Clinical Pastoral Education Human Relations 609 Rabbi Julie S. Schwartz Hebrew Union College - Jewish Institute of Religion & Jewish Hospital of Cincinnati School Year, 1998-99 Welcome to Clinical Pastoral Education! You have chosen a unique program of Clinical Pastoral Education and it is the intent of this syllabus to describe your setting, delineate your professional and academic responsibilities, and to prepare you for your role as a hospital chaplain. The Foundations of Clinical Pastoral Education Clinical Pastoral Education (CPE) was conceived by Richard C. Cabot as a method of learning pastoral practice in a clinical setting under super- vision. The concept was enlarged by Anton T. Boisen to include a case study method of theological inquiry - a study of "living human documents." As clinical education developed, other leaders opened the doors to the integra- tion into pastoral practice of knowledge from medicine, psychology, and other behavioral sciences. It was not until after some forty years of experience, development and practice of clinical pastoral education by several organized but un- coordinated groups that the Association for Clinical Pastoral Education ACPE) was formed in 1967 by the merger of several of these groups (i.e.; The Institute of Pastoral Care, Inc.; The Council for Clinical Training, Inc.; the Association of Clinical Pastoral Educators; and the functions of certification and accreditation of the Lutheran Council in the U.S.A.). The ACPE has thus become the standard-setting, accrediting, certifying, resource agency in the field of clinical pastoral education. It accredits institutions, agencies, and parishes as clinical pastoral education centers to offer programs of CPE and certifies supervisors to conduct these programs. These ACPE-accredited centers and clusters offer clinical pastoral education (1) as a part of theological education; (2) as continuing education for the ministry; (3) as training for institutional chaplaincy; (4) as training for pastoral counseling; (5) as training for certification as supervisor of clinical pastoral education; and (6) as training for other specialized ministries. (Theological schools give academic credit for clinical pastoral education according to the credit system of each school.) Local History The Clinical Pastoral Education program at the Jewish Hospital of Cincinnati was begun in September, 1990. At that time, Rev. Henry Marksberry, Director of Pastoral Care and Education at Bethesda Hospital, joined with Rabbi Julie S. Schwartz to sponsor a school year unit of Basic CPE at the Jewish Hospital. This provided students at the Hebrew Union College-Jewish Institute of Religion a viable option for enrolling in CPE and it enabled the Jewish Hospital to have increased pastoral care for all patients. The program grew to include a summer intensive unit in June, 1990. The Jewish Federation of Cincinnati and Jewish Hospital then increased funding to this program so that summer student stipends became available in 1991. Bethesda Hospital, now part of Tri-Health, continues to provide satellite certification for all units of CPE offered through the Jewish Hospital/ HUC-JIR program. The Jewish Hospital/HUC-JIR program is presently involved in seeking independent accreditation for its CPE program. A Definition of CPE Clinical Pastoral Education is theological learning by experience in a clinical setting, under the supervision of a qualified teacher-practitioner of pastoral ministry in the company of intern peers. CPE provides a process for integration of other aspects of theological education into a personal theology and professional style of ministry. The goal of CPE is to give an intern opportunities to function as a minister while receiving guidance to render pastoral care. The intern's own unique gifts in ministry are called forth, recognized and strengthened. This course is accredited as a full unit of Clinical Pastoral Education, meeting the standards of the Association for Clinical Pastoral Education (ACPE). Upon successful completion of this course and with the recom- mendation of the intern's supervisor, the certification of this unit is registered with the ACPE. This course is fully accredited as theological education by member seminaries of the ACPE. Registration for credit at a theological institution is the responsibility of the intern, as is payment of any seminary course fees and tuition. The two main educational purposes of this program are: to provide the intern with an opportunity to render pastoral care to individuals under stress in a general hospital setting and to master a body of technical skills and academic materials related to pastoral care functions. In the process of fulfilling these purposes, the intern will be able to plan individualized learning goals and evaluate theological and pastoral pre- suppositions and procedures within the context of a relationship with a chaplain supervisor. The Objectives of CPE: 1. To develop the skills to provide intensive and extensive pastoral care and counseling to people in crises and other life situations 2. To understand and utilize the clinical method of learning 3. To utilize the support, confrontation and clarification of the peer group for the integration of personal attributes and pastoral functioning 4. To learn utilize individual and group supervision for personal and professional growth and for developing the capacity to evaluate one's ministry 5. To develop the ability