Pastoral Counseling: A National Mental Health Resource Print

Table of Contents

1. Executive Summary
2. The Moral and Economic Imperative of Mental Health Coverage
3. The Role of Pastoral Counseling
4. The Efficacy of Pastoral Counseling
5. The Education of Pastoral Counselors
6. The Cost-Effectiveness of Pastoral Counseling
7. The Principle of Consumer Choice
8. Pastoral Counseling and Preventive Care
9. The Pastoral Counselor in an Era of Managed Care
10. Pastoral Counselors in Relationship With State Licensing
11. Conclusion

EXECUTIVE SUMMARY

Pastoral Counselors are ministers or persons endorsed by a religious faith group who are also mental health professionals. They have received specialized graduate training in both religion and the behavioral sciences and practice the integrated discipline of pastoral counseling.

The American Association of Pastoral Counselors (AAPC) represents over 3,200 Pastoral Counselors and more than 100 pastoral counseling centers in the United States. AAPC Pastoral Counselors relate to more than 80 faith groups including the Protestant, Catholic, and Jewish faiths. Additionally, these AAPC certified and affiliated Pastoral Counselors have access to faith group congregations with membership of over 20 million people, with outreach to millions more.

The American Association of Pastoral Counselors affirms as a moral imperative that the American people, without exception, must have access to quality health care. It also affirms, as a matter of societal responsibility, that mental and emotional illness must be covered on the same basis and to the same extent as physical illness. It has been demonstrated that equitable coverage of mental and emotional illness will result in the lowered utilization of costly physical health care while such coverage will cost only a few dollars per covered person a year, a small proportion of the cost of coverage for all conditions

Pastoral counseling represents a major national resource for community mental health services, both therapeutic and preventive. This is because religious communities are one of the principal gateways for those seeking relief from human suffering, including mental and emotional illness, drug and alcohol abuse, family conflict, depression and suicide, child and spousal abuse, juvenile delinquency, and other societal problems of our day. Pastoral counseling has now become a major provider of mental health services in this country, accounting for over 3 million hours of treatment annually in both institutional and private settings, offering individual, group marital, and family therapy.

Pastoral counseling is also recognized as a national mental health resource in the public's preference for a spiritually oriented modality of treatment as demonstrated by a 1992 Gallup Poll. This survey showed that 66 percent preferred a professional counselor who represented spiritual values and beliefs, and 81 percent preferred to have their own values and beliefs integrated into the counseling process.

The American Association of Pastoral Counselors is a member of the national mental health community, actively participating in a number of health and mental health coalitions. From a professional perspective, the ethics and standards of the AAPC require that their Pastoral Counselor members work in close collaboration with other mental health professionals, imploring the latest and most effective psychotherapeutic modalities of treatment. There is ample evidence that many mental health professionals in other disciplines are beginning to recognize the value of the spiritual dimension in the healing process and are beginning to develop it in their own work. The AAPC also requires that their Pastoral Counselor members hold a continuing responsible relationship in their
local religious communities.

Pastoral Counselors certified by the American Association of Pastoral Counselors are highly educated professionals. By studying theology as well as psychology, Pastoral Counselors are trained in two disciplines instead of one. The typical education and training for the AAPC Pastoral Counselor at the membership level of Fellow consists of a Bachelor's Degree from a college or university, a 3 rear professional degree from a seminary, and a specialized masters or doctoral degree in the field. A significant portion of this education is spent in clinical training. The primary levels of AAPC certified membership are: Member - an apprentice certification; Fellow - indicating full clinical competence; Diplomate which qualifies one to work as a supervisor of ministers and Pastoral Counselors. The AAPC also sets standards for accreditation of pastoral counseling centers and approval of pastoral counseling training programs. A large number of universities, graduate training programs, graduate schools of theology, and seminaries around the Country prepare ministers for pastoral counseling.

Pastoral counseling is one of the most cost-effective modalities of treatment in the field of mental health. One factor that makes this possible is the willingness of Pastoral Counselors to work at modest salaries as compared to other mental health professionals. The not-for-profit orientation of pastoral counseling centers and the decreased overhead costs, when working in partnerships with congregations, also contributes to this cost-effectiveness. It is the prevailing ethic of pastoral counseling that every effort is made to treat everyone, regardless of ability to par. Nevertheless, as demand grows for mental health services by Pastoral Counselors, and with insufficient insurance coverage and managed care availability, the pressure mounts to find wars to deliver services to all in need.

