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Why “Christian Counselors” Need to be Licensed by the State

Sometimes “Christian counseling” gets a bad name. And for good reason. There have been many cases of churches handling issues such as sexual abuse “in house” or pastors committing acts of spiritual abuse. It is important to distinguish what Christian counseling should be in contrast to what it sometimes is. In Christian circles, there are more nuanced terms, including “biblical counseling,” “nouthetic counseling,” and “deliverance” ministries. How can we tell the difference between all these things, especially when we are in need of help?

From the beginning of my writing about Church Therapy, I have always maintained that church therapists (or any other form of Christian counselor) should be licensed at the highest level. I recently obtained my National Board Certification as a Certified Clinical Mental Health Counselor to continue to advocate for Christian counselors to adhere to the highest standards in our society and to demonstrate that Christians can and should provide the best quality care. Because those in the Christian community often do turn to their churches first for help, professionally trained and licensed Christian counselors need to be immediately accessible and available to help.

Having a therapist on a church staff can prevent improper handling of abuse situations because licensed counselors are mandated reporters. (This is legally different for counselors versus pastors in many states.) A licensed counselor is always obligated to report child abuse to authorities, whereas in many states pastors or non-professionals have blurry lines.

A professionally trained and licensed church therapist can also educate the congregation and pastoral staff around issues of mental illness, sexual abuse, and trauma, and in doing so create a culture in which these types of issues are handled with appropriate treatment. Rather than a secretive, “in-house” approach, church therapists are actively connected to the community. I am in regular contact with my clients’ psychiatrists, doctors, and case workers, and when needed local authorities. There is no suspicion of those outside the church, but rather cooperation to make sure every available resource is utilized to protect victims and to care for those in crisis.

Finally, in the Church Therapy model I advocate for use of evidence-based therapeutic practices. We need to be using treatment models that have been proven to work, integrating neuroscientific, biblical, and psychological principles to handle mental health issues in ways that succeed. There is no perfect treatment approach, but we must apply the highest levels of truth and research to inform our treatment rather than making up our own uninformed theories. What untrained, lay counselors in the church produce for treatment models is no more biblical, and certainly no more scientific, than the humanistic theories of Freud. And in fact it does far more damage because it is done in the name of Jesus.

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Budgets & Billing: Making Church Therapy Work

Once you have thought through the ethical implications of the Church Therapy model (click here for posts in the “Ethics” category), you may find yourself asking, “So how does this work practically?” There are a variety of different options for making church therapy work for your church.

The Ministry Model

In some churches, counseling is viewed as a ministry and there is no charge for meeting with a counselor. Most often, the counselor is the pastor and this differs from Church Therapy because here counselors are not serving both as a pastor and as a professional counselor for their church. That does not mean that a church therapist cannot be on the church payroll. In some contexts in which money is plentiful, a church (or group of churches) could pay a salary to a Christian professional therapist and enable them to offer free counseling to church members. Unfortunately most churches are either not in the position to pay a professional counselor a salary or they do not prioritize it. Other churches may feel that because a professional counselor can earn fees from other sources they should do this and free up church monies for other needs. Additionally, in the ministry model a counselor can choose to donate a few hours a week to be a counseling minister for free, but this is limited unless the counselor has no need for an income.

The Self-Pay Model 

In this model, the clients pay a certain fee per session. This can be done in a variety of ways, but most common would be a sliding scale fee based on income. You can also have a set fee that everyone pays regardless of income but doing this will limit access to your services. Regardless of what exact amount you charge per session, you have two options for processing that money. The counselor can be officially self-employed and manage the money on his or her own, or the counselor can be an employee of the church and turn in all fees collected into the church. The church bookkeeper would then take out all taxes from the fees collected (both the employer and employee portions of Social Security and Medicare) and pay the counselor according to the rate agreed upon. In the self-employed option, the counselor may or not pay rent to the church for office space. If the counselor is officially an employee of the church, some of the fees collected may be set aside to cover building use costs. Either way, the fees collected cover all taxes and costs of the counselor’s position unless the church is willing to cover building costs and increase the pay of the counselor.

The Insurance Model 

Using insurance to pay for counseling has some wonderful advantages and some serious downfalls. In this model, the counselor must already have a license and usually a few years past state licensure in order to obtain contracts with insurance companies. Essentially, the church is inviting the counselor to come on church staff to set up a private practice. Because insurance companies can only contract with an identified clinician, this model requires that the counselor be officially self-employed. Reimbursements from insurance companies are paid directly to the counselor and he or she is responsible for all self-employment taxes and record keeping. If you live in an area that has primarily low-income clients, insurance payments can mean that you can earn a living wage and the client will typically pay nothing. In a more affluent area, the client’s insurance may require a higher co-pay or your clients may be able to self-pay at a higher rate than an insurance company! The downsides of working with insurance companies include bureaucratic headaches, claim submissions, mandatory diagnosing, and session limits. In this model it is up to the church to determine whether or not to charge the counselor rent for office space or donate the space to the counselor in exchange for some staff responsibilities.

