I am continuing my journey through Doing the Right Thing, and Chapter Two addresses the moral issues of choosing “treatment plans.” When I entered the mental health field in midlife, there was a general acceptance of taking billable time to get to know a patient, both in terms of establishing rapport and getting a sense of the personal issues and problems of a new patient. However, when I started in the public health system with Medicaid, I would have to submit an evaluation and a treatment plan in a 50-minute window before getting a penny. This is general third-party practice today, to the degree that by the time I closed my office in 2014 my software would only let me perform a 90801 on first visit—diagnostic and treatment planning.
For mental health providers, treatment planning, perhaps surprisingly, was one of the hardest things to do. Medicaid, for example, gave me templates that read something like this: Johnny will reduce his incidence of impulsive interruption of his class room by 25% over four sessions. Treatment plans are geared to concrete outcomes, and more and more to quantifiable outcomes. Some of my third party payers, like United Health Care, required an admissions symptoms test that I would administer during first visit. The test would be repeated after the fourth or sixth session and also sent to the insurance company. Patients typically and understandably underreported or even failed to report symptoms at the first visit, not wishing to make a bad impression on me (or maybe fearful that I would order an involuntary hospitalization.) And thus, after a few weeks and a few billings, I would get a reasonably friendly letter from the company, commending me on my success and wondering if further treatment was necessary.
But on the other hand there is a moral imperative here, too, to cut to the chase and address the need of the patient, since his or her comfort, health, and safety depend upon both symptom and causal understanding and treatment intervention. As church workers we might not be accustomed to think of our interactions with our public in such ways, but the skill of identifying both need and best intervention is of immense help to the suffering, many of whom are attracted to the church—at our invitation. Moreover, given the shortages of personnel—not just priests, I might add—it is an appropriate stewardship of ministerial time to develop analytical skills of “ministerial” or service planning.
In the book I cited above, John Peteet, M.D., cites a moral dilemma of counselors who address patient treatment planning from their own preferences: some counselors focus on self-determination, others on medication, some on child compliance to parents in all situations, no matter how dysfunctional the household. The textbooks recommend collaboration between the patient and the provider in treatment planning options, though as Peteet observes, there is no hard and fast guideline about how this collaboration takes place. If all patients knew how to collaborate on treatment plans, they wouldn’t need me in the first place and I’d have to do out and get an honest job. State laws recognize an inherent imbalance of insight between patient and provider—hence the prohibition against sexual contact, as “informed consent” is deemed impossible in relationships of power. I might add here that many a first session in my office began with a patient declaration that “I’m not taking drugs.”
I think what Peteet may be driving at is that one size does not fit all, and that counselors may not be totally honest with themselves in addressing the patient’s need. Two reasons come immediately to mind: (1) we tend to work from the information and algorithms we know; and (2) there is a good chance that therapists themselves have sought psychological treatment, and perhaps tend to fall in love with the treatment style that made them better. So a counselor may very well have predilections toward therapy modes that will dominate most treatment encounters.
Let’s be frank here and admit that dispositions and predilections influence so much of our church work—personal work, team work, and planning. The great danger with church work is the subtle—and many, many times not so subtle—way we have of representing our gestalt of religion as God’s, or the universal Church’s. This, too, is a power imbalance that church ministers must constantly examine themselves for.
I could point out a number of examples, but one that keeps coming across my desk is the unrest of some Catholic bloggers regarding Pope Francis’ recent encyclical on marriage and the family. Among the complaints is an alleged absence of clarity on Church doctrine regarding marriage and the reception of the Eucharist. The line of thinking, as I understand it, is that pastoral variance for individual couples will destroy the certainty and clarity of Church doctrine and “confuse the faithful.”
There is a part of me that wants to ask if the denial of pastoral flexibility is any less confusing. But more to the point, I also wonder if part of the unrest is due to a genuine fear of disorder in general. The Church, in some ways similar to a therapist, becomes the object of “transference” in which the patient (or the Catholic) projects upon it what he or she needs it to be. I am not venturing into a sacramental debate here, but I think it is difficult for many to conceive of a Church like a field hospital among the wounded, where experience and Spirit-filled instincts carry weight alongside of established principles.