to make optimum use of one's religious heritage, theological understanding, and knowledge of the behavioral sciences in pastoral ministry to persons and groups 6. To become aware of how one's attitudes, values, and assumptions affect one's ministry and to acquire a self-knowledge which permits pastoral care to be offered within one's strengths and weaknesses 7. To become aware of the pastoral role in interdisciplinary relationships and to work effectively as a pastoral member of an interdisciplinary team 8. To become aware of how social conditions and structures affect the lives of others and of oneself and to effectively address these issues in ministry 9. To develop the capacity to utilize one's pastoral and prophetic per- spectives in a variety of functions such as: preaching, teaching, leader- ship, management, pastoral care, and, as appropriate, pastoral counseling Learning Components Clinical Coverage: The program occupies 40 hours a week for a ten (10) week period in the summer; 14 hours a week for a 30 week school year extended unit. Approximately 60% of this time is allocated for actual pastoral care to patients, family members, and staff. During the school year extended unit, students' congregational service is included as clinical experiences. The remainder of your time is occupied by seminars, group meetings, worship, supervisory conferences, reflection, writing, reading, and informal interaction with peers. During the summer, mornings are generally scheduled for group learning and afternoons are intended for clinical work. During the school year unit, a 3 ½ hour weekly seminar is devoted to group learning with a bi-weekly hour didactic session. During both the school year and summer units, interns serve four (4) overnight chaplaincy rotations at Bethesda Hospital, including at least two (2) 24 hour weekend rotations. These overnight rotations supplement the clinical requirements and provide students with an opportunity to provide pastoral care at a major trauma center. Students will schedule these rotations at their convenience with the following strictures: school year students shall serve at least two (2) rotations during the fall semester and summer students shall serve their first overnight by the conclusion of the third week of the unit. All students shall attend all scheduled group meetings and supervisory conferences. Absences must be anticipated whenever possible and negotiated with the supervisor. Any clinical hours missed must be made up as soon as possible. The intern is responsible for maintaining adequate communication with the clinical supervisor, unit personnel, and with any patient, family member, or staff person expecting him or her, regarding any schedule changes. During the school year unit, the student shall complete a monthly time sheet. Supervisory Conferences: Each intern will meet with his or her super- visor once weekly, ordinarily for a fifty minute period, for individual supervision. The intern is responsible for preparation for this conference in order to make the best use of this time. Written materials for the supervisory conference shall be submitted to the supervisor at least 24 hours in advance of the meeting time so that the supervisor has adequate time to read the intern's materials. The supervisory conference provides the intern with the opportunity to focus on individualized learning issues and objectives so as to make the best use of clinical training for the intern's theological education. The conferences may focus on any aspect of the intern's clinical training, including the written materials presented. Just as each student is treated individually, each supervisor will have individual styles, methods and requirements. Learning Covenant: Each intern will develop an individual learning contract, consistent with the objectives for Basic CPE, to guide and direct his/her particular program educationally during this unit. Particular goals and commitments for attaining them will be included. This learning contract is prepared by the intern in negotiation with the individual supervisor. A guideline for developing your learning contract is in Appendix A. Each intern takes the initiative to determine specifically what s/he wants to learn. The intern forms a written proposal of goals to be pursued during the unit of CPE, the methods s/he will use to accomplish the goals, and the criteria and manner of evaluating progress. S/he interacts with the super- visor if further definition is needed. The goals can be renegotiated as learning foci shift or become clarified. The emphases are on taking responsibility for personal learning, developing skills for formulating goals, and using feedback and consultation. Goals need to be realistic, specific, appropriate to the clinical setting and the time limits of the CPE program, and measurable and/or observable. Attention must be given to the Objectives of Basic CPE. These objectives deal with professional and personal identity and the use of consultation to enhance professional competence. Journal: Prior to each supervisory conference, the intern will submit a reflective journal sheet for the preceding week. The recommended format for this journal is included in the prepared binder. However, after consul- tation with the supervisor, the student is welcome to adapt the journal process to his or her own style. The integrative summary is not intended as a mere "report of activities", but is meant to represent the intern's