Chapter 32: Problems and Possibilities of Interprofessional Cooperation by E. Mansell Pattison
The development of community mental health programs is predicated upon the development of interdependent working relationships between direct mental health treatment services and agencies, institutions, groups, and people in the community. Since the clergy and the churches are a major segment of the community there has been considerable interest in the development of effective working relationships between mental health professionals and the professional clergy.
During the 1940s and 1950s there was considerable interest in the so-called rapprochement of psychiatry and religion. During that time most of the problems of interprofessional cooperation centered around conceptual issues. By and large mental health professionals and clergy had their own domains of professional concern which did not significantly overlap. Both had concerns for the welfare and healing of distressed persons, but their respective approaches rarely crossed paths. During those two postwar decades there was an exploration of the conceptual issues that had seemed to loom so large in the debates of the earlier decades. The success of these conceptual explorations seemed to some a "fait accompli" after a time; for areas of agreement were reached by some, others felt that they had explored the ideas of the other professional group and finding them wanting had discarded them, while still others "bought" a psychological line or a spiritual line, so to speak. Thus the seeming conceptual rapprochement may have turned out to be an uneasy truce, without a clear exploration of the differences in points of view of mental health professionals and clergymen. Such conceptual issues included: naturalism vs. supernaturalism; monism vs. dualism; free will vs. determinism; whether man is morally good, bad, or neutral; how to eradicate mental distress and social problems; the values of the concept of unconscious motivation; absolute vs. relative moral codes; and the desirability of examining one’s religious beliefs.
Up until 1960, this pattern of relationship worked fairly well, for neither group of professionals had any great necessity to work intimately with the other. However the development of sophisticated chaplaincy training programs and pastoral counseling training among the clergy, and the development of community mental health programs by the mental health professionals, brought the two groups of professionals into a number of areas of professional overlap or mutual concern. This introduced problems of professional role conflict that were added to still unresolved, but more hidden, conceptual conflicts.
Although this chapter is concerned primarily with issues related to interprofessional cooperation in community mental health services, these cannot be discussed without calling attention to the fact that behind the issues of professional role allocation still lie conceptual disagreements that often play a major role in preventing effective collaboration and the working out of mutually satisfying professional roles. As we shall see, most problems in interprofessional relations involve combinations of both conceptual and role conflicts.
Cooperation in Referral. One of the major areas of community mental health where collaboration is most necessary is in the area of referral. Clergy are most frequently the first professionals in the community to whom people in emotional distress turn. Thus, community mental health services were planned to establish liaison with the clergy so that the emotionally ill could be quickly and effectively referred to the appropriate mental health services. Likewise the pastor, beset by many troubled persons, was looking for mental health resources to assist him. Theoretically the situation appeared ideal for mutual collaboration where both professional groups would profit.
However, after some five years’ experience with community mental health programs, it appears that such collaboration has not developed. It is estimated that over one-third of clergymen’s clients suffer from severe mental illness. Yet the clergy refer only 33 percent of such severe cases to mental health facilities, whereas general practitioners refer 88 percent of such clients. In terms of total case-contact, several recent surveys demonstrate that clergy refer less than 1 percent of their contacts to mental health resources. To look at the problem from the other side, data from community mental health services reveal that only from 1 to 8 percent of their referrals come from the clergy. Even in model community mental health centers, including several which are church-sponsored, the figures are minimal -- for example: 2 percent, 1 percent, 4 percent, "few."
These findings have stimulated a number of research studies to determine why the clergy -- community mental health center referral network has not developed as was envisioned. Several major reasons have been demonstrated.
First, there is a marked discrepancy between the role definitions and role functions of the clergy as defined by mental health professionals and as defined by the clergy. Mental health professionals tend to restrict and confine the role of the clergyman and even may voice grave warnings about the clergy assuming professional functions or encroaching on mental health domains. Hence the message is transmitted overtly or covertly to the clergy that liaison and referral is acceptable only within certain limited boundaries. Disagreement over those boundaries may lead both the mental health professionals and the clergy to withdraw from contact and collaboration as the easiest way to resolve the conflict.
Second, other studies have shown that mental health professionals engage in an asymetric relationship with professional clergy. That is, while mental health professionals usually acknowledge referrals from social agencies and physicians and will in turn refer patients back, with clergy referrals the referral is not acknowledged, nor is referral back to the clergyman made.