Thus, in my teaching, when I encounter students who feels it necessary to speak “for the Church,” (usually wrongly, as it turns out, cloaking themselves in their understanding of orthodoxy) I have to wonder, too, if such a person is prepared to take responsibility of his “treatment plan.” It may never occur to some individuals that their public statements may be discouraging other Catholics from seeking pastoral care in second marriage situations.
I just looked at my clock and I am scheduled to teach catechists in one hour. But we will continue the discussion.
There were a number of factors that led to my closing of my private psychotherapy practice facility near the end of 2014. Not all of them were profound, by any means. One factor was simply the expiration of my lease; I was reluctant to make another long-term commitment after retirement age, although my work setting, with its park and lake all around, was ideal. Another was my wife’s retirement and a desire to have more time with her. And, I closed up the shop the day before the new DSM-V coding became mandatory for third party or insurance payments. This fifth volume, I hear, has produced more heat than light, akin to the Common Core controversies I hear about from teachers and Facebook.
However, there were other factors as well, and I think the most pressing issue was the responsibility of “giving advice” around which people actually made significant decisions. I am not so vain as to think all of my pearls were eagerly gathered; I don’t follow my own providers’ instructions to the letter, either. But I suspect this is a factor of aging: the older you get, the more you realize the potential for good or harm in your words and behaviors in any setting, not just counseling settings.
Although I closed my office eighteen months ago, I still maintain a license and am still state required to take my 36-hours of coursework to renew. (Catechists, are you listening?) I use an on-line service which requires the reading of books followed by an on-line test. I shopped around for some courses recently and found one that required the reading of Doing the Right Thing: An Approach to Moral Issues in Mental Health Treatment. Every night before supper I take 30-45 minutes to plod through it and mark off answers on a copy of the test I downloaded courtesy of the company. It is hard not to get 100% but you do have to read the book.
The opening chapter of Doing the Right Thing addressed not just what kinds of advice are professionally appropriate, but whether a therapist should even offer moral advice at all. If you have attained a certain age, the very discussion of such a thing seems incongruous. Therapists probed, not preached. Freud himself employed exploration of the psyche and interpretation, not the giving of advice. The American icon Carl Rogers originally termed his “client-centered” theory of psychology “non-directive.” By the 1980’s and 1990’s the ethical textbooks of the mental health profession were generally hardnosed about any intrusion by the therapist of his values or his personal life.
At another level, though, many of us knew that not only was it impossible to keep our personalities out of our work but our values as well. I remember a summer school course in the 1980’s offered by an elderly psychoanalytic Freudian, a true old-school practitioner. He told us that back in the day he had a patient who, session after session, rambled on about how, in childhood, the parent would not give the patient a penny for a pickle during the Depression. Our speaker laughed. “Finally, I reached in my pocket, produced some change, handed it to the patient, and said, ‘Go out and buy all the damn pickles you want, and then get on with your life.’”
This old-timer, for all his immersion in the Freudian and the Rogerian traditions, had not lost his common sense, either. Sometimes the direct intervention is the correct one. However, it should not be the easiest one or become standard in the way that we assist others, and in the context of our blog there needs to be considerable discussion among church ministers about the best ways to help parishioners and the general public.
For one thing, the old church/state separation about laws and liabilities no longer exists. There are bishops, clergy, and laity now dealing with the long arm of the law for failure to report child abuse, for example. I suspect that church ministers—paid and volunteer—will be held to higher criminal standards of reporting. How about Eucharistic ministers who visit the elderly and observe family neglect or abuse, physically unsafe accommodations, psychological deterioration, etc.? What are the legal obligations here, and what standards do we bring into play?
But how liable are catechists and church ministers for the more commonplace advice we give or fail to give? It is important that we understand how seriously some people take our opinions and suggestions—from matters of religion to issues of personal problems. The Church does advertise itself as a place of unconditional love and acceptance, so the expectation is hanging out there that the Church is a kind of AAA on the highway of life. But, it does matter whether you are trained to pump gas or trained to dismantle and rebuild a Mercedes engine. In parish life it does matter whether you are trained and certified to teach religious studies or certified in Canon Law to advise and direct annulments. (You can certainly do both, but the skill sets are not interchangeable.)
Because of the fluid nature of parish life—we interact on many levels on varieties of projects and we may actually be neighbors—we tend to look at all of our parish contacts as “friends” or comrades in the faith, forgetting that (1) our ministry requires us to represent the Church publicly, whatever our private opinions might be, and thus we are not always able to be as “chummy” as we might like; and (2) we are often privy to information from parishioners that we cannot share, and sometimes when cornered we have to feign ignorance.
