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Boundaries in Church Therapy

Many people ask me, “How does it work for the professional therapist to see clients at his or her own church? Doesn’t that violate counseling boundaries?” This is a great question that is worthy of attention. Clearly professional counselors are bound by ethical codes, such as the one created by the American Counseling Association. Boundaries must be in place to protect the therapeutic relationship, the client, and the counselor.

Licensed therapists practice in a variety of settings, such as hospitals with a group milieu and agencies that offer wraparound services (multiple providers offering different aspects of treatment all around a common goal). Those in private practice typically only see the client in the office and do not interact with clients outside the office. For the private practice setting this is absolutely essential for both the client and the counselor as this is the agreed-upon context in which the work can take place.

Church therapists are professionals working on a church staff. You are a part of the church’s leadership team, offering insights and education to pastors as well as providing care in the context of the church. Your office is in the church building. When thinking about appropriate boundaries, it is critical to first look at the context of treatment. Where and how have both you as the counselor and your client agreed upon for treatment to take place? In church therapy, both the counselor and the client have entered into treatment with the understanding that work will take place in the church building, that the pastors are a part of the treatment team (be sure to have the client sign releases for any pastor or other provider to whom you may speak), and that the counselor will be present in other areas of the church building at other times when therapy is not in session.

Now we enter the more complicated realm: when the church therapist and client see each other in the church setting but OUTSIDE the therapy office, how do they interact? I personally begin treatment with the client by talking about this before we begin any work. I assure them that I will never ask them follow-up questions or get therapy updates outside of the therapy office. I ask the client to use my voicemail to reschedule appointments rather than approaching me in church. Once I was even asked if I would ever share a prayer request about one of my clients… (That would be a big NO!). My clients and I may wave or say hi in the church building, just as I would with anyone else. The goal here is to make your interaction with clients at church mirror your interaction with anyone else. Remember, even the fact that a client is coming to see you must remain confidential along with the content of the therapy itself. Only those for whom the client has signed a release form can know that he or she is in treatment with you. To be a successful church therapist, you MUST be on guard to keep very tight lips.

Because the church therapist is on church staff in the role of professional therapist, anytime he or she is in the church building he or she is in that role. Those in private practice or agency work have the right to expect that their church experience will be their own and will not become complicated with client interactions. Their place of work is outside of the church setting, and as a result their client interactions are all separate from their church lives. However, the church therapist is one who has felt a calling to church leadership AND to counseling. Therefore, your expectation is to be “on” when you are at church. This is more similar to the role of pastor in the sense that your social/spiritual life is supplementally fed outside of your church.

It is critical for the church therapist to realize that he or she cannot develop many intimate friendships at church. I personally have a small handful of confidants, 2-3 of whom attend my church and 2-3 of whom do not. Those I trust who do attend my church never ask about my work and I never discuss it with them. We also have a clear understanding that (much like the pastor) when we are at church I am in the role of on-staff therapist. Within that church leadership role, I lead ministries related to prayer and caring for the soul. My focus is not on catching up with my friends at church. Rather, we set aside intentional times to connect outside of church. I will talk in more detail about this in a later post about self-care for the church therapist.

The American Counseling Association has some helpful information on this topic. Here is a useful link  related to dual relationships: http://ct.counseling.org/2006/12/new-guidelines-on-dual-relationships/

The following article which can be read in its entirety on web.ebscohost.com also offers help on this topic:

Haug, I. E. (1999), Boundaries and the Use and Misuse of Power and Authority: Ethical Complexities for Clergy Psychotherapists. Journal of Counseling & Development, 77: 411–417. doi: 10.1002/j.1556-6676.1999.tb02467.x

*One final note: the article focuses on “clergy psychotherapists” in which the therapist IS the pastor. In my definition of church therapy, the church therapist is on staff for the primary purpose of providing counselor and does not take on pastoral roles with clients. This role definition is useful in the development of clear role expectations.

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Increasing Accessibility: When Proximity Works

Since the time of Freud and his trained psychoanalysts, there has been a belief in the counseling world that counselors must be distant from their clients. While boundaries are critical to any successful therapy experience, human connection does not need to be rejected. Carl Rogers certainly did his part to change this idea, emphasizing the importance of genuineness and unconditional positive regard given by the counselor. Now there is much data to support the idea that the relationship between the therapist and the client is the largest factor in the success of the therapy.