The Hybrid Model 

If the church therapist is working towards licensure or newly licensed, he or she can seek out a partnership with a larger mental health agency. In my early days as a church therapist, I began with the self-pay model but because I live in an economically depressed area I found that even $5 was more than people could afford to pay. The church did not have money to pay me a salary so I maintained another part-time job for needed income. Within my first year I developed relationships in our community and ultimately pitched the idea of a partnership to the VP of a secular mental health agency. The agency hired me to work as a fee-for-service clinician with them doing outreach in the community via my church office. I was clear throughout the process that I was offering professional Christian mental health counseling and in the end they paid me at a slightly higher rate because I had this specialty! They also agreed to pay the church a set amount monthly for the use of the office space. This model worked well until I was able to secure my own contracts with insurance companies. Again the downfall is mandated diagnosing and significant amounts of paperwork.

I offer consultation services to any church seeking to hire a church therapist onto their staff. What model might work best for your setting? I’d love to hear your thoughts and comments.

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No Place for Shame to Hide

It’s everywhere you go, chasing you like a shadow. It stops in to your job or your home uninvited when you least expect it. It lurks in dark corners that you pretend are not there, except in those times you run into the dark to feel hidden for a while.

Shame. A byproduct of a broken heart. Not quite regret, though they are close friends. Embarrassment is a distant cousin. But shame lives in the core of your identity. It seems to define who you are, it whispers lies about what others think.

Everyone has a past. Some carry good memories, others bad, and still others have empty spaces where memories have been forgotten, intentionally or otherwise. These memories give definition to identity. Without memory, we would simply float in a confused vacuum with nothing tying us to anything else. But with memory, pain lingers and wounds are carried far beyond the original damage done.

Imagine walking into a church for the first time in your life, your past and shame following close behind. Truth hitting lies and lies fighting right back, eager to keep the prize they have won in your heart. This is the context of the church. Truth and lies in a bitter battle for souls.

Sadly, many churches lose this battle. Some don’t try to fight. Some fight lies with more lies. And some have good intentions but ran out of weapons long ago. But there are some places where safety exists. Where the healing power of Jesus can reach into this heart-battle and command an end. Where freedom is found and hope is given.

But then what? What is the next step in rebuilding an identity crippled and withered for so many years? For many, it’s therapy. A place to talk, explore, be understood, and develop new ways of seeing oneself. When the church refers people to therapists outside the church, a gap is created. It’s an unintentional gap, but a gap nonetheless. And it is in that tiny crack where shame can hide and resurface long after the “issues” seem done.

This crack is the place in which a person can hide with their doubt and fear. They can develop a “church self” and a “therapy self.” Between those is that place where a person can wonder if the church would really accept them if they knew everything the therapist now knows. And it is the same place where that person can also wonder if the therapist truly cares or if it is just a job. It is the reason that in traditional therapy, clients and therapists are terrified of running into each other in another setting. Reality: this is actually another person I am interacting with! Shame must flee within the confines of those four therapy walls, but shame does not like encountering acceptance in a different context. Fear shouts, “You can’t love me here! Only there!” And often therapists are unsure how to treat clients as people no matter where they are, with awkwardness translating into, “I didn’t sign up to see you right now…”

Church Therapy closes this relational gap, as the church provides therapy within its own context of safety. A licensed professional who is present in the church as a leader and staff member communicates, “We accept you. Tell us everything and we will still be here. You are person who is loved.” It creates a different level of presence that breaks down those artificial barriers that are stigmatizing even though they are accepted practice in the counseling world. I can’t stop caring about my clients when they (or I) leave my office. They can’t write me off as caring only because it is my job to do so. I am present in their lives in a holistic way, on a team with their pastors who are providing additional support and care. Shame is smacked in the face as acceptance and understanding replace fears of rejection. A fully authentic spiritual community reproducing greater authenticity as it accepts each member unconditionally. It is here that healing is found as Christ’s love penetrates every dark corner of the mind and forms a new creation, doing away with the old for good.

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Should Christian Counselors Work in Secular Environments?

