Science in Christian Perspective
Pastoral Psychology and Counseling*
FREDERIC M. NORSTAD**
From: JASA 14 (December 1962): 99-103
One of the great and stimulating experiences of this speaker's life is the frequent opportunity afforded him to participate in institutes, workshops and seminars involving psychologists, social workers, psychiatrists and medical doctors. He and his colleagues who work in the field of pastoral counseling and psychology are deeply indebted to these professions and the increasing dialogue in which it is our privilege to participate.
But a group such as yours will readily recognize that there are frustrations involved in such conversations. We most often meet in a disparity of attitude and concept which limits the benefits and prevents us from really understanding each other. You will appreciate, then, my pleasure over the privilege of participating in your program in the conviction that here we meet most essentially as Christians-as brothers in the faith-as a fellowship of those who are in the Way together.
Most often interdisciplinary conversations center on the questions of training, techniques and method instead of the more basic essential problems rooted in Christian theology and its derived anthropology. Before all other questions comes the simple one-"What is man?" Who is this being that represents the object of our concern and effort? So we turn first of all to the anthropological assertions which must underlie any discussion of pastoral psychology and counseling.What Is Man?
The first assertion is that man exists by the will of God. God, Who established the tremendous magnitudes and velocities of space, Who cancels out time in eternity, Whose feet are familiar with the paths of the light years, Who had been creating from eternity, paused in that great moment and said, "Let Us make man in Our image." Notice the pronouns. God here reveals something essential about Himself and of significance in understanding the nature and purpose of human existence. It is the Trinity speaking. The community and fellowship which was, is and shall be-the Eternal Relationship-Father, Son and Holy Spirit. They had been living from eternity in meaningful relationship and were now about to expand the family.
The most significant thing I can know about myself is simply this--God wants me! And if me, then every man. This is the most incredulous thought of all and
man in his incredulity rejects it if he can.
The second assertion: We are persons. "And God formed man out of the dust of the ground and breathed into his nostrils the breath of life, and so man became a living soul." The life within us is from Him. We are living souls. Now the soul is not some fraction of out being. The term is not to be used in some dichotomous or trichotomous description of human being. The soul is the sum total of all that we are under and before God. It is best understood in terms of the word person.
And herein lies the image of God. He is person-three person-a personal God. And we are in His image. Even as He is person, we are person. The difference lies in the fact that He is Divine person; we are human person. We are persons for a purpose. It is on the basis of this common denominator that we have fellowship with Him. We are the Sons of God and heirs of the kingdom-the children of the family.
The third assertion is this: As persons we are free and responsible. These two go together. If I am but a puppet controlled by the strings of God's will, I am not responsible. He is. But as a person I have both the privilege and the fearful responsibility of choice. Nor am I but the instrument of my impulses bound in a genetic straight jacket, laced and buckled by social determinants.
It is at this point that guilt takes on its reality. It is not an illusion to be explained away. Deep down within the human psyche is a God-implanted awareness that we must love and not hate. If we violate this law of God implanted in our hearts, we experience guilt. If we repress the direct cause and effect of the guilt experience, we will express it nonetheless in substitutional or projective forms with which all psychotherapists are so familiar.
The fourth assertion: Man has exercised his God-given "right" to do wrong and has become by nature sinful and unclean. Freud may have misinterpreted the nature and meaning of "id" but what he observed was tragically true. The stinking cesspool of id makes its unholy demands and with each demand there comes the counter demand of conscience. And I must choose. It is at the point of my choices that I become guilty. Over id's demand I have little or no control. But I am responsible for my choices. Luther stated it this way. You cannot prevent the birds from flying over your head, but you can stop them from making nests in your hair. But can I? Yes and no. I am by nature given to at least imperfect choices. I am a member of a fallen family and have the characteristics of that family, but in another sense I am constantly recapitulating the fall in my own personal decisions. This is my dilern'ma! "0 wretched man that I am; who shall deliver me?"
The fifth assertion: God's love has pursued me. He will not let me go. If I am to be free of Him I must tear myself away. It will not be by His letting.
I submit that we cannot really understand man without considering the Gospel. Most simply stated the Gospel is the amazing fact that God loves and wants us. As a result of this loving and wanting He pursues us even into the intimacy of the incarnation. "He became flesh and dwelt among us." "He who knew no sin became sin." In answering the question, "What is Man?" how can we ignore the most important fact about him. Loved by God-with such a love. By way of the atonement God has found a way to forgive my impertinent rebellion. Sin and sins are not to be explained away nor subjected to psychiatric absolution in the transference phenomenon. They are to be forgiven by God, our personal and true Father. The Holy Spirit calls, enlightens and sanctifies us to the end that we may be reconciled into the fellowship with God and His family once again.