The American people have embraced the principle of freedom of choice for many decades. This is carried forward to their right to select providers of their choice in any health care delivery system. The ability of consumers to choose Pastoral Counselors for mental health services would impact cost-containment in a positive manner because of the relatively low cost and high accountability of pastoral counseling.

Pastoral counseling represents a paradigm for preventive mental health care. From the perspective of community prevention, early and easy access to pastoral counseling centers through the family and church- or synagogue-based and other referral services provides the patient with early intervention before the illness or problem becomes chronic and/or resistant to treatment. The Church or synagogueis a natural community gateway through which millions of persons pass each week, and through which a wide spectrum of mental health and societal problems are presented, many of which are amenable to early intervention and treatment. In addition to the church or synagogue setting, Pastoral Counselors provide outreach preventive services in the hospital setting, in prison, in the university, in the military, and in the primary and secondary school.

Pastoral counseling is a discipline which has been consistent with the goals of managed care by providing quality service with preventive care, working with the total person, and producing cost-effectiveness. Provider processes involved in patient care such as utilization review, cross-discipline cooperation and referral, goal-oriented continuing education, on-going quality improvement, and operational efficiency have long defined the proficiency processes of Pastoral Counselors. In an era when managed care is assuming an ever-growing role in the present pluralistic health care delivery system, and at a time when a majority prefer to be treated by a professional counselor who represents spiritual values and beliefs, the services of Pastoral Counselors must be made available in managed care settings.

Pastoral Counselors possess a depth of training that is significantly beyond that of many other mental health professionals of the core disciplines. Theirs is a discipline which maintains the natural connection between the physical, mental, and spiritual dimensions. It is now recognized across the mental health field that this connection fosters a sound and lasting foundation for treatment of the whole person. Moreover, Pastoral Counselors have successful treatment rates equal to those of the highest quality of mental health services.

Nevertheless, at this point, the majority of Pastoral Counselors are able to obtain state licensure only through a discipline other than their own. This provides them with neither the desired nor the appropriate pastoral counseling identity. The AAPC is currently pushing forward a national effort to promote state legislation for the licensing of Pastoral Counselors. This process takes time. Con currently, Pastoral Counselors are informing policy-makers, the various managed care systems, and those involved in the development of national health care proposals that pastoral counseling is a national mental health resource that is being sought by the public and that fulfills, in an exemplary manner, the highest standards for quality and cost-effective mental health care delivery.

Pastoral counseling is a valuable national mental health care resource which should be integrated into the national health care delivery system as that system is being reshaped to make it more responsive and accountable to the needs and desires of the American people.

THE MORAL AND ECONOMIC IMPERATIVE OF MENTAL HEALTH COVERAGE

The American Association of Pastoral Counselors (AAPC), a national organization which represents over 3,200 Pastoral Counselors and more than 100 pastoral counseling centers nationwide, affirms that it is a moral imperative that the American people have access to general health care treatment. Today, 37 million Americans under age 65 have no health insurance, and millions more have inadequate coverage.

AAPC also affirms that, as a matter of moral societal responsibility, as well as sound public policy and cost effectiveness, mental and emotional illness must be covered on the same basis and to the same extent as physical illness in any health care delivery system.
Lack or inadequacy of mental health care means that many people will go without needed treatment, or that they will receive inappropriate, costly, and unnecessary treatment that is covered under a health care system.

As reported by the National Institute of Mental Health, during the course of their lives about 22% of the current adult population in this country, or about 40 million adults, will have a mental disorder. Without needed intervention, billions of dollars will be lost to our economy through lost productivity and the condition of many will grow worse year by year, requiring more costly treatment and hospitalization.

In addition to this group, it has also been estimated that more than half of those who go to a physician with physical symptoms aye suffering from mental or emotional illness with no real physical cause. Psychological problems adversely impact physical wellbeing as do problems of the spirit or soul. In the absence of mental health care, or because of the inability of a primary care physician to recognize or effectively treat mental health problems, a large number of people will continue to contribute to the rapidly escalating costs of the health care delivery system through inappropriate, ineffective, and costly treatment with repeated visits. Also, failure to provide adequate outpatient benefits for mental and emotional illness will result in higher utilization of more expensive inpatient hospital benefits.

Of grave concern is the fact that under the present health care delivery system, two-thirds of the children in need of mental health services (estimated to be 12 percent of Americans under the age of 18) do not receive them, exacerbating costs to society as these children mature and their mental and emotional illnesses tend to become chronic. On the other hand, there is ample evidence (e.g., Massad et al, 1990 and Fiedler and Wight,1989) that treatment of mental and emotional illness can lower medical expenses by reducing medical utilization.