Despite this move towards relationship and connection, the mental health field still has systemic flaws when it comes to decreasing stigma and increasing accessibility to services. Many still believe that all dual relationships must be avoided, despite changes made in 2005 to the American Counseling Association’s code of ethics allowing for “helpful” dual relationships. Many therapists believe that they cannot be known at all by their clients, even though it is often helpful for clients to hear that their counselor shares in human experiences.

Within the church context, extending genuine love to others is a key principle demonstrated by Jesus himself. Human connection, infused with the love of God, is a powerful force of change that can produce healing. Church therapy, then, must be centered around the idea that we foster genuine love within our therapy. Within this framework, the church therapist is one who is known and who is available. There is no stigma in needing love, since this is the state in which we all find ourselves. There are no barriers to accessibility of counseling, because it is available to all in the church who are in need.

When a person experiences a problem in life (whether it be trauma, depression, anxiety, or adjustment problems), one of the most difficult things he or she could do would be to go to an unfamiliar office in a building they have not seen before and talk to a stranger about the deepest hurts of the soul. Without church therapy, this is the only option for obtaining professionally trained help. But church therapists have had the opportunity to demonstrate to those in the church that they are trustworthy. Proximity, usually avoided in counseling relationships, actually offers safety and comfort. The church therapist’s office is located right within the church walls, directly in the place of deep security and familiarity.

Many in the mental health field would argue that anonymity and distance make therapy a safe experience for the client and therapist.  For some, this may be true. However, it is my belief that proximity and familiarity actually offer a kind of safety that allows those who would otherwise avoid counseling to feel able to enter in. Church therapy promotes accessibility and decreases stigma because it creates a church culture that says, “We expect you to need help. We are here for you.” This culture inherently encourages those who might not have sought help otherwise to come and receive services that can free them from emotional burdens.

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Addressing Dual Relationships: Should Pastors Counsel?

In most ethical codes for counselors, there is mention that the counselor should seek to avoid dual relationships that are deemed harmful to the client. There are some areas that are never a good idea (having a sexual relationship with a client) and there are some grey areas (living in a small town and coaching Little League where a client’s child is a participant). Some dual relationships can be prevented, and some are unavoidable especially in smaller communities. Christian communities, even within large cities, can often feel small, with many overlapping circles. Unless you live very far from where you work, even the Christian counselor in private practice is likely to have some unavoidable dual relationships with clients.

Dual relationships, however, are not always harmful. The very first question to be asked with dual relationships is this: does the relationship help or harm the client? In an article published on the website of the American Counseling Association, one of the authors gives an example in which he counsels parents who are raising children with muscular dystrophy. The counselor is knowledgeable in this area because he too has a child with muscular dystrophy. As the counselor serves on agency boards and is active in the community in support of causes related to muscular dystrophy, he frequently interacts outside the counseling arena with his clients. This example is highlighted as a beneficial dual relationship, in which the counselor actually gains MORE credibility with his clients because of his work outside the therapy context.

In 2005 American Counseling Association Code of Ethics was updated to increase clarity about dual relationships and opened the door for beneficial dual relationships to exist. This change was of tremendous help to the Christian community, as counselors available to help church members face this problem daily. Can you see clients from your own church? Can a pastor serve as both a pastor and a counselor? Are these two roles or one?

The Church Therapy model suggests that the professional on-staff counselor is always in the role of counselor. Most larger churches no longer have only one pastor; rather, a team of church leaders work together to handle preaching, teaching, pastoral care/visitation, mercy ministries, and discipleship. Because of the growing awareness of mental health issues within the church, more of these problems are coming to light and are requiring treatment. A church therapist can serve as the person who handles these issues, both with individual therapy and with groups, leaving other pastors freed up to focus on other responsibilities.

Pastors will always meet with parishioners to help them walk through life’s challenges. But when these challenges involve complex emotional issues that will take more than 2-3 meetings to resolve, the church therapist can take over. Because in this model the church therapist is a licensed professional, he or she can properly assess, diagnose, and treat these mental health issues within the context of discipleship and spiritual growth. In this team approach, the pastor can do more of what pastors do very well: admonish, teach, correct, and offer care and support.

