseling can be traced throughout Judeo-Christian history (Box 1).3,4 As early as 1861, Congregational minister Horace Bushnell of Hartford, Conn., advised parents of the importance of the first 3 years of life in the development of a child’s character.5
Pastoral couseling was shaped by the scientific exploration of the human mind in the late 19th century. William James’ 1890 work, The Principles of Psychology, described the nature of human consciousness and contributed significantly to what became the profession of psychology.6 At the same time, Sigmund Freud was developing his theories of the unconscious. Whereas James explored the dynamics of the individual mind, Freud explored interactions with significant persons at critical periods of development, bringing out the importance of relationships in psychological organization.
The study of the psychology of religion was well underway by the turn of the 20th century, with the publication of E. D. Starbuck’s The Psychology of Religion (1899) and James’ The Varieties of Religious Experience (1902). Ministerial training programs introduced courses in the psychology of religion to help clergy educate and counsel parishioners. Rollo May’s The Art of Counseling (1939), which was presented as a series of lectures to Methodist student workers, is regarded as the first systematic study of counseling techniques. It incorporated the theories of Freud, Jung, Otto Rank, and Alfred Adler.3
Physicians also helped to nurture pastoral psychotherapy by providing clinical experience to seminarians:
- William Keller, MD, of Cincinnati supervised five students from Bexley Hall, an Episcopal seminary in central Ohio, in 1923.
- Richard C. Cabot, MD, then on the faculty of Harvard Medical School, collaborated with minister Anton T. Boisen to develop a clinical pastoral training program at Worcester State Hospital in Massachusetts in 1925.3
- Psychiatrist Smiley Blanton, MD, collaborated with the Rev. Norman Vincent Peale in the 1930s to form the American Foundation of Religion and Psychiatry. The New York-based organization—now called the Blanton-Peale Institute—provides clinical training for pastors and pastoral counselors.
Clinical pastoral education has allowed clergy to practice counseling under the supervision of experienced professionals and has laid the foundation for the pastoral counseling profession.
A ‘theology of relationship’
The theological and community focus of modern pastoral counseling have led some to describe it as a “theology of relationship.”7 Extending from Freud’s understanding of the impact of relationships during infancy on subsequent personality development and Erik Eriksons’s work on the formation of identity through relationships later in life, pastoral counseling considers the individual’s relationship to the community of humankind to be a significant determinant in mental health and illness.
Ministry views all persons as related to one another as creatures of God’s creation. In this fellowship, it is believed that individuals can find meaning, wholeness, and the ability to transcend the pain of life’s experience.
Contrary to James’ view of individual consciousness as finite and Freud’s limited focus on relationships within the immediate family, ministry asserts that all persons are connected, and this connection can be a route to healing. Responsibility to other human beings and to the world is seen as a component of these healing connections. As such, pastoral counseling includes an ethical dimension in the psychotherapy process.
A goal of pastoral counseling is to guide individuals towards greater wholeness within themselves and in their relationships with others. Six dimensions of this growth have been described:
- enlivening the mind
- revitalizing the body
- renewing and enriching intimate relationships
- deepening one’s relationship with nature and the biosphere
- growth in relation to significant institutions
- deepening and vitalizing one’s relationship with God. 2
Credentialing of pastoral counselors
Pastors of any religious congregation can function as pastoral counselors. Clergy generally do not counsel outside their parishes, although they may do so even if they lack training beyond seminary. Some clergy have developed excellent skills in counseling and psychotherapy through mentorship, self-directed study, and their own psychotherapy and are competent pastoral counselors. However, certification by the American Association of Pastoral Counselors (AAPC) provides assurance that a counselor has met certain minimum training requirements.
Most pastoral counselors who practice in mental health agencies have obtained AAPC certification. The AAPC accredits pastoral counseling centers, approves training programs, determines credentialing criteria, and ascertains whether an individual has met educational and experiential requirements. It also offers a referral service for persons seeking a pastoral counselor (Box 2). 8
HOW TO LOCATE A PASTORAL COUNSELOR
- American Association of Pastoral Counselors (AAPC) referral service
- Pastoral counseling centers can be found in the Yellow Pages or on the Internet. Many centers are accredited by the AAPC.
To be certified, a pastoral counselor must have a theology-based master’s or doctoral degree or a comparable degree in pastoral counseling. An AAPC member supervises one-third of the required hours of pastoral counseling experience. A supervised, self-reflective pastoral experience is also required, usually through clinical pastoral education (CPE). This training promotes the integration of theology and behavioral science that is central to pastoral counseling.