Comprehensive cost and feasibility studies (e.g., Reed, Myers, and Scheidemandel) have shown that the cost of providing coverage for mental and emotional conditions is relatively low compared to treating physical illness -- a few dollars per coverage for all conditions. It is a sad fact that many benefit structures discriminate against the treatment of the mentally and emotionally ill. Minimum outpatient benefits which contain unreasonably high deductibles and high co-payments, together with limits on the number of visits and the choice of providers, discourage outpatient treatment. As a result, for many people symptoms intensify to the point of requiring costlier inpatient forms of treatment. These kinds of cost distortions must be corrected if patients are to receive the most appropriate and effective treatment and if the system is to utilize its Resources wisely.

Mental and emotional disorders and substance abuse are: among the most serious problems facing our nation. They account for a tragic toll in human misery that touches most of our lives and severely weakens the fabric of our society. Fifteen percent, or 27 million of the 184 million adults in the U.S. 18 years of age and over experience a mental disorder within any 6 month period, and 12 percent under 18 suffer from a mental or emotional disorder.

Thousands of individuals and families are faced with the unacceptable choices of not seeking treatment, receiving inappropriate or ineffective treatment, or facing bankruptcy because of inordinately high costs. From a fiscal standpoint, this vast problem accounts for more than $250 billion lost to our society each year through lowered productivity and other indirect costs. Mental illness, including depression, can be as functionally disabling as a serious heart condition and more disabling than other chronic physical illnesses such as lung or gastrointestinal problems, angina, hypertension, and even diabetes (Wells, et al, 1989).

The AAPC endorses the enlightened work of Congressional members spearheaded by Rep. Mike Kopetski (D-OR), Rep. Ron Machtley (R-RI), and Rep. Bob Wise (D-WV) in their sponsorship of House Concurrent Resolution 52, and Senator Richard Shelby (D-AL) in his sponsorship of Senate
Concurrent Resolution 16 in the 103rd Congress. The resolutions express the sense of the Congress that mental health care benefits must be comparable to those for physical health care benefits.

THE ROLE OF PASTORAL COUNSELING

Religious communities are major gateways for those seeking relief from human suffering and from the mental and emotional illness which is often its byproduct. Millions of Americans attend their places of worship on a regular basis and millions more attend infrequently. In addition, there are those who suddenly and desperately turn to a religious institution as a possible solution to their problems - the everyday problems that beset today's society: alcoholism and drug abuse, child and spousal abuse, family and societal violence, suicide, homelessness, AIDS, alienation, family conflict, depression, and anxiety.

Religious communities have traditionally sought to provide spiritually-based solutions for those in trouble. Clergy have listened intently to personal problems for centuries, and have cultivated a spiritual counseling response to those suffering from mental and emotional disorders.
This spiritual counseling, an important ministry of the faith community, has given rise to a recognized and certified discipline in the mental health field which integrates theology with the behavioral sciences. This discipline is known as Pastoral Counseling or pastoral psychotherapy.

Many who seek help from ministers, priests, and rabbis are suffering from mental and emotional illness. Traditional spiritual counseling continues to help many of these people. It was recognized long ago, however, that in many cases specialized professional care was necessary for effective treatment.

Though psychotropic drugs have provided significant advances in the treatment of serious mental illness, a wide range of mental and emotional disorders Require psychotherapy. U.S. Representative Jim McDermott (D-WA), a member of the House Ways and Means Committee and a psychiatrist by profession, stated, "The chance to help patients by prescribing drugs represents a major advance in the treatment of mental illness, but it is no substitute for the caring and concern every doctor should show for every patient, or for the nonmedical services patients often need in order to achieve real health." For many, pastoral psychotherapy is the treatment of choice.

In the 1920's, The Reverend Anton Boisen, Father of the Clinical Pastoral Education movement, revived the important role of clergy in the treatment of mental illness by placing theological students in supervised contact with patients in mental hospitals. This innovative educational program brought disciplined training to the historical linkage between faith and mental health.

The integration of religion and psychology for psychotherapeutic purposes began in the 1930's with the collaboration of Norman Vincent Peale, a renowned minister, and Smiley Blanton, a psychiatrist, to form the American Foundation of Religion and Psychiatry, now the Institutes of Religion and Health.

The role of pastoral counseling has, therefore, evolved through the years from religious or spiritual counseling to pastoral psychotherapy which integrates theology and the behavioral sciences.
Pastoral counseling has now become a major provider of mental health services in this country, accounting for over 3 million hours of treatment annually in both institutional and private settings, offering individual, group, marital, and family therapy.

