Mental Health Clinical Pastoral Education—A Specialized CPE Program

Abstract

This article describes the design and implementation of a Specialized Mental Health Clinical Pastoral Education (CPE) program for clergy and theological students of all spiritual, religious, and cultural backgrounds. Addressing the need for mental health competencies in religious leaders and chaplains, this training equips participants with specialized skills in individual and group mental health spiritual assessment and spiritual care. Program participants become effective members of a multiprofessional team, gain knowledge of mental health philosophies of concordant and discordant spiritual orienting systems, and gain greater relational capacity. The Mental Health CPE Program includes traditional and novel CPE elements: (1) clinical practice, (2) group and individual supervision, (3) didactic presentations and journal clubs, (4) verbatim (Protocols of patient encounters) and case presentations, (5) group leadership training and practica, and (6) experience of faith reflections. This article provides insights into the origins of CPE, a description of the implementation in a free-standing psychiatric hospital, and observed developmental changes of program participants. We include graduates’ anecdotal feedback about their learning experience and its impact on their leadership in chaplaincy and in religious communities. Additionally, we report on areas for future development and further study of the effectiveness of Mental Health CPE.

1. Introduction

The intersection of spirituality/religion (S/R) and mental health is a crucial aspect of person-centered treatment. The influence of S/R on mental health can have both positive and negative effects (Bonelli et al. 2012; Rosmarin et al. 2013; Rosmarin 2020; Cheng and VanderWeele 2020; Mosqueiro et al. 2020; Lucchetti et al. 2021; Pargament and Exline 2021). Individuals often turn to S/R for solace and support in coping with mental illness, but they may also face challenges such as marginalization and pressure to conform in S/R communities (Wong et al. 2018; Nguyen 2020; Campbell 2021).

At the forefront of this complex relationship are religious leaders, who often serve as first responders, surpassing the frequency of engagements with mental health providers (Wang et al. 2003; Parcesepe and Cabassa 2013). For instance, many S/R leaders encounter at least one suicidal individual annually, yet only a fraction feel equipped to effectively support them, with fewer than half making referrals to mental health providers (Mason et al. 2021).

The critical need for equipping clergy with education in mental health spiritual care and specialized counseling skills has been underscored (Bledsoe et al. 2013; Hays 2018; Mason et al. 2021; Center for Disease Control 2024). Successful training interventions for religious leaders should be experiential, allowing for the integration of personal and professional lived experiences. Moreover, education in mental health spiritual care should aim to raise awareness and modify stigmatizing spiritual orienting systems, such as beliefs in demon possession, lack of faith, or insufficient prayer. Additionally, clergy plays a role in creating communities that utilize spiritual and religious resources to contribute to mental wellness and promote education about spirituality and mental health. There is also a need for a reciprocal referral system and effective collaboration between clergy and secular mental health providers.

Few comprehensive training programs equip chaplains and clergy with skills in mental health assessment and spiritual care within multidisciplinary and community contexts. Military chaplains receive training in suicide prevention and PTSD through the VA and DoD (Wortmann et al. 2021; Cooper et al. 2023), and there is growing recognition of the need for similar training in general medical settings (Pennybaker et al. 2016). However, mental health education in seminary programs is limited and inconsistent. Counseling courses are typically electives focused on relational issues, with minimal hands-on experience. Most clergy take fewer than five mental health-related courses, leaving many feeling unprepared to meet congregants’ mental health needs (Copello and Yancey 2025). Previous research has shown that clinical pastoral education effectively enhances chaplain capabilities, emotional intelligence, and counseling self-efficacy, while also fostering transformational learning, personal growth, professional identity, and reflective practice (Szilagyi et al. 2024).

1.1. Methodology

This paper employs a descriptive and exploratory approach to present the origins, development, implementation, and significance of an innovative Mental Health Clinical Pastoral Education (CPE) program designed for clergy and religious students from diverse spiritual, religious, and cultural backgrounds. Grounded in the robust outcome framework established by the Association for Clinical Pastoral Education (ACPE 2025), the program seeks to address the documented gap in mental health training for religious leaders and chaplains by integrating interdisciplinary didactic materials, reflective practice, and experiential learning to enhance participants’ competencies in mental health and spiritual care. We present the structure and educational components of the program, including curricular content and underlying pedagogy. While formal outcome evaluation remains in development, this paper includes preliminary qualitative feedback from recent program participants to illustrate perceived impacts and areas of growth. Though the methodology is limited in scope and generalizability, the participant reflections provide meaningful insight into the program’s relevance and effectiveness in addressing mental health training needs within spiritual care education.

1.2. Origins of Clinical Pastoral Education

Clinical pastoral education was first developed in 1925 by Anton Boisen, a clergyman who experienced three lifetime hospitalizations for psychosis and dementia praecox. Boisen, who distinguished levels of severity of mental illness, insisted that his mental health crisis was a significant mystical and spiritually transformative experience. His delusions began while revising his theological statement to prepare for future employment and caused his family to commit him to a psychiatric hospital. There, he was administered sedatives and hydrotherapy baths, and was beaten and restrained. While Boisen recognized that he was delusional, he insisted that his experiences had a purpose (McCullough 2023).