thoughtful reflections about the components of the program as they inform one another and the assimilation the intern has made of these into his or her own learning. Verbatim Reports: During both the school year unit and the summer unit, all students are required to complete eight (8) verbatim reports. There are different reporting formats for students completing an initial unit and sub- sequent units. (See appendices B and D, "Verbatim Record of A Pastoral Call.") One of these reports must be written about a pastoral experience during the first week of the unit. Students in the school year unit must also include one verbatim report per semester which is based upon a pastoral interaction at the student pulpit. The remaining reports shall be written according to a schedule established by the student and supervisor, but all students must complete at least four (4) of the required reports during the first half of the unit. During the second half of the unit, the accounts may follow the report form or these may be expressed through narratives, poems, art work, or in any other format agreed upon by supervisor and intern. Didactic Seminars: These are held weekly during the summer and bi- weekly during the school year, conducted by local supervisors, or other professionals, to aid the intern's grasp of theoretical concepts, and to provide necessary information for skill development to equip the intern to be an effective pastoral care-giver. Students will be asked to suggest topics for these seminars during the first week of the unit. Verbatim Conference: This group meets twice a week during the summer and weekly during the school year. Interns select dates to present a verbatim report and lead the group in focusing on particular issues for pastoral care. Identity of all patients, families, and staff must be anonymous and strictly confidential. Meditation: Each morning or evening group CPE session begins with this informal worship time. Students and supervisor rotate responsibility for leading meditation. Fifteen (15) minutes are set aside for this session and all are encouraged to use the entire time allotted. Students may choose to follow more formal liturgical standards, to experiment with creative settings, and to incorporate music and other sensory experiences into their planning. Retreat: During the summer unit, the students will participate in an overnight retreat mid-unit. This experience enhances and deepens personal growth and group functioning. During the school year, the overnight retreat will be scheduled in conjunction with the Reading Week/Exam Week period. At tendance is required. Focused Issues Group: This group meets weekly to explore core issues of identity development and spiritual formation. A selection of themes evolving from theological reflections, clinical interactions, and personal experiences provide the basis for this guided discussion group. Open Agenda Group: Not all of life is lived in intimate relationships. Not all of pastoral care is interpersonally intimate, per se. But pastoral care is done in the context of interpersonal intimacy, and it behooves us therefore to understand and be effective in building and maintaining intimate relationships. Following Buber's model of I-Thou relationships, we struggle to know one another and to be known by others. This requires candid truth-telling, even when this is most difficult or potentially painful. Truth withheld to protect from pain makes us judges of others, creates an imbalance of power, decreases intimacy, freedom, and trust. This group meets twice weekly during the summer and weekly during the school year, and the members contract for individual and interpersonal learning. Therefore the members are the agenda, and this group provides opportunities for learning about self, about others, and to explore interpersonal relationships in a committed environment. Group Contract: In this group you are invited to: give, seek and take clarification (about self, a relationship, another, feelings, thoughts, attitudes, behavior, and/or beliefs); give and take support (for self another); give, seek and take confrontation (about self, a relationship, another, feelings, thoughts, attitudes, behavior, and/or beliefs); give, seek, and take self-disclosure (of self, of others). Effective contributions to persons or the group will usually be those which come from one of these foci: be "up front." Tell it the way it is "inside." What is honestly going on inside me right now? What have I been sitting on? What do I feel? What do I need? What am I aware of about myself, about you? What is going on in this group -- dynamics, hidden agenda, pairing? The facilitator is in the group because of an interest in interpersonal growth. While it is true that the facilitator brings certain special resources to the group because of theoretical background and experience, the purpose is to put as many resources as possible at the service of the group. The facilitator subscribes to the same contract as the other members. In the beginning, the facilitator will be more active, for one function is to model the kinds of behavior called for by the contract. The facilitator is also responsible for assuring group members' safety and a safe learning environment until the group can take responsibility for maintaining this standard. Another function of the facilitator will be to invite others to engage in contractual behavior. Eventually in the group, there should be no