Third, some community mental health centers have established referral policies which accept referrals only from medical or social agency sources and exclude clergy referrals. This has certain screening advantages, but it also is a powerful deterrent to the clergy.
Fourth, effective clergy referral has been found to correlate with education, social status, and theological attitude. Clergy with little education have low referral rates, whereas clergy with the highest education have the highest referral rates. Clergy with low social status in the community have low referral rates. They indicate that communicating with high-status mental health professionals would "show them up" or "expose their inferiority." On the other hand, high-status clergy have high referral rates. Finally, several studies have revealed that clergy of the more conservative theologies tend to refer less, but also try to cope with the most severe problems. These clergymen tend to define all emotional problems as spiritual ones, and consequently deal with all problems in a spiritual manner with the least psychological sophistication. On the other hand, it has been shown that clergy of more liberal theology are apt to have exceedingly high rates of referral of all types of problems. They tend to define all problems as psychological and eschew any spiritual approach to human problems.
Fifth, many of the clergy trained in the decade of the 1960s have received basic, and at times advanced, training in pastoral care skills. Such pastors have redefined their role in relation to those seeking help in distress. These clergy consider that they have the knowledge, skill, and responsibility for the care of many of the problems they see. Thus these clergy have a lower referral rate because they elect not to refer as a professional decision.
Sixth, many clergy have not had the opportunity to acquire skills in pastoral care that will equip them to handle skillfully referrals, or to communicate easily and knowledgeably with mental health professionals.
Seventh, at least a few years ago many mental health professionals did not define the role of the pastor as including primary care, and only suggested that pastors refer all emotional problems. This was unrealistic, and many pastors have had no guidelines as to which type of problems might best be handled by the pastor, and which problems might best be referred to mental health services.
In summary, the area of referral illustrates both the conceptual and role problems that have interfered with successful development of referral cooperation. Yet this is an area in which both groups of professionals may indeed profit from establishing a working liaison with each other.
Cooperation in Consultation. As the churches have become involved in mental health activities there has been increasing need for consultative services with mental health professionals. Such consultation may occur at many levels: consultation to pastors concerning problem clients with whom they are working; consultation to a pastor and the church administration regarding human relation problems in the congregation; consultation to groups or programs in a congregation that are designed to assist people in the church; consultation to a local, regional, or denominational administration in regard to evaluation of religious candidates, human relations problems in the administration, or denominational programming related to mental health issues; consultation to a group of churches who sponsor a joint community program. Such joint consultation will benefit the mental health professionals in that it will foster the contributions of the churches, while it will benefit the clergy and churches in providing assistance in the achievement of their tasks.
There are several problems that may arise in such joint enterprises. First, there is the problem of reductionism. By this I mean the tendency to translate the concepts and ideas of the other professional into one’s own frame of reference. Thus the psychiatrist may reduce all the concerns of the clergy to psychological problems, or the clergy may reduce all the concerns of the psychiatrist to spiritual issues. A corollary to this is to implicitly or explicitly use the other professional for purposes other than what has been contracted in the consultation. For example, a psychiatrist may use a consultation to prove himself superior to the clergyman or expose the neuroticism of religion; or the clergyman may use a consultation either to seek a covert means of therapy or perhaps to gain power and prestige for an administrative maneuver. It is incumbent for effective consultation that both professionals have respect for their own professional discipline and role, and seek to use the help from the other for the purposes contracted, while avoiding aggrandizement of the other.
Another problem in consultation is that of syncretism, that is, conducting consultation in such a way that disagreement is avoided at all costs and the parties must stick together regardless of the means used or the goals set. If effective consultation is to occur both parties must feel free to see issues from their own point of view, yet respect other viewpoints that may suggest modifications. Frequently mental health professionals feel they cannot be of much assistance to clergy with whom they do not agree philosophically, while clergy may feel that a psychiatrist who shares no common theology cannot possibly be of value. It may prove fruitful to spell out carefully areas of disagreement in consultation so that differences can be respected and not interfere with the mutually agreed upon goals of consultation.
A final problem in consultation may be that of competition. Here either party may wish to win out and gain power over the other. This may be an intellectual competition, such as psychiatrist proving that the clergyman is dead wrong in his entire approach, or vice versa. Or the competition may be administrative or political, in terms of responsibility and power to make decisions or direct actions. Usually, openly competitive consultations quickly abort; however, subtle competitions may develop which can effectively sidetrack the consultation work from its intended goals. The end result, however, is a hollow victory.