On this second point, as a church minister you will inevitably be asked for advice or an opinion, and this exchange can take place in a parish office or behind the backstop at a parish softball game. The range of subjects is potentially limitless: will reading Mother Faustina improve my prayer life? Should I put my mother in an assisted living facility or am I breaking the Fourth Commandment? Should I quit my job? Should I take out a second mortgage to send a child to a Catholic college? In the best of all worlds these questions are best directed toward (1) a confessor or certified spiritual director; (2) a gerontology social worker, for starters; (3) a vocational counselor, and maybe one’s financial advisor; and (4) a financial/retirement planner, again for starters.
In many cases you are part of his or her discernment process; the average person knows the targeted professional specialty, but he or she may not want to jump with both feet into the care or consult of a professional where hard decisions need to be made. So casual interlocutions are safer because they allow for more wiggle room; the questioner can gauge your emotional reaction to the question as well as your general opinion of the situation. Here is where caution comes to the fore. As Ben Bradlee said to Woodward and Bernstein in All the President’s Men, “Just make sure you’re right.” There is something intoxicating about playing expert, about being asked. The hubris can blind us to the fact that real lives with long-range impact can flow from our input.
By contrast, there are individuals who approach us over and over about the same problem. After a while it becomes evident that the person enjoys the attention and sympathy of a church worker and has no real interest in giving it up. After all, aren’t church people always supposed to be nice, and available? Not necessarily. I had a rule of thumb as a pastor and a therapist. I allowed two sessions for a parishioner or patient to “tell his story.” If the third session began as a rerun of the other two, I would stop the narrative, acknowledge that I had the picture, and begin planning behavioral changes with the person to rehearse for the next session. Sometimes giving advice is not the head trip we imagine it to be.
On Monday morning I enjoyed some good pastry down at the Chancery of my diocese as I was in attendance with a task group created to intensify the Catholic identity of our diocesan schools. I say “intensify” because in recent years I feel that a fair amount of progress has been made with incorporating Catholic school teachers into the evangelical mission. As a catechetical instructor of personnel in my own diocese, I remember a day not so very long ago when members of my team dreaded teaching classes of Catholic school teachers. Courses in catechetical formation were perceived as (and at times presented as) “hoops” to jump through by the teachers in attendance. To a point it was understandable, as there was no significant paradigm on our part as instructors to incorporate the large majority of school teachers who were not, strictly speaking, “religion teachers,” into the full mission of the Catholic parish/diocesan school.
I am experiencing fewer and fewer attitudinal problems in recent years. I’m sure they exist, and yes, I still have the occasional professional teacher who updates a Facebook page while I explain how many angels can dance on the head of a pin. But the teachers I talk with personally and in small groups seem to have much more interest in (1) issues of faith that relate to them personally, (2) their professional competence in the areas of theology and religious education, and (3) the quality—or more often, the lack—of Catholic identity, behavior, and knowledge of the faith among the parents. It is intriguing to me to hear this third issue come up in school settings, because this used to be the main complaint of religious education volunteer instructors, as in the failure of parents to bring their children to Mass on Sundays.
I am also starting to hear from teachers that they would like high quality theological formation in places, formats, and times more conducive to learning. (Presently our courses are offered regionally on 7-hour Saturday presentation days and intensively during weekdays in June after schools close.) I am favorably disposed to this input though with a few provisos. These would include (1) cost; (2) availability of competent theological faculty to meet multiple styles of demand, and (3) the general difficulties surrounding “continuing education” in all professions.
I have sitting on my desk next to me a mailing from the Institute for Brain Potential, a brochure inviting me to a 6-hour seminar in Orlando on “Memory, Stress, and Alzheimer’s Disease.” The IBP is accredited by the Florida Department of Health to provide CE or continuing education hours toward the renewal of my state mental health license. This April 28 workshop is being held at a DoubleTree Inn in East Orlando; as workshops go, this 6-hours is a bargain at $79. Most mental health CE programs from companies like Cross Country run in the $180-$220 range. The presenter is a teaching Ph.D. psychologist from South Florida. The cost of tuition is paid by the participants; some employers might help bear the costs for staff employees as a perk but if you are a private practitioner or consultant, it’s your cost minus the tax deduction. I am not conversant with CE requirements for electricians, portfolio managers, and tax preparers, but my guess would be that continuing education is, generally speaking, a cost of doing business, a fact that has not percolated throughout the Catholic system, for reasons I will cite below.
