When To Refer: A Guide for Member Care Providers

by Amber Goodloe, LPC

One of the questions we often get from member care providers (and clients) is “How do I know what kind of help do they need?  When is member care ‘not enough’ and clinical counseling should be considered? When would something like spiritual direction be more appropriate?”  Navigating these questions can feel daunting at times as we want to ensure that those in our care have the right kind of support to navigate what life throws at them. 

Before diving in, let’s define what I mean by these terms:

• Member care: Member Care is the ongoing preparation, equipping and empowering of global workers for effective and sustainable life, ministry and work. (www.globalmembercare.com)
• Spiritual Direction: Spiritual direction is an interpersonal relationship in which we learn how to grow, live, and love in the spiritual life.  (It) involves a process through which one person helps another person understand what God is doing and saying (Richard Foster).
• Clinical counseling: Clinical counseling is a therapeutic process that helps people manage mental health issues. It involves working with a licensed professional to address emotional, psychological, and behavioral challenges.

With physical illnesses it’s sometimes easier to tell when to take someone to the doctor: if they’re bleeding and it won’t stop, if their arm is clearly bent in a way it’s not supposed to, or they have just been sick for so long that you want to make sure it’s not something bigger.  With mental / emotional health it’s a very similar process for assessing what people need.  Sometimes it’s obvious when people need professional care:

• they are having suicidal ideation or engaging in self-harm
• there has been an affair or other marital crisis
• they have been through an intensely traumatic event (i.e. assault, loss of child or spouse, etc) and aren’t coping well
• they are dealing with an addiction

Other times it can be a little murkier – is it “bad enough” to warrant counseling? How long do I let them try to address it on their own before recommending they get more help? Life overseas is stressful; how can I tell when the stress is too high?  When is it normal grief and when does it become unresolved? It’s important to remember that there’s no single right answer here. We each navigate challenges in our own way, with varying levels of resilience, so my first recommendation would be: talk to the person. Don’t just assume or guess you know what they need or don’t need.  This might seem simple (or even condescending) but it’s easy to jump to conclusions without really listening to someone and evaluating their situation with them. 

While talking with them, here are a few questions to consider:

• Is their ability to function in any way impaired by their emotional / mental state? (i.e. are they struggling to get out of bed, are they unable to take care of themselves or their family, are they significantly behind in work / ministry goals, are they having panic attacks and therefore avoiding certain activities?)  If yes, counseling is likely going to be what they need.
• How long have these symptoms been present?  A short period of sadness / stress / anxiety might not warrant professional care if they have the tools to manage and process and regulate their bodies.  However, if symptoms have persisted for more than 4-6 weeks it’s worth re-evaluating what is needed.
• How have mental health challenges affected their life? Have they experienced conditions like depression or anxiety? If so, what strategies do they use to manage their symptoms, and how successful are they in maintaining their well-being?
• What have they tried to address the issue?  Have they availed all their options already and feel stuck or do they not know where to start? 

Another thing to be aware of also is that those with a history of trauma and abuse may experience intense or new triggers on the field, and an area they’ve seen a lot of healing from in the past may resurface in a new way.  It’s important to be aware of this and also be able to normalize it for that person and help them assess what they need.  If they are having flashbacks, nightmares, or other disruptive symptoms from a traumatic event they will most likely benefit from counseling.  Additionally, sometimes the stress of moving overseas forces people to see how certain experiences impacted them in ways they weren’t aware of, and they may see the need to address them for the first time.  For example, someone may have been bullied as a child but never felt the need for counseling until their child experiences the same thing and the parent finds themselves unexpectedly overwhelmed by memories and emotions, impacting their ability to offer comfort and guidance. When difficult memories surface, it’s important to empower that person to process them at their own pace. Evaluate their capacity to manage the emotional impact of these memories, and if they are struggling to cope and the memories are significantly affecting their daily life, professional intervention may be beneficial.