In summary, there are many levels at which consultation may be part of the community mental health program. This is one of the potentially most fruitful areas of cooperation, for the benefits may accrue long after the completion of a consultation project. To be successful, however, consultation must be a collaborative enterprise between two professional who bring their own unique skills, knowledge, and concerns to the task at hand.
Cooperation in Treatment. Here we may consider opportunities for collaboration in the care of a patient who is receiving mental health treatment, either on an outpatient basis or on an inpatient basis.
In terms of outpatient care, patients in various types of psychotherapy were traditionally treated alone, and the problems were dealt with solely by the psychotherapist. More recently it has been found that the emotionally ill profoundly influence those around them and are influenced in return. Thus we have seen the development of joint treatment of married couples, family therapy, and treatment programs that enlist the aid and cooperation of relatives and friends. In instances where the pastor has a close and ongoing relationship with a parishioner who enters therapy, the pastor may play a role complementary to that of the psychotherapist. The therapist may inquire, question, observe, probe, interpret, and restructure in terms of the patient’s emotional dynamics; while the pastor may continue to provide support, guidance, and a continuing reality of the life of the congregation and the patient’s religious faith and practice. Some therapists have compared this to the needs of the child for both correction and instruction on the one hand, and love and nurture on the other hand.
In terms of inpatient care, we come more directly to specialized pastoral roles, in most instances a chaplaincy role. A number of recent studies indicate that there is considerable strain at the present time in the function of the chaplain. Mental health professionals tend to define the chaplain’s role solely in terms of traditional religious functions such as conducting worship services and administering the sacraments. However, chaplains with clinical training tend to define the bulk of their work in nontraditional areas such as pastoral visitation to patients, counseling patients, teaching in in-service programs, developing liaison with the community, conducting clergy training, performing administrative work, teaching religious classes, participating in research, working with volunteers, counseling employees, and doing religious group work. This list suggests many opportunities for vital contributions to a community mental health center program, but also represents unresolved role conflicts.
Other areas of cooperation include joint enterprises in community education projects such as those concerned with alcoholism, drug abuse, sex education, parent-child relations, marital relations, race relations, problems of poverty. Both groups of professionals may bring particular insights, knowledge, and skills to such educational programs.
Finally, mental health professionals and professional clergy may join forces in developing programs of social action in the community. Here they will probably work with other professionals and disciplines in the community who also have concern for social problems. In such programs both groups of professionals may be only part of larger community programs under the leadership of other citizens.
To sum up this chapter, it should be pointed out that there are many areas of joint concern to both groups of professionals. There are areas of conflict regarding conceptual issues and professional roles. These problems cannot be ignored. However, the fact that problems exist does not mean that inter-professional cooperation cannot be developed successfully. Indeed, the honest facing of areas of conflict may be an avenue toward the development of successful collaboration.
Action programs aimed at increasing interprofessional cooperation should focus on these needs:
1. The need for locally based in-service training programs for parish pastors. Such training should be geared not toward developing specialists, but toward enhancing and enlarging their pastoral care skills and providing them with skills and knowledge to collaborate with mental health professionals.
2. The need for education of mental health professionals in the structure, function, and role of the clergy and church institutions, and how to collaborate with them.
3. The need for establishing clear communication between local community mental health services and the clergy of the community, so that effective means of referral collaboration can be established.
For additional reading
Clinebell, H. J., Jr. Basic Types of Pastoral Counseling. Nashville: Abingdon Press, 1966.
Halmos, Paul. The Faith of the Counselors. New York: Schocken Books, 1966.
Hofmann, H., ed. The Ministry and Mental Health. New York: Association Press, 1960.
Klausner, S. Z. Psychiatry and Religion: A Sociological Study of the New Alliance of Ministers and Psychiatrists. New York: Free Press, 1964.
Linn, L, and Schwarz, L. W. Psychiatry and Religious Experience. New York: Random House, 1958.
Oglesby, W. B. Referral in Pastoral Counseling. Englewood Cliffs, N.J.: Prentice-Hall, 1968.
Pattison, E. M., ed. Clinical Psychiatry and Religion. Boston: Little, Brown, 1969.
Westberg, G. E., and Draper, E. Community Psychiatry and the Clergyman. Springfield, Ill.: C. C. Thomas, 1966.