The same cost challenges face religious continuing education in Roman Catholic institutions, in our context parish schools and religious education format. The tuition for our 7-hour programs is $15/class (and a teacher can now register on line with a VISA card). I honestly don’t know how that fee is charged, whether schools pick it up for teachers or each teacher pays his or her own way. My guess would be more of the latter. In any case, the $15 does not really cover the costs of professional religious training. The Orlando profile is probably very similar to many U.S. dioceses. We do not have a Catholic College within our boundaries, nor a library or faculty of theologians with advanced degrees. There is no diocesan owned central facility (comparable to a DoubleTree) to conduct regular courses. We are not awash in Ph.D.’s. We improvise in every one of these areas, depending upon the proffered hospitality of parishes and schools, for example, to host and feed teachers and catechists from around the region.
This segues into the second point, the availability of instructors, facilities, and formats. In my conversations with the folks downtown, I get the impression we do not have a strong bench of instructors beyond our present starting line-up. I can’t recall any discussions over the years regarding qualifications for our in-house instructors. Years ago a fair number of priests, laicized priests, and religious sisters were actively engaged. However, as the clergy retire and decrease in number, the newer priests from overseas manfully struggle with language and what I would call “the American Catholic idiom of theology,” which can make advanced teaching prohibitively difficult, though there have been remarkable exceptions. I should add here that until fairly recently religious sisters continued to maintain a high profile as DRE’s or faith formation directors, although their numbers decrease, too. Generally, the credentials today seem to be an accredited master’s degree in religious education or theology and considerable pastoral and religious educational background.
The extent of the catechetical leadership personnel problem today is brought home more clearly in two intriguing reads, When the Sisters Said Farewell (2012) and Double Crossed: Uncovering the Catholic Church’s Betrayal of American Nuns (2007). While both works explain the travail of religious sisters’ communities in the United States in the twentieth century—before and after Vatican II—they also provide insight into our present day dearth of a strong cadre of “professional formers” to teach and mentor those in religious faith formation. The “Catholic presence” we seek to replicate today was not just the academic excellence of religious in the classroom, but in truth it was the religious life of the convent transposed into the school setting—prayer at particular hours, liturgical observance, silence, modesty in dress, obedience—all of the qualities of a convent writ large in, say, 1960. Moreover, given the large numbers of young sisters teaching in the schools (and the religious education programs or “released time” programs, I hasten to add) the practice of veteran teaching sisters mentoring the younger teachers was very strong in many communities.
The stipend of the religious nuns who taught me (1954-58) was $25/month, from what I have been able to learn. (I had Christian Brothers 1958-62.) I would tell anyone who asked that I received an excellent academic and religious formation in my Catholic school. And while our catechetics and theological outlook has expanded since then, when we talk about “Catholic identity” in schools and religious education programs, we are—correctly in my view—harkening back to an academic/faith standard that served us well.
On Monday night, when I kicked back with my wife to talk about the day, I harkened back to the movie that scared us to death in the summer of 1975, “Jaws.” When Sheriff Brodie laid eyes on the size of the challenge of the great white shark, the cigarette fell out of his mouth and he walked back to the irascible Captain Quint: “I think we’re gonna need a bigger boat.”
Catechists and church workers in particular are often looked to by fellow parishioners as “in the know” about Church matters of all sorts, from why is Easter so early this year to how did St. Luke know exactly what the Angel Gabriel said to Mary and vice versa. It goes with the territory, and there are many things we should know because they go with our responsibilities. I had a funny (to me, anyway) experience a few weeks ago when I was conducting a seminar for Catholic professionals. I remarked in passing that the previous Sunday’s diocesan Catholic Charities appeal was having difficulties reaching its goal, and someone on the church payroll asked, “Oh, was that last Sunday?”
It is good to have a handle on such things, if for no other reason than pride of professional appearance. The expectation will always be there, along with the strong probability that you will be expected to come up with a good “grace before meals” at any gathering of Christians, family or otherwise. If you launch right into “Bless us, O Lord…” there will be an unspoken but general consensus that, given your church connection, you wimped out, that anybody could have done that. This is Catechetics 101: once you accept the bishop’s mandate to teach the Apostolic Tradition to folks of any age under the Roman Catholic umbrella, you are not anybody anymore—your faith life, your personal life, your professional competence, become an extension of Jesus’ command to preach and teach the good news to the ends of the earth.