Five years later, with the help of personal and professional supporters, Boisen, the psychiatric survivor and mad prophet (McCullough 2023), became the chaplain at Worchester State Hospital, where he himself had been hospitalized. His lived experience led him to a patient-centered and recovery-oriented approach to spiritual care. In learning from the living human document, he dedicated himself to the scientific study of spirituality, religion, and mental health, and used the therapeutics of religion (LaBat 2022). Remarkably, Boisen’s vision did not just focus on individualized experiences of spiritual transformation. His work also endeavored to bring about social change in religious communities.

In training future S/R leaders by bringing them into encounters with suffering persons, he aimed to help them to avoid the error of religiously conservative colleagues who offered treatment without diagnosis, while also preventing clergy from the mistake of his liberal friends (who) supplied neither treatment nor diagnosis (Boisen 1924). Since in Boisen’s experience psychotic processes ultimately became constructive, he was convinced of the therapeutic effect of S/R experiences. Boisen was a mystic who believed in the benefits of the support and challenge of a fellowship of the best, which included God (LaBat 2022). He was a clinician who was well versed in the diagnostic differentiations of psychiatric disorders as defined in his time. He also was a theologian who saw mental illness as the price we had to pay for being (human) and having the choice and the capacity for growth (Boisen 1953). Transcending his denominational roots, he was curious about patients’ mysterious, sacred, and unusual experiences and engaged the meanings of objects, symbols, and metaphors (LaBat 2022).

Boisen was intent on learning from, reaching toward, and respecting those who were, like him previously, warehoused before effective pharmacological, neurotherapeutic, and psychotherapeutic remedies becoming available. In bringing theologs into Worchester State Hospital, he created cohorts who worked together with the enthusiasm of discovery in the effort to formulate the laws of the spiritual life, with which religion must ever be primarily concerned (Boisen 1924). In short, Boisen’s clinical, educational, pastoral, and scientific work aimed at breaking an opening in the wall which separated medicine and religion (Powell 2025).

Other leaders who developed ways to bridge the divide between religion/spirituality and the mental health disciplines are Helen Flanders Dunbar and Russell Dicks (ACPE n.d.), pastoral theologian Seward Hiltner (Hiltner 1951), and Howard Clinebell (Clinebell 1972). From the late 20th century, systematic research demonstrated positive relationships between religious involvement and mental health outcomes. Harold G. Koenig systematically reviewed religion’s supportive role in mental health (Koenig 2012). Kenneth I. Pargament developed the concept of religious coping, emphasizing the complex role that spirituality plays in adjustment to stress and illness (Pargament 1997). Major professional bodies, such as the American Psychological Association (APA) and the American Psychiatric Association, have issued guidelines recognizing spirituality’s role in clinical care (Richards et al. 2023; American Psychiatric Association 2013). On the other hand, integrated spiritual care models increasingly include chaplains as part of multidisciplinary teams, particularly in palliative and trauma care settings, legitimizing spiritual care within mental health treatment (Cadge 2012).

1.3. Clinical Pastoral Education

Clinical Pastoral Education (CPE) has evolved over a century to become the primary educational model for spiritual care providers across diverse settings such as hospitals, hospices, campuses, correctional facilities, and the military. It serves as a prerequisite for board certification in professional healthcare chaplaincy in the United States, Canada, Australia, and New Zealand (Szilagyi et al. 2024). The Association for Clinical Pastoral Education (ACPE) is the leading accrediting and standard-setting organization for CPE programs.

Accredited ACPE-CPE programs are designed to address essential outcomes such as spiritual formation, self-awareness, relational dynamics, spiritual care interventions, and professional development. The educational journey is structured into four levels: Level 1A focuses on understanding the role of spiritual care, Level 1B delves into deeper reflection on spiritual care practice, Level 2A emphasizes competent provision of spiritual care, and Level 2B requires students to demonstrate competent self-supervision and self-evaluation of their spiritual care.

The Mental Health CPE Program at McLean Hospital is committed to admitting students at all levels to enhance mental health chaplaincy competence across various training stages. Despite the clear need for mental health CPE programs, they remain scarce. Only four CPE programs, including the one at McLean Hospital, specialize in mental health, with two based in state hospitals and two in private, free-standing psychiatric hospitals.

The scarcity of mental health CPE programs can be attributed to various factors. Sigmund Freud, forefather of psychology and psychiatry, was interested in making sense of how the unconscious influenced feelings and behavior. However, he saw religion as an illusion to be replaced by reason and logic (Freud [1927] 1989). As a result, religion became stigmatized in psychiatry. A biomedical–social–spiritual model of psychiatric care is still rare today, leading to the marginalization of spiritual and religious meaning-making in mental health care. Additionally, the impact of Boisen’s mental health episodes led to the cessation of financial and ideological support for the first unit of CPE at Worchester State Hospital in 1925, coinciding with the rise of an understanding of mental illness as primarily organic in nature, further stigmatizing spiritual and religious approaches to care (LaBat 2022).

