It ain't broke, so we aren't going to fix it (the CPE certification blues)

In the world of chaplaincy and clinical pastoral education (CPE), the person who trains other folks is called a supervisor. I'm in the process of working towards certification as one such supervisor. It's not like any other process I know.

When one starts training to become a doctor, for example, one knows that one has a long and difficult road ahead. But you _can_ feel pretty confident that if you work really hard and your health holds out that you will be able to finish the process. And you know how much time it will take you to finish. None of that is true of the CPE supervisor process.

Many people (including people I know) are never able to get their final approvals (from the committees we appear before, periodically) despite years of sacrifice and good work with their chaplain students. And the process can take from three to six (or even more) years.

In my view this process is profoundly broken. There is a wonderful report put out last summer by a task group from the Association of Clinical Pastoral Education (ACPE) that clearly spelled out the ways in which the process is broken and made concrete recommendations to fix it. I was so heartened when I first came across this report. The message it sent me is that this organization (the ACPE) was willing to confront its problems and work to fix them. [I first wrote about the report, here.]

So I was deeply shocked at the ACPE's annual conference last week to learn that the powers that be at the ACPE rejected the report at the beginning of the week. One senior CPE supervisor told me that the board did this because they had decided that the process was working. After all, this supervisor said, some 87% of people who appeared at a recent committee meeting were approved by their committees.

That statistic totally misses the point, in my view. The real question is not how many people pass on a particular day, but what the attrition rate from the whole process is -- ie, how many people start the process, but are never able to finish. I don't know what that stat is, but I wouldn't be surprised to hear it is as high as 50%.

And then there are all the people who are discouraged from entering the process at all when they find out how unpredictable it really is. Is it any wonder that there are currently only seven Jewish supervisors who have been fully approved? Is that tiny number alone not a sign of a process that is broken?

Of course the powers that be at the ACPE will maintain that they did listen to the report (and that they have appointed a new committee that will study reforms). One senior CPE supervisor told me that there were three areas the board will want reforms along the lines of what was in the report:

• curriculum
• position papers
• the training relationship

Another senior supervisor told me that what the board really recognized was that there is a great deal of inconsistency in how supervisors are trained in different programs. That needs reform, this supervisor said.

But I say that reforms are not enough. If the leadership does not recognize that the process is broken then no amount of tinkering with it will make any significant difference. The tragedy is that many areas of the country have a shortage of CPE supervisors. If more supervisors are not approved than students wanting to do CPE -- including people training to be pulpit clergy -- will have to be turned away. And that is a tragedy for their future congregants and other people they minster to with pastoral care. CPE is by far the most effective way to train people do pastoral care.

I would love to hear reaction from leaders in the ACPE to what I have said here . They (or anybody else who is concerned about this) can leave comments here by clicking the "comments" link, below.

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I want to add one thing -- I do not think that I personally have been treated unfairly in any way during my own process. And I believe that I personally have the resources and skills to navigate this process despite the fact that it is broken. But I have never been a person to sit silently and let an injustice stand just because it doesn't affect me. I don't know who I would be if I was to be such a person. I certainly wouldn't be me.

Opening up an oral tradition

יום ראשון ט' בשבט תשס"ז

One of the things that shocked me the most when I started to get to know people training to be CPE supervisors was how many of them -- even people who had been training for years! -- had serious concerns about whether they would ever be able to finish the process. In all my encounters with various professional educational processes, I had never seen anything like this. In rabbinical school, for example, there was some attrition. But that was mostly in the early years (of what is typically a five to six year process); by the time people had invested a lot of time, they were almost sure to be able to finish.

The stress and grief that these supervisors-in-training (SITs) I was meeting were experiencing was so high. It's hard for me to imagine what it would be like to invest years of your life in a demanding and consuming processes and have it all come to naught. [A CPE supervisor, by the way, is essentially a person who trains other people to be chaplains or who provides chaplaincy training to seminary students.]