In last week’s post, I addressed the question, “Is Scripture Enough?” and explored the Christian counselor’s role in bringing healing to those with mental illness. The Church Therapy model suggests that pastors and professional Christian counselors can work well as a team to support those in their care. However, presently very few licensed counselors work in church settings. Some have private practices that are advertised as Christian-focused, while others have practices that do not overtly state that they are Christian. Many Christians who are counselors would not identify themselves as “Christian counselors,” but instead would say that they are simply Christians who are professional counselors by trade.

One line in last week’s post got me and a few others thinking about where Christian counselors should work. I wrote, “…many of these Christian counselors have chosen to work completely outside the framework of the Church or discipleship. I find this to be tragic, as many well-trained Christian counselors do not see it as their role to serve the Church.” Does this mean that all Christians who are trained as counselors should work in church settings? Would that even be possible?

First, allow me to reject my own question that serves as the title to this post. There is no “should” when it comes to ways God can choose to call people. Christians work in secular settings in all kinds of different professions, from doctors to carpenters to teachers. I am not about to limit the work of the Holy Spirit by making a blanket statement that all Christian counselors must be called to work in a church or alongside a church directly. We are all ambassadors and ministers of the Gospel when we care for and bring love to our neighbors. We weep with all who weep, not just other believers.

On the other hand, the Church has at times been a hostile place to licensed counselors as the mental health debate has raged on over the past 50 years. The thing that I find tragic is that many Christian counselors I have personally known would have loved to work in a church or come alongside in some way to use their gifts for the edification of the Church. Yet there were no in-roads for them to do so. Many I knew in my graduating class at Gordon Conwell ended up in secular settings not because of a calling, but because that was where they could find a job. Even my church did not “hire” me so much as give me the opportunity to create something that did not exist and for which they could offer no money. The pastors and I have had to figure out a lot along the way, including how to create a sustainable role for me both financially and structurally. I started writing this blog as a way to flesh out all the different aspects of how to make it possible for counselors and pastors to work side-by-side.

Professional Christian counselors are an asset to the Church and pastors must begin creating pathways for them to serve in churches. Some may be called to work in secular settings but may desire to serve the local church by offering a workshop on a mental health topic or leading a Stephen’s Ministry. Others may have a burden and desire to work on a church staff, and pastors can make that possible through the Church Therapy model.

My message is simple: every single believer has valuable gifts and all of them are welcome in the kingdom of God. Pastors and professional counselors are working towards the same ends with different roles, gifts, and skill sets. Until this spiritual war is over, we are in an “all-hands-on-deck” place. We can’t afford to send anyone away because we want to debate about psychology and theology. People need help, and we need to make every resource available where they need it most: the Church.

 

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Forms Are Boring But Important

Paperwork isn’t the most exciting thing to talk about, but it is essential to keeping good documentation and minimizing liability. Unfortunately, in the mental health field everyone has re-invented the wheel hundreds of times over, so the paperwork of some agencies is daunting for any clinician. If you are a licensed counselor interested in offering mental health care in your church, you have to have the proper forms to comply with HIPAA, insurance companies, and ethics codes.

In an intake packet, you need an informed consent form that tells clients the information they need to make a decision about whether or not to enter counseling. Information about the counselor’s license and skills, client rights, emergency protocols, and billing procedures are some of the things that should be included. Here is an example of a basic informed consent form. For Church Therapy, you should also include a description of the relationship between the counselor and the church staff and ways confidentiality will be handled. A financial agreement is needed if you are accepting payment of any kind, including insurance. This form would indicate the amount the client will pay, the payment methods accept, whether or not a fee will be charged in the event of a no-show, and how billing will be handled. If you are billing insurance, the client’s copay should be listed as well as the fee that will be charged for any visits that occur in the absence of insurance coverage (such as if there is a lapse in coverage and the client does not notify you).

Confidentiality is a primary goal of any therapist. Any information shared verbally or in writing must be preceded by a signed authorization/release form. This includes information given by the counselor to any other church staff. In my practice, I have all clients who attend the church sign a release for me to be able to speak to the other pastoral staff if needed. I discuss our team approach and ask them if they feel comfortable with the model. Overwhelmingly parishioners are grateful for the open communication and are happy to have a team of people working together alongside them. On occasion, there are clients who want certain kinds of sensitive information kept private, and this can be noted on the release form to limit the kind of information shared. Of course, even with a release form, the counselor’s job is to share only the information necessary to provide care and coordinate services. All clients should be notified that reports of child abuse, elder abuse, or threats of self-harm or homicidal ideations can and will be released without the need for authorization. Here is an example of an authorization/release form.