AAPC was founded in 1963 as an organization which certifies Pastoral Counselors, accredits pastoral counseling centers, and approves training programs. It is an interfaith organization representing in pastoral counseling work more than 80 faith groups including the Protestant,
Catholic, and Jewish faiths. It is non-sectarian and respects the spiritual commitments and
religious traditions of those who seek assistance without imposing counselor beliefs onto the client.

Pastoral psychotherapists work with the classified mental and emotional disorders and utilize a variety of forms of psychotherapy with the disciplined integration of relevant theological and spiritual perspectives. Pastoral Counselors either practice through pastoral counseling centers, hospitals, clinics, prisons, universities, religious settings, or are in private practice. In whatever setting, they draw faith and strength from their participation in the faith group and congregation with which they are affiliated.

The ethics and standards of AAPC require that Pastoral Counselors work in conjunction with others and not in isolation. The AAPC requires that they hold a continuing responsible relationship in their local religious communities. Pastoral Counselors receive ongoing supervision and consultation in order to provide optimum treatment as well as protection to the counselees, and they engage in a peer review process to ensure the utilization of the best possible care for patients. At the same time
Pastoral Counselors are an intrinsic part of the mental health delivery system, collaborating with the other mental health disciplines and employing the latest and most effective psychological techniques combined with the spiritual dimension. When medication is deemed necessary, the Pastoral Counselor refers the client to a psychiatrist for necessary evaluation. In short, Pastoral Counselors provide clinically accountable and spiritually sensitive care to those who seek their assistance.

AAPC in recent years has become a partner in the larger mental health community as well, joining with such organizations as the National Mental Health Association, the American
Psychological Association, the American Association for Marriage and Family Therapy, the American Psychiatric Association, and the National Association of Social Workers to work on behalf of the mentally ill. AAPC has also begun to work with federal mental health agencies such as the Substance Abuse and Mental Health services Administration and the National Institute of Mental Health, to link pastoral counseling even closer to the core mental health disciplines. AAPC has become a member of the Interreligious Health Care Access Campaign, a national interfaith group for health issues. It is also represented in the National Quality Caregivers Coalition, sponsored by the Rosalynn Carter Institute, and the Rosalynn Carter Symposium on Mental Health Policy. In addition, AAPC functions as a principal organization in the Congress on Ministry in Specialized Settings (COMISS), an interfaith coalition of 15 of the various professional, ecclesiastical, and provider groups in the fields of pastoral care, counseling, and education.

THE EFFICACY OF PASTORAL COUNSELING

Pastoral Counselors have treatment success rates comparable to those of the highest quality of mental health services. A study underwritten by The Samaritan Centers, a network of pastoral counseling centers, indicated that 80 percent of their clients reported having been helped.
Pastoral counseling, offering a modality of treatment which maintains the natural connection between the physical, mental, and spiritual dimensions, believes that this connection fosters a sound and lasting foundation for mental health treatment of the whole
person.

In this awareness of the spiritual dimension in human wholeness, Pastoral Counselors stand in good company. One of Carl Jung's chief contributions as a psychoanalyst and writer was to bring spirituality into psychology. Another influential writer, Abraham Maslow, brought spiritual aspects to therapy. William James, America's most influential early psychologist, studied religious experience as an expression of levels of growth. Psychiatrist Karl Menninger was a pioneer in the integration of the psychological and the theological disciplines because he believed in the"inseparable nature of psychological and spiritual health." M. Scott Peck, best selling author and psychiatrist, effectively expresses that belief in our own day.

Famed editor, Norman Cousins, stated, "Over the years, medical science has identified the primary systems of the body -- circulatory system, digestive system, endocrine system, autonomic nervous system, parasympathetic nervous system, and the immune system. But two other systems that are central to the proper functioning of a human being need to be emphasized: the healing system and the belief system. The two work together. The healing system is the way the body mobilizes all its resources to combat disease. The belief system is often the activator of the healing."
A Gallup Poll conducted in February 1992 determined that 66 percent of those surveyed prefer a counselor who represents spiritual values and beliefs, and that 81 percent prefer to have their own values and beliefs integrated into the counseling process. Pastoral counseling is particularly responsive to these people in integrating the spiritual and psychological dimensions of human experience and attending to the values and beliefs of the client.