It turns out that the "powers that be" in the CPE have recognized that there is a problem. They issued a report that summarizes the problems and recommends solutions. Basically, the report identifies a great deal of inconsistency in the education of SITs. There is no real standard path or curriculum. But, perhaps worse, there is a great deal of inconsistency between how supervisors are trained and how they are certified. That is, the people who serve on the certification boards that decide whether someone will be approved (certified) to be a supervisor are not the same people who are actually involved in training SITs. So, the SIT hears one thing from the person who is training him or her, and then goes before a committee and is shocked to be told that they have it all wrong and maybe should give up trying to become a supervisor at all.

Here is the way the report puts it (emphasis mine):

. . . there are often differing expectations between those who provide supervisory education and those who certify. We note that the language, concepts and methodologies valued by the volunteers who work in certification is often different from the expectations (and understanding of the standards) of both supervisory educators and candidates. This has unfortunately led to too many painful and conflicted experiences. One systemic result may be that our methods of evaluation of supervisory candidates and associate supervisors tend to focus more on subjective assessments of personal integration than on professional competency. Both are essential, but the feedback from those who have experienced the certification process as students and as educating supervisors suggests we have erred on the side of subjectivity, with an “oral tradition” that is difficult to comprehend.

I was really interested here by the use of the term "oral tradition". This expresses some of how I have felt about the process of entering supervisory education. I felt like I was approaching a very closed world where it was impossible to get information except by meeting an insider who was willing to talk with you. That is -- unlike let's say law or medical school -- I could not just get on the Internet or go to a bookstore and find things to read that would help me understand what was involved. Finding out about rabbinical school, also, I must say was something of an "oral tradition", but there were more people to talk to and more ways of getting at that information.

There was another thing that shocked me when I started to meet SITs -- learning that, for many of them, the obstacle is completing some theory paper. I found this very surprising. Although these theory papers are major projects, the assignment didn't seem to me to be much more demanding than for a term paper in a graduate school class (ie, we're not talking about a PhD dissertation here!!). I would have thought that a person with so much at stake in terms of his or her career would just, at some point, force themselves to sit down and write the thing.

But, it turns out that it is not just the people I met who are having trouble with the theory papers. The problem is endemic according to the report:

. . there is broad acknowledgement of the value of theory paper requirement and there is clear evidence that theory papers required of supervisory candidates are a significant stumbling block for a large percentage of students in supervisory education

Here is the introductory paragraph for the report's recommendations to fix the problems (emphasis, mine):

Recommendations: It is evident from the above analysis that the goals of streamlining the supervisory education process and ensuring attainable and measurable outcomes will only be met with significant structural process improvement efforts. We believe a cultural shift in the supervisory education and certification components of our organization is necessary, toward objective and quantifiable competency assessments and definable measurements of personal and professional integration. We believe that the education and development of our future supervisors needs to be organized around a universal core curriculum, definable best practice standards for supervisors who provide supervisory education, and clear competency standards for candidates. We believe that the ACPE needs to assure consistency, standardization and expertise in its certification processes or move toward professional certification processes used in other parallel professions. And we believe the supervisory education experience itself needs to move toward a collaborative, mentoring model that supports both personal integration and professional competency development. At the same time, we recognize that the subjectivity that is inherent in our education and certification processes is of high value and contributes both richness and depth to our unique organizational culture. Indeed, we find ourselves wanting to protect the subjectivity of our individual educators and certifiers while still promoting consistency in our interactions, assessments and evaluations.

The report has a series of recommendations about the theory paper requirement. They include:

require that all written material, including the two theory papers, be submitted five months prior to the scheduled Certification Commission appearance date; that one month be given to the committee to assess the materials according to a scoring grid (adapted from CAPPE); that the results of the scoring grid be provided to the candidate, including specific recommendations for satisfying the standards; that, if necessary, the candidate be given sixty days for a re-write and re-submission of papers; that the committee again have one month to assess the materials, and that, if the papers do not meet standards upon second submission, the appearance before the Certification Commission be canceled

Probably one of the most important recommendations of the report was that the "associate" level of CPE be eliminated.


