When Mary Bailey of Takoma Park sought help for stress and anxiety, one thing was clear to her: She didn't want to see a psychologist or psychiatrist.

A health care worker, mother and evangelical Christian, Bailey says that "being a Christian guides the choices I make and how I make sense of the world. I didn't think a psychologist or psychiatrist would be sensitive to that."

So Bailey, like increasing numbers of people seeking help with personal problems, called a pastoral counseling center. She was matched with a therapist with an MA in psychology and "enough religious background to know what I was talking about and guide me," Bailey said.

While their discussions were not overtly religious, "we both knew that there's a purpose for the different challenges I was dealing with," Bailey said. "We could say things like, 'Let's leave it to God.' "

The number of counselors who integrate a faith-based world view with academic training and licensure is increasing, said Douglas Ronsheim, executive director of the American Association of Pastoral Counselors (AAPC).

Pastoral counseling is often the choice of high-profile figures who find themselves in trouble. Seeing a pastoral counselor demonstrates that they are dealing with their lapses while avoiding the stigma often attached to treatment by psychologists or psychiatrists. When Bill Clinton, the Rev. Jesse Jackson, former U.S. House Speaker Bob Livingston and Fox TV personality Bill O'Reilly faced scandals prompted by their personal behavior, each sought help from pastoral counselors.

In the past five years, the number of academic programs granting degrees in pastoral counseling has doubled nationally, said Ronsheim, a Presbyterian minister and pastoral counselor with a PhD in marriage and family therapy. Four universities have launched pastoral counseling tracks in the past year. The pastoral counseling program at Loyola College in Maryland has doubled its enrollment since the late 1980s, according to its chair, Joseph Ciarrocchi.

Carl Siegel, executive director of the Pastoral Counseling and Consultation Center of Greater Washington (PC&CC), says its client base is up 10 percent since 2000.

Ronsheim and others say the field's expansion is the result of several converging trends: the psychological fallout from 9/11 and subsequent terrorism alerts; the evangelical movement's increasing influence in America; pastoral counseling's low cost compared with medical-model therapy; and the long-standing tradition of people in crisis turning to religious institutions for help.

The AAPC commissioned a study in 2000 that found that more people seeking counseling for a serious problem said they would prefer to see a religious counselor (29 percent) than a psychiatrist (27), psychologist (17) or family doctor (13).

Members of the therapy mainstream appear to be taking notice: One of the American Psychological Association's bestselling books is "Integrating Spirituality Into Treatment: Resources for Practitioners," published in 1999.

The Oldest Profession

"For most of our country's history, counseling has been done by pastors," said Harold G. Koenig, a professor of psychiatry and behavioral sciences at Duke University Medical Center, noting that a tremendous amount of counseling is still conducted by clergy in one-on-one sessions with congregants. Koenig's research shows that the estimated 350,000 clergy in the United States spend an average of 15 percent of their time on counseling. This adds up to more time spent on counseling than the entire membership of the American Psychological Association working 40 hours per week, he says.

Pastoral counselors who take over some of the clergy's duties are providing a critical service, said Siegel, an Episcopal minister who has a PhD in clinical psychology.

"Pastors are now trained to see a congregant for two or three sessions, then to refer that person to pastoral counseling," he said. "Otherwise they spend 75 percent of their time in individual counseling with a small portion of the congregants, which is not healthy for the congregation as a whole."

Furthermore, although many members of the clergy are trained in crisis counseling, they may lack the skills necessary to deal with more-complex, long-term psychological problems such as reverberations from abuse, according to Siegel.

But for many Americans the choice isn't between seeking help from their pastor or from a pastoral counselor. It's pastoral counseling vs. psychotherapy.

Kristin J. Leslie, an assistant professor of pastoral care and counseling at Yale Divinity School, believes many clients choose pastoral counseling over psychotherapy because "there is a perception that the psychologist would medicalize a spiritual problem."

More to the point, she added, there is a widespread perception that mainstream psychologists and psychiatrists are hostile to religion. Freud famously described religion as an "obsessional neurosis."

