01. Introduction
The economics of providing mental health services is becoming increasingly costly and uncertain. The uncertainty is due primarily to the “current political-social-economic tenor of self-reliance that is taking hold in the country,” and is evidenced by large funding cutbacks, especially in mental health. Armstrong, in one of the lately lead articles of the October 1981, issue of the APA Monitor calls upon psychologists to be cognizant of the particularly vulnerable position of community mental health centers due to their susceptibility to budget cutbacks. Unfortunately, these present economic woes only compound the serious shortages of manpower resources faced by community mental health centers (Zax, 1980). Clearly, alternative resources will be necessary to meet the economic and manpower shortages experienced in the mental health field.
It is the thesis of this paper that the church, with “its proximity in the community, its self-supporting financial arrangement, its consistency in providing a stable social environment” (Uomoto, 1982), and its relatively untapped human and physical resources is in an opportune position to awake from its posture as a “sleeping giant “ (Clinebell, 1970) and avail itself as a mental health resource.The present writers are indebted beyond the above cities to a paper presented by Jau Uomoto at the meeting of the Christian Association for Psychological Studies, Atlanta, April 1982.
02. The Present Need
In 1961 the National Institute of Mental Health in cooperation with thirty-six different participating national and social welfare agencies appointed the Joint Commission on Mental Illness and Health (Rappaport, 1977). It was the comprehensive report of this group that has directed and informed United States mental health policy. Rappaport (1977) has listed the findings of their final report in terms of specific recommendations which address broad need areas. These need areas, delineated by the Joint Commission, are summarized as follows: (1) A national mental health program requires solution to the three most basic needs: “manpower, facilities, and cost.” (2) A national mental health program requires the establishment of research and training facilities, “especially in rural areas where such institutions are sparse.” (3) The use of and training for nonprofessionals (i.e. volunteers, clergymen, physicians, educators, etc.) is a vital alternative for meeting manpower needs. (4) Treatment and preventative services should be made available in the local community (“Specifically, the report set the objective of one mental health clinic for every 50,000 people . . .”). (5) There is a need for public education with regard to mental illness and subsequent acceptance of those suffering from mental illness into an informed and caring community. (6) The final need area addressed by the Joint Commission was that of “financing the delivery of mental health services.” The federal government was given and assumed the lion’s share of this major responsibility.
In an attempt to critique the results of the Joint Commission report and answer the question , “where does community mental health now stand?” Rappaport (1977) draws upon the efforts of many others (partially listed below) and offers the cogent evaluation—“There is no evidence that the mental health of America has improved.” The present author(s) suggest that this is due to the fact that, by-and-large, the “needs” outlined by the Joint Commission remain unmet. Partial documentation for this statement follows. (1) Two-thirds of the nation’s catchment areas expected to develop mental health centers have not done so (Windle, Bass and Tauber, 1974). (2) Sarason (1972) has argued that mental health centers (the buildings) when built may serve only as “distractions” or “alien bodies” in the community. “They generally perpetuate the problem of limited resources . . . and they often cost more than the services provided in them.” (3) Windle, Bass and Taube (1974) further charge that the mental health centers are not responsive to the changing needs of the surrounding populations (i.e. not consumer oriented); and they state that (4) there is a need for an augmentation to the services the centers are able to offer. (5) A need remains for community education concerning mental illness and the role of community mental health centers. Windle, Bass and Taube (1974) found that when adults living in selected areas where there is a center were interviewed and presented stories about people with problems and asked where they should go, only three percent chose mental health center. (6) Most centers lack sufficient arrangements for the provision of continuity of care (Rappaport, 1977). (7) As stated in the introduction, the discrepancy between the supply of manpower resources and the demand for these resources is a continuing trend (Zax, 1980).
As a means of summary, it appears that in 1982, as in 1961, an effective national mental health program requires the solution of three major problems: “manpower,” “facilities,” and “cost.” Other, more specific problem areas concern the need for: the provision of additional services; education and social change within the community; a more consumer/community-oriented focus for the provision of services; and research and training opportunities for future providers of mental health services.