I also, by the way liked the way the report phrased some of the problem that chaplains and CPE face today:

We are also aware of two significant challenges to the future of our organization. The first significant challenge is the changing landscape of American religion and its evolving role in culture and society. We note that religious expression has become more diverse and that health care institutions, in particular, have given rise to new – and some would say competing - forms of spiritual care, leading to experiences of marginalization and decline in authority.

The intersection of religion and psychology

יום ראשון י"ז בטבת תשס"ז

I’ve been reading Jack H Bloom’s The Rabbi as a Symbolic Exemplar (one of the most influential books in recent decades on the training of rabbis in professional skills), and have been wrestling with how much I both agree and disagree with much of what he says.

One of the main aspects of Bloom’s work (not surprisingly as he is both a rabbi and a psychotherapist) is his view that religion and psychology are complimentary to one another (see, Neil Gillman’s foreword, pg. x).

I, on the other hand, have long viewed them as being almost complete opposites -- ones that are often in conflict with one another. But this view has been deeply challenged ever since I started to get serious about chaplaincy and, especially Clinical Pastoral Education (CPE), which is, at its core, profoundly committed to the complimentary use of the insights that both religion and psychology give us.

So, here is my current attempt to resolve/understand the conflict – it all centers on a fundamental cornerstone of my theology: on the Bible’s declaration that mankind was created in the image of God (בצלם אלוהים/btzelem elohim).

I can only begin to explain the very profound and complex meaning בצלם has for me. But, one part of it is the belief that every human is unique and is inherently beautiful in that uniqueness.

So, I think I now see psychology as doing two things that are in tension with one another -- 1) doing violence to בצלם, and 2) aiding in our understanding of it:

• Violence – that is, when psychology takes us away from understanding the individual as unique (and thus beautiful). Psychology does this by its very nature because it routinely has us categorizing and labeling people.
• One very common case of this that I have seen many times is when a psychotherapist diagnoses a person as a borderline. Usually, that is the end of the psychotherapist having any desire to further work with the person – the diagnosis essentially means the person is untreatable. . . . As a chaplain – someone motivated out of a religious tradition (with בצלם deeply within it) -- I am not so quick to give up on people in this way.
• Aiding – that is, aiding in our understanding of the uniqueness and beauty of each individual. Or put another way, psychology is useful to me when it (as does religion for me) fits in with the search for truth. . . . that is, the truth of what life, humanity and existence are all about. . . . The tools and theories of psychology help open my eyes to things about the (holy!) individual before me that I could not have seen without it.

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The magic of parallel process (and the clinical rhombus)

יום ראשון כ"ו בכסלו תשס"ז

For those of us who have gotten involved in teaching people to perform pastoral care, one of the most amazing things we first learn about is parallel process. In its simplest form, this is when a student chaplain is describing a patient visit and you realize all of a sudden that the student is acting just like the patient acted with the student!! Sometimes, the student will (completely unaware, mind you) be speaking in almost exactly the same way – in the same language -- as the patient spoke with the student.

This parallel process is extremely helpful in supervising students. First, it gives the supervisor great insight into what are the important personal and pastoral issues that the student is now working through for his or herself (you just have to look at what the student is saying about the patient’s issues to learn about the student’s issues). Second, it gives you great insight into what is happening with the patient (just observe the way the student is acting to learn about the patient).

When I first heard about parallel process, I didn’t believe it – why would it happen, I asked myself? But then, once I started looking for it, I saw it all over the place. So, I started to believe that parallel process existed, but I still had no understanding at all about why it existed. That is, it became just a sort of wonderful magic to me.

