To facilitate acceptance of a mental health referral, the pastor must first foster an open and trusting relationship. This allows the person to voice his/her concerns openly and honestly. The pastor should encourage the person to express feelings about the proposed referral. Once any objections or feelings of rejection are identified, the pastor should clarify why the referral is being made. And, the pastor should emphasize that he/she will continue to give spiritual support and guidance. This process does take some planning and takes enhanced listening skills (both verbal and nonverbal). But, the goal is very important - that of getting the person to accept the referral. Furthermore, simply getting the person to the door of a mental health resource is of little value if the person arrives too frightened, angry, confused or defensive to be able to listen or work at the therapy. The person who accepts the referral out of compliance, or simply to please the pastor, family or friends, may still be closed to any mental health therapy. The goal of the referral is not to force an unwilling person to spend a few minutes with a mental health professional or a support program. The goal is to help the person go to the mental health professional and/or program or agency with openness and hopefulness. a. Dealing with Objections

The fear of the stigma and the blow to the person's self-esteem can be confronted by using two interviewing techniques: empathy and addressing negative feelings. These are suggestions. When dealing with someone with a mental illness, do what is most comfortable for you. Use empathetic statements, acknowledge and validate the person's emotional experience. For example, "You might feel it is beside the point to be told to see a mental health professional when the pain you are feeling is spiritual. I will continue to work with you on the spiritual issues that are troubling you. But, I think you also need some additional help with some of these problems that may have another cause." 

Addressing negative feelings others may have about people needing mental health therapy is also a way to acknowledge and validate the person's perceptions. For example, what consequence does the person most fear when others learn about the referral? Does the person have a concern about negative feelings of people close to him/her, such as family members? This is especially so when family members are people with whom the pastor has contact. A solution can be to have them return with the person and jointly discuss the referral and what it means to the pastor, the person needing therapy and the family. 

Remember that feelings of depression can lead a person to believe that the illness is a punishment from God. If the person believes there is a theological connection between him/her and the illness, let that person know this is not the case. Reassure the person that God cares for him/her and the pastor will be there for the person. 

In addition if the person in need of help and/or those concerned about this person are in need of additional information about the importance of therapy and available mental health services in the community, that information should be made available quickly and in a short but in-depth form. b. People with Mental Illness

When the person's resistance is an integral part of a mental illness, it can be useful to point this out to that person. The pastor can explain that the person's resistance is part of the problem that needs treatment. And, that if the problem was less troublesome, the person would not feel the same way about a referral. 

Learning about the person's prior experiences, if there are any, with mental health care can help clarify objections and make it possible to satisfy or work around them. If the person displays inappropriate behavior the pastor may not be able to change it, but can respond appropriately. Remember, the pastor may be the only support that person has. c. Reassurance of Continuity. If a person is feeling rejected because of the referral, the pastor must counter this feeling. The person should be reassured that this referral is not a rejection and that the pastor will still be there to assist the person with theological and spiritual issues. This can be demonstrated by scheduling a follow up appointment shortly after the person's first visit to a mental health professional or program. If the person is hospitalized, ask for the person to give consent for the pastor to visit him/her in the hospital and to mention his/her name among those for special prayers due to being hospitalized. Affirm that the church is a place that will always be there to accept the person as they are. And, that if one is out of the congregational community for a period of time, an accepting, nonjudgmental congregation and pastor will continue as a caring community for that person. For example it is helpful for the pastor to tell the person he/she will be remembered in the regular prayer cycle.  

Suggestions used in this section are not set in concrete. These are simply techniques that sometimes are successful. They are to be used to help the person and those close to him/her develop their own strategies that complement professional treatment. At times, none of these suggestions seem to alleviate the inappropriate actions and feelings of the person. In such a case, the pastor should assure the person of his/her concern and support. The pastor should help the person to a quiet, comfortable place. Depending on what has worked in the past, if the pastor has a history with this person, the person can either be left alone, or have someone stay with him/her. Then, the pastor should contact someone who is close to the person or a mental health professional for assistance or, in a crisis situation, for an intervention. 