Having made these assertions, I submit that man cannot be understood in any other light. These are the greatest facts about him. They determine the nature of his existence as well as the purpose and goals of his being. Man exists in order that he might live in meaningful relationship with God and from that dynamic draw the power for his meaningful relationship with his fellow man.Definition of Pastoral Counseling
Against the background of the foregoing I would like to attempt a definition of pastoral counseling. But first a little history. For many decades after the advent of modern psychology the church and its ministry simply ignored or too frequently unintelligently attacked this great potential. In the twenties when the so-called modem liberalism was sweeping large segments of Protestantism particularly along the eastern seaboard, many churchmen reached out toward the new psychology as an answer to the vacuum created by the sloughing off of many traditional Christian doctrines. Empirical observation replaced revelation. Scientific proof became the ultimate norm. It was in this unhappy situation that modern pastoral counseling had its origin. The result was a considerable secularization of the ministry of pastoral care. Tragically this situation is still too often with us.
But through it all there has come an increasing awareness on the part of conservative theologians that psychology and psychiatry have important things to say. A new appreciation is developing today for the contributions which these allies make to the understanding of the human being and for the insights in dealing with sick and distressed fellows. As both psychology and theology have become more humble and less defensive they are developing the capacity to hear each other speak out of their own body of truth and are discovering that truth is not of two but one kind-Truth is of God.
Pastoral counseling is evangelical in its purpose and goals. It seeks to relate man to God in meaningfulness and from that relationship to derive the power to live in meaningful relationship with fellow man. Karl Menninger defines mental illness in terms of the loss of capacity for successful interpersonal relationship. Pastoral counseling is therefore therapeutic.
It is confession. The church has always recognized the necessity of confession. But its concept of confession has often degenerated into a recital of sins. Sins are often seen as blemishes on the surface rather than pebbles which reveal the bed rock from whence they have been chipped. At this point psychiatry has been of immense help-sometimes unwittingly so. The psychiatric concept of catharsis allows no such artificiality or superficiality. Here is real purgation-a flushing of the depths. Modern pastoral counseling seeks to make confession this deeper thing. We have learned much about method and technique from psychology and psychiatry. In the setting of fear-casting love, we seek to communicate the courage to explore self in depth!
Most people are all too willing to repudiate responsibility for sin. We use such expressions as, "I made a mistake," "I slipped," or the more modern, "I goofed." Pastoral counseling should help a person realize that his actions are the direct outgrowth of what he is-of his very nature. I believe that all men have this awareness, though it is often clouded and confused. Man is universally aware of his guiltiness. This awareness may be confused and distorted, but it is there, conscious or unconscious.
Shortly before World War 11 I read Frazer's major anthropological work, The Golden Bougb. Here Frazer suggests only one exception to the ubiquity of guilt. The Papuans of New Guinea, says Frazer, practice head hunting with no signs of guilt feelings. Shortly after reading Frazer, I was sent to New Guinea by the Navy Department. When we waded ashore on that first dark night, I regretted Frazer's erudition. Sometime later it was my privilege to accompany a Papuan Christian back into the hills to his native village. The expedition was for evangelical not anthropological purposes. The native lad who was my host was concerned about his parents and particularly his aged grandfather. The old man asked some embarrassing questions. How could I criticize head hunting as killing? What about our guns and bombers? In the course of our conversation he described the head hunters' ritualistic feasts. They were not the appetite serving orgies I had imagined. They were rather religious in nature. As each part of a human body was eaten a prayer was made that the virtue of the particular organ or muscle be communicated to the person partaking. But here is the significant point. The meal concluded with a prayer to the spirit of the departed one, asking that he not hold this against them. Guilt! God has established His law within the human psyche. It is wrong to hate-right to love. However we may dull our conscious awareness of the voice of conscience, its voice still speaks out of the depths of our being.
Many Christians feel guilty simply because they do not feel guilty-at least in conscious terms. Our guilt feelings are brought into sharp and painful focus only in the awareness that we sin as sons of the Father against our brothers.
The superficial recital of real or imagined sins is not confession. Confession requires true perspective and acceptance of responsibility. This is the goal of the confessional aspect of pastoral counseling.
It is revelation. Man cannot arrive at knowledge of his identity by reason or observation. He walks in something akin to amnesia until in the light of faith his identity is revealed. Part of the tension of his existence is the presence of some intuitive awareness that he is somebody-but who?