The history of CPE highlights the ongoing need to integrate spiritual care and education into mental health services. By understanding the historical context and addressing the current scarcity of mental health CPE programs, the field can work toward an approach to mental health care that more routinely incorporates S/R dimensions and chaplaincy care.

1.4. Materials and Educational Methods: An Innovative Spirituality and Mental Health Program

In 2015, McLean Hospital established the Spirituality and Mental Health Program (SMHP) with the goal of enhancing treatment outcomes by addressing patients’ spiritual needs, training clinicians to assess spiritual needs, and conducting innovative treatment research. David H. Rosmarin, PhD, ABPP, Director of the Spirituality and Mental Health Program and Associate Professor of Psychology in the Department of Psychiatry at Harvard Medical School, leads the SMHP in examining the impact of spirituality and religion (S/R) on mental health outcomes. The program has developed effective methods to address S/R issues as part of evidence-based clinical care and evaluates how S/R may functionally connect in positive and negative ways with mental health struggles.

Rosmarin created a multi-session Cognitive Behavioral Treatment (CBT)-based protocol called spiritual psychotherapy for inpatient, residential, and intensive treatment (SPIRIT) to integrate spirituality into acute psychiatric care. Additionally, several psychometric measures to assess S/R were developed by Rosmarin.

Chaplaincy services were added in 2017, and since 2019, chaplaincy has responded to spiritual care consults in all inpatient, residential, and partial programs, led spirituality groups, and provided spiritual crisis and staff support, as well as chaplaincy care to the institution. Annually, chaplaincy provides between 1700 and 2000 individual spiritual care encounters and approximately 550 spirituality groups with about 3300 patients participating.

Furthermore, the Mental Health Clinical Pastoral Education (CPE) program at McLean Hospital has been fully accredited through the Association for Clinical Pastoral Education (ACPE) since 2024. To date, 31 CPE students have graduated, with two students completing more than one CPE program.

1.5. Goals of Mental Health CPE

While all CPE programs are designed to meet the ACPE Outcomes and Indicators, the overall goals of Mental Health CPE are to

• Initiate, deepen, and end care relationships that allow for in-depth assessment of S/R needs of psychiatric patients and develop appropriate plans of care;
• Use a wide variety of individually curated S/R resources in dialogue with mentally ill persons;
• Develop mental health competency through experiential learning, including group leadership skills;
• Learn about the role of mental illness in a variety of S/R orienting systems;
• Communicate effectively across professional roles and support the treatment alliance;
• Build relational capacity by increasing awareness of how thoughts, feelings, and behaviors impact relationships with others.

1.6. Mental Health CPE Description

Overview: The Mental Health CPE Program is structured to provide a comprehensive learning experience for students, encompassing both clinical and educational components. The clinical aspect involves 300 h of hands-on spiritual care provision in various patient care areas, including trauma and dissociative disorders, geriatric psychiatry, substance use disorders, anxiety and mood disorder units, psychotic disorders, general psychiatry, and eating disorders. This exposure to diverse psychiatric patient populations allows students to gain valuable insight and practical skills in managing different mental health conditions.

In addition to the clinical hours, the program includes 120 educational hours aimed at enhancing students’ knowledge and understanding of mental health care. These educational hours focus on reflective clinical practice through experiential learning methods such as verbatim and case discussions, individual consultation, teachings of the knowledge base, experience of faith papers, process group sessions focusing on intra-, interpersonal, and group-as-a-whole development, and journal clubs discussing relevant research papers. These educational activities not only deepen students’ understanding of mental health issues and improve spiritual caregiving skills, self-awareness, and emotional intelligence (Szilagyi et al. 2024), but also encourage critical thinking and the application of evidence-based practices. Overall, the mental health CPE program is designed to equip students with the necessary clinical skills and knowledge base to excel in mental health chaplaincy, while also promoting personal and professional development through reflective and experiential learning.

1.7. Orientation

The orientation of the program includes a wide range of essential learnings and experiences for CPE students in the mental health setting. These include:

• Safety Issues: Understanding and adhering to safety protocols and procedures in clinical areas to ensure the well-being of both patients and staff;
• Appropriate Behaviors in Clinical Areas: Learning and practicing behaviors that are suitable and respectful within the clinical environment, maintaining professionalism and sensitivity to patients’ needs;
• Structure on Inpatient Units: Gaining an understanding of the organizational and operational structure of inpatient units, including the roles of different staff members and the flow of patient care;
• Recovery-Oriented Care: Embracing an approach to care that supports and empowers patients in their journey toward recovery and wellness;
• Clinical Boundaries and Confidentiality: Understanding and maintaining appropriate boundaries and confidentiality in the context of providing spiritual care in an inpatient psychiatric setting;
• Trauma-Informed Care: Developing an awareness of trauma-informed practices and approaches to care that consider the impact of trauma on individuals;
• Roles of Interprofessional Team Members: Understanding the roles and contributions of various multiprofessional team members in providing comprehensive care to patients.