When the pastor attempts to counsel in a therapeutic sense in addition to all these other roles, the power differential becomes too great. I have personally seen very complicated situations in which pastors are involved in both counseling and church discipline. In my opinion, the person providing a safe place to talk and work through issues cannot be involved in making church discipline decisions. This dual role undermines therapeutic safety and trust. The Church Therapy model allows for the person undergoing church discipline to continue to see the church therapist, even if he or she has had to be removed from ministries or other areas of the church. In this way, the church continues to offer an option for healing and restoration and the therapist maintains a safe relationship with the client.

Pastors play many roles: shepherd, mentor, coach, leader, guide, teacher, host, and hospital visitor. Adding therapy into that mix often leads to confusion and boundary crossing on the part of both the pastor and the client. Ethical, professional therapy done right will keep the therapy space sacred. Even when the church therapist interacts with the client in other parts of the church building, the therapeutic relationship is kept at the forefront. Confidentiality and clear expectations have been established and are maintained as the top priorities of the church therapist. A pastor simply cannot maintain all of this and do his or her job of leading well.

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The Impact of Trauma on Relationships and Spiritual Growth

Throughout my career as a counselor, I have worked with many people who have experienced trauma, some of whom suffer from Post-Traumatic Stress Disorder (PTSD). When we think of PTSD, we sometimes assume these are veterans or victims of violent crime. Less obvious, and certainly far less often disclosed, are victims of sexual abuse by family members. Sadly, this is a common occurrence and as a result  many in the Church suffer with lasting affects of this quiet type of trauma.

I have seen commonalities in the responses of those who have been hurt or traumatized by family members. Their relationships with God and with other close, seemingly “safe” people are affected by the trauma of their pasts. This is especially true in a church context, in which the family environment can be triggering for those who have experienced abuse at the hands of those who were supposed to be trusted authority figures.

I created a worksheet that helps explain these patterns, which disrupt one’s relational and spiritual life. It also shows a way to break the cycle using mindfulness of the present.

Click here to view the worksheet: Trauma Response Cycle

Please feel free to share this worksheet with others, and check out my books on Amazon for other helpful resources on mental health and spiritual growth.

 

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Groups, Workshops, and Classes: How the Church Therapist Can Expand the Reach

Church Therapy is primarily focused on providing mental health services such as individual, couple, and family counseling in the church setting. However, the Church Therapist can play a key role in the life of the church in many other ways. In the infographic explaining the Church Therapy model, consultation is mentioned, and this is primarily done with the pastors on specific cases or general questions about mental health issues.

For the general congregation, the Church Therapist can be a valuable resource even for those who do not directly seek counseling services. For example, I lead a weekly Recovery Group that is free and open to anyone. Other ideas could include peer-support groups for mental illness that the Church Therapist oversees as well as issue-specific groups like a trauma group or depression group. This type of group therapy can be billed through insurance companies.

The Church Therapist can also offer workshops. I offer psychoeducational workshops on my books as well as other helpful materials out there related to emotional health for the Christian life. Workshops can be half-day or full-day, and can be held in the church auditorium to avoid overhead costs of renting space. Making this type of event a norm in your church helps keep mental health at the forefront of conversation and offers people valuable tools for their own positive growth.

Finally, the Church Therapist can teach Sunday School or elective classes on topics related to mental health and the Christian life. I have created an 8-week small group curriculum designed to decrease stigma and educate Christians about mental illness. These classes can provide education for the whole congregation, whether or not they personally struggle with mental health issues. This information helps create a culture of understanding which goes a long way when a person comes to anyone in the church expressing a struggle.

The presence of a therapist on staff at a church creates a culture that has an ongoing dialogue about emotional and mental health issues. This culture, through all the various ways the Church Therapist engages with the congregation, opens doors of safety for those who are suffering so that they can get the help they need.

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The Church as the Therapeutic Milieu

Throughout my career in the mental health field I have worked in almost every type of therapeutic setting out there — inpatient hospital, outpatient clinic, in-home outreach, group home/residential setting, and the church. I believe it is because of my wide range of experiences that I have come to view the church as a therapeutic milieu, with staff addressing a variety of needs and peer groups in which to work out therapeutic problems. Church Therapy is not tremendously different in therapeutic structure from secular mental health agencies that provide therapists, case workers, psychiatrists, crisis teams and the like all working together on a single case. But unlike these secular settings, Church Therapy works with the whole person, including their spiritual development as an integral part of addressing their mental health needs.