leader, but a high degree of shared leadership. This will be the case if individual members take the initiative to contact one another according to the terms of this contract. While we are always free to tell anyone what we choose to tell them about ourselves, when others entrust themselves candidly to us, they do so with the trust that they remain in control of who has the information. They gave it only to you. Keep it. This does not apply, of course, to public information about us (race, gender, job, professed faith, education, family status, etc.) Evaluations: Formats for evaluations will be given out by the supervisor. Each intern will submit a mid-unit typewritten evaluation prior to the regular supervisory conference that week. Both intern and supervisor will write a final evaluation which will be discussed during the final supervisory conference. As required by seminaries, grades will be submitted based upon these evaluations and student/supervisor collaboration. Pastoral Care Responsibilities And Expectations While there are priests and ministers available for assistance in emer- gencies, CPE interns provide the primary pastoral care for patients in the Jewish Hospital. Students will, in consultation with supervisor and one another, be assigned as the chaplain for various floors in the hospital. Immediately upon receiving your floor assignments, you should write your nursing staff an introductory letter in which you offer a brief personal history, your day and evening telephone numbers, and the ways in which you would like to be serve as chaplain to the floor. Request that this letter be posted for all floor staff to read. Essentially this is your congre- gation and the patients, family, and staff are your congregants. Obviously no chaplain can see everyone, every time. Because of time limitations and the fiscal sponsorship of this program by the Jewish Federation of Cincinnati, HUC-JIR students should prioritize visits to patients according to the following criteria: 1) Patients listed on census as Jewish with no congregational affiliation. 2) Patients referred by nurses or ward clerks. 3) All other patients. Please remember, however, that you are the chaplain to all patients on your floors, regardless of religion or perceived staff need. You should distribute calling cards to all patients visited and leave them in rooms where you have been unable to personally contact the patient or her/his family. Calling cards are available from Carolyn DeYoung. Pastoral Conduct Remain in close working relationship with hospital staff. Informal visiting with doctors, nurses, etc., will convey your availability as a chaplain. Inclusive language and conduct is required. Errands, telephone calls, mailing letters, the giving or lending of money to patients or others is not ordinarily a part of pastoral care responsi- bilities. These should not be done without clearing these matters with the supervisor. In the best interest of the patient, confidential information from patients, families, staff members and medical charts is to be shared only with other staff professionals or within the educational program. When you visit patients who are members of Jewish congregations in the Cincinnati area, it is expected, according to standards of professional courtesy, that you will contact the rabbis of those congregations. You need not divulge confidential material but merely inform the rabbi that one of his or her congregants is in the hospital and that you have made a pastoral call to that patient. You may wish to offer continuing support to the patient according to the rabbi's wishes and your professional evaluation of the patient's needs. When you visit a patient who requests a minister of his or her particular faith group or who requests baptism, confession, "last rites" or similar sacraments which must be administered by a clergy of a particular faith group, please consult the clergy contact list posted in the chaplains' room. Student termination from a CPE Program will occur only in extreme situations and for sufficient cause within the course of supervised educational placement. Because of administrative and pastoral responsibility to patients, hospital staff, hospital families, and other students, the following may be grounds for dismissal: 1. Disregard for someone's safety or well being; 2. Unethical, abusive, exploitative, or inappropriate clergy behavior (See Appendix C: CPE Intern Grievance Policy); 3. Inability to work under supervision or to bring one's work under supervision; 4. Disregard for stated hospital policy and procedures; 5. Unwillingness to serve: insubordinate and/or belligerent behavior; 6. Changes in student behavior or function which, if evidenced or known at time of application, would not have met admission criteria. The ACPE Grievance Policy is included as Appendix D. You must familiarize yourself with this policy and document your understanding of said policy. General Information Dress Code: Professional appearance is required at all times while in the hospital, even when not visiting patients. This means coat and tie for men, skirt and hose or appropriate slacks for women. Photocopying: Students may use the copy machine for the Volunteer Office or submit their materials to Jean at HUC. Name Badge: Students must call John (569-2006) in the Security Office at the Burnet Jewish Hospital Building to arrange a picture appointment and to be processed for their photo ID badge. This process must