Studies suggest that many mental health professionals in other disciplines are beginning to develop the religious dimensions in their own work. They are recognizing as never before the power of spiritual commitment creatively used in the healing process. The ever-growing interaction and collaboration between Pastoral Counselors and the larger mental health field is helping to bring this about. Richard Simon, Ph.D., editor of the Family Therapy Networker, stated in a recent article that "the rigid divorce between spirituality and psychotherapy may no longer be necessary, that the two are moue compatible than we once thought." Pastoral counseling has matured rapidly as a behavioral discipline and continues to gain increasing acceptance as a core mental health discipline.

Practitioners in the field are constantly evolving therapeutic theory and methods to enable the discipline to advance further and effect higher rates of success outcomes.

"It only makes sense that religion and psychology - each of which is concerned with the fullness of the human experience should be recognized as partners, because they function as partners within the human psyche." (Dr. Arthur Caliandro, Senior Minister, Marble Collegiate Church, New York City)

THE EDUCATION OF PASTORAL COUNSELORS

A certified Pastoral Counselor is an ordained clergy person or endorsed religious person who has received specialized training in religion and the behavioral sciences, and who is certified by the American Association of Pastoral Counselors (AAPC)2. In addition, the Pastoral Counselor may be state licensed as a professional counselor or in a number of mental health specialties, such as marriage and family therapy, clinical psychology, or social work.

By studying theology as well as psychology, Pastoral Counselors are trained in two disciplines instead of one, providing a unique opportunity to integrate them both into an effective psychotherapeutic process. As a result of this dual training, Pastoral Counselors are among the most educated and competent of mental health professionals.

Candidates seeking certification by AAPC are thoroughly tested and evaluated to assure that AAPC certifies only the most competent individuals who have extensive education and clinical training and who possess the highest morals and personal standards. Following certification by AAPC, the Pastoral Counselor must submit an annual self-report form which verifies continued adherence to the standards of practice set forth by the Association, including their continued good standing within their faith groups.

In its certification role, the AAPC has as its purposes the following: "professional excellence of pastoral counselors; exploration, clarification and guidance of human life, both individual and corporate, at experiential and behavioral levels through a theological perspective; relations with ecclesiastical groups; inter-professional relationships; and increased understanding of the ministry of pastoral counseling." (AAPC Constitution) Typical education and training for the Fellow level Pastoral Counselor consists of a Bachelor's Degree from a college or university, a 3 year professional degree from a seminary (e.g., M.Div., or B.D.), and a specialized masters or doctoral degree in the field, (e.g., M.A., S.T.M., Th.M., S.T.D., or D.Min. (clinical degrees)), and Ph.D. or Th.D. (teaching/clinical degrees). A significant portion of this education is spent in some clinical training setting. Many university schools of theology, graduate institutes, and seminaries around the country prepare ministers for pastoral counseling. The standards set by AAPC requite intensive studies in the behavioral sciences and numerous hours of clinical training and supervision. Among the clinical areas considered important by AAPC to achieve educational objectives for pastoral counseling are: Psychopathology, Group Dynamics, Theories of Personality and Personality Development, Theories of Counseling and Psychotherapy, Research Methods in the Behavioral Sciences and Theology, Interpersonal Relations, and Marriage and Family Dynamics. This clinical training involves the completion of at least 1,625 hours of supervised clinical experience and 250 hours of direct approved supervision of one's work in both crisis and long-term situations.

While some mental health core disciplines require their professionals to obtain only one review for certification, and thereafter to adhere to the standards set by their discipline, AAPC certified Pastoral Counselors must be reviewed each time they seek a higher level of membership in AAPC.

The basic level of AAPC membership is the Member level which is seen as a temporary step on the way to the Fellow level. Those at the Member level must remain under the supervision of those professionals of their discipline who have a greater degree of experience and expertise in pastoral counseling than they do. At the Fellow level, the counselor receives recognition of competence to work without constant direct supervision. The highest level of membership in the AAPC is that of Diplomate, which qualifies one to teach and supervise Pastoral Counselors, pastoral counselors-in-training, and clergy in their pastoral care ministries.

In addition to setting standards for the certification of individual Pastoral Counselors, AAPC also sets standards and offers accreditation for pastoral counseling centers. This includes the approval of training programs in pastoral counseling. Periodic reviews are made of all accredited centers and approved training programs to assure maintenance of the high competence required by the standards.

THE COST EFFECTIVENESS OF PASTORAL COUNSELING

Pastoral counseling is one of the most cost-effective modalities of treatment in the field of mental health.