Recently I was working with a client who has difficulty with trust in relationships. We have spent a good deal of time in individual therapy processing the trauma that is at the root of her lack of trust, and we have wrestled through what it means to build safe relationships. Because she has been hurt within her former church, we had a critical therapeutic decision: run from the church because it is not safe or run to the church in a new way that rebuilds trust and actually allows Christ to restore what was broken.

One of the things that is essential in any therapeutic milieu is safety. Whether you are on an inpatient unit or in a client’s home, there are various boundaries and structures that make that environment safe or unsafe. And just as there are many secular therapeutic settings that turn out to be unsafe because those structures collapse, there are many church settings where there is not relational, emotional, or spiritual safety. Let this not cause us to give up altogether on the church context. Rather, we must build new church cultures and structures that restore safety and rebuild trust. The Church Therapy model is designed to do just that, bringing a professional counselor onto a church staff in order to influence the church culture in a direction of emotional safety and create accessible mental health services within the church.

As I worked through strategies with my client about how to work on building trust, I raised the idea of using our Wednesday night small group setting as a means of testing the waters. Here we have exactly what we are looking for: a place to build relationships slowly focusing on a Bible discussion rather than on personal issues. The fact that the small group structure exists in a context with which we are both familiar creates a tremendous opportunity for healing. Safety is there because I can oversee the entire process from a therapeutic standpoint. I can help her navigate the challenges because I am heavily involved in the Wednesday night program as a church staff member. Were I operating in a off-site, private practice, I would not have the opportunity or influence to guide that process correctly. And without that ability to sculpt and shape the context to which I am sending a client, a great deal of damage could be done if the small group turns out to be emotionally unsafe after all. I also have the ability to help the client interpret and understand various social dynamics because I have first-hand knowledge of those dynamics. I am not merely relying on the client’s report of what happened in a small group; I am a direct witness to the program as a church staff member.

The Church Therapy model does not exist merely to provide mental health services within the church as a set apart ministry. The Church Therapist uses the entire church context as a therapeutic milieu in which the client can grow and experience transformation.

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Christ in Counseling

Mention the words “church” and “counseling” in the same sentence and I assure you the response will be surprising. While the Church has been a place people have turned to during emotional struggles for centuries, the development of modern psychology has sparked an intense debate within the Church. What causes mental illness or emotional struggles? What is the best way to address those issues? Should a pastor provide counseling or is that the job of a professionally licensed therapist? Does embracing certain aspects of psychological study mean we are compromising our faith?

Many have jumped to conclusions about the Church Therapy model, asserting that I have somehow sold out on my faith because I have studied psychology and advocate for professional licensure. Previously on Twitter, a person I do not know who has never asked a single question about this model wrote to me: “Counseling minus Christ equals deception.” Whoa. I have learned not to take these comments personally, but it did get me thinking about how to articulate my views on the role of Christ in counseling. First of all, I want to clarify that the Church Therapy model is primarily focused on counseling those who are already following Christ. Of course there may be some who are in a seeker-phase of the spiritual journey, but typically those who come to a church for counseling are already Christians. I do not believe it is the role of a counselor to proselytize in a counseling session, so for this reason Church Therapy does not seek to gain new converts.

Counseling in the Church Therapy model is part of the discipleship process as spiritual growth and emotional health provide increased freedom. Christ is 100% at the center of this process because he alone is able to supernaturally change lives. However, that does not mean that my primary methods are quoting Scripture or praying with clients. At times these can be helpful, but more often psychological strategies such as Motivational Interviewing or Cognitive Behavioral Therapy are far more effective in helping a person overcome various emotional challenges. For this reason, training in the Bible is not enough to train a person to be an effective counselor. Even basic helping skills like active listening, though useful on some level, are not enough to train a person to be a competent counselor.