03. Church-Based Centers: A Critique
There is scant information in the published literature to date regarding church-based counseling services. Unpublished doctoral dissertations represent the most helpful attempts to systematize knowledge in this area, beginning with Hathorne in 1960 and most recently including Sandbek (1979) and Pickens (1981). This section is based almost entirely on Sandbek’s work, which included a survey of thirty-nine church-affiliated centers across the nation and an in-depth study, including personal visits, of eight centers.
The church counseling center is a fairly recent phenomenon. Seventy-one percent of the centers reviewed by Sandbek were no more than ten years old. He also reported a forty-three percent increase in denominationally sponsored centers over the twenty years prior to his study. Yet, both Sandbek and Pickens agree that the phenomenon of church-based counseling services is established to the extent that we can begin to gain from past experience. The purpose of this section is to briefly highlight general strengths and weaknesses of presently extant centers as a shorthand way of presenting information culled from the research of Sandbek, and to a much lesser degree, Pickens. It is hoped that past experience, represented in those strengths and weaknesses, will suggest directions for future development of church-based services.
The most salient strengths arising from the church-based counseling model are six in number, including two that have not been explicitly addressed, but are intuitively direct applications of existing centers. The most obvious advantage of church centers is that they add to the existing volume of counseling services available. King, as cited by Sandbek, reported nine of ten ministers admitting their parishioners had problems beyond their time or ability to effectively deal with them. This, in combination with the fact sixty percent of these centers start because of a response to a felt need in the community or congregation illustrates that church-based services help to fill a gap not adequately served by the available volume of traditional mental health services.
The second advantage of church-based centers is that they generally provide services at a lower cost compared to the norm for the professional community. Three of the centers for which Sandbek had more specific information reported not turning people away for lack of ability to pay; two reported sliding scales with scholarships available for those on the low end of the scale; and one noted fees approximately $5 to $10 below the community norm.
Thirdly, because the church interfaces peoples’ lives over a broader range of areas than any other social institution, it has tremendous potential for instigating social change. The centers reviewed by Sandbek were, in fact, engaged in areas beyond counseling, including teaching, consultation, workshops, community projects, research and lay counselor training. Thirty of the thirty-nine centers reviewed reported this type of information, averaging twenty-eight hours per month per center on additional activities beyond counseling.
The fourth strength associated with church-based counseling centers is that they are able to provide services which take value structures, especially spiritual value structures, seriously. Sixty-six percent of the counselors working at centers surveyed by Sandbek had received formal theological training, with eighty-eight percent of these being at the graduate level. When this is considered along with the fact that eighty-four percent of the centers use clergy as referral sources, it is evident that these centers have a great potential, which is being realized to some degree, for the integration of psychology and Christianity on a practical level.
The final two strengths to be mentioned were not explicitly addressed by either Sandbek or Pickens but are intuitively direct results of church-based centers as they now exist. First, these centers are more community control oriented than most traditional counseling efforts. The church represents a ready-made system for community-controlled programs. As mentioned earlier, sixty percent of the centers reviewed by Sandbek arose out of pulse-taking efforts regarding existing need in the community. It is this type of responsiveness to need, in combination with the church networks and committees which provide ongoing monitoring of how the need is being met, which places churches more in line with the concept of community control.
Finally, the involvement of churches in counseling and human service programs is advantageous from an ecological perspective. Many church facilities lie dormant for much of the week when they could be used effectively to meet more of the needs of the community. One study which was reviewed outlined the establishment of church-based clinics which replaced idle church buildings with medical and psychological services to make better use of these facilities on a seven day a week basis while providing low-cost care.
Moving to weaknesses associated with current models of church-based counseling centers, these fall under four main headings, including fee structure, social change, program evaluation and research, and the need for a wider base of services. Beginning with current fee structures, although the fees offered by church centers are generally lower than for similar services provided by the secular community, there is room for improvement. Those centers offering to subsidize clients who cannot afford treatment have to absorb expenses which are frequently crippling. Over one third of the churches studied by Sandbek listed financial problems as a consistent obstacle to achieving their goals, and all six of the centers admitted financial struggles were a concern. The problem is one of being able to provide low-cost services while maintaining salaries high enough to support competent counselors.