be completed by the end of the first week of classes. Badges will be available from the Volunteer Office once they are ready. The name badge must be worn at all times when acting as a chaplain at the hospital. Volunteer Status/Meals: Students hold volunteer status while working as chaplains at Jewish Hospital. This requires that students keep Volunteer Hours Record Sheets. As volunteers, students receive a daily food allowance at the cafeteria. Students must complete a volunteer application form and have a TB Skin Test performed. Students will receive an application by mail and this must be completed and returned to the Volunteer Office on the first day of class. To arrange the TB test, call Alliance Medical Health (569-2101) at the Burnet Jewish Hospital Building. Tests can be done on all weekdays except Thursday. Students must return to have the test read be read at the same location 38-72 hours after the first visit. Employee Health is inside the South entrance of the Hospital. Illness/Hygiene: Please be certain that you wash your hands before each visit as well as before eating and before leaving the hospital. Use the staff sinks, not patient room sinks. If you know that you may have a contagious illness, do not work in patient care areas. If you have moderate health concerns, protect yourself and your patients by wearing a mask. Parking: There is significant parking congestion at Jewish Hospital. During class times, students may park in the North Lot, that is the lot across from Jewish Hospital at the corner of Galbraith and Kenwood Road. When serving clinical hours, students may park at the Kenwood Towne Center corner lot which is reserved for "Come & Go" Jewish Hospital employees. After the Parking Garage opens in late October, this parking policy may be changed. Do not park in any other lots. Chaplains' Room: During the 1998-99 School Year Program, the Monday section will meet in the Waiting Room Lobby of the Breast Center, first floor. The Thursday group will meet in the Meditation Room. All groups will gather in the Registration Lobby on the first day of class before moving on to respective classrooms. Lockers: During the day, purses and other personal belonging can be stored in lockers in the volunteer office. Overview Of Written Requirements School Year Unit 1998-99 1. Completed learning contract by Friday, September 11, 1998 2. Eight (8) written verbatim reports 3. Weekly reflection journal, completed before supervisory hour 4. Completed final evaluation, due May 28, 1999 5. Project Report demonstrating completion of reading Program Requirements 1. 14 hours work/study in the hospital/congregation each week 2. Four (4) overnight chaplaincy rotations at Bethesda North Hospital. Two of these are to be 24 hour duties and two are to be 12 hour duties. 3. Participation in all group activities 4. Participation in overnight mid-unit retreat (to be scheduled during the January break) APPENDIX A A Learning Contract Outline For Clinical Learning CPE uses a contractual method of education to assist the chaplain to focus his/her learning goals and to maximize possibilities for growth in the areas selected. This method allows for goals to be self-formulated and individ- ually tailored. After the chaplain submits proposed goals along with methods of attainment and evaluation, s/he interacts with the supervisor if further definition is needed for a mutually agreeable outline. The outline is thus arrived at through a process of consultation and can be renegotiated as learning foci are shifted. The emphasis is on developing skills necessary to formulating goals, using consultation, and taking aggressive responsibility for learning. Goals need to be 1) realistic, 2) specific, 3) time-phased, and 4) measurable or observable. In reviewing the objectives of CPE, you may notice that the areas for growth are in four categories: (1) Professional/Pastoral (2) Intrapsychic/Personal (3) Interpersonal (4) Conceptual/Academic A few guiding questions in writing your goals are included below: (1) What are you willing to do to reach this goal? (2) How will you know when you have reached it? (3) How can you sabotage reaching this goal? (4) What would you gain through sabotage? (5) What goals are you avoiding for now? The learning contract itself is a process and can be re-negotiated by the student and supervisor. APPENDIX B HUC-JIR/Jewish Hospital Chaplain: Supervisor: Verbatim No.: Date of Call: Number of Prior Calls: Length of Visit: Patient: Age: Sex: Marital Status: Religion: Hospital: Residence: Occupation: I. Preliminary: Information obtained prior to call, and/or summary of previous calls. II. Preparation: Needs of patient anticipated, if any; your plan for meeting them; things for which you sought to be alert; how you prepared yourself; and how did you feel about this call going into it. III. Observation: Physical situation as observed on entering room and approaching patient before conversation; your initial impressions and mood. IV. Interview: Type the conversation word-for-word. Note non-verbal as well as verbal communications. Describe sensory- grounded behavior and include your interpretations of non- verbal communications. Use "C" for chaplain and "P" for patient. Use other letters to clarify other persons involved. Number all responses in serial order, i.e., C1, P1, C2, P2, etc. V. Analysis: A. Patient: 1. Assess your rapport with the patient. Was the patient open and personally available? Assess the level of trust the patient extended to you. 2. What are this patient's needs? To what extent does the patient recognize them? How effectively were these needs addressed? 