1.8. Program Elements

The CPE learning process is powered by the cycle of experiential learning through action–reflection–action (Kolb 2014), supplemented with conceptual understandings and evidence-based knowledge. The educational elements of the Mental Health CPE Program encompass a diverse range of content and goals aimed at providing a comprehensive understanding of inpatient psychiatric treatment and fostering a recovery-oriented approach to spiritual care (see

Table 1. Program elements and related goals.

Program Elements	Goal
Unit-based rounds	Understanding inpatient psychiatric treatment, multiprofessional collaboration
Peer specialist teaching	Destigmatization, Recovery-orientation
Electro Convulsive Therapy and Transcranial Magnetic Stimulation	Destigmatization, Understanding of psychiatric illness as illnesses of the brain
Inpatient therapeutic and psycho-educational groups	Destigmatization, Learning coping skills, Introduction to therapeutic modalities
Documentation in the medical record	Mental Health spiritual care skills, Role clarity
Didactic instruction	Mental Health Competency, Knowledge base on S/R and mental health
Verbatims and case studies	Standardized competencies Identifying symptoms of psychiatric illness Mental health-effective communication, Spiritual care skills, Use of S/R resources to support S/R coping Broadening of S/R experiences
Clinical practice	Mental health competency, Confidence in the professional role of the chaplain
Group leadership training	Knowledge in group theory Development of group leadership skills Introduction to at least one spirituality group protocol Group leadership experience with different psychiatric populations
Boundaries practicum	Practice identifying and setting physical, relational, emotional, personal, spiritual boundaries
Experience of faith papers Attachment and forgiveness Surviving Covenants with God The therapeutics of one’s spiritual orienting systems	Exploration of CPE students’ own experiences of S/R struggles leads to a deeper sense of compassion and greater forbearance as students engage with patients
Capstone Paper	Statement of the CPE student’s position exploring the intersection of mental health and their spiritual orienting system and outlining plans for future involvement in mental health ministry

). Students observe an experienced chaplain’s practice using an observation tool, which facilitates reflection and orients CPE students to expected behaviors in spiritual care (Jones et al. 2004). In unit-based multiprofessional rounds, students learn about the clinical roles, safety, and disposition planning. They also observe psychiatric interviewing and teaching, as well as contribute to recovery-oriented treatment. Peer specialist teaching focuses on destigmatization and empowerment through sharing lived experiences and advocacy. Watching patients undergo various therapeutic interventions, such as electro convulsive therapy and transcranial magnetic stimulation, aims to enhance knowledge of neurotherapeutic interventions and destigmatize psychiatric illnesses as brain disorders. Additionally, participants observe inpatient therapeutic and psycho-educational groups to gain insight into stabilization, mutual support, psychoeducation, group facilitation, and coping skills. Students also learn to document spiritual care assessments and interventions in the medical record, knowing that patients and team members have access to this legal document. Co-signing is required by hospital policy and offers an opportunity for ongoing education throughout the program.

Didactic instruction (see Table 1) covers a wide array of topics, including an overview of the research of S/R and mental health, suicide and suicidality, mood and anxiety disorders, psychotic disorders, trauma and dissociative disorders, trauma-informed spiritual care, critical empathic listening and attending skills, models of grief and complicated bereavement, addressing S/R struggle, personality development and spirituality, healthcare disparities in mental health, SAFER training (which trains students in interventions when others use biased language in the clinical context), as well as teaching on a wide variety of S/R interventions and resources. Introductions to CBT and Acceptance and Commitment Therapy (ACT) offer CPE students a way to work with patients’ beliefs and ideals, regardless of immediate rewards. Discussions of selected readings in spiritual care and selected research articles additionally help develop mental health competency and knowledge base in spirituality and mental health.

Verbatims and case studies (see Table 1) play a crucial role in the development of mental health competencies in spiritual care, particularly when it comes to identifying symptoms of psychiatric illness and effective communication. Through experiential learning, Mental Health CPE students build confidence in their professional role and cultivate an empathic understanding of their patients. The utilization of verbatims and case studies facilitates the recall of affective, behavioral, and cognitive data, enabling chaplains to recognize the symptoms of psychiatric illness and explore the range of spiritual and religious experiences. Moreover, the analysis of interpersonal dynamics in psychiatric illness and the adaptation of communication styles aid in the development of essential listening and attending skills. Furthermore, Mental Health CPE students enhance their self-awareness, reflect on spiritual and emotional boundaries, and provide spiritual care across concordant and discordant spiritual orienting systems. Spiritual care and communication skills acquired through the study of verbatims and case studies prepare Mental Health CPE students to provide individualized spiritual care to persons struggling with severe mental illness.

Six-hour group leadership training (see Table 1) is another crucial program component in the Mental Health CPE Program, which introduces participants to group dynamics and theories. It provides an understanding of the stages of group development, emphasizes the importance of group cohesion and communication, and equips students with effective group facilitation techniques, including handling disruptions and conflict. By engaging in role-playing scenarios and receiving feedback from peers and educators, CPE students practice and refine their group leadership skills, creating a safe and normalizing space for patient groups. While many students may have prior group leadership experience, Mental Health CPE specifically focuses on adapting these skills to the unique challenges of a psychiatric setting. Students learn to set a clear frame, share goals, present ground rules, and practice facilitation skills, ultimately contributing to patients’ stabilization, socialization, and coping strategies.