CPE generally involves closely supervised work as a hospital chaplain, with classroom instruction and small-group discussion of cases that students encounter on their rounds. These discussions help students:
- identify clinical and theological issues in patients with physical and mental illness
- become aware of their own issues when dealing with patients (i.e., sources of potential counter-transference)
- work toward a mature personal theology.
To receive AAPC credentials, a pastoral counselor must be recognized by a religious organization. Although ordination is not required, the individual must work within a local religious community and be endorsed by its leaders. This requirement helps ensure that the candidate conforms to a generally accepted interpretation of religious experience and not some idiosyncratic personal theology.
Interviews. After the candidate’s training documents have been received and approved, the candidate meets with a three- to four-person certification committee. This 90-minute interview is intended to educate the candidate and promote clarity of purpose within the profession, as credentialing is based solely on the written documents. The committee:
- reviews an audio- or videotape of a therapy session that reflects the candidate’s work
- talks with the candidate about integrating basic theologic concepts and theories of psychology and behavioral science, both professionally and in therapy
- attempts to determine the sophistication and maturity of the candidate’s personal theology
- explores the candidate’s awareness of his or her own psychodynamic characteristics and tendencies.
WHEN IS PASTORAL COUNSELING APPROPRIATE FOR YOUR PATIENT?
- To obtain a standard spiritual assessment
- Loss or bereavement
- Chronic or terminal illness
- Guilt, vocational confusion, or lack of direction
- Conflicts regarding patients’ own religious beliefs or those of their families
- Conflicts related to patients’ interpretation of the Bible or other religious texts
- To help patients re-enter the community after institutionalization
- For patients who believe their mental illness is a punishment for having insufficient faith
- As a segue into the mental health system
- Patient rejects religion or spirituality
- Patient views pastoral counseling as a means to deny the need for psychiatric treatment
- Treatment by another clinician might “dilute” therapy
- Patient uses religion to obtain special privileges or to feign health and functioning
- Role confusion exists because the counselor is the patient’s seminary teacher or pastor
Source: Adapted from Oates WE. The religious care of the psychiatric patient. Philadelphia: The Westminster Press, 1978.
Psychotherapy is no longer required for AAPC certification, but candidates are asked what they have done to ensure that their personal conflicts do not interfere with their ability to provide psychotherapy and counseling. The interview concludes with suggestions to encourage the candidate’s personal growth and professional development.
Working with pastoral counselors
Pastoral counselors are especially well-qualified to address certain types of mental health problems (Box 3).9 A psychiatrist who can identify these problems and make the appropriate referral will provide an important service to the patient.
When to refer. Patients experiencing loss or dealing with bereavement are often struggling with theological questions and can benefit from therapy from a pastoral counselor. Chronic or terminal illness likewise can bring up existential questions, and pastoral counselors can explore with the patient the meaning of suffering, providing spiritual healing when medicine offers no cure.
Some patients frame their mental illness as punishment for a past wrongdoing or sin, and standard psychotherapy is limited in its ability to confront this religious belief. Misinterpretation of biblical or other religious texts can support dysfunctional views of illness, and pastoral counselors can help guide patients to more informed and healthy views of the role of religion and spirituality in health. To help with this, they might bring into therapy such spiritual concepts as faith, forgiveness, reverence, stewardship, evil, suffering, and repentance.
The position of many pastoral counselors as pastors of religious congregations can help some patients make the transition from institutionalization to community life. These counselors can help patients connect with community resources and social groups associated with the patients’ religious affiliations. Some patients newly-diagnosed with a psychiatric illness may be reluctant at first to see a psychiatrist but will see a clergy member. In these cases, pastoral counselors can provide a pathway into the mental health system.
When not to refer. Referrals to pastoral counselors should be avoided when patients are perceived to be using clergy involvement to avoid psychiatric treatment. Some patients might use religion to get special privileges in treatment or to try to look healthier or more functional than they are.
Pastoral counseling is also contraindicated:
- when role confusion might result, such as when the pastoral counselor is also the patient’s pastor or seminary instructor
- in patients who denounce religious involvement or beliefs.
Split treatment As is done with psychologists or social workers, psychiatrists can split treatment with pastoral counselors and prescribe psychotropic medications. Regular communication among all clinicians ensures consistent treatment goals and reduces the risk of splitting dynamics and behaviors.