So how can it be that I claim Christ is at the center yet I highlight modern psychological techniques as superior methods for therapy? Perhaps an illustration would help clarify this point. A couple of years ago, I walked alongside some friends whose baby had lost oxygen for nearly 15 minutes at birth. He was rushed into the NICU and placed on a cooling pad, an advanced treatment for babies at risk for brain damage at birth. The baby had to be on the cooling pad for 72 hours before any testing could be done to assess brain damage. During this time the goal was to slow the development of brain cells in order to stop any further damage. That was the longest 72 hours I have ever experienced as we prayed and fasted and poured everything we had into seeking a miracle for this baby (who the doctor’s warned would probably be very brain damaged). Every day that I see that little boy, who has little to no signs of brain damage today, I see a walking miracle. Was Christ at the center of his healing? Absolutely. Did the doctors use a modern method to facilitate that process? Yes.

Using researched strategies to address mental health issues is no different. We no longer have to accept the ideologies of Freud, Jung or Skinner in order to believe that modern psychology has a lot of knowledge to offer. Even most secular counselors do not hold tightly to these early definitions of psychology. The Church Therapy model connects biblical, psychological and biological truths in order to most effectively move a person towards healing and life change as they deepen in their walk with Christ.

Unfortunately, even many Christian counselors do not view counseling as part of the discipleship process and they counsel many non-believers. They can help them change certain aspects of their life, help them cope, or improve their communication skills. But this does not move them into deeper relationship with Jesus. The Church Therapy model is a true integration of Christian faith and psychological study. Both are in mind at all times as the Holy Spirit moves in the midst of effective therapeutic strategies.

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Why We Blame People For Their Mental Illnesses

Most people in and out of the Church can accept that mental illness is real when manifested in a visible way. Someone who has witnessed a person with schizophrenia in a psychotic episode would have no doubt that that illness is real (though some in the Church might actually assess that as demon possession). But what about someone living in reckless ways during a manic episode of bipolar disorder? What about someone who struggles with suicidal thoughts? Where is their faith? Is that sin or illness or both? Are those even the right questions to be asking?

Enter a theology of sin that is not big enough for biological factors to be at play. Those of us Christians who have the privilege of being mentally well generally believe that we are able to control all of our thoughts and choices. When we are tempted, we need to flee from temptation. When we worry, we need to cast our cares on God. These are the responsibilities of the Christian to stay on the narrow path. Perhaps even in this theology we place ourselves in too powerful a position over our own lives. We have to remember that if we have it together, that is solely by the grace of God. Romans 9:16 is helpful here: “So it is God who decides to show mercy. We can neither choose it nor work for it.”

But how do malfunctions of the brain factor in here? Are some more capable of self-control than others? In my book, On Edge: Mental Illness in the Christian Context, I use an example of a person with developmental disabilities. Certainly (hopefully!) no one would expect a person of limited intellectual capacity to have a well-developed theology in order to enter the kingdom of God. (And by the way this is not a requirement Jesus placed on anyone regardless of capacity.) Can, for example, a non-verbal person with autism receive salvation if they cannot understand the Gospel and cannot “confess with their mouth that Jesus is Lord”? Or are they shut out from the Kingdom?

Similarly, a person struggling with depression may not be able to consistently engage at church. They may struggle with doubt or have thoughts of killing themselves. Is this because of a lack of faith? Or is their disordered brain incapable of overcoming these thoughts no matter how much faith they try to muster? And why is it their responsibility to fix this themselves?

This is where the Church has to do its job: demonstrate love and compassion. Why is it not the entire Church’s responsibility to spiritually carry those who are struggling to carry themselves? Why do we not enter into these situations to offer care and non-judgmental support? Why do we have to have a neat and tidy explanation and evaluate the person’s spiritual standing before helping them?

I would like to challenge the Church to rise up to support, love and defend those with mental illness even when we don’t know how to understand or explain it. Let us reach out with open arms to those who are marginalized, misunderstood and downtrodden. Let’s show the love of Jesus and get off the judgment seat in every way. Messages from the pulpit that support a “try harder” theology are unhelpful for all of us. May we live and preach the Gospel in its entirety.

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CXMH Interview — MUST LISTEN!!

Hi everybody! An extra post in here to share this interview that I did with Robert Vore and Steve Austin on their CXMH podcast (which is awesome, go subscribe!). These guys are such great leaders in the conversation about mental health in the church.

This is one of the most comprehensive interviews I have ever given about how the Church Therapy model works, and I’m super excited to share it with you! Thanks for listening and supporting the cause of fighting the stigma of mental illness in our churches.