You are also required to have a record of basic demographic information, like date of birth, phone number, address, preferred language, and an emergency contact person. (I have my clients sign a limited “emergency only” release form for their emergency contact person just in case.) I recommend using an electronic record system (services like Office Ally, Simple Practice, or TheraNest are phenomenal for taking care of client demographics, progress notes, and billing seamlessly).

Finally, it is critical to have a good intake form that asks the right questions and gives you the information you need to diagnose and treat the presenting problem. Additionally a Mental Status Exam form and a treatment plan form are important intake documents. The following templates are ones I have created to simplify the intake process and keep paperwork easy but complete:

Adult Mental Health Intake

Adult Treatment Plan

You can also use screening and assessment tools such as the PHQ-9 to quickly diagnose depression symptoms or determine suicidality. If you are looking for an additional comprehensive resource, I would recommend a book titled The Paper Office, now in its 5th edition which includes information about electronic health record-keeping.

 

 

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Crisis Intervention

Today I was reminded again of the role a counselor can play on a church staff. If you have ever worked at an urban church, or any larger church as well, you probably know that Sundays are an all-hands-on-deck kind of day. Anything can happen at any time. You just never know. And in Lynn, Massachusetts, you really just never know what a Sunday will bring.

We had a missionary sharing a testimony about a young girl with a troubled past. As she shared, a women in our congregation was both moved and triggered into what appeared to be a somewhat dissociative state. She began wailing loudly and shouting, “That’s my story! That’s my story!” But it was not entirely coherent and it was unclear what was going on. The usher team went to her but were unable to coax her from the room. My husband tapped me and I went to her seat. I looked at her and used body language to show her I was listening. I heard her say again, “That’s my story!” so I told her that I wanted to hear her story, but we would need to go into the lobby for her to tell it to me. She gladly came with me and we helped support her weight to walk out the door as she was so hysterically crying. We ended up outside and someone brought her a cup of water. I sat with her and listened to what she could tell me between gasping for breaths. She had been abandoned as a child and was never able to forgive her mother, but today after hearing the testimony of a young girl she said she was set free and she could finally forgive.

In the meantime, the disruption triggered a few other people with mental health issues. One man came to us outside and said, “Are you okay? Are you okay? Are you okay?” and had difficulty responding to our reassurances that she was okay and being taken care of. He too needed reassurance and to know his concerns were heard. He told us that he had just gotten out of the psychiatric hospital, where the patients look out for each other. We moved him from the situation and told him we were glad he was there. At the same time, another man nearby started talking loudly and repeatedly about how he won at bingo last night. His perseverating continued until I could pull away from the woman (now being listened to by the missionary who had been speaking earlier), and I went to the man to hear his story of bingo victory. I congratulated him on his $25 prize and thanked him for telling me about it.

It struck me that in all of these situations, the key to de-escalation was listening and joining with the person in his/her version of reality in that moment.  Everyone just wants to be heard and believed. Everyone wants someone to be glad they are there. Everyone wants to be treated like a person. Afterwards, I debriefed with our usher team who had done a great job calmly and respectfully helping serve each person, and I shared with them some of the de-escalation strategies I had used. Church Therapy is about so much more than the four walls of my office. It is about understanding mental illness and using informed practices to handle every person with dignity and care. Church Therapy creates a church culture that does not bat an eye when someone exhibits symptoms of mental illness in a more visible way. We are simply ready to respond and provide care in any way needed. Because of this, everyone feels welcome and safe.

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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.

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Counseling, Evangelism and Discipleship Part 2

Last week I laid out 3 reasons why counselors should not also be in the role of evangelist with their clients who are non-believers. This week, we’ll follow up on that topic by talking about why counselors in the church setting are an important part of the discipleship process for those who are already following Christ.

The Goals of the Client and the Counselor Go Together

A therapeutic process requires a high level of respect for the client and his or her own goals. This autonomy is important because if the counselor is driving the therapeutic process with his or her own agenda, there is too much room for abuses of power and manipulation. That context is not a safe space in which to heal. However, when a client who is seeking to grow in their relationship with Jesus comes to the church to meet with the Church Therapist, the client almost always desires spiritual understanding as a part of their mental health care. One of the biggest complaints I hear from my clients who have been to secular therapists is that they did not feel their secular counselor could truly understand their spiritual lives. In the Church Therapy model, both the Jesus-following client and the counselor understand with full disclosure from the start that in the therapeutic process the client would like to grow closer to God.