When working with someone who has a mental illness the pastor should try to think of what the person may be experiencing that may account for these symptoms. If the pastor has some history with the person, he/she should try to identify what happens when the person becomes ill. Then the pastor should structure limits, behaviors and responses in an appropriate way. He/she should try to avoid focusing on the details of the person's behavior. He/she should try to keep the interaction as normal as possible. The pastor should use statements that give his/her perspective rather than imposing perceived behavior on the person. For example instead of saying "You are not interested," try "I am concerned because you seem disinterested." 

The pastor should use an open, caring, accepting manner that is genuine. People with these illnesses pick up on false behavior that can be demeaning or threatening to them. When the pastor listens to the person, it should be true listening that encompasses both verbal and nonverbal responses. The pastor should try to understand what is being said and what is not being said from the person's perspective. Remember that the pastor's concern and interest is very important to the person, even if he/she is unable to show it. The pastor should remind the person that God cares for him/her. If the person expresses an interest in the illness and its consequences, the pastor can work with the person to learn about it. The pastor should be a resource for information and referral. If the person wants to have a serious discussion, the pastor should attempt to do it remembering that many severely ill people are rational as much of the time as they are symptomatic or psychotic. 

For example, Wagner (1985, 83-86) describes his work with a severely depressed woman. She was a pastor's wife who gave the repeated message to all who came in contact with her of "Woe is me, I don't know why things are so terrible for me." 

Wagner engaged her in dialogue. The conversation not only involved listening to her "woe is me," but also listening for what was uniquely hers as a person. She expressed it particularly in relationship to her husband. Wagner indicated to her that she had been heard. He also offered her other possibilities and ways of handling her anger as alternatives to internalizing it and allowing the anger to devour her and make her feel worthless. Her recovery was slow and painful. In the end this chaplain reports he learned what it meant to be patient, while the pastor's wife learned what it meant to be more fully human and that God accepted her in her humanness. 

Hopelessness: For both the person who is ill and the family, visual representations of how the illness affects the brain can be very freeing. It becomes very clear to all involved that these illnesses do change the way the brain looks and functions. Matching the person with others who have recovered and are going on with their lives is also helpful. Seeing a videotape, such as those listed in the bibliography, can be very helpful in illustrating these points. 

Apprehension and fear of failure or rejection: In describing this type of concern a consumer says: "I had fears. I am scared to death that I'm going to do something out of line." The pastor should convey an accepting, friendly, understanding and genuine manner and not be judgmental. He/she can give an understanding response to the person's concern. After all, the concern is reasonable, since the person may have failed may times in the past. For example, "I know it is hard to live with. Fear of being inappropriate, failing, being hurt or being rejected happens to all of us." 

If the person has difficulty forming and maintaining relationships, the pastor can help the person use appropriate behaviors and set limits on bizarre and odd behavior. The pastor should affirm the person when he/she uses appropriate behavior and acknowledge that this takes a good deal of work, concentration and self-control. The person should be allowed to discuss unusual and disturbing perceptions and should be cautioned that it may not be appropriate to share these perceptions with others, except for his/her therapist. The person may be unable to give up these unusual perceptions. However, he/she can begin to learn to manage them. 

If the person decides to participate in congregational activities or to volunteer to do a task, it is helpful to develop a structure with the person. Simple, structured tasks are less threatening as first steps toward resuming responsibilities. It is very helpful for the pastor to go over an outline and schedule for what will be happening and what is expected and then give the outline to the person. The interaction should be as predictable as possible and mutually agreed upon. Time should be allowed for the person to "ease into" the project. It is unreasonable to expect regular participation all at once. The pastor needs to support the person in what he/she is able to do. Focusing on what the person does do, not on what he/she does not do is most helpful. The pastor should learn when to apply gentle pressure and when to "back off." 