3. What are the resources available to help meet his/her needs? 4. What social conditions and structures affect the patient (and the chaplain)? B. Chaplain: 1. How effectively did you listen to this patient? How empathic were you? 2. What were your emotional reactions? What was your internal dialogue of thoughts and feelings during this visit? 3. What is your evaluation of the effectiveness of this pastoral call and suggestions for improvement? Identify the critical turning points in the interview. VI. Theological Reflection: What are some of the theological issues which you note in this encounter? Choose one of those issues and reflect upon it from a Biblical, theological, philosophical and behavioral science perspective. What insights from your reflections inform your ministry with this patient in this instance and any future contacts you may have with the patient? VII. Future Pastoral Care Plan For The Patient: Discuss your plans for future pastoral are of this patient should you have the opportunity for another pastoral call. VIII. How Do You WANT To Use The Group To Assist In Your Learning? APPENDIX C CPE Intern Grievance Procedure HUC-JIR/Jewish Hospital As you begin your experience of Clinical Pastoral Education in our center, we WANT to inform you of two items from the Standards and Procedures of the Association Clinical Pastoral Education. One of the items relates to complaints. The second relates to your records. I. Grievance Procedures: If you have a concern about a serious educational, ethical, or professional violation, you are encouraged to follow one of the following paths: (1) First, seek to work it out in a informal face-to-face contact in a spirit of collegiality and mutual respect. (2) If this is not satisfactory, you can approach another supervisor in the area and ask them to be in consultation with the two of you. (3) You can ask the seminary you attend to have someone in the Dean's Office hear your concerns with you supervisor. (4) If all the above is done without satisfactory results, you are encouraged to put your concerns in writing and follow the ACPE Standards. Complaint Procedures are found on pages 47-55, Standard 400-470, ACPE STANDARDS, 1993. A copy of the Standards may be found in the HUC-JIR Dean's Office. II. Intern's Records: Each intern's final evaluation is kept on file at HUC -JIR for five years only (Standard A115). We cannot send your records to anyone without WRITTEN request. Intern's signature attests to reading of and agreement with this document I have carefully read and agree to the service and learning structure responsibilities outlined in the syllabus for this course. I have read the information about appeal procedures and CPE records. I understand that I will be given a copy of my supervisor's final evaluation. I understand that no other copies will be released without my written permission. I further understand that it is my responsibility to keep my CPE records, and that the center's records may be destroyed (after three years) except for a face sheet. Name: Date: APPENDIX D HUC-JIR/Jewish Hospital Chaplain: Supervisor: Verbatim No.: Date of Call: Number of Prior Calls: Length of Visit: Patient: Age: Sex: Marital Status: Religion: Hospital: Residence: Occupation: I. Preliminary Data: Patient: (Initials Only on first copy) Admission Patient Date: Location: Referred by (or reason for selection) Additional information learned prior to call (give source) or summary of previous calls: II. Preparation: In light of what you know about patient, yourself, the current situation, give areas of concern, self-preparation, approach.) III. Observation: (All sensory impressions upon approaching patient, but before conversation begins.) IV. Verbatim Report of Call: (Use separate sheets, number pages, include non-verbal communication [in parenthesis], allow three inch margin on right, number patient and Chaplain responses.) V. Analysis of Patient Situation: 1. List of topics discussed in order, using patient's words and phrases when possible. 2. Identify underlying theme(s), concerns of the patient, anxiety laden issues. 3. Pastoral assessment of patient's problem, spiritual diagnosis, dominant problem. The judgments on which you function in pastoral care. 4. Meaning of illness for the patient. Function of the illness in existential experience of patient. 5. Remaining questions about the patient, puzzling features (differential diagnosis). 6. Resources available to meet patient's needs apparent from verbatim material, admitting information. (Not recommendations.) VI. Analysis of Pastoral Functioning: 1. Length of call: Minutes. 2. Evaluate process call by major phases (e.g., Opening, Middle, Closing). 3. Evaluate your pastoral care methods - successes, failures, consistency, etc. 4. Understanding and insights developed during call about patient and about self. 5. Describe relationship - level of empathy, rapport, your feelings about patient, how you think patient felt about you, etc. VII. Recommendations for Continuing Pastoral Care: Include specific pastoral care practices/need for interdisciplinary referrals, specific reasons, etc. VIII. Theological Reflections on the Pastoral Call: Theologize about the issues involved in patient's life, pastoral functioning, the relationship, medical treatment, etc.