It is the prevailing ethic of Pastoral Counselors that every effort is made to make mental health services available to those who seek them. This has been and continues to be a common practice despite the rapidly escalating costs of providing service. Sliding scales for patients soften an often otherwise undue hardship for receiving therapy. Nevertheless, as demand grows for mental health services by Pastoral Counselors, and as third-party payments grow increasingly less available, the pressure mounts to find solutions that will not leave poorer patients and the uninsured without needed quality service.

To illustrate the cost-effectiveness, the nationwide average fee collected per 50-minute session is just under $50 for certified Pastoral Counselors. A number of factors have enabled Pastoral Counselors and pastoral counseling centers to provide quality service at a lower cost than other mental health disciplines and to be among the most cost-effective providers of quality mental health services. One factor is the willingness of Pastoral Counselors to work for relatively modest salaries. Also, the ability of pastoral counseling centers to function cost-effectively relates to their not-for-profit orientation and to the fund-raising efforts by boards of directors, church and synagogue contributions, and decreased overhead costs when working in partnership with congregations.

A few insurance companies have authorized reimbursements for pastoral counseling and some pastoral counseling centers have reimbursement relationships with managed care organizations, employee assistance programs, and self-insured corporations/ organizations. However, there is still insufficient insurance coverage and managed care availability, both for mental disorders in general and for care by qualified Pastoral Counselors. This insufficiency is in part, due to lack of knowledge, misperception, and confusion about mental illness and pastoral counseling. Pastoral counseling should not be denied to patients who wish to avail themselves of this modality of treatment because of lack of recognition by third-party payers.

THE PRINCIPLE OF CONSUMER CHOICE

The right of consumers to select providers of their choice in any health care delivery system, and in any system of national health insurance, is a universally articulated desire.

National organizations interested in health care reform have included this principle almost without exception. For example, the American Association of Retired Persons (AARP), one of the most powerful advocacy groups in the country, has stated, "All individuals should have a reasonable choice of health care providers. Cost containment efforts should not unreasonably limit choice of providers. Consumers should be provided with sufficient information about health care providers and treatment options to make informed health care decisions." The National Mental Health Leadership Forum, an umbrella group composed of the major national mental health organizations, has also endorsed the principle of consumer choice as one of the foundations of health care reform. It stated that, "A consumer-sensitive health care system will provide for consumer participation in treatment planning decisions, including service selection, service provider, service timing, and service setting. It should also ensure a range of service settings as part of an integrated delivery system, and should ensure that services are delivered in the least restrictive environment practicable." The coming of age of pastoral counseling has been marked through its recognition by other core mental health professions and the growing demand for pastoral counseling services by mental health consumers.

The ability of consumers to choose pastoral counseling for mental health services would impact cost-containment in a positive way because of the relatively low costs and high accountability of pastoral counseling. (Rf. The Cost-Effectiveness of Pastoral Counseling)

The demand for a pastoral oriented therapy modality is well documented by the Gallup Poll (1992) in which 1,000 persons (50 percent male and 50 percent female) were surveyed. Sixty-six percent preferred a professional counselor who represented spiritual values and beliefs, and 81 percent preferred to have their own values and beliefs integrated into the counseling process.

This poll revealed a broad base of consumers who value the kind of mental health services which qualified Pastoral Counselors offer. That expressed preference cut across all demographic categories: sex, age, region, education level, and race.

On the first question of that poll, the sample population was asked, "If you had a serious problem in your life that required counseling, would you prefer to see a professional counselor who represents spiritual values and beliefs?" The following results were obtained: 66 percent replied yes, 33 percent replied no, 1 percent did not know, and 0 percent refused to answer. Of those who replied, 44 percent were male and 56 percent were female. Of the 66 percent who replied in the affirmative, 62 percent were male and 70 percent were female. The age distribution was as follows: 32 percent were between 18-34; 35 percent between 35-54; and 33 percent were aBe 55 and above. The geographic region for these affirmative responses were: 18 percent from the northeast; 37 percent from the south; 26 percent from the north central; and 19 percent from the west. The educational background showed that 52 percent were high school graduates or less, 27 percent had some college, and 21 percent were college graduates. Incomes of the affirmative respondents demonstrated that 32 percent had incomes of up to $20,000; 36 percent with incomes of $2040 thousand; 14 percent with $40-60 thousand; and 13 percent had incomes of $60,000 and above. The second question was asked, "If you had a serious problem in your life that required counseling, would you prefer to see a professional counselor who integrates your values and beliefs into the counseling process?" The following breakdown was obtained: 81 percent replied in the affirmative; of those, 79 percent were male and 81 percent were female. Thirty-five percent were between the ages of 1834; 37 percent between 35-54; and 28 percent at least are 55 and above. Regionally, 20 percent were from the northeast; 34 percent from the south; 25 percent from the north central; and 21 percent from the west. Educationally, 47 percent were high school graduates or less; 28 percent had some college; and 25 percent were college graduates. Incomes of the respondents showed that 28 percent had incomes of up to $20,000; 35 percent between $20-40 thousand; 17 percent between $40-60 thousand; and 15 percent had incomes of $60,000 and above.

