The church attracts people with problems, including mental and emotional problems. This is not a negative criticism. People with emotional problems see the church as a caring, concerned community and turn to it for help. The wise pastor is aware that he is not capable of meeting every need of every per son, and so he builds a list of other persons and agencies—psychiatrists, clinical psychologists, psychiatric social workers, certified counselors, hospital chaplains, mental-health centers—to whom he may wish to refer individuals.
The pastor then builds a working relationship with each of these professionals and agencies so that his list is more than mere names. As pastors we have many opportunities to make referrals. According to a study done some years ago, 42 percent of those seeking help turn to their pastor first (Gurin, Veroff, and Feld Study, 1959). But this same study revealed that only 9 percent of those who come to us are ever referred to another professional. What happens to the remaining 91 percent? Of course, many of them have no desire to look to anyone else for help. This says something about the kind of help people expect to receive from us. Usually they are looking for "spiritual" help that will enable them to cope with their problems or to maintain their present life style. Rarely do they turn to a pastor for help in changing their personality or life style. For this kind of help they are more likely to go to a psychiatrist than a pastor.
Also, in many cases no referral is necessary, because the person seeking help feels that his pastor has provided the help he needs. In the Gurin survey 65 percent of those who saw a pastor said they were helped. Thus, many of those who come to us would see a referral to a psychotherapist as unnecessary or inap propriate if not actually insulting.
Why do pastors make referrals?
Yet, pastors do make referrals. Ac cording to the Gurin study, pastors refer to a professional psychotherapist or mental-health agency one of every eleven who come to them for help. Some of the reasons we as pastors make referrals are: We may consider that the per son's needs are beyond the scope of our professional competence. Or we may doubt our ability to counsel. Those who have problems beyond our expertise should be referred to an appropriate source of help. But making a referral does not always indicate that we are aware of the advantages of doing so; it could be that we are simply confused and don't know what else to do.
We may need to set limits on the number of clients we are seeing. Preaching the Word, preparing sermons, teaching the pastor's class, conducting Bible studies, and chairing the quarterly business meeting leaves us little time to see more than two or three counselees per week. So we deliberately limit the number of sessions with each person. When a person still needs help after one or two sessions, we make a referral to a professional counselor or psychotherapist.
Sometimes we make a referral be cause the client is either a church officer or a close personal friend. We get around this potential problem by referring the client to another pastor or to a professional therapist. Some pastors have a reciprocal arrangement to counsel each other's parishioners.
We may make a referral because we don't like the person or because we feel that there is not a good relationship be tween us. We are convinced that some one else, anyone else, could establish a better therapeutic relationship.
Let's observe some reasons why pas tors make so few referrals (only 9 per cent of those who come to us for help initially).
We may be ashamed to admit either to the parishioner or to ourselves that we cannot help the sheep of our own flock. We believe that, as Christ's undershepherds, we should care for the flock over which He has made us overseers, and our fear of being criticized should we apparently fail to do so may keep us from making a referral.
We may feel indirectly responsible for our parishioners' problems. "After all, if I had been taking proper care of the flock, this person would not need special help. The very least I can do is to try to help him somehow."
Sometimes we resist making a referral because we are afraid that the client will tell the other therapist too much about the situation in the church and then someone else will know about our "failure" to care for the flock. We are protecting our reputation.
Conversely, we may fear that the other therapist will woo our clients from us. We may enjoy having people look to us for help, and consciously or unconsciously are competing for the privilege of ministering to the client. We fear that if we make a referral, the person may not need us anymore.
We may fear that the "worldly" therapist will harm the "vulnerable" parishioner and destroy his faith.
We may not recognize the seriousness of the clients' problems and their need of psychotherapy. It is understandable that we might lack formal training in differential diagnosis. Most pastors, how ever, are able to read their own feelings and are aware when the clients' needs are beyond their expertise. Still, we often turn a deaf ear to what our better judgment may be telling us.