Pastoral counseling seeks to assist an individual to come into adequate self awareness in terms of the truth of his identity. This must always be the starting point in healing. It is at this point that many pastoral counselors make their most grievous mistakes. As a counselor I find it necessary to spend far more time on the problem of identity than on the problem of guilt. When a person grasps the startling fact that he is the son of God and an heir of the kingdom other problems present themselves for more ready solution. If I conceive of myself as a "worm," I will find the redemption incredible. But if I can grasp the prior fact that I exist because God wants me in His "eternal company," then the second article is not so preposterous. I am firmly convinced that people develop more of a sense of awe when they experience the truth of the first article than they do over the consequent redemption.
It is absolution. Herein lies one of the strengths of pastoral counseling. It provides a wrapping up, a conclusion, a sealing of the experience. Here is the pronouncing of God's forgiveness and acceptance. Most of us make this proclamation first in informal terms, followed by the symbolic laying on of hands and formal absolution. Having received balm and healing, the counselee now hears in effect the admonition, "Arise and go, your faith has made you whole."
I think it is obvious that these factors in pastoral counseling do not follow in strict sequence. One cannot really hear confession without also proclaiming the revelation. Indeed, one cannot really confess without the light of the Gospel to shine in the dark places. Nor could one have the courage to confess without knowing that he was heard by a God who loves. In like manner there is a sense in which the absolution is constantly given as a part of the process.
One of the greatest discoveries of the twentieth century is the essential wholeness of the person. Total man has inseparably related needs in the areas of body, mind, emotions, spirit and social relationships. In this regard the challenge confronting our generation is to build a team approach to the health needs of man.
Human ecology is the study and treatment of the total human being as he stands in dynamic relationship to his total environment. The term human ecology, while not new, is not in common usage. In employing it to describe our program we refer to a concept of what the human being is as well as an approach to the treatment of his health and difficulties. From both theology and modern science we derive our conviction that man is a complex inter-relationship of physical, mental, emotional, social and spiritual factors. These factors cannot be understood except in terms of their inseparable inter-action. Man influences, and is influenced by, social, physical, and spiritual forces.
Treatment of his disorders and ills calls for the fullest possible understanding by both physican and patient of these internal and external inter-relating forces. The resources of medicine, psychiatry, social work, theology, and education need to be integrated. This calls for a team approach by qualified physicians, surgeons, psychiatrists, clergymen, and medical social workers. Such a team approach must rest on inter-disciplinary cooperation, communication, understanding, and mutual respect.
The growing edge of modem medicine, both as a science and as an art, brings into sharper focus the great need for an over-all approach. As science probes more deeply into the mystery of man's nature, it reveals clearly the complex inter-relatedness of the facets of his being. It is no longer logical simply to ask the physician to heal man's body, the psychiatrist to treat his emotions, the social worker to bring him into adjustment with his environment, or the clergyman to minister to his spiritual needs. From the deeper investigations of these professional disciplines comes testimony that their lines of discovery and treatment converge on each other. They meet at the point of man's nature as an indivisible being. An unfortunate, though understandable, lag has been experienced in putting this concept to work in helping the patient. This lag can be overcome through the creation of ecologically oriented hospitals and medical schools.
Specialization in medicine has brought vast blessings to mankind. Through it great strides have been taken toward better understanding of disease and consequent improvement in treatment. The result has been longer life with less pain and suffering. But this specialization has also been accompanied by serious negatives. The person has often been lost in the process. For example, physical diagnosis may show a stomach ulcer, but the person is involved in both the cause and the effect of that ulcer. To retain fully the advantages of specialization, we must develop in our care of the sick such interdisciplinary communication and coordination as will heal the person instead of merely patching up his stomach. This is the core of what we call the ecological approach.
But now we come to the proverbial "sixty-four dollar question," How can representatives of such divergent disciplines, the products of such specialized educational processes enter into effective communication and cooperation? The typical medical college may give an hour or two to a Protestant minister, a priest, and a rabbi. This time is usually spent in briefly examining some of the distinctive practices of these faidi groups as they may relate to such questions as "When should the priest be called?" "Who can baptize in the case of emergency?" etc. Schools of social work do little better. For the most part religion is regarded in terms of the institutionalized church and a social phenomenon. Psychiatry has traditionally viewed religion primarily in terms of its real and imaginary destructive distortions. But perhaps the most puzzling deficiency of all is found in theological education. Even in the light of Biblical anthropology-the doctrine of man-little attention is given to the whole person and when a pastor defines his task as a spiritual ministry to the souls of men, he is probably giving evidence of a fractional concern.