Low self-esteem and the resulting lack of motivation: A former Air Force officer describes his feelings: "There is a sense of loss when I see others doing well. I feel a social disparity between us." The pastor can affirm the person's value. Honest compliments and encouragement are very important to anyone struggling to regain their self-worth and dignity. It is very supportive when the pastor spends time with the person, just for the sake of being with him/her, or matches the person with someone in the congregation who is willing to be a supportive, nonjudgmental friend. Those interacting with the person should focus on the person's strengths and what the person has accomplished and treat this in a positive way. Dwelling on past failures or inappropriate behaviors or expectations is not helpful. If the person exaggerates his failures or weaknesses, the person should be assisted in solving the problem or changing the behavior if this offer of assistance is well received. The person should be reassured that the healing process takes time. Small accomplishments, such as going to worship, or keeping an appointment to see the pastor, are progress. For that person getting out of bed, organizing him/herself to get dressed, having breakfast (often having to make it him/herself) and finding a way to travel to see the pastor or to attend worship is a major accomplishment. This is particularly so when the person has recently returned to the community. 

People with mental illness often lack the motivation or courage to make decisions. When helping a person with this difficulty, the pastor should keep the session structured, consistent, simple and focused. If the decision is a small one and seems to be causing unwarranted anxiety, the pastor might suggest a decision. For example, if the person cannot decide whether to attend the coffee hour after services, the pastor can suggest that the person try it for fifteen minutes, rather than the entire hour. 

Withdrawn Behavior: The pastor should not interpret withdrawal as rejection. It is often a normal response to more stimulation than the person can handle at that moment. A consumer notes, "It may not be withdrawing from social contact but from a confusing or terrifying experience." The person may need "time out" from the situation. It is helpful to find a quiet place for the person to be alone. The person should know that place is always available and be encouraged to use it if the need arises. This could well be the pastor's study or the sanctuary when services are not being held. The person should be left alone and allowed to rest and have time to cope with the confused thoughts and sensations the he/she may be experiencing. Demands should not be made of the person at this time. Perhaps a quiet, restful setting is all the person can handle. For example do not say, "Do you think you would be better off at home, so should I call you a cab so you can go there?" Instead, say, "Stay here as long as you want. I'm available for you, if you want me." The pastor should not view this as a step backwards. He/she should realize that some days are simply better than others in any recovery process. 

If the person does not need a quiet time alone, he/she may simply need the pastor to acknowledge the inability to interact with ease. For example, "I am glad you kept this appointment, I know it is not always easy getting yourself over here to talk with me." If the person has trouble getting started, the pastor can try to initiate conversation by focusing on something that is relevant to the person. If the person has difficulty in making contact, the pastor should make direct contact and keep the initiative in the interaction. 

The pastor and the congregation should understand that when the person is first home from the hospital, the person will need more rest and lower levels of activity and personal interactions than usual. This diminishes over time. If the person cannot see the pastor or resume activities within the congregation, this should be recognized as an often temporary situation. The pastor should let the person know that he/she is available when the person is ready. The pastor can check in with the person regularly by sending a note, giving a message to a family member, or by telephone, if the person is up to receiving calls. Members of the congregation should be reminded that the person is not shutting them out, but is simply unable to handle a great deal of stimuli, activity and interactions with a number of people during this recovery time. Encourage them to send a card or note, telephone the person and leave a message if the person is unable to come to the phone, or let the person know he/she is in their prayers. 

Relapse: Relapses are temporary. Recovery has happened before and it can happen again. Many illnesses, including mental illness, have remissions and then flare up again due to changes in body chemistry, or when medications are not taken or have adverse reactions over time, or when the living situation changes. 

Memory loss and processing information: With some mental disorders there may be a temporary memory loss or a slower ability to process information that is a result of the illness, treatment or medication. A consumer says: 

I have difficulty with working memory. It's difficult sometimes in school when I will have to go over and repeat and repeat and repeat things like logic and algebra. They were a forte of mine. It's difficult now. I keep getting grades on my consults saying my judgment and insight are wonderful, but that doesn't help processing that information or an interaction between you and me. Understanding is really tough.