In the Mental Health CPE Program, CPE students have the opportunity to gain clinical experience through hands-on practice of at least one of two group protocols. The first protocol, SPIRIT groups, provides psycho-education about the intersection of spirituality and mental health struggles, and supports positive coping through cognitive or behavioral interventions that integrate S/R. Patients are guided in the exploration of S/R issues and connect with others in the group. The second protocol, Sacred Story groups, involves bibliotherapy using sacred stories from various S/R traditions to facilitate meaning-making and reflection on mental health struggles.

Mental Health CPE students lead spirituality groups on eleven different inpatient and residential areas, allowing them to gain experience working with diverse patient populations. In leading these groups, they learn to shift from focusing on individual spiritual-orienting systems based on specific identities to using the lens of mental health chaplaincy to engage the various dimensions of multiplicity. This includes considerations of race, ethnicity, S/R or humanistic orientations, sexual orientation, gender identity, gender expression, age, disability, socioeconomic circumstances, national origin, indigenous heritage, geographic background, physical characteristics, veteran status, and politically based spiritual ideologies. This educational opportunity and clinical contribution enables Mental Health CPE students to gain greater experience and understanding of group leadership skills, as well as practice with a variety of clinical populations.

A boundaries practicum (Table 1) focusing on relational, emotional, spiritual, personal, and physical boundaries provides an invaluable opportunity for Mental Health CPE students to apply their learning in a tailored and practical setting. By engaging with a case example that aligns with their individual learning needs, students can gain a deeper understanding of how to navigate and respect various boundaries in the context of offering spiritual care to a person struggling with mental illness. This hands-on experience allows students to integrate theoretical knowledge with real-world scenarios, honing their skills in establishing and maintaining healthy boundaries in their future ministry practice. One graduate stated,

Before CPE, I would say ‘yes’, ‘yes’, ‘yes’, ‘yes’, ‘yes’,…then go back home and complain and complain and yet, I’m the one saying ‘yes’. CPE gave me the ability to say ‘no’, which I didn’t have.

A capstone paper (Table 1) exploring the intersection of mental health and the student’s spiritual orientation, and outlining plans for future involvement in mental health ministry, serves to reinforce the student’s learnings from their mental health CPE experience.

2. Report of Changes in Participants

Drawing on constructive–developmental theory, the participants in our observed program showed significant developmental changes over time, reflecting the transformative nature of Mental Health CPE. This program, designed for ministry and chaplaincy education, aims to not only impart knowledge, but also to fundamentally alter individuals’ perceptions and processing of information and experiences. According to Kegan’s concept of the shift from subject (I AM) to object (I HAVE), this change encompasses deep-seated self-identifications and perceptions that are often not readily available for objective reflection (Kegan 1982). With this transformation, the Mental Health CPE student develops permeable boundaries between the intra-personal (I AM), the inter-personal dimension, and the spiritual care role or membership role in the CPE peer group, chaplaincy, and multidisciplinary team.

In the context of mental health chaplaincy, the focus of engagement is on the mind, both of the spiritual care recipient and the provider. Mental Health CPE leads to changes of the mind—self-concepts, perceptions, cognitive processes, problem-solving, and language use (American Psychiatric Association 2018). As a result, Mental Health CPE students emerge with a transformed approach to mental health and spiritual care, as well as significant personal growth, enabling them to have and reflect on perceptions, thoughts, problem-solving, and language use. We observed five areas of developmental change: Mental Health CPE students gain increased confidence as first responders and spiritual care providers. They gain deeper empathy for individuals with mental health diagnoses, enhanced mental health chaplaincy skills, develop emotional and cognitive self-differentiation, and a stronger grounding in their own spiritual orientating system.

2.1. Confidence in the Role of a Mental Health Chaplain

Initially, the context of a psychiatric hospital is anxiety-provoking to most CPE students. With greater awareness of safety risks, the fear of doing harm increases. One student commented:

It is hard to comprehend that people who walk around and talk, and wear street clothing are so sick and at risk. People look no different than anyone else. I don’t want to say the wrong thing.

After initial concerns are overcome, Mental Health CPE students document spiritual assessments and write narrative summaries that include a spiritual history, interventions, outcomes, and spiritual care plans. Patients often assume that conversations with chaplains, like all clergy, are confidential. CPE students, who are primarily responsive to consult requests, are trained to obtain informed consent, a process that involves informing patients that chaplains write clinical notes, thus empowering them to decide what they are comfortable with sharing. Furthermore, students’ documentation is co-signed by the CPE educator as required by hospital policy. Chart notes are therefore an ongoing educational tool as well, ensuring that the documentation process offers a means of recording patient interactions in spiritual care.

Confidence in their role also grows as Mental Health CPE students are included in patient treatment plans by other professional team members or as patients offer affirming feedback. Students come away with greater empathy.