But the night is not entirely dark. There are some evidences that a dawn is approaching. To be sure there have been some stars in the sky all through this dark night, exceptions to the general rules which we have been discussing. Perhaps, even a moon has been shining to remind us that there is a sun. But I am quite sure that a few streaks of light are beginning to appear in the east. A new day is approaching. God's grace has not been entirely lacking in the efforts of individual disciplines toward deeper understanding. At least it can be said that their deepest investigations have caused them to look a little bit to the side and to realize that each of the other disciplines holds some knowledge of man and of his nature which relates to their knowledge. At least one medical college has symbolized this awareness by appointing a theologian to its faculty. ocial work has been increasingly in communication with medicine and particularly psychiatry, and in theological education there is some evidence that the church is becoming aware of the relationship between die spiritual on the one hand and the emotional, physical, and social on the other. Within the last decade seven Lutheran theological seminaries have put full time clinically trained professors on their faculties in order to facilitate communications with other professions and the knowledge held by other disciplines. I would like to m now to theological education and the evidences that our seminaries are becoming concerned about the orientation of the theological student in the healing arts.Clinical Pastoral Education
At this point it is necessary to recognize the growth over the past thirty years in what is known as Clinical Pastoral Education. Such men as Anton Boisen, Dr. Richard C. Cabot, Austin Philip Guiles and others became concerned at about the same time about these very problems. Perhaps, Pastor Boisen's main thrust was in the direction of convincing the mental hospitals of the pertinence of pastoral care. I think it can be said.that Dr. Cabot's main concern was in the direction of the theological seminaries. Some of you may recall that he offered to most of the theological seminaries on e eastern seaboard a lecture entitled "A Year of Clinical Education for Theological Students." I think Dr. Cabot had rather the worst of it. To convince theological seminaries and their faculties at that time that a doctor had anything important to say to theological students was a difficult task indeed. Most of them politely rejected his offer. But conviction is a power to be reckoned with, and the tenacity of such individuals as those named above, and an increasing number of others down through the years, has borne its fruits. The number of accredited clinical pastoral training centers numbers more than 150 in die country today. Many of these centers work in more or less direct cooperation with certain theological seminaries. A few find themselves in very direct relationship to the curriculum of one or more seminaries.
It may be best for me to speak in terms of die program with which I am best acquainted. But first let me give the general background. Out of the efforts of such men as Dr. Boisen and Dr. Cabot, working primarily in the Boston area, clinical training for theological students and pastors got its start at first with little or no recognition from theological seminaries. The felt needs of theological students and pastors found students applying for such experiences. As time proved out the effectiveness of this educational process, more and more centers were established around the country under the direction of trained chaplain-supervisors. The inevitable happened-organizations were formed. You may be acquainted with the Institute of Pastoral Care and the Council for Clinical Training. About twelve years ago clinically trained pastors within the Lutheran Church began to see that the values of this type of experience could best be promoted within the framework of our own theology and ecclesiastical structure. Lutherans felt here, as in other areas, that ecumenical approaches created almost insurmountable problems. Concomitant with this development, representatives of a Council for Clinical Training, The Institute of Pastoral Care, Protestant theological seminaries which are running programs of clinical pastoral training independent of those two organizations, and the Lutheran group began working towards commonly accepted standards. After many meetings covering a period of about three years the standards were ready and referred to each of the groups for their own ratification. These were, of course, minimal and for the most pertained to mechanics. A great deal of individuality exists in the expressions in these various groups. This is certainly understandable and is perhaps desirable. Each group made modification of the standards in terms of some additions to the minimal requirements.
In brief summary, the standards are set up on a quarter basis. Clinical pastoral training is a full time supervised experience in ministering to people in crisis situations. The center must be under the supervision of an accredited chaplain-supervisor who has had a minimum of five quarters of such training and has been found by the accrediting committee to be qualified by personality, as well as by training, for this rating. He must serve first as an acting supervisor while his course is scrutinized and evaluated before he may be given full accreditation. Courses must be structured in such a way as to allow adequate opportunity for interpersonal relationships with both patients and professional staff. The center-general hospital, mental hospital, correctional institution-must regard this program as part of its educational function and not simply view it as something to be tolerated. The standards emphasize that the main stuff of the learning process is found in the patient interviews. The accurate recording of such interviews into a case study and the presentation of these cases to the group, which includes the students, the supervisor, and resource persons from other professions, is a major activity.