PASTORAL COUNSELING AND PREVENTIVE CARE

Pastoral counseling goes hand-in-hand with preventive mental health care. From the perspective of community prevention, easy access to pastoral counseling centers, through referrals from places of worship and other community and professional referral sources, provides the person with early intervention before the illness or the problem becomes chronic and/or resistant to treatment.

Treatment through a pastoral counseling center or a private practice Pastoral Counselor also mitigates the stigma often associated with the treatment of mental and emotional illness provided through a traditional psychiatric hospital or medical hospital. Persons have already acquired a level of comfort with their religious setting and, therefore, are less resistant to entering a pastoral counseling center. This setting, consequently, often provides a more acceptable and more therapeutic atmosphere that helps to bring a person into communion with one's true identity.

Places of worship are community gateways through which millions of persons pass each week.
Many of their problems and illnesses can be referred though the clergy to pastoral psychotherapists quickly, sometimes preventing individual and family tragedy before it strikes. Mental health education workshops are offered by Pastoral Counselors though church and synagogue settings.
Many pastoral counseling centers also perform developmental and mental health screening to avoid and ameliorate illness. Pastoral Counselors also work in collaborative Relationships with other mental health professionals in designating treatment plans that optimize care and follow-up for patients who require other levels of treatment or specialization.

Pastoral Counselors provide preventive services in the hospital setting, in industrial and corporate settings, prisons, universities, the military, and primary and secondary schools, as well as in church and synagogue settings. In general, the entire community becomes a service arena for detection and prevention. Pastoral Counselors are in a position to provide crisis-oriented assessments in early diagnoses of many debilitating personal states, and to effect appropriate outpatient treatment of these and other conditions.

Other forms of preventive mental health services by Pastoral Counselors are counselor education for community clergy and others who are able to share this education in their communication with individuals, families, congregations, and the broader community. In addition, they participate in the development of a host of community mental health services such as half-way houses, hospices, and the like. Because certified Pastoral Counselors bring a mature, wholistic, and experienced presence to the public need for preventive services, their participation in these types of preventive activities helps to ease the enormous pressure on the mental health care delivery system and thereby saves taxpayer dollars.

THE PASTORAL COUNSELOR IN AN ERA OF MANAGED CARE

As has been illustrated, Pastoral Counselors combine the spiritual dimension of human life with the technical skills of modern psychotherapy to address the wholeness of the person in ways unmatched by other disciplines. The grounding of the Pastoral Counselor within his or her faith group, whether Protestant, Catholic, or Jewish, constitutes the foundation from which springs their desire to Respond to human suffering. This foundation equips the Pastoral Counselor for the goal of assisting all persons, irrespective of creed or background, to reach his or her fullest expression of integrity, identity, and dignity.

Because of the extent and rigorousness of their training in the technical skills of modern psychotherapy, it has been clearly detailed that Pastoral Counselors have a depth of training significantly beyond that of many other mental health professionals. Most Pastoral Counselors proceed to earn doctorates in ministry or psychology by which to further their skills.

Today, America spends more and moue on health care only to receive less and less for the dollar. This dilemma has given rise to the managed care industry. Now, within the era of managed care, the question arises as to the manner by which pastoral counseling will have a place within managed care parameters. Because for many years Pastoral Counselors have implemented processes and procedures only now considered standard by and for managed care, the answer has to be that the character of the work of Pastoral Counselors is integral to managed care goals. Provider processes involved in patient care such as utilization review, coss-discipline cooperation and referral, goal oriented continuing education, ongoing quality improvement, and operational efficiency have long defined the proficiency processes of Pastoral Counselors.

Second, managed care has gone beyond the simplistic goal of "front end" cost saving. As Dennis O'Leary, President of the Joint Commission on Accreditation of Healthcare Organizations says, "Quality will be the central issue for the Rest of the century. . . . Patients will be channeled to those who can prove they provide quality and cost effective care" (1992). In this era of "second generation" (Freeman, 1992) managed health care, this emphasis on quality of care supersedes the simple mechanics of cost containment because of the benefits derived from "doing it right the first time" (Freeman, 1992). Today's managed care focus on the benefits of quality care which begins Right at the start, should be integrated with the client's
desire to Receive that care from those who appreciate the spiritual depth of the total person. When thinking in these terms, the Pastoral Counselor almost singularly occupies the position for the kind of therapeutic response most desired by managed cate organizations and client alike.