One student commented, Now I lean in…I do a lot more listening…and carry less projections of stigma.

As students develop growing competence, they also witness the positive impact of interprofessional team interventions, including S/R care, on patients’ recovery and discharge from the hospital. This can instill a sense of confidence as they use clinical terms, provide psycho-education, and utilize S/R resources to address patient needs. However, as they encounter the severity of mental health crises, they may begin to emotionally distance themselves, acknowledging the profound illness of the individuals they serve.

2.2. Empathy

Students shift from wanting to help mentally ill people to being open to encountering persons who carry diagnosis of mental disorders. A student puts it this way:

One of the greatest lines that I heard in Mental Health CPE is not to say, ‘he’s bipolar’ but ‘he’s a person suffering with bipolar affective disorder’. He has a disease. He is a person with a disease…that to me was a huge, huge take away. that I got - separating the disease from the person’s identity.

In the process of Mental Health CPE, students inevitably explore their own inner psychological landscape as well. Through individual and group supervision, they contemplate their feelings of hopelessness, despair, exuberance, zealousness, anxieties, experiences of loss, relational challenges, and significant life events. They also examine in the process group and in individual consultations their methods of avoiding reality and coping with uncertainty, moments of dissociation and derealization, attachment dynamics, and tendencies to become overly involved or remain distantly observant. Throughout the program, students witness and experience the continuum from mental wellness to severe mental illness. As a result, CPE students increasingly align with the patient and the healthcare team against the illness. Upon completion of the program, a graduate reflects:

At the core is the dignity of every human being. Seeing past the mental health issue or disease to the person underneath. I go back to the human document. That people are so much more…They carry wounds we can’t see, but when you look them in the eyes you treat them with dignity. You slow down. You pace your conversation and make them understand they are the most important person in your world right now. And when you start with that human dignity, then you can help them be seen for who they are, as a person and not as the disease.

2.3. Mental Health Spiritual Care Skills

When engaging in independent spiritual care, Mental Health CPE students often feel initially that the context is no different than others. Their existing interpersonal and care-giving skills are usually affirmed and helpful to the patient. While their naivete may contribute to patient care by offering human connection, kindness, and normalcy, they may not fully understand the complexities of severe mental illness. Recognizing the symptoms of mental illness is crucial for developing mental health spiritual care skills.

As students learn to inquire about patients’ S/R beliefs and how these intersect with mental illness, the clinical case method becomes a cornerstone of CPE learning. Initially, it is aspirational to use the 7 × 7 spiritual assessment model (Fitchett 1993). However, as CPE students learn to connect with deeply troubled individuals, they also make use of key clinical information that becomes increasingly valuable. A graduate reflected:

I realized that spirituality and religion could be a big part of the problem. That was a huge learning… Someone would say, ‘Yes, I am spiritual’ and I am like ‘I’m here’ and then, they start talking and I realized this is a problem… I had no idea that spirituality could manifest that way.

Allowing the patient to lead the discussion while managing the symptoms of psychiatric illness is a significant advancement. Over time, the skill of semi-structured interviewing enables CPE students to avoid being drawn into the interpersonal dynamics of psychiatric illness while also not controlling or shortchanging the patient’s sharing. In case discussions, aspects of S/R, such as beliefs, meaning, vocation, obligation, experience, emotion, doubt, courage, growth, ritual, practice, community, authority, and guidance (Fitchett 1993), are elicited from the presented material. Students also learn to more knowledgeably work with concordant and discordant spiritual orienting systems. Another graduate commented:

A huge moment…was learning that for specific Christian faiths, thoughts and actions were weighted equally, which is very different in Judaism. So, while they had no control of their own thoughts, they were also now doing all these bad, sinful actions. Being able to help them connect the dots with how that was relating to what their doctors were telling them about their illness. You know, help them take the pressure off…

Throughout the program, the CPE cohort and educator collaborate to identify and address biases and assumptions about mental illness, as well as the diverse S/R experiences of patients.

Here is this Latina, who I thought for sure was Roman Catholic, but she grew up atheist. Later in life she studied Buddhism and she meditates all the time. She was so knowledgeable. I am embarrassed that this was a surprised to me.

Over time, Mental Health CPE students refine their understanding, work with biases they have of patients, engage with the projections placed upon them, and develop greater skill in articulating their own and others’ psychological states. They begin to delve deeper into patients’ S/R experiences and concentrate on enhancing their coping mechanisms. They become adept at assessing whether a patient’s cognitive appraisals of their spiritual and religious experiences are linked to positive or negative emotions. For instance, they consider whether a person perceives their challenges as part of a divine plan or as a lesson, or whether the patient feels punished, abandoned, lost, guilty, or haunted.

CPE students learn to connect patients with supportive and benevolent sources of S/R coping, often affirming the individual’s worth, dignity, and sense of being blessed. They encourage active acceptance as a S/R practice and facilitate patients’ engagement with S/R communities. They assist in integrating S/R practices into daily routines and guide patients toward behaviors such as meditation, prayer, or journaling to reduce impulsivity, hopelessness, or anxiety. Drawing from the patients’ values, students help to explore how purpose and meaning can contribute to greater quality of life in patients.