This is the precise reason that the faith formation of Catholic school teachers, catechists, lay parish leaders, bible study coordinators is so critical in the extension of the Spirit’s grace, and at this stage of my life I think it is the most important ministry I can engage. However, I am a licensed mental health therapist, too, and yesterday I was listening on my I-phone to On Being a Therapist: Fourth Edition (2010) by Jeffrey Kottler, something of a classic in this profession and a terrific read for church ministers, too. Kottler includes a chapter on continuing education, which he concludes does nothing for practitioners but lines the pockets of the companies who provides such services. Here’s a stat to reflect upon: while one day of continuing education for catechists in my diocese costs $15 or thereabouts, essentially the bare bones delivery cost; the average fee for the same day of mental health training is $190. Big Pharma is not the only winner in the present day health care environment.
Kottler goes on to discuss the attitude that most of us have about “continuing education:” hoops to jump through. An educator himself, he has his own stories about providers who spent a one-day race on-line from course to course and finishing a year’s worth of certification in eight hours. In truth, I relish continuing education in both fields, theology and mental health, but in the profit-driven mental health education market, most offerings currently focus upon trauma and eating disorders and, in my view, are repetitious and not always research-driven or sufficiently established.
The best continuing education courses are those that not only interpret my experience but engage the frontiers of my ignorance. I am eternally grateful to Gregory Lester, Ph.D., for example, a psychologist from Denver whose regular workshops in Orlando opened my experience to personality disorders, particularly as they afflict church clergy, administrators, ministers and volunteers. One personality disordered staff member can hold an entire parish or school emotionally hostage—think of a narcissist, a histrionic, an anti-social personality, etc. Sadly, the strategies most common to our experience of resolution—prayer, reasoning, traditional counseling, accommodation—are the least likely interventions to resolve local stress. (Dr. Lester, incidentally, has served several dioceses in screening seminarians.)
I apply my own definition of professional formation to the more specified cohort of catechists and teachers: interpreting one’s own faith and life experience and engaging the frontiers of the unknown. There is pain and exhilaration in the formative process—a Catholic school teacher, for example, may have to face the very real incongruence of interpreting the Catholic worldview for students when he or she has major angers or doubts about “the Catholic way.” On the other hand, there is exhilaration that comes from the immersion into mysteries and historical experiences that transform how we think of our own worth, not to mention the precious jewel we hand on—and I hasten to add that all Catholic school teachers, not just the “religion teachers.” I address my own teaching to the life of the catechist or teacher; the classroom strategies only make sense when teachers can say “our hearts are burning within us.”
I would not teach a continuing education program that involved jumping through hoops, and I sure wouldn’t pay $200 (or $15, for that matter) to take one. During this week I am experiencing a happy confluence of several things that do not involve hoops: in several hours today I will be engaging six Catholic school teachers on their home turf for the first of three meetings on our diocese’s “Ministry and Catechetics 101,” the opening course in our formative sequence for catechists, teachers, and parish personnel. This is a little diocesan experiment involving working in a seminar-like setting instead of a larger classroom/lecture format, at times more conducive to teachers’ schedules, with opportunities for that graduate school feel of personal engagement. I completed a similar 101 course setting at another school a few weeks ago, and I was amazed and edified at how our group evolved in just three weeks. Granted, I did not get to about 90% of the “official curriculum,” but Common Core in that group focused more upon personal and corporate identity and religious experience, and we broke up with a hunger to continue.
Another happy occurrence was a request I received yesterday from my boss downtown—a very thoughtful man, recently promoted to his directorship--asking my thoughts about our 101 introduction. I plan on giving his request the full attention it deserves, but off the top of my head I would suggest several things.
In my 101 seminar earlier this year, the final point (9) was intense, varied, and highly productive. I did not “rein it in” due to clock considerations. I don’t believe that every vital Church issue has to be raised in every course, so we never “got” to Social Justice, Catechetical Church Documents, and a myriad of other issues. I like to think, though, that the evolving faith hunger of the participants—on their own and through structured learning opportunities—will take them there—with no hoops!