I noted earlier that each of the groups engaged in clinical pastoral education maintains the prerogative of individual expression. I think that the distinctive emphasis within the Lutheran and other denominational groups is first of all in seeing clinical pastoral education as a part of theological education which is best carried out in direct relationship to one of the theological seminaries. As a result of this emphasis there is probably a greater degree of the integration of theological knowledge on the one hand with medical and psychological knowledge on the other. The preamble to the standards as presented by the National Lutheran Council states that "The Christian church in emulating Christ's concern for suffering and distressed people down through the centuries has shown its faith by its works of healing love. Pastors have brought and daily bring comfort, consolation, and God's grace and forgiveness to sin sick and suffering souls. Using the Means of Grace entrusted to them by the Lord and their enlightened insights into the nature of man."
I will use the particular program in which I am personally involved as an example of at least what one school is doing in the field of clinical pastoral education. While in scope it may be of somewhat larger dimensions than is true of other theological seminaries, it does represent the direction in which many others seem to be moving.
There are two main aspects to our program. First, the academic: courses are offered under the general heading of Pastoral Counseling. A required course given in the senior year deals with common stress factors in persons as they react to their environment and how these stresses may result in emotional and physical breakdown as well as disturbance of social relationships. Included also are discussions and descriptions of the symptoms in each of these categories, and, of course, there is discussion of the role of the pastor not only in ministering to these persons but also as a part of the health team.
In addition to this required course are several seminars. For example, Case Studies, Mental Illness and Lutheran Theology, Christian versus Freudian Concepts of Anxiety, and the Meaning of Suffering (based on job and Isaiah). In addition we also offer seminars which are essentially experiences in group therapy.
The clinical component, however, is the one most emphasized. It is our belief that pastoral counseling is a clinical subject lending itself more readily to clinical instruction than to classroom lectures. In implementation of this program the seminary has nine fully accredited clinical pastoral training courses in as many institutions under the supervision of accredited chaplain supervisors. Six of these centers are located in general medical and surgical hospitals. Two are in state mental hospitals and one in a state correctional institution. Each center must meet the standards referred to above. Of particular importance again are the attitude of the administration and staff toward the program, the availability of adequate clinical opportunities, the availability of adequate professional personnel as lecturers and resource persons in the discussions and the willingness of the staff to cooperate with the students in the course. The course consists basically of pastoral ministration to people in crises. From these experiences, case histories are written and presented for discussion to fellow students, supervisors, and representatives of the pertinent disciplines sitting as a group. As further foundation and background for these discussions, lectures are presented by the various professions and their sub-specialties represented in the institution.
Our goals could be stated as follows: in general we want the student to develop insights, knowledge, and experience which will enhance his ministry to people. This may be broken down into four specific goals: (1) personal growth, (2) professional growth, (3) better role definition, and (4) increased facility in interprofessional communication. In the setting of the general hospital, in addition to the content indicated above, students are introduced to the study of anatomy and physiology, the symptornotology of the various disease entities and the hows and whys of particular therapies. They serve for a time as orderlies, witness births and autopsies, attend clinical pathological conferences, etc. The counterpart of these activities is carried out also in the mental hospitals.
The program started eleven years ago with one center. The course was offered only for the summer quarter and, of course, was not required for graduation from the seminary. Eight students represented the capacity of the center. Today approximately seventy students can be accommodated for the summer quarter. In addition, two of the centers operate during additional quarters of the year. One of these accepts only men who can spend a minimum of one full year in the capacity of Resident in Pastoral Care. This center accepts six such residents, and next September will inaugurate a program of research fellowships, again on the basis of a minimal one year period. Incidentally, this hospital gives each resident a stipend of $5,000 per year and each research fellow $7,000 per year.Conclusion
If the concept of human ecology is based on valid theological and scientific conclusions it would seem obvious that medical education should be theology related. If we talk about serving the whole man, a question is begged, "What is man?" and further, "Why is man?" Once we start to answer those questions, we come, whether we want to admit it or not, to theology, and if we say that theology has no particular place in medical education then we have already made a theological judgment in the area of anthropology.
The need is for an institution organized in such a way as to preserve the finest in medical training in a setting of ecological resources and attitudes, adequately financed and dedicated to the treatment of man as the whole being that he is. We believe this is demanded by the most profound observations of medicine, natural sciences, behavioral sciences, and theology. This should be an institution where medical students, graduate students of theology, social workers, and psychiatrists could come together for at least a part of their training.
Perhaps, what we are talking about here is a twentieth century form of the New Testament relationship between religion and health. The time may well be full for a return from the great conceptual dispersion. Servants of God, exquisitely trained as physicians, social workers, psychiatrists and pastors, men of common faith and of common Christ-derived concern, should move together in common effort toward common goals in the service of God and the God-loved among whom we move. Perhaps, it could be said in this connection also that "What God hath joined together, let not man put asunder."