On Thursday, I went to a presentation that helped me start to better understand parallel process. The presentation was on an article about the clinical rhombus (The clinical rhombus revisited: learning through resistance and change). The clinical rhombus (see diagram below) was articulated by Ekstein and Wallerstein in their (see their 1972 book, The Teaching and Learning of Psychotherapy).

The rhombus helps illustrate the dynamics of various three-party relationships in the supervisory process, especially the dynamic between the supervisor, the student/chaplain and the patient. What it graphically illustrates is that the student sits in the middle of this interaction, and that it is the student who is the party in common that allows parallel process to happen.

In his book, The Supervision of Pastoral Care, David Steere, gives an excellent explanation of how parallel process can happen:

[S]upervisees unconsciously identify with their patients and involuntarily behave in such a manner as to elicit in the supervisor the same emotions the supervisees experienced while working with their patients. (Steere, 46-7)

I bolded the word ‘identify’ above to illustrate the theoretical understanding behind how this works. Identification – along with the related, projection -- is a psychological concept that emerges out of a Freud’s work. It is identification and projection the make parallel process work.

Steere says that the parallel process may even be a way the student unconsciously seeks help from the supervisor with things that he or she cannot consciously articulate:

[Parallel process is the student’s] unconscious attempts to show the kind of behavior the patient is exhibiting with which the [student/chaplain] needs the most assistance. What cannot be conveyed
verbally the [student] acts out with the supervisor, assuming the client’s tone, manner, and behavior while reporting the case. (Steere, 47)

Put another way, the student is so overwhelmed by the difficulties he or she had in trying to care for the patient, that the student can’t put these issues into words (especially the parts that had to do with non-verbal behavior). So, the student (again, unconsciously, mind you) sets up a kind of role play with the supervisor: the student takes the patient’s role, while the supervisor is forced to take the chaplain’s role (which the student found so difficult and overwhelming in the actual interaction with the patient).

It was also helpful to me to realize, in rereading Steere, that Ekstein and Wallerstein had borrowed some of their terminology from social work. This was especially helpful to me in building my understanding of how and why learning to accept pastoral care is one of the most important elements of learning how to give pastoral care:

Since supervision in social casework teaches a helping process, it must become a helping process itself, so workers can experience what they are learning to use with their clients. . . . An intimate relationship exists between one’s ability to be helped and one’s capacity to become a helper. As students overcome their own difficulties in receiving help through supervision, they are able to give help to their clients. What social workers described as problems in helping and being helped, Ekstein and Wallerstein discussed as learning problems and problems about learning. (Steere 49; some emphasis mine)

If you look at the diagram above, you will see Ekstein and Wallerstein’s terms learning problems and problems about learning. I’ve always (and still!) find these terms clumsy and non-intuitive (which makes it hard to remember what they mean!). I’ve put the original social work terms in parenthesis; I think they’re much more intuitive and that there’s nothing about them (other than tradition!) that makes them inappropriate for use in pastoral care.

The clinical rhombus helps illustrate how the problems in being helped come up in the relationship between the supervisor and the student, whereas the problems in helping come up between the patient and the student. The parallel process is when the student acts out those problems in helping with the supervisor. In effect, this turns the problems in helping also into a problem in being helped. And, thus, if the supervisor can aid the student in addressing the problems in being helped then the problem in helping is addressed, too!! This is the magic of why learning to accept pastoral care helps one learn to give pastoral care.

The Discipline for Pastoral Care Giving

יום שני כ" בכסלו תשס" ז

The immediately below post was my handout for a presentation I gave, today, about The Discipline for Pastoral Care Giving (apologies for the poor formatting in the transfer to the blog). The "Discipline", as its creators like to refer to it, is a very sophisticated system for assessing patients (that is, doing a spiritual assessment) and then using that assessment for creating plans for how the chaplain will best care for the patient. The system is based on defining "outcomes" that can then be measured. Since they can be measured, the chaplain can better explain to others (and to patients) about what it is exactly that a patient does and how that work might benefit patients.