What if their struggle is spiritual in nature?  Have they lost faith in God or are they struggling with their calling?  Do they feel abandoned by God?  These questions can be a result of stress / depression / trauma (in which case counseling would be appropriate) or they can be strictly spiritual and a natural part of a spiritual journey, in which case pastoral care or spiritual direction might be a better option.  In counseling we do often discuss spiritual / faith challenges, but that is not generally our primary focus or training. In these scenarios it’s important to take a holistic view of the person to help them evaluate the root of their challenge.  If they are functioning at a normal level and feel emotionally stable but have deep spiritual questions, clinical counseling is not what they need most.

KIDS & TEENS

Another area to consider is kids and teens.  Your role likely involves helping parents know when and how to get appropriate care for their kids.  Like adults, some scenarios should involve an automatic referral:

• Self-harm or suicidal ideation
• Any experience of abuse (physical, sexual, emotional)
• Severe behavioral regression
• Uncontrollable angry outbursts
• Bedwetting and/or frequent nightmares
• Going through something significantly traumatic
• Debilitating anxiety / panic attacks

However, beyond addressing significant concerns, kids and teens can benefit from counseling for a range of challenges.  These may include difficulty transitioning to a new location, social anxiety, being bullied, struggles with self-esteem, or challenges in the parent/child relationship.  Kids of all ages need, and thrive with, adult support and guidance, so the first step would be to see if a parent or a mentor could help them process what’s going on.  However, if over time their symptoms are not improving, then reaching out to a counselor is a good next step.

In all you do, when someone is struggling it’s better to ask for more help than is needed than to “wait and hope for the best.”  Early intervention can be key to helping people maintain health and thrive in their contexts.  If you or someone you know may be in need of a counselor, please don’t hesitate to reach out to us at Olive Tree to help evaluate what’s needed. 

In the meantime, here are some resources that might be helpful for those who are in the “in-between, not quite ready for counseling” stage. 

Faith and Spirituality Struggles

• Sacred Rhythms: Arranging Our Lives for Spiritual Transformation by Ruth Haley Barton
• Disappointment with God by Philip Yancey
• Spiritual Direction: Wisdom for the Long Walk of Faith by Henri Nouwen
• Learning to Walk in the Dark: Because Sometimes God Shows Up at Night by Barbara Brown Taylor
• Survival Guide for the Soul: How to Flourish Spiritually in a World that Pressures Us to Achieve by Ken Shigematsu 
• Crazy Love: Overwhelmed by a Relentless God by Francis Chan
• Invitation to a Journey: A Road Map for Spiritual Formation by M. Robert Mulholland, Ruth Haley Barton

Emotional Struggles

• Uninvited: Living Loved When You Feel Less Than, Left Out, and Lonely by Lysa TerKeurst
• Boundaries for Your Soul: How to Turn Your Overwhelming Thoughts and Feelings into Your Greatest Allies by Alison Cook PhD, Kimberly Miller MTh LMFT 
• Rhythms of Renewal: Trading Stress and Anxiety for a Life of Peace and Purpose by Rebekah Lyons 
• Emotionally Healthy Spirituality: It’s Impossible to Be Spiritually Mature, While Remaining Emotionally Immature by Peter Scazzero 
• The Ruthless Elimination of Hurry: How to Stay Emotionally Healthy and Spiritually Alive in the Chaos of the Modern World by John Mark Comer
• The Cry of the Soul: How Our Emotions Reveal Our Deepest Questions about God by Dan B. Allender, Tremper Longman

Member Care Resources:

• Grit to Stay Grace to Go: Staying Well in Cross-Cultural Ministry by Sue Eenigenburg and Eva Burkholder
• Rerouted: Caring for Missionaries When Unexpected Trials Bring Them Home by Candice Schroeder
• Essentials for People Care and Development: A Collection of Best Practices, Research, Reflections, and Strategies (Missio Nexus Improve Series) by Geoff Whiteman, Heather Pubols
• Serving Well: Help for the Wannabe, Newbie, or Weary Cross-cultural Christian Worker by Jonathan Trotter, Elizabeth Trotter
• Expectations and Burnout: Women Surviving the Great Commission by Sue Eenigenburg, Robynn Bliss  
• Looming Transitions: Starting and Finishing Well in Cross-Cultural Service by Amy Young
• Third Culture Kids: A Gift to Care For by Ulrika Ernvik