Another influential psychologist, Albert Ellis, wrote that "devout, orthodox, or dogmatic religion (or what might be called religiosity) is significantly correlated with emotional disturbance. . . . The . . . devoutly religious person tends to be inflexible, closed, intolerant, and unchanging."

Though Freud's and Ellis's perspectives have limited influence on current therapeutic practice, the perception lingers, according to Koenig. Many Americans also perceive that psychologists and psychiatrists are not themselves religious and therefore may not understand their perspective, Leslie said. A recent survey of U.S. physicians published in the Journal of General Internal Medicine found that psychiatrists are among the most secular physicians, a conclusion consistent with earlier studies.

"When you've got that much hostility in two areas that should complement each other [religion and social science], you need a middle group" to broker peace, Koenig says. "Pastoral counseling does this."

Many mainstream psychologists agree that pastoral counseling can treat a subset of problems. Gerald Koocher, the incoming president of the American Psychological Association (APA) and dean of the Simmons College School of Health Studies in Boston, said "there definitely is a role in society for people of faith to delivery counseling services."

Although the APA has no official policy on pastoral counseling, it does have members who are pastoral counselors, ordained clergy and people of faith who may address religious or spiritual issues in the course of treatment, Koocher said.

"You have to ask what is the nature of the services being provided," he emphasized. "If it's a crisis of religious faith, a traumatic social event or a marriage crisis, a member of the clergy with counseling skills and training may be a wonderful service provider."

But "if someone who is depressed or suicidal tells me that pastoral counseling is the first place they go, I'm going to wince at that," Koocher said. He worries that a pastoral counselor untrained in psychopathology may fail to recognize schizophrenia, dementia or serious depression, he said.

He is also concerned about regulation and oversight of pastoral care providers who are not licensed by the state. "How do you know if there have been complaints about the [counselor], and what are the client's remedies if something goes wrong?"

The Matter of Lucre

Those in search of spiritual truths also have to take into account earthly matters such as cost of treatment.

For Mary Bailey, who at the beginning of her pastoral counseling treatment attended weekly sessions, "cost was an issue. . . . [Long-term therapy] was not a luxury we could afford." Though the pastoral counseling center (like some conventional psychotherapy practices) operated on a sliding scale, charging less than $100 per session in the beginning, she had to stop therapy due to the cost. (Her insurance did not cover the care.)

At PC&CC, which runs pastoral counseling clinics at seven locations in the District, Maryland and Virginia, its 400 clients per month also pay on a sliding fee scale. Siegel, the executive director, says that clients pay anywhere from nothing to $200 per session, with an average fee around $110. Siegel said that insurance providers cover the cost of therapy sessions for about 60 percent of its clients.

Insurers often require a results-oriented treatment program, with outcomes that can be measured and tracked. This alone has brought some uniformity and professionalism to pastoral care it might not have otherwise had.

The question of insurance coverage prompted the Loyola College program to overhaul its curriculum several years ago, offering preparation for licensing to its pastoral care students, Ciarrocchi said.

Successful Outcomes

Debbie Schechter, a former attorney who lives in Chevy Chase, was exposed to pastoral counseling in 1992, when her 5-year-old son Jonathan died of brain cancer. "A pastoral counselor from the hospice counseled my husband and I, and it was very valuable," she said.

Schechter, who is Jewish, decided to give up her 25-year law career to counsel others on bereavement issues. But she was disappointed that "there was no way to talk about religion or spirituality" in her social work program. She enrolled in the pastoral counseling program at Loyola, where she has completed one year of a three-year MA degree.

She may be typical of the next generation of pastoral counselors. Two-thirds of the students in the Loyola pastoral counseling program are laypeople, and most will not be working in church settings, according to Ciarrocchi.

Schechter is considering working in private practice or in a hospice. That was where, when she received pastoral counseling, "a whole new realm opened up," she said.


Alison Buckholtz last wrote for Health about military spouses' deployment dieting

techniques. Comments: health@washpost.com.

When under stress, Mary Bailey of Takoma Park sought help from a pastoral counselor who understood her evangelical Christian beliefs.Douglas Ronsheim, director of the American Association of Pastoral Counselors: The ranks of such counselors are growing.