On the other hand, we may resist making a referral because we are confident that we can handle the situation ourselves. This assessment may be true, but often we have an exaggerated opinion of our ability. A pastor with a "God complex" sees a referral as tantamount to admitting that he is less than omnipo tent.
Resistance of the client
Another factor in the low rate of referrals made by pastors is the resistance of the client. Making a referral involves much more than just recommending that one who has come to us for help go see a psychiatrist or other professional. Referral is skilled work demanding all the competence we possess.
Many times the person being referred interprets this act as rejection. These feelings are likely to be heightened when the referral is to a psychotherapist. In such cases the individual may see him self not only as "unloved" by his pastor but as being pronounced "sick in the head"—a diagnosis much worse than being just "sick" or having a "spiritual problem." And, to be quite honest, sometimes we are rejecting our parishioners when we refer them to another professional. We may be trying to get them off our back. If we take time to deal carefully with the person's resistance to being referred, the parishioner is less likely to experience rejection and more likely to interpret the referral as an act of genuine caring.
The client's resistance is often associated with his expectations. Usually a parishioner turns to his pastor because he believes the pastor is the one most qualified to help. Therefore, an attempt to refer him to another professional is resisted because it implies that we are not agreeing with his judgment and that we are suggesting he needs a different kind of help. The referral process needs to deal with expectations. We need to explore what the individual understands his needs to be and what he believes we are capable of doing for him. This may involve some reality orientation. Some who turn to us for help may, in our opinion, need the help of a physician, a surgeon, or a psychiatrist. But in their opinion all they need is a "prayer of a righteous man." Some come expecting that we will put our hand on the spot and exorcise their pain. Others expect that we will anoint them with oil in the name of the Lord. Others are not sure just what we will do, but they believe that in coming to show themselves to us they will be healed just as the lepers were cleansed by showing themselves to the priests.
Therefore, to refer such a person to a physician, a surgeon, or a psychiatrist, and have him show up for his first appointment requires more than just writing the name of the doctor on the back of our card. We will need to be frankly honest in regard to what we believe we can and cannot do to help.
Factors for successful referrals
A positive relationship between our parishioners and ourselves is the single most important consideration when making a referral. The more confidence our members have in us, the more likely they will be to turn to us for help initially, and the less likely they will be to resist a referral from us to another professional. When we desire to be helpful and recognize the importance of a good relationship, we accept our share of responsibility in developing a good rapport with those who may later turn to us for help.
A skillful evaluation of the problem is also important. It is here that most of us sense our inadequacy because we lack training and experience. Seminaries are recognizing a need for more emphasis in this area, but most of us still feel we have a long way to go in understanding and evaluating people. Although we may lack diagnostic skills, we can improve the referral process by faithfully giving the client our evaluation in a straightforward manner, kindly and honestly, without exaggerating or minimizing the situation as we see it. By employing deceit we may manipulate a client into seeing a therapist, but at the same time we may be establishing dynamics that will get in the way of therapy and possibly cause a sudden termination of treatment.
The client is more likely to accept the referral when he or she is not just "tossed," like a basketball, but handed over carefully. There are several ways of doing this. The two therapists may have a conference to discuss the client's history; the client may be seen in a joint therapy session by both therapists; the two therapists may both see the client separately while the referral is being effected and while the resistance to the referral is being dealt with; the pastor may continue to provide "theotherapy" throughout the period the client is receiving psychotherapy. While the last option may seem to be the obvious choice, it is not easy in practice, for it requires a clear definition and distinction of roles and good cooperation between the two therapists. The danger is that some patients are manipulative and will try to play one therapist against another. Sometimes the therapists have conflicting goals for the client.
Referral, then, is a process in which both the resistance of the pastor and the resistance of the parishioner are explored and dealt with. The process is a part of pastoral care to a person's entire health—physical, mental, and spiritual—and is often the most helpful act we can perform for a parishioner. By in creasing our efficiency in making referrals, we can increase the effectiveness of our own ministry and at the same time increase our profession's contribution to a broader field of ministry.