It is bewildering, demeaning and disturbing to have difficulty with or to forget what one knew or found routine in the past. Sometimes the religious rituals and patterns the person previously has received comfort from are temporarily forgotten. Reacquaint the person with his or her religious traditions or the congregation's normal patterns and ways of doing things. It is also disturbing for the person to be around people who seem to know the person, but the person cannot remember them or what their relation is to the person. Again, the pastor can reacquaint the person with those with whom he/she is likely to interact. 

People suffering from dementia may experience permanent memory loss. The same sense of bewilderment, confusion, and loss is operative in this situation. People working with the person should accept what the person is able to remember. For example, if the person cannot remember that it is April 10, but does remember that it is Sunday, that level of functioning should be accepted in a positive, relaxed manner. 

In all cases, people interacting with the person should slow down their speech and interactive responses. At times the pastor may need to repeat what has been said. It is helpful to use short, simple, uncomplicated word structures and sentences. 
 
Difficulty in processing information: This can be a result of too much internal or external stimuli. As noted in the previous section, it can also be a result of medications which can slow down the person's ability to respond. The pastor should slow down his/her delivery and use sentences and words that are short, simple and uncomplicated. Some things may need to be repeated. Opening more than one topic at a time should be avoided. The discussion should be concrete, simple and devoid of excessive details. 

Sometimes the person displays a very ordinary demeanor, which often masks all kinds of stimulation problems such as an acute sensitivity to noise, light, odors or temperature. People with these difficulties need a quiet, tranquil setting in order to interact with others. When the pastor has an appointment with the person it would be helpful to hold all telephone calls, and eliminate outside noise, activity, or the odors of a meal being prepared. For a person with an intense sensitivity to sensory stimulation, this decrease in receiving any stimuli can be very helpful and allow the person to be as calm and focused as possible. 

The person should be assisted to avoid situations where there may be too much going on for him/her to handle. For example doing a task in a high activity setting rather than in a room where the person can close the door and draw the blinds, may be asking too much of him/her. The pastor might schedule appointments, when there is very little activity going on in the building. And, if the person should arrive early for the appointment, a quiet, restful place to wait is most helpful. 

Anxiety, agitation or aggression: Direct contact should be in a quiet, supportive way. If the person is severely disturbed, the pastor should stay calm, keep eye contact and retain a calm facial expression and body manner. For example, it is quite obvious that a pastor is fearful or worried, if he/she has a calm facial expression, but is clutching the arms of the chair and is sitting rigidly. This behavior can easily exacerbate the situation. Using simple, calm, quiet speech and keeping the interaction relaxed is very helpful. The pastor should not attempt to force the person to make a decision if the person is highly agitated, aggressive or anxious. 

The pastor can slow down and ask the person to slow down. The pastor can offer reasonable reassurances such as, "We have plenty of time." However, the pastor should not become condescending or give responses he/she may not believe at the moment such as, "everything will be okay." The person may pick up on this and become more distressed. The pastor should not demand answers or a response. The person should be given plenty of space. The person may be having very disturbing sensory perceptions. Therefore the pastor should not reach out to touch the person or make any sudden moves toward him/her. The pastor may perceive physically reaching out to the person as a loving gesture of reassurance. The person may not see it that way. Sensory stimulation should be decreased at such a time. For example, if the person is in bible class or service, it might be advisable to help the person to a safe, quiet place to give the person a chance to calm down. 

If the person is becoming increasingly aggressive, limits should be set in a calm, non-threatening way. Past violent behavior is the single best predictor of future violence. If the person gives a warning such as, "I'm going to get those people, before they get me," it should be taken seriously. The pastor should get professional help for the person, if it seems warranted. 
 
Regressive Behavior: Sometimes an anxious or agitated person will display regressive behavior. The person may be returning to a lower level of functioning in an attempt to reduce his/her distress. At such a time the pastor should be empathetic. It is helpful to use a clear, concise delivery and be realistic about what can be accomplished during this time. 