I got interested in learning about the Discipline because of an article I read about the Navy's adopting of the Discipline for its chaplains (the article was in a publication from the Association of Professional Chaplains ). One one hand, the article said that Navy wanted to start "thinking with a business mind about developing standards of practice."

I get very concerned whenever I hear people talking about chaplaincy (or any form of spiritual work) as a "business". In essence, I think this marginalizes what we're all about -- because a key part of almost all spiritual work is, in particular, to espouse and advocate for values that are non-material. That is, we (chaplains and clergy) by definition stand for the idea that there are Ultimate values far beyond the mundane and material concerns of everyday life (and business!). If we abandon that stance, I think we lose the very essence of who we are and why we are working in a setting like a hospital at all. We need to remind people -- and ourselves!!! -- that Holiness is a key part of what we do.

On the other hand, I am very attracted to many elements of the Discipline. It promises better coordination and communication with the rest of the medical care team (doctors, nurses, etc). As its creators like to say, it "demystifies" what it is that chaplains do. It allows the creations of documents authored by chaplains that other members of the team can easily understand.

In our discussion, today, we focused for a bit on the use of spiritual language that does not explicitly reference God. This is part of a trend in spiritual care -- to use what are, in effect, code words for God -- phrases like "spiritual values" and "ultimate hopes".

We use these _secularized_ phrases for at least two reasons:

• To be more inclusive -- that is, not to offend people who do not believe in God, or who use different religious language than we might have in our own tradition.
• To have our writings sound more like something anybody on the care team could write (that is, to make us more like the rest of the medical care team).

One person reflected that this all leaves us (that is, chaplains as a whole), two ways to go in the future:

• Secularization, or
• Marginalization (that is, other members of the care team -- doctors, nurses, social workers, psychotherapists -- do most of the spiritual care work, and a chaplain only gets called in for explicitly religious activity, like prayer).

I, of course, hope that marginalization is not where we are heading. I believe passionately that it is (trained!) chaplains who are by far best equipped to provide spiritual care, especially around death and crisis. This is for many reasons, but one of the biggest that comes to mind for me is that we base what we do upon the "wisdom of an ancient tradition." . . . . Or at least that is what I do. I believe that my authority -- to have the nerve, so to speak, to think I can care for people spiritually -- rests upon my having steeped myself in my ancient tradition. . . . In effect, that steeping in the tradition has been an encounter with God for me. It's shaped me profoundly. It informs the compassion and empathy I can feel for people. Without it, all my training in counseling and spiritual care techniques is for nought. It counts for nothing unless I bring with me my deeply held belief that every human reflects a piece of the divine. . . . That the Holy is found in the encounter between people.

In response to this, my supervisor imagined the cycle of "The Discipline" as a little circle floating on the ocean of wisdom we take from our ancient traditions -- that is, "The Discipline" is just the "surface" part of what we as chaplains can communicate with people outside our profession about what we do and what we are all about.

I look forward to imagining ways that frameworks like the Discipline can be applied in chaplaincy settings to improve what we do and make it more understandable to patients and staff. . . It's exciting work!!!!!!!!!!!!

The Discipline (my handout)

The “Discipline of Pastoral Care” Cycle

Needs, Hopes, Resources – emphasizes that the patient is not just a need (or problem); the patient also has hopes and resources. Examples: Feelings, vocation, family, purpose, faith, community, world view, religious history, journey, ultimate values, dreams. Profile Concept of Holy Meaning (illness?) Hope Community Contributing outcomes Shared (with the patient) Sensory-based –(eg maintained more eye contact, as opposed to patient was less withdrawn/sad) Communicable – one sentence rule of thumb How to know you’re done for now