Emotional Freedom and Spiritual Freedom Go Together

One of the key reasons that mental health care is part of the discipleship process for Christians is that emotional freedom and spiritual freedom go hand-in-hand. Usually when emotional brick walls are hit and a person is emotionally stuck, their spiritual life also gets stuck and they have trouble moving forward in their relationship with God. When trusting others is a challenge due to abuse in the past, for example, the client often struggles with how to understand what it means to trust God. Or some who face symptoms of depression or anxiety as Christians can at times get stuck feeling like a second-class Christian due to stigma that blames them for their symptoms. Growing in the ways they treat the symptoms of mental illness frees them up to engage more fully with God when they stop blaming themselves. When clients become emotionally free in a certain area, they are also spiritually growing because their emotional state no longer holds them back.

The Church and the Counseling Process Go Together

One of my favorite aspects of the Church Therapy model is that it is a team approach. The church context provides more than just one therapist working with one client. Rather, a client is a participant in the church community and the Church Therapist can use that context to more fully help the client grow. At times when a client is going through a depressive episode, for example, the Church Therapist can (with the permission of the client, of course!) alert the pastoral staff who can go do a home visit or bring a meal. Or when a client is struggling with social anxiety, the Church Therapist can help recommend a small group or activity that would be safe or manageable for that client. The therapeutic process is a holistic one, in which the whole church body provides space for healing. When a therapist is present on a church staff, it creates an emotionally safe, stigma-free culture in which this is possible.

Mental health care and discipleship are a perfect fit, and it is one reason why churches need to be a part of the solution in responding to mental health needs. Next week, I’ll follow up on this topic and explore why it is so critical for churches to provide quality mental health care.

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The Truth About Liability

One of the biggest concerns that pastors and counselors raise about the Church Therapy model is liability. Having a professional practice within the church setting could expose the church to certain risks that would not be present if the church simply refers those with mental health problems out to a nearby practice. When treatment occurs within the church setting, the risk of lawsuit could be higher.

liability

To address this concern, let us first look at some common liabilities for churches. We’ll begin with perhaps one of the biggest liability risks that almost every church has: the youth group. Whether a church employs a youth pastor or has a volunteer staff, a youth group presents a host of legal dangers. Gathering a number of individuals for whom impulse control is difficult and taking them in church vehicles to engage in activities such as swimming, skiing, or boating is a pretty risky endeavor. Yet I have not met a pastor who would discourage all youth outreach and activity for fear of liability risk.

A second liability risk is untrained counseling ministries. Biblical or lay counselors do not carry professional insurance and are not bound by state ethics boards. These ministries pose a much larger legal risk than Church Therapy because counseling is being done outside the bounds of state licensing boards and professional standards. A church paying a pastor to counsel or allowing lay leaders to offer counseling ministries could be sued if a parishioner showed signs of mental illness that were not properly diagnosed or treated and then went on to commit a crime or harm him- or herself.

Click here for a great article outlining these and other legal risks churches face.

The Church Therapy model reduces the risks of legal liability in several ways. First, a Church Therapist is a licensed professional who is upholding ethical standards for practice. Secondly, the Church Therapist can and should carry their own professional insurance of at least $1,000,000 per incident and $3,000,000 aggregate. No other type of church staff member has an ability to carry additional, personal insurance covering their ministry activities. Third, the Church Therapy ministry can be set up as a sole-proprietor private practice or even an LLC. While operating in the church building and on the church staff, the Church Therapist will likely have contracts with insurance companies that will not be in the church’s name. My practice, for example, is legally my own but is housed within the church and operates seamlessly within the church’s daily life.

The larger question that one must ask when thinking about liability is this: what makes the Church Therapy model worth doing? Why not just refer out and avoid the entire issue? Let us again consider the youth group. There are plenty of youth organizations in any given town or city. Why doesn’t the church simply refer the youth who come to the church out to engage in the activities of those agencies? If the YMCA is going on a fieldtrip, why not send the youth with them and avoid a church liability risk? Hopefully the answer is obvious. If the church is to have influence and work in unique ways to heal the hurting and guide the lost, it must run its own programs to do so. Community partnership is wonderful, but liability cannot be the reason we abdicate our God-given role to shepherd and lead. It is central to the Church Therapy model that services provided excellently within the church setting present a more accessible means of treatment that can be done directly in the context of other forms of spiritual growth and discipleship. Referring out to a private practice immediately decreases the rate of follow-up in accessing those services, removes the partnership with the pastor in the counseling process, and disconnects the parishioner’s mental health recovery process from the way the church is already working with that person.

Don’t let fear be a driving force in your thinking as a pastor or counselor. Working with broken people is a risky business, and we must be willing to take on reasonable risk while at the same time maintaining a quality of work that is above reproach.