Pastoral Counseling: The art of referral
Editorial note: In the January 2002 issue of Ministry, we published an article by Marvin Moore entitled "Recovery and Pastoral Ministry." Letters of disagreement with the article vied with letters of praise. As a result of this difference of opinion, we have asked Larry Yeagley, one of those who questioned the article on co-dependency and who is a premier pastoral counselor in the Seventh-day Adventist Church, to write an article articulating some of the principles a pastor might consider as he or she seeks to find effective refer ral sources for those who might need counseling beyond the arenas of the pastor's expertise.
I understand that Gus Anderson is your parishioner. Is that right, Pastor?" asked the cardiologist. "Yes," I responded. "I just began my ministry here, so I am not well acquainted with him."
"I don't think that matters. Right now Gus needs your help. Our cardiology team is doing everything we can, but Gus is discouraged and has spiritual issues that we are not trained to handle. Medicine is our expertise, not religion. I think you can make a difference."
The doctor's phone call during the first month of my pastoral internship taught me a valuable lesson in referral and collaboration. Our results were gratifying. After that experience, whenever Gus introduced me to his friends he'd say, "I want you to meet the pas tor who helped save my life."
Years later I was a hospital chaplain. An oncologist stopped at my office. "I'm Dr. Frank. I'm new here and will be admitting cancer patients to the cancer unit. Quite often I have to deliver bad news to a patient. I consider myself a good clinician, but I'm not good at picking up the pieces after I bear bad news. I'm taking you with me to do spiritual follow-up after I visit with families in tough circumstances."
Dr. Frank knew he couldn't do it all. His ability to refer and collaborate made his medical practice more effective.
Pastors who minister within the limits of their competency and use the skills of referral and collaboration when parishioners are in emotional crises are a valuable asset to any congregation. They will realize more healing and spiritual growth in their churches.
Willa D. Meylink and Richard L. Gorsuch reported that while 40 percent of all people seeking help approach a clergy person first, less than two percent of them are referred to mental health professionals.1 This and similar studies indicate a need for pastors to develop their referral and collaboration skills.
What can a pastor do?
Seminary training prepares clergy to counsel people in spiritual matters, to apply biblical concepts to daily life, and to lead congregations in family-friendly worship. Spiritual care-giving is definitely the pastor's area of competency.
Preventive counseling can also be the unique role of pastors, provided they take time to develop what Henri J. M. Nouwen referred to as therapeutic personhood. This requires ongoing study of how Jesus treated people and the prayerful practice in following His methods.
Preventive counseling includes giving hope and encouragement with compassion and a gentle, pleasant voice. Loud oratory that judges sin with scowls and angry voice tones does not produce hope and healing. Proclaiming God's grace to meet the trials of life breeds positive attitudes and the belief that problems can be surmounted by God's ample, intervening power.
Some time ago I spoke to a large congregation on the west coast of the United States about Jesus' desire to enter into our brokenness and loneliness. More than ten years later I met a family in the east coast of the United States who had attended church that day. They told me that they had just gone through a shattering tragedy. They knew that God had led them to that church on that day. They returned home with confidence that God would walk with them through the shadows of sorrow and depression. This is what I call preventive counseling from the pulpit.
Samuel Chadwick once said that pastors should always speak as broken to the broken, as dying to the dying. I heard Henry Nouwen say that the pastor should never come as strong to the weak, as healthy to the sick, as triumphant to the defeated. The pastor must identify with the infirmity of the infirm and compassionately walk alongside the weary traveler.
Ernest E. Bruder wrote, "Deeply troubled people need a pastor with more than just the requisite skills to detect the depth and extent of their difficulties. They need one who can communicate meaningfully to them that, come what may, they can never be separated from God's compassion and concern."2 An emotional crisis can actually be a time of greater openness to the healing grace of God.
Mental health professionals with whom I have worked considered my role to be advantageous and even enviable. In many cases I already knew family histories, including emotional crises. Sometimes I was part of a person's support system during and long after the counseling process. I was a likely person to collaborate with the mental health professional, should that be advisable and agree able to all parties.
As hospital chaplain, I took part in many disaster drills. When the "victims" arrived at the emergency room, several physicians with various specialties served as a triage (treatment assignment) team. They diagnosed those involved and sent them to the appropriate treatment areas. I was a member of the comfort and consolation team. I was never part of the triage team because making medical decisions is not my expertise.
Pastors should become acquainted with the observable symptoms of emotional disorders so they can recognize the need for specialized help, but they are not usually equipped to do psychological triage and diagnosis. Ideally they should have access to a triage professional with the necessary skills.
Some churches contract with a mental health professional to do triage. A few of the pastors in my area have professionals in their churches who volunteer their services to the pastor. The triage professional may or may not end up doing the treatment. Ideally, any referral will be done with the consent of the parishioner and the collaboration of the pastor and the triage professional.
Recently I asked a licensed psychologist when a pastor should refer. His response: almost always. He and other professionals I interviewed emphasized that this answer is not meant to devalue the role of the pastor. It simply is a recognition that the training of most pastors and the training of mental health professionals are different. Both play a major role in the care of church members and others who are in an emotional crisis.
Developing a referral base
Just because the pastor is not an expert at triage, doesn't mean there is no need for him to build a referral base. Ideally the triage person should work with the pastor and the parishioner in making the referral. Many church members are more comfortable about making an appointment with a professional whom the pastor knows.
The following ways of developing a referral base were gleaned from interviews with pastors, social workers, and psychologists who are practicing and teaching doctoral students.
Word of mouth. Listen to parishioners who have had counseling. They'll tell you who to see and who to avoid.
Your predecessor. You'll save time if your predecessor shares his or her referral list with you and indicates the outcomes of referrals he or she has made to particular mental health professionals.
Other pastors. Attend your local ministerial alliance and become acquainted with ministers who have had a fairly long tenure in your community. Once you feel confident of their judgment, ask them to recommend competent mental health professionals.
Physicians. Physicians in your congregation and your family physician may be aware of successful counselors and psychiatrists.
Interview. Mental health professionals are usually willing to be interviewed by phone or preferably in person. They see this as a way of expanding their practice. Ask about their education, licensure, fee scales, average length of treatment, personal religious affiliation or philosophy, approach or approaches used, willingness to consider a person's spirituality and faith values in the treatment process, willingness to collaborate with a person's pastor when appropriate and agreeable with the counselee, willingness to learn about the counselee's belief system.
Seminars. Attend seminars that address mental health topics. Listen to the professionals and ask questions about their methods of treatment.
Mental health agencies. Visit agencies that provide mental health services and ask the director about the therapists and their areas of competency.
Funeral directors. Many funeral directors are aware of counselors who are competent to treat complicated mourning situations.
Ministerial alliance. If you are involved in alliance programming, invite various counselors to share their areas of counseling. One psychologist told me such an appointment resulted in several clergy coming to her for counseling.
Chaplaincy. Volunteer your services as an on-call chaplain at your local hospital. This puts you in touch with medical and para-medical professionals who often know reliable mental health professionals.
Keep notes. When parishioners report favorably or unfavorably about their counseling experience, make notes for future reference.
What to avoid
Counselors who refuse the services of mental health professionals may risk the mental health and even the life of the counselee. I have met patients in psychiatric units who attempted suicide and suffered from severe depression for years because "counselors" discouraged them from consulting professionals who would have successfully treated them.
Avoid counselors who have little regard for the sanctity of marriage commitment. A nationally known marriage counselor conducted a conference in my city. He told couples who came for counseling, "You need to know that I believe in saving marriages. If you are here to save your marriage, I'm your counselor. I'm not in the business of helping people to justify divorce." I admired his approach.
Beware of a counselor who is fixated on one method, some "proven" formula or trendy technique that has supposedly worked for most people. A widely read pop-psych author claims that his "biblical" method heals 60 percent of depressed clients without the use of antidepressants. He relates no research data to back up his claim.
Repressed memory therapy is suspect in the eyes of the mental health professionals with whom I have worked. This approach often creates false memories that complicate the healing process.
Treatment that involves extremely long periods of time and consists mainly of introspection and looking to the past is seldom productive.
"A clinician who regards all religious belief to be pathogenic is not only disregarding the weight of empirical evidence but also is likely to manifest this prejudice in practice."3
Counselors who subscribe to the co-dependency/recovery grassroots movement should be avoided on the basis of the analysis of competent professionals, some of whom have authored well-received pastoral counseling texts. Advocates of the codependency disease theory make bold and sometimes contradictory claims.
Sharon Wegscheider-Cruse believes that 96 percent of the population have the primary disease of codependency. Anne Wilson Shaef states that trying to generate definitions of co-dependency from a rational, logical premise is a manifestation of this disease process. She estimates that 80 percent of all helping professionals are co-dependent and perpetuating the disease.
There are few who are not affected by the "disease." In Melody Beattie's book Co-dependent No More I counted 234 characteristics of this "disease" which she claims is not an all-inclusive list. She sees this "disease" as a process that must be treated by attending recovery groups for the rest of one's life. John Bradshaw claims that 100 percent of people today are co-dependent.
On the other hand, according to Stan J. Katz and Aimee E. Liu most of the feelings and behaviors listed as co-dependence traits are perfectly normal. They do not indicate that we came from dysfunctional families or are in one now. They do not seek to prove that we are addicts or that we have a dread disease. All they maintain is that the authors of these lists have contrived a theory so broad, so multifaceted that it is virtually meaningless. "According to co-dependence leaders such as Bradshaw, Shaef, and Melody Beattie, everyone is sick until proven healthy. This rule particularly applies to anyone who works in a medical or mental health profession."4
Feelings of rejection can be avoided if pastoral referral is prefaced by a statement similar to the following. "I do not feel competent to guide you in this matter. I would do you a disservice by trying. I value you too much. I'd like to help you find a competent counselor who can help you move through your situation as quickly as possible. With your written permission I will work with you to find the best referral. This doesn't mean I will not be available to encourage you spiritually; in fact, I will meet with you a week or two after your first two appointments to make sure you are satisfied with the referral. Throughout and after your counseling I will be a part of your support system."
It is appropriate to tell your parishioner that you are willing to collaborate with the counselor, not as a second professional counselor, but as a spiritual guide. This, of course, would be with written consent.
An occasional phone call, informal query, or personal visit can be a source of encouragement to your parishioner.
When I began chaplaincy in psychiatric units, I was viewed with skepticism by some mental health professionals. It took two years of persistent effort to gain permission to attend treatment team meetings.
Progress has been made since then. Empirical research into the effects of integrating spirituality into treatment has been encouraging. More and more, pastors are valued by mental health professionals. Both disciplines are communicating to the benefit of people in emotional and spiritual crises.
Ministry reserves the right to approve, disapprove, and delete comments at our discretion and will not be able to respond to inquiries about these comments. Please ensure that your words are respectful, courteous, and relevant.comments powered by Disqus
1 See Journal of Psychology and Christianity 7 (1988)1: 56-72.
2 Ernest E. Bruder, Ministering to Deeply Troubled People (Philadelphia. Fortress Press, 1964), 50.
3 William R. Miller, ed., Integrating Spirituality Into Treatment (Washington, D.C.: American Psychological Association, 1999), 12.
4 Stan J Katz and Aimee E. Eiu, Tne Codependency Conspiracy (New York: Warner Books, 1991), 16, 17, 43