Secondly, with regard to social change, churches are involved in additional activities beyond counseling, as discussed previously, yet there needs to be much more of this. Sandbek notes that, on the average, church centers spend only about one quarter of their time in areas such as education, consultation and lay training. From an ecological perspective, this represents a failure to capitalize sufficiently on a tremendous potential advantage which is unique to churches.
Another weakness is that many church centers are not conducting program evaluation or general research. Bandbek quotes Hathorne as saying that “research programs which analyze and evaluate the clinical experiences of the centers are the best means of improvement and advance.” Yet, based on the information provided by Sandbek and Pickens, it does not appear that this area is being addressed sufficiently. Besides “lay counselor training, centers reviewed by Sandbek reported “research” as the lowest category in terms of hours committed per month.
The fourth weakness is an evident need for church-based centers to provide a wider range of psychotherapeutic services. Fifty-one percent of centers in Sandbek’s study are still heavily influenced by psychoanalytic methods. This mode of psychotherapy is not as helpful for less verbal, less insight-oriented clients which are frequently being served by these centers. To be successful providers of psychotherapy, church centers will need to be more innovative in the future, depending less on traditional methods and more on methods which are consistent with the needs of their clientele. There is also a need for better methods of assessment. Only fifteen percent of church centers listed by Sandbek were making use of psychological tests, which are often a quicker, more cost-efficient way to obtain behavioral samples necessary for an accurate assessment of the client’s situation. Finally, the training of counselors is an issue. While it may be placing a great burden on these centers to require formal training in both psychology and theology, it certainly is, nevertheless, desirable. Some centers reviewed did not require their counselors to have any formal theological training, which certainly undermines the centers’ unique ability to address spiritual issues. Other centers suffer because of the lack of availability of a licensed professional, such as a psychologist, to act as supervisor or consultant.
04. Present Model
To this point, this paper has reviewed the findings of the Joint Commission Report on Mental Illness and Health in terms of specific recommendations which address broad mental health need areas. It has been posited and documented that, for the most part, the “needs” outlined by the Joint Commission remain unmet. Presently existing mental health service delivery shortcomings center around the need for: (1) additional manpower and facilities (logistical considerations); (2) lower cost services; (3) an increased volume of services; (4) education and social change within the community; (5) a consumer-oriented focus; and (6) research and training opportunities for service providers. Finally, specific contributions of existing church-based counseling centers have been critiqued in terms of their unique contributions to the need areas outlined by the Joint Commission’s Report. The remainder of this paper focuses on a brief description of what will be referred to (tongue-in-cheek) as the “Fuller Model.” This model is viewed as possessing definite potential for application within the community mental health arena because it: (1) improves upon many of the areas of weakness existing in “more traditional” church-based counseling models; (2) addresses directly the “need” areas outlined by the Joint Commission Report; and (3) proposes a cost-effective methodology for interfacing clinical training and service delivery needs. Stated more allegorically, it is a specific plan of action that involves awaking the “sleeping giant” (i.e. Churches and Temples—Clinebell, 1970) and teaching it how to employ the “sleeping computer” (i.e. the machinery of psychology—Maloney, 1973) for its own and the community’s benefit.
This model will be described within the following pages in terms of how it addresses the major need areas outlined by the Joint commission.
05. Logistics (Facilities and Manpower)
The human and physical resources of the church in America are staggering. To the problem of an inadequate number of community mental health centers, the churches of American could offer 352,000 “seldom used” physical plants. To the problem of manpower shortages, the churches offer a pool of 160,000 clergymen (often with training or a willingness to be trained in human development skills), and over 132 million parishioners (Clement, 1978). These figures are best dramatized when it is realized that the church-to-mental-health-center ratio is over 200 to 1. Perhaps most importantly, the church as a social institution cuts across socio-economic strata—every vocational, education, ethnic, racial, and political group finds representation in our churches (Clement, 1978). The pastor’s potential contribution to mental health service delivery appears immeasurable. This is only partially evidenced in the fact that the pastor is the most frequently used contact person for all troubled individuals seeking help in times of trouble (Clinebell, 1970).