Furthermore, Mental Health CPE students deepen their understanding of disparities in societal perceptions and treatment of mental illness, as well as the social hierarchies and historical power structures that shape these perceptions and treatments. For instance, a patient experienced conflict with his healthcare team while they were working to help him to gain insight into his illness. The situation escalated and the young man ended up insulting the social worker. Subsequently, a CPE student who was present during the rounds took the initiative to approach the patient individually. The student validated the patient’s feelings of frustration, encouraged him to live according to his Christian faith, and suggested that he offer a written apology for his behavior. In reflection, the CPE student stated:

Sweet kid, rough childhood, tough illness. We had to have a talk about forgiveness. When I was in the nursing station, he held his letter of apology up against the glass. Faith can help him get along.

2.4. Self-Differentiation (Table 1)

It is indeed a profound experience for students to engage with individuals who have severe mental illness. It is unavoidable that these encounters also lead to a deeper understanding of the complexities of their own minds, as well as the various factors that have shaped their mental, emotional, relational, and spiritual well-being. The power dynamics inherent in providing care to individuals behind locked doors can be discomforting, especially as students hold the keys. This dynamic underscores the distinction between patient and spiritual care provider. Furthermore, the reality that many patients pose a risk to themselves or others brings to light experiences of suicidal ideation, suicidal behavior, and completed suicides in the context of students’ lives. These encounters can have a transformative effect on students, prompting them to reflect on their own experiences and perceptions regarding mental health and well-being. A graduate of the Mental Health CPE program stated:

And then, walking away and reflecting on it…I am changed as well. It’s a reciprocal relationship… seeing that person, recognizing the change in the human document.

Discussing verbatims in a collaborative and supportive learning group provides opportunities for teaching, feedback, and connecting around similarities while learning from emotional and S/R differences in the peer group. Students learn to become more flexible in their communication styles and deepen reflective listening skills in the CPE peer group. Through this process, participants develop a deeper understanding of mental illness and improve their spiritual care giving skills in a diverse and interdisciplinary setting.

2.5. Grounding in One’s Spiritual Orienting System

Mental Health CPE students witness patients’ ongoing struggles, including medications not working, psychosis not resolving, relapse of depression or substance use, ongoing housing instability, lack of resources, repeated readmissions, and the compounding effects of multiple diagnoses. There are times, when patients’ disorganization, depression, chaotic thinking or frustration is difficult to bear. A student stated:

I have formulated my theology of suffering…But seeing the enormous impact of these diseases makes me wonder, does spirituality really help?

The experience in Mental Health CPE can shake the foundations of the student’s spiritual orienting system. As CPE students witness the depth of suffering, they consider also how their loved ones or they themselves could end up in their patients’ place. They experience their own helplessness and powerlessness, and encounter S/R struggle. One student recalled:

When I met this patient who had a bike accident and ended up with psychosis secondary to his Traumatic Brain Injury (TBI) and he was on his third hospitalization, I thought, ‘Oh my god, this could be me.” I felt so vulnerable.

When Mental Health CPE students reach the limits of their ability to contribute as chaplains, individual supervision becomes crucial for providing the support and guidance needed to navigate S/R struggles. They learn in deeper ways about S/R struggles, including struggles with the Divine, doubts, or demons, as well as their moral struggles, struggles with S/R communities, and vocation and ultimate meaning (Pargament and Exline 2021). Additionally, they witness the pain caused by S/R communities and families in relation to issues such as sexual identity, gender expression, and various forms of abuse.

Furthermore, Mental Health CPE students become aware of the detrimental effects of punishing God appraisals and demonic or satanic forces on mental health, leading to greater depression, anxiety, and suicidality, as well as diminished psychological wellbeing. They are motivated and also reach the limits of addressing these issues to alleviate the suffering of patients. Additionally, they learn how S/R struggles can lead individuals to nihilism, causing a sense of meaninglessness, interpersonal distress, fractured community relationships, and a perceived absence of God or a Higher Power that can deeply impact a person’s identity.

The crisis experienced by most students in Clinical Pastoral Education (CPE) is fundamentally educational. One student noted:

If my patients can have hope, who am I not to?

It is the sense of vocation that is tested and also guides students in the process. In reaffirming their bedrock beliefs, they find greater acceptance of suffering, deeper compassion, as well as ongoing intellectual curiosity. When writing experience of faith papers on topics such as attachment and forgiveness, surviving, covenants with God, and the therapeutics of their own spiritual orienting systems, CPE students delve into their own experiences of spiritual and religious struggles. This reflective work leads to a deeper sense of compassion and greater forbearance as students engage with patients.

The CPE process also fosters increased self-awareness, including S/R integrity, and encourages the beginning use of self. This personal and educational journey is a rewarding aspect of CPE, as it equips students with the tools to engage more effectively with their patients and their own spiritual growth. One CPE student reflected:

Sometimes when we do our best care, the care isn’t enough, and the illness wins and being able to know that I put in my best work and that God knows I did my best and that I know I did my best and that that’s holy.