Because of long established relationships with health resources such as volunteer groups, churches, and synagogues, the Pastoral Counselor makes care available across the entire spectrum of health care. Consequently, a community-based provider system which includes primary prevention (preventative care), secondary (early intervention), and tertiary (effect containing) levels of care can be integrated into treatment profiles.

Clearly, the Pastoral Counselor is equipped as are few others for working with the total person. FOR that Reason, Pastoral Counselors must be considered one of the primary choices of caregivers sought by managed care clients. Though the spiritual dimension is seldom mentioned in the training of other disciplines, the previously discussed Gallup Poll indicates that Pastoral Counselors bring to the care-giving relationship what most people seek. And, they do so as no other providers are trained to do. It was recently estimated that by 1995, 55% of the population will be involved in some form of managed care, while only 6% of Reimbursement will come from traditional indemnity insurance companies (Oss, 1992). That would mean that an increasingly larger and larger number of Americans under managed care will prefer a therapist who presents the skills, interests, and training unique to the Pastoral Counselor.

PASTORAL COUNSELORS IN RELATIONSHIP WITH STATE LICENSING

It has become obvious to most professional disciplines that professional identity and service specificity must be clarified and articulated to protect and serve the public. The practice of state licensure incorporates both a legally defined professional identity and the parameters of service. In addition, licensure assists in regulating educational requirements, training, and skill development of the various disciplines in order to assure that the public will get what they are seeking when attempting to select a professional service. Most states also provide for gate-keeping and complementary processes necessary to adequately oversee the profession in question.

The managed care industry has, almost uniformly, decided to accept state licensing of professionals as the critical requirement by which to determine acceptance into managed care networks.
Specific provider organizations frequently exceed that baseline expectation, but generally begin consideration of a prospective provider at the state licensure level. Problematically, Pastoral Counselors exceed the training requirements for many managed care organizations, but in general have been unable to receive state licensure. Thus, the state often does not recognize therapists who are better trained than those it already certifies!

Pastoral Counselors, because of their unique Relationship to faith communities, have been in a confused position in relation to state Regulation. Except in 3 states as of 1993, a concern for the historical separation of church and state has made it difficult for most pastoral counselors to be licensed as Pastoral Counselors. At this point the majority of Pastoral Counselors are able only to be licensed by means of disciplines other than their own. This provides them with neither the desired nor the appropriate pastoral counseling identity.

However, currently there is model legislation which wisely understands that while Pastoral Counselors are accountable to their faith groups for their theological, religious, or faith issues, they can also be fully accountable to the state for the quality of mental health/psychotherapy services they provide.

The provision of services under the legal identity of other disciplines continues to be a significant dilemma for Pastoral Counselors. Paradoxically, though unable to obtain their own licenses, they increasingly hear the public's loud voice seeking to use the services of a therapist/ counselor who considers their Religious/faith perspective/values and who will work with that in the process of healing. Hence,as Pastoral Counselors have been more clearly attempting to identify themselves as the professionals able to respond to that voice.

At this point, the AAPC is in the process of developing a plan to promote state licensing of pastoral counseling nationally. Concurrently, Pastoral Counselors are informing the public, the various managed care systems, and those involved in the development of national health care proposals that, on behalf of the public, pastoral counseling is a national Resource necessary for the public welfare and sought by public desire.

The public must be able to make use of these qualified providers, not only through legally identified state licenser, but also through managed care and/or national health care systems.

CONCLUSION

Pastoral counseling is a mental health discipline which integrates the spiritual and psychological dimensions of human experiences. This mental health modality of treatment is being recognized for its value by growing numbers of mental health professionals and has become the treatment of choice of a large number of consumers as demonstrated by a recent Gallup Poll. Pastoral counseling affirms that every American has the right to be covered for health care and that mental and emotional illness must be covered on the same basis and to the same extent as physical illness. Pastoral counseling is highly compatible with the principles enunciated as necessary to effect national health care reform, including cost effectiveness, high quality of service, preventive care orientation, and professional excellence.

Pastoral counseling is a national mental health care Resource which should be integrated into the national health care delivery system as it is being reexamined to meet the needs and expressed choices of the American people.

Last Updated on Saturday, 23 January 2010 09:42