The Fuller Model, as other church-based approaches, attempts to utilize the physical and manpower resources of the church (i.e. the use of the physical plant for office space and program delivery; the involvement of the pastoral staff and parishioners in program delivery). It goes somewhat beyond existing approaches in its recognition of the reluctance of many pastors and parishioners to become involved in mental health programs, as a viable church ministry, and its consequent employment (projected) of attitude change/mental health education workshops to facilitate this involvement.
06. Low Cost
The cost of service delivery—for the delivering agency and for the receiving agent—is one of the main stumbling blocks to effective community mental health programs. It is in light of this fact that both Bledstein (1976) and Haskell (1977) invite professionals to reexamine the issue of how best to serve people. They believe that this service should include greater efforts to give the profession away in ways that do not diminish that integrity. Park (1974) reiterates this point. He states that, “Technical capabilities and strategies need to be developed to give the social sciences away.”
The Fuller Model was designed to provide mental health services within a church setting that requires: (1) minimal investment on the part of the church (approximately $60 per week) and (2) minimal cost to the service recipients (22 to 48 percent of what is available through traditional counseling clinics which also provide a sliding fee schedule). In addition to these factors, the model provides for the “giving away” of services through various educational and training experiences. Very briefly, the “low cost” qualities of the model are preserved because of the following features: (1) The training and utilization of nonprofessionals; (2) the employment of a Training/Research “transmission” Paradigm (please see Training/Research section for details) which maximizes the time involvement from experienced psychologists; and (3) the returning of a large share of the fees charged to the maintenance of the program.
07. Training/Research
Clearly, the mainstay of the Fuller Model is the Training/Research (“transmission”) Pyramid (see Appendix B), which is an adaptation of Seidman and Rappaport’s (1974) “educational pyramid.” This system uses experienced psychologists, graduate students, and church member nonprofessionals in a cooperative support system. In this system a licensed psychologist trains and supervises several graduate students, who provide services within local churches. In addition to the provision of counseling services, the conducting of church and community wide needs assessment surveys, and the leading of skills training workshops, these graduate students supervise yet large numbers of nonprofessionals within the church who serve as therapeutic agents for various target populations within the church and surrounding community. Not only does this model provide a seemingly efficient use of person-power resources (i.e. maximizing the impact of a “professional’s” time), but it is also felt that this model, especially when the “professional” is affiliated with an educational institution, will provide excellent, unique training and research opportunities for the graduate students involved. And, perhaps, most importantly, at least according to the maxim that perhaps, most importantly, at least according to the maxim that “the best predictor of future behavior or past behavior,” more future “professionals” interested in church-based delivery systems may well be a by-product of the “pyramid.”
08. Consumer Orientation/Community Control
Rappaport (1977) has criticized the establishment of mental health centers under the control of mental health professionals, pointing out that frequently these service systems have limited potential to meet the diverse needs of a given community. “As long as such centers are placed under the control of a given profession, rather than a community, they will serve more to advance the well-being of that profession than of the community” (p. 298).
The Fuller Model of church-based service is built upon and dedicated to a consumer-oriented or community-controlled approach, whereby the people of the community determine the content of services to be offered. The goal is to provide “access to environmental resources for enhancement of existing community strengths” (Rappaport, p. 296) rather than to impose services.
The process of involvement in the present example reflects the community-controlled approach. It has moved through two phases thus far. The first phase involved consultation with the pastor and the church governing board through a series of meetings designed to generate a rough estimate of the nature of the church’s psychological needs.” Based on these interviews, the second phase was begun with the construction of a needs assessment instrument designed to tap the church’s psychological needs by survey of its members.
The needs assessment instrument has two purposes: (1) to determine specific need areas within the congregation and (2) to solicit preferences with regard to possible formats (lecture, workshop, family counseling etc.) through which people would like to have these needs met. It consists of fifty-seven items tapping six broad areas, including time management and interpersonal relations, for example. For each item person list a rating on a scale of one to ten reflecting the personal significance of that need area, and for items rated above six, they are asked to indicate suggestions for a format to meet that need.