Plan Clear Communicable Responsibilities distinguished – who does what? the chaplain? the patient? another team member? Mutual (consent?) Integrated (with the medical care team) Interventions – can range from questions to confrontation to prayer to silent hand holding to reading scripture to personal sharing and and everything in between. (p. 24) Resources Presence Relational Intentional Non-judgmental Faithful Applying the discipline does not explicitly change [these behaviors], but it does raise our consciousness and intentionality. . . it blunts tendencies to “do what we always do” and keeps us focused. (p. 25)

Measurement Sensory-based (as it was with outcomes) Indicies Communicable Reflected Spiritual care providers are so accustomed to picking up on what’s going on right now and imagining what’s next [that we overlook] the distance we have come. . . This “overlooking leads to a lot of unnecessary anxiety [and] extra work. (p. 25) If the chaplain is not organized enough [and] does not have the courage . . . to look back on goals set [then targeted interventions can’t be made]. (p. 27) [W]e need to realize that even as we go about assessing, we are effectively giving pastoral care. (p. 27)

No one dies alone

יום שני ו' בכסלו תשס"ז

It's a tremendous program started at a hospital in Oregon to provide volunteers to sit with dying patients who have no family. And now we're bringing it to our hospital! Tomorrow night I will be one of the teachers in our very first training session for volunteers in our own No One Dies Alone program.

I am so happy to be a part of making this happen. It's such an important program . . . . and my participation really fits in with my vision of how chaplains need to operate in today's hospitals. The fact of the matter is that very few facilities have the financial resources to afford to fund a large department of trained chaplains to work with every patient.

The effective professional chaplain, therefore, needs to function largely as a catalyst to help others to provide spiritual care to patients. That means that the roles for the chaplain need to be: chaplain as educator and chaplain as leader and coordinator. In my work with No One Dies Alone, I am functioning in those kinds of roles and thus acting as a catalyst to provide compassionate and spiritual care for patients who don't have their own resources.

Here is a short excerpt from what the Oregon hospital's web site has to say about No One Dies Alone:

No one is born alone, and in the best of circumstances, no one dies alone. Yet from time to time terminally ill patients come to Sacred Heart Medical Center who have neither family nor close friends to be with them as they near the end of life.

No One Dies Alone is a volunteer program at Sacred Heart that provides the reassuring presence of a volunteer companion to dying patients who would otherwise be alone. With the support of the nursing staff, companions are thus able to help provide patients with that most valuable of human gifts: a dignified death.

A business?

יום ראשון ה' בכסלו תשס"ז

The lastest issue of "Healing Spirit", a chaplaincy advocacy kind of publication from the Association of Professional Chaplains, includes an article on a program that the US Navy went through to upgrade its chaplaincy services. The article says that a Navy steering council decided

two things -- to establish the best practice for chaplain/patient interaction, charting, and working with providers; and to start thinking with a business mind about the development of standards of practice. [Emph. mine]

Now, I'm a big believer in having really solid policies and procedures (if nothing else, it helps us appear professional in the eyes of the rest of the medical care team and we need that if we're going to be trusted by the team to be full partners in patient care). But, I seriously wonder if we're ultimately undermining ourselves by talking about functioning like a "business".

Isn't one of the things that we're supposed to be (as chaplains) is a living, walking, breathing alternative to viewing _everything_ about patient care as being about a business (and numbers and charts and graphs and everything that goes along with that)? Isn't part of our job to be someone who insists that patients are human beings and not just diagonses and revenue sources. Aren't we supposed to be a walking embodiment of the fact that there are values that we (that is, every human being) holds _higher_ than just numbers and business? Isn't that what we mean when we talk about ourselves as being advocates of "holisitic" care?

Anyway, the plan that the Navy decided to use is the Discipline for Pastoral Care Giving, which is something I've heard of before that was developed by Larry VanderCreek and others. It's some kind of comprehensive spiritual assessment and communication too. I think it's something that the time may have come for me to learn more about.

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