Another student noted at the end of the program:

I learned just how many people live in the in between spaces. So many people are pulling from different religions and spiritualities.

2.6. Experiential Knowledge of Mental Illness

The Mental Health CPE program intentionally does not provide a general overview of psychopathology. Students learn from their patients, review of medical record, participation in clinical rounds, and via journal club and lectures from the McLean Hospital faculty. A CPE graduate reflected:

The most important thing I learned is not to get hung up on the diagnosis, but to ask the question, ‘what is it like to be you today?’

The integration of interprofessional communication, didactics, and ongoing verbatim and case presentations facilitates the development of an experiential map in students’ minds. As CPE students perceive mental illness more deeply, they cultivate the ability to remain non-anxious, engage in deeper encounters, stay present with suffering, overcome judgment, and integrate cognitive and affective knowledge of mental illness. This educational approach supports students in gaining a comprehensive understanding of mental illness and enhances their capacity to provide compassionate care in diverse healthcare and S/R settings. One CPE student stated:

I can now identify and, in my head diagnose things that before I might have thought ‘something seems off’, but …now I can lean in, I don’t get freaked out…

As CPE students impact the milieus of their assigned units, staff groups, and individual clinical teams, as well as the institution-as-a-whole, they realize that they can continue their impact as graduates of the Mental Health CPE program. Following completion of CPE, many alums start group-based mental health ministries in their congregations, including grief groups and support groups for those struggling with psychiatric illness or caring for someone who does. One clergy stated,

My hope is to reduce the stigma related to people with mental illness… If I talk more about it in the church, in the community, people will be able to seek treatment, seek help, and reduce the stigma.

Another graduate noted,

…advocacy work…I learned how much I can do just by being out there in the world. Not just for my own community…

One alum noted the positive impact on her leadership of her congregation’s board. For many, the leadership role of the community clergy in relationship to mental wellness is clarified. One graduate stated,

I’ve learned to differentiate what’s my role and what is somebody else’s role…I also know there is spiritual care to be done and that’s not the therapist’s work. Differentiating my role from mental health clinicians has been a big piece...

Overall, the program tests and nurtures students’ sense of vocation. Ultimately, it is their passion for making a positive impact on the world that motivates program graduates to apply their learnings in various contexts beyond Mental Health CPE.

We founded an organization that serves as a referral agency for mental health treatment in our community. And training in mental health competencies in our rabbis is ongoing.

3. Conclusions

The Mental Health CPE program addresses the need of psychiatric patients for S/R care, and it offers future religious leaders and chaplains specialized training in mental health spiritual care. The program addresses both the standardized CPE competencies as well as mental health competencies. Mental Health CPE is unique in its focus on the human mind, and it leads to a unique learning experience that changes and transforms students’ minds. It may have the potential also to impact a lifetime of service in ministry and chaplaincy. The program elements offer individual and group supervision for individualized and group learning. Mental Health CPE students’ clinical group leadership in spirituality groups informs and enhances their learning in the CPE group. Personal formation and differentiation facilitate crucial developmental changes, including confidence in the mental health chaplaincy role, increased empathy toward persons with severe mental illness, mental health spiritual care skills that are transferable to other contexts of S/R leadership, self-differentiation, grounding in one’s spiritual orienting system, and experiential knowledge of mental illness.

The Mental Health CPE program at McLean Hospital continues to develop based on students’ feedback. Students may benefit from of didactic instruction that are immediately connected to case scenarios and additional practica/simulation. Ongoing improvement in the materials used in teaching as well as core readings can also improve students’ experience. Future attention will also focus on the arc of the program, arranging educational sessions and topics with even greater thoughtfulness. While it makes for a unique experience for first unit CPE students to participate in Mental Health CPE, there may also be limitations that more advanced students would not face.

This report presents an initial collection of informal feedback from participants regarding their experiences in the program. While these reflections offer valuable insights, future steps will involve a more rigorous evaluation of the program’s impact on participants’ attitudes, knowledge, and competencies related to mental health and spiritual care. Planned next steps include a qualitative study utilizing focus groups with program alumni to assess the extent to which the Mental Health CPE program achieves its intended goals. Additionally, we hope to explore potential long-term effects on the mental-health-related ministries that alumni are engaged in within their respective spiritual and religious communities. Further studies can also expand on existing studies of the effectiveness of aspects of CPE and conduct similar research on the specialized Mental Health CPE program. Furthermore, the effectiveness of program components could be studied, such as group leadership training and the implementation of Sacred Stories groups in mental health and S/R community settings. Other avenues may include the study of the impact of Mental Health CPE on chaplains’ and clergy’s mental health competencies. Future studies could provide insights into improving comprehensive Mental Health CPE programming, further fostering applications of learnings for alums and the communities they serve. Additionally, gathering evidence that reflects patient experiences of spiritual and religious (S/R) integration in mental health treatment may further inform best practices for incorporating S/R perspectives into clinical care.