Thus far, the instrument has been administered to the congregation, the results have been analyzed by computer and summary has been presented to the congregation (see appendix). Future plans are to (1) administer the survey to community members who make use of the church’s day care program, most of whom are often not church members; (2) construct a format that can be computer scored; (3) begin to address the issue of constructing a survey which would tap community (or congregation) strengths and the availability of existing resources as well as needs.
09. Social Change
As stated earlier, the church has tremendous potential for effecting positive change in the community because it can involve people in diverse ways which touch various areas of their lives. From its inception, this model has attempted to maximize this potential. Because counseling services meet the needs of only some embers in the community, possibilities for lectures, workshops, classes, sermon topics, weekend retreats, consultation, and community projects have been considered from the start and will form an integral part of the Fuller Model as it is applied. In this way it is believed that resources can best be mobilized to effect optimal “person-environment fit” (Rappaport, 1977) between the community and its members representing and promoting positive social change.
As noted by Sandbek (1979) the most difficult step for churches to make toward becoming active in meeting the general psychological needs of its members is often the first one. Outside of finances, the biggest concern churches have is how to win the support of the laity for church involvement in service delivery (p. 103). The particular congregation in view here was unusually receptive to the idea of church-based services, making the selling task much less a factor than might often be expected. Because the future application of the church-based model depends heavily upon mobilization of laity support and the building of understanding, an important part of this model will involve the development of effective means of communication regarding the potential for the church in the realm of psychological service. One proposal presently being considered is the construction of “attitude-change workshops” that would provide areas for discussion of these issues and hopefully lead to congregational support of church-based psychological services.
10. Volume of Services
This particular model of church-based services goes beyond simply adding to the number of hours of service available to the community. “Volume of services” pertains to the range of available services as well as to the sheer number of hours represented. In this case, not only does the service relieve the pastor and staff of the church of unreasonable caseloads and long waiting lists; it also taps the resources of the Fuller Seminary community. A network is established which explicitly embraces the faculty of the Graduate School of Psychology, which is made up of licensed clinical psychologists, and includes the potential for tapping the School of Theology and the school of World Missions. One of the problems for church-based centers mentioned earlier is that they do not have adequate professional services, such as those provided by a license psychologist (Sandbek, p. 117); they offer a limited range of mode of psychotherapy (Sandbek, p. 92); psychological testing is seldom used (Sandbek, p. 95); traditional services are too strongly emphasized; and many counselors lack theological training. With the relationship to Fuller, this model provides an excellent resource of meeting those needs more effectively and represents an example of maximizing available resources in this particular community.
11. Religious Values/Practical Integration
Psychology is becoming increasingly aware of the importance of taking values, especially religious values into account in its study and treatment of the human person. “Religion is at the fringe of clinical psychology when it should be at the center. Value questions pervade this field, but discussion of these is dominated by viewpoints that are alien to the religious subcultures of most of the people whose behavior we try to explain and influence” (Bergin, 1980, p. 103). The present model is dedicated to taking values seriously, especially including Christian values in this particular case.
Both the church and the Fuller community benefit from this model, which preserves Christian values. First, the church community is afforded an extension of currently limited opportunities for psychotherapy which safeguards and utilizes their faith. Second, as the church becomes involved it is enlarging its present ministry to its members and the community at large. Many church centers (about one quarter) are established primarily to are established primarily to church enlarge the ministry of the church (Sandbek, p. 80). Third, not only does the church gain an opportunity to be involved in the integration of psychology and Christianity, but members of the Fuller community benefit similarly as well. The Fuller Graduate School of Psychology was designed “so that by reading, listening to and understanding the expressions of both theology and psychology, a fresh wisdom would shift into consciousness” (Fuller Catalog, 1982–83, p. 113). It is committed to the idea that psychology is incomplete without theology and that theology based psychological centers, students are afforded a unique opportunity to be involved in the integration of psychology and theology in practice.
There are also benefits of this model which extend to psychology and the Christian Church on a more general level. The conceptual foundation for this project represents a marriage between the ecological perspective of community psychology and the principle of the community of believers of the Christian Church. Each of these perspectives has its unique, yet not always unrelated history, but they are explicitly being brough together in this model. It is firmly held that both psychology and the Christian Church stand to reap many benefits from this relationship.
Fuller Theological Seminary Graduate School of Psychology