The person needs reassurance about what is going on and why. This is especially true if the person is just returning from the hospital to the community, or seems to be degenerating into an acute episode. Remember that the person is more fragile when the illness flares up or right before or after that happens. The pastor should realize that regression, withdrawal or acting out can be an attempt to stabilize perceptions, or a reaction to overloaded sensory impulses. 

The pastor should realize that this person is struggling to regain his/her balance and control. His/her fears, anxieties and concerns are very strong. Consider the way you would want help if you were terrified. In such a situation one may misinterpret others' intentions, believe they do not understand, and acutely feel other people's irritation and impatience. At such times people tend to exaggerate other people's tension, resistance, denial and anger. 
 
Bizarre behavior: The pastor should set firm limits. In setting limits and distance, the pastor should do this in a supportive, non-rejecting way. The pastor can explain to the person how his/her actions make the pastor and members of the congregation feel. The person can be encouraged to limit these behaviors to private situations. In general, one must set limits on unreasonable and bizarre behavior before tension builds. Expectations should be clear, simple and realistic. If the person seems overstimulated, the pastor should limit input and not force discussion. If the person is displaying unsound judgement, the pastor should remain rational and reinforce common sense. 

Very often bizarre behavior involves hallucinations and delusions. Hallucinations are inaccurate perceptions that impact the senses and delusions are inaccurate beliefs. 
 
Hallucinations: In dealing with hallucinations, one can agree that these are special experiences that the person may see, hear, taste, touch or smell. And, that these experiences may be shared by nobody else. If the person says: "I see demons in this room," the pastor should not make a flat statement that is a complete denial such as "There are no demons in this room!" If the person says he or she sees David with his harp sitting next to him, the pastor can agree that he/she may actually see David, but that the pastor and others in the area do not. A consumer who is a peer counselor advises: 

We can't play into what a person with a mental illness is experiencing or describing. At the same time we can acknowledge, "Yes, I understand that is your reality and that's what you're experiencing. However, it is not what I'm dealing with, so it's hard for me. Can you tell me about that?

The pastor can assure the person that he/she is there to be with the person. The pastor can confirm that the person can regain control and lessen the effect of the voices he/she may be hearing or the images he/she may be seeing. The pastor can focus on real sounds and sights and use real experiences. Stress can be diminished by providing a relaxing setting and decreasing stimuli. The pastor should not argue with the hallucination and not make light of it. 
 
Delusions: In dealing with a delusion the pastor should not argue with the person about the delusion, as it will not change the person's perception and may be perceived as threatening or unsympathetic. 

It is helpful to understand and closely listen to the person's fears. The pastor can empathize with the delusional thinking. He/she should not attempt to dissuade the person or to show the faulty logic of this symptom. He/she should reinforce reality. For example the pastor might say: "I don't find or see anything that shows me this is happening, but I understand how frightening it might be to feel the devil is watching you and directing everything you say and do." The pastor should never make light of, or make fun of, the delusion. It is unreal to the pastor, but very real to the person who has it. 

If the person seems extremely agitated, fearful or aggressive the focus should be shifted from the delusion. The pastor can do this by suggesting he/she needs some assistance with a task. Or, the pastor can talk about music or sports, or guide the conversation toward a subject the person enjoys. 
The pastor can suggest that fixed ideas and preoccupations, such as "I can't move, or they will destroy me" or "I must help the Pope," or "I must drive out the devil from this place," may be changed if he/she and the person can start writing down facts together. Talking about ways to change the delusion or preoccupation often may include assistance from a mental health professional. The pastor might say: "What exactly is troubling you about this situation? What is certain, what is probable, and what is only a possibility? What rank of importance is this trouble or feeling? What can you do to change this? What can I or others do to resolve this problem?" 
 
Feelings of depression: If the person displays depression, frustration, loneliness and/or feelings of guilt he/she should be allowed to ventilate these feelings. This can be done verbally or nonverbally. The pastor should listen and accept what is said. The person should be allowed to cry. It is very supportive when the pastor spends time with the person, even if it is spent in silence. The pastor should avoid attempting to cheer the person up and should understand at this moment, the person is feeling very low. Platitudes and biblical references may make the situation worse. Just as the pastor should not argue with delusions, he/she should not argue with depressions. If the person could "pull himself or herself out of it," the person would not be clinically depressed. Instead, the pastor can acknowledge the person's pain and let the person know that there is understanding of what a difficult experience it must be to have this pain. When the person is feeling somewhat better, the psalms that express anger, frustration and despair may be of help. 
 
Disorganized thinking and slow responses: If the person is clearly not grounded in reality, the pastor can listen for kernels of truth, or wait for a better time to discuss the situation with the person. The pastor should not encourage the person to express accelerated, illogical thoughts. This can quickly degenerate into disconnected, unintelligible speech. It is helpful to look directly at the person and communicate in a simple, clear, practical way. The pastor should avoid focusing on more than one topic at a time and use a calm, quiet delivery and calm body language. 

The person may be having difficulty in processing information. The pastor should not display impatience or annoyance, as this can agitate the person. The person may require extra time to respond to what has been said, as other thoughts or sensations may be interrupting the ability to process what has transpired. If there are other people involved in the interchange, the pastor can act as a buffer for the person. For example the pastor can suggest the person leave the room for a quieter setting. 

The pastor can decrease stimuli, by turning off any music or closing a window to reduce outside noise and activity. The session should be kept structured, consistent and not free wheeling. Problem solving ideas that may be of help

Not all peculiar or unacceptable habits and behaviors can be changed. It is helpful to focus on one change at a time. It may mean the pastor and the congregation accommodating themselves to this person's behavior, if that is a reasonable option. It is helpful to: 

Identify the problem and work on one problem at a time. 
State the problem clearly and exactly. 
Select reasonable solutions/options. 

Assist the person in understanding the consequences when the option is not followed. 
Review the results together and redesign the plan as necessary. 

Remember to suggest, or make requests. Do not make demands or become confrontational. The pastor should state clearly what is important to him/her and the congregation in a positive, nonjudgmental, unthreatening manner. For example say "I would like you to . . . ," or, "we would really appreciate it if you would . . . ," or "It is important to me (and/or other members of the congregation) that you help us by . . ." 

It is usual for a pastor to encounter some situations where a person with a mental illness divulges information which poses a threat to his/her own well-being or the welfare of others. Many of the problems persons in all the helping professions confront can result from the boundaries around confidentiality. 

Being honest with the person is most important. For example a pastor can say: 
"The information you have just told me, means that you may hurt yourself or someone else. It puts me in a difficult position. I am bound by law to prevent harm to you or anyone else. Therefore, it is not possible for me to keep this information confidential. Do you want to work with me on these feelings and threatening thoughts? How can I help you with your anger? What do you expect me to do now that you have told me this?"

Often people under emotional stress or with a mental illness, consciously and/or unconsciously, want to put the moral responsibility for their actions on the pastor. It is important to explain that this is not what ministry is about. Ministry is about helping people make decisions that are both moral and healthy. The pastor cannot prevent the person from doing wrong or even command them not to do wrong. However, the pastor can inform the person's conscience so that the person can be responsible for his/her actions. 
 
When a person has already hurt someone or committed a crime, the pastor might be able to work with the person to move him/her toward identifying a course of action that leads the person to entrust him/herself to the justice system. In any case, informing the person of the fact that the pastor cannot condone the person making his/her guilt the pastor's problem, will, hopefully, lead him/her to find a meaningful way to deal with their own sense of guilt, shame or confusion. Offering the person the support needed to do the moral and healthy thing is what ministry is about. It separates information that is confidential from information that is potentially dangerous. Understanding Denial

When mental illness first strikes, family members may deny the person has a continuing illness. During the acute episode family members will be alarmed by what is happening to their loved one. When the episode is over and the family member returns home, everyone will feel a tremendous sense of relief. All involved want to put this painful time in the past and focus on the future. Many times, particularly when the illness is a new phenomenon in the family, everyone may believe that since the person is now doing very well that symptomatic behavior will never return. They may also look for other answers, hoping that the symptoms were caused by some other physical problem or external stressors that can be removed. For example, some families move thinking that a "fresh start" in a new environment will alleviate the problem. 

Sometimes, even after some family members do understand the reality of the illness, others do not. Those who do accept the truth find that they must protect the ill person from those who do not and who blame and denigrate the ill person for unacceptable behavior and lack of achievement. Obviously, this leads to tension within the family, and isolation and loss of meaningful relationships with those who are not supportive of the ill person. 

Families may also have little knowledge about mental illness. They may believe that it is a condition that is totally disabling. This is not so. However, it is difficult to know where to turn to get information. Without information to help families learn to cope with mental illness, families can become very pessimistic about the future. The illness seems to control their destiny rather than the family, including the ill member, gaining control by learning how to manage the illness and to plan for the future. It is imperative that the family find sources of information that help them to understand how the illness affects the person. They need to know that with medication, psychotherapy or a combination of both, the majority of people do return to a normal life style. It is also imperative that the family finds sources of support for themselves. In both cases, clergy can play a critical role in identifying resources in the community that can help the family build the knowledge base that will give them the tools to assist their loved one and themselves. Understanding Stigma

Even when all members of the family have the knowledge to deal with mental illness, the family is often reluctant to discuss their family member with others because they do not know how people will react. After all, myths and misconception surround mental illness. For many, even their closest friends may not understand. For example, the sister of a young man with schizophrenia pointed out that when a friend's brother had cancer, all his friends were supportive and understanding. But, when she told a few, close friends that her brother has paranoid schizophrenia, they said little and implied that something must be very wrong in her family to cause this illness. Family members may become reluctant to invite anyone to the home because the ill person can be unpredictable or is unable to handle the disruption and heightened stimulation of a number of people in the house. Furthermore, family members may be anxious about leaving the ill person at home alone. They are concerned about what can happen. The result is they go out separately or not at all. 

The result of the stigma in so many areas of daily life, is that the family becomes more and more withdrawn. When others do not accept the reality of mental illness, families have little choice but to withdraw from previous relationships both to protect themselves and their loved one. They are unwilling to take any more risks of being hurt and rejected. Not surprisingly, all of this can lead to withdrawal from actively participating in the life of the congregation and to a crisis in faith. In this situation a pastor can be tremendously helpful by reaching out to the family and by working to create an atmosphere of acceptance and hospitality within the congregation for the family and the person who is ill. A consumer describes how his priest has helped this to happen in his congregation. 

St. Peter's has established a health ministry. One of the charges of the health ministry was to establish a mental health subcommittee. One of its responsibilities is to continually bring to the congregation, through the Sunday bulletins, items about mental illness. We also put books in the library and a poster about support groups on the bulletin board. We let people know that others are up front about this. So, maybe they will come out of the closet and ask for the help they need from those of us who deal with this every day. Understanding Frustration, Helplessness and Anxiety

It is difficult for anyone to deal with strange thinking and bizarre and unpredictable behavior. Imagine what it must be for families of people with mental illness. It is bewildering, frightening and exhausting. Even when the person is stabilized on medication, the apathy and lack of motivation can be frustrating. A mother mentions how her daughter, when asked to put her clothes in the closet, looked at the freshly pressed blouses for over an hour before making a move to hang them up. What was a matter of routine for this young woman in the past, now seemed to take an inordinate amount of time. Even though the parent knew it was not so, she had to fight the feeling that her daughter was deliberately not doing this one, small task. 

Another parent described how her son would no longer come out of his trailer home to get food to make a meal. So, she became a delivery service. She brought food to the trailer, left it outside and hoped her son would open the door and take the food. He only did so after she left, because he did not want to speak with her, as he believed that if he spoke to her, aliens would "zap" her and she would become one of "them" This went on for eighteen months, until his situation deteriorated to a point where he was deemed a "danger to himself and others," and was hospitalized. The ongoing pressure and dismