I had two church members who were threatening suicide whom I had to refer to professionals. My dad while in a nursing home, threatened suicide. When I informed the nursing home personnel of Dad’s threat, they immediately called the police who transported dad to the hospital. This is the law in N.C.
In Kent R. Hughes’ The Pastor’s Book the subject of when to refer your counselee is covered in chapter 10 by Robert W. Evans. The chapter is entitled “Pastoral Counseling.” Dr. Evans is well qualified to discuss this topic: Robert W. Evans is pastor-teacher at Christ Church in Pleasanton, California, and president of Veritas Ministries International. He has a Ph.D. in clinical psychology and a Ph.D. in systematic theology, having received his education at UCLA, UC Berkeley, Fuller Theological Seminary, Trinity Evangelical Divinity School, and Harvard University, among others. Prior to his call to full-time ministry, he was a psychologist in both hospital and private practice (p. 522).
Dr. Evans advises: Don’t fail to collaborate and refer. No counselor is good enough to do it all. Learn to refer to trusted professionals with whom you have nurtured a good working relationship and do so often and early. One of my saddest experiences as a psychologist was speaking with an elderly Christian man and church leader who had killed his dear wife of many decades by repeatedly stabbing her with a knife. He had been seeing a pastoral counselor for some time who had failed to refer him when there were clear signs and symptoms indicating that he should have done so. It is hard to make a mistake by referring.
Difference referrals a counselor may receive or make
Dr. Evans provides the following scenarios when to do referrals.
1. Counselee initiates contact.
These are the most productive because the counselee knows he has a problem and has taken the initiative to do something about it.
2. Court-ordered therapy referrals.
These are the least productive because they are the opposite of the counselee who initiates the contact. The court-ordered counselee is there most of the time only because of necessity.
3. Third-party referrals.
These can become counselee-initiated contacts when Dr. Evan’s example is followed:
When a third party asks him to contact a friend in need of counseling, in most cases, he replies: “I appreciate your concern for her and your confidence in me. Would you please ask her to contact me? Here’s my card. And please tell her that I am happy to receive her call and that I am very much looking forward to speaking with her.” In short, encourage self-referrals whenever possible, but be like the Good Shepherd, who goes after his sheep whenever necessary.
4. Emergency referrals.
Dr. Evans states you should stop counseling and, when appropriate, advise the counselee that you need to make an immediate call for help if he begins talking about harming himself or someone else, committing a crime, abusing/neglecting a child or elderly person, or showing signs of being gravely disabled. By “gravely disabled” I mean any disturbance in the quality of his thinking (e.g., the counselee’s speech is odd or confused), reality testing (e.g., the counselee is saying or doing things that suggest he is not connected to the real world), or his ability to care for his own or a dependent’s health and/or safety needs (e.g., appearing disheveled, malnourished, at risk for placing himself or another in a potentially harmful situation, lacking basic hygiene, or intending to drive while intoxicated).
Pierre and Deepak agree: You must disclose information that protects people from abuse or deadly harm. When a person threatens suicide, homicide, or any abuse of children, elderly folks, or dependent persons, you must immediately report to authorities. If you have reasonable suspicion or direct admission from your counselee that such abuse has occurred already, you must report this as well (Pierre, Jeremy; Reju, Deepak. The Pastor and Counseling (9Marks) (p. 119). Crossway. Kindle Edition).
5. Must referrals
Dr. Evans gives three examples of must referrals.
1) when there are disturbances in sleep and appetite. In this case, the counselees’ medical doctor should be called to make an appointment.
2) if the presenting problem(s) for counseling is/are beyond your proficiency, you should refer. Sometimes the counselor quickly knows when he is not equipped to help someone responsibly with a particular problem ... should there be no progress at all after three or four sessions, you should refer.
3) Referrals should be made with those suffering from major mental illness or long-standing and pervasive disorders in mood or identity.” Pierre and Deepak mentioned neurological issues like dementia would be an example when the pastor must make a referral.
Pierre and Deepak noted that “The fall gave us not only a spiritual bent toward sin but also a decaying body. Disease corrupts every part of the body, from muscular and cardiovascular systems to endocrine and neurological (which includes dementia). We are stewards of the body as much as the soul. Thus, pastors should always encourage regular medical care” (Pierre, Jeremy; Reju, Deepak. The Pastor and Counseling (9Marks) (p. 125). Crossway. Kindle Edition).
The debate on the subject of a referral to a secular psychologist or psychiatrist
Dr. Evans shared his view: All things being equal, I refer to a competent Christian psychologist or psychiatrist when that option is available. However, I refer to a competent non-Christian psychologist or psychiatrist before I refer to an incompetent Christian psychologist or psychiatrist if I must choose.
Pierre and Deepak add that “a good psychiatrist knows that his or her focus should be on the medical aspects of the problem and not venture into spiritual, moral, or relational counsel (Pierre, Jeremy; Reju, Deepak. The Pastor and Counseling (9Marks) (p. 127). Crossway. Kindle Edition).
When the pastor must make a referral, Pierre and Deepak give these suggestions for helping the pastor help his member locate medical or psychiatric help? The answer lies in finding the right kind of doctor. Here is what you need.
1. A doctor who is competent.
2. A doctor who is willing to communicate with the pastor.
3. A doctor who is affordable.
Health insurance is only becoming more complex to figure out. Costs are dependent on whether a doctor is in-network or out. Added to this complexity is the recent reality that many private practices have stopped billing insurance at all because the reimbursement process, red tape, and hassle are so cumbersome that the quality of the practice suffers.
6. Should referrals.
Should referrals are made so that the pastor does not overextend himself. Dr. Evans sets a common procedure that can be followed by most full-time pastors: You may want to consider starting by offering fifty-minute sessions, as appropriate. That would translate into between two to four hours of counseling a week. That’s plenty. Additional requests for counseling might best be referred to others, depending on the nature of the issue or problem. For most pastors, when this number is exceeded, it is time to refer to other churches or counseling ministries that the pastor trusts.
Three Resources in Your Community for Referrals
Pierre and Deepak discuss these three resources:
The counseling resources you will find in your community will generally fall into one of three categories: (1) church or parachurch counseling, (2) professional counseling, One church counseling ministry in our area is LIFE SUPPORT COUNSELING at Triad Baptist Church in Kernersville, NC. (3) medical or psychiatric help.
In their discussion of professional counseling, Pierre and Deepak gave this disclaimer: “We would warn you more strongly against a professional Christian counselor who is weak in his biblical framework of human problems than against a psychologist who does not claim to be Christian. The lines of distinction are at least clear in the latter case. In the former, they are blurry ... A guy with a Bible is not enough” (Pierre, Jeremy; Reju, Deepak. The Pastor and Counseling (9Marks) (pp. 122-23). Crossway. Kindle Edition).
Pierre and Deepak gave this example. Let’s say a professional Christian counselor and a professional secular counselor advise your member to go into his bedroom and punch a pillow when his wife angers him. This seems reasonable. It’s certainly better than punching his wife, and the pillow is replaceable. If the professional Christian counselor has advised this, your member might assume that this is biblically based advice. After all, it doesn’t seem unloving to others or dishonoring to God to treat a pillow viciously. A professional Christian counselor giving such pillow advice would likely cite Scripture to make his point, maybe showing how Jesus directed his anger appropriately by overturning the money changers’ tables and not striking the money changers themselves. And this would seem reasonably biblical to your member. But the problem with this advice is that it’s based on a faulty understanding of people: that their negative impulses should be expressed so long as they are directed toward safe objects. This reasoning is only a sad attempt to baptize an unbiblical anthropology. The apostle Paul would scoff at such advice, saying that it merely indulges a “fit of anger,” which is a “work of the flesh” (Gal. 5:19–20) (pp. 123-124). Crossway. Kindle Edition.
Pierre and Deepak conclude their chapter on referrals with this advice: The bottom line is that you cannot hand off responsibility for the soul of a member to another caregiver, Christian or not. Referral is not a handing off, but a problem-specific supplement to the biblical view of life you are responsible to instill. This process is not always clear, but with the principles laid out, you’ll have a good chance of maintaining the biblical discernment you’ll need to use outside resources wisely (p. 128).
In this chapter on Pastoral Counseling, Dr. Evans covers the theory and practice of pastoral counseling which is a great compliment to Pierre’s and Deepak’s chapter eight in The Pastor and Counseling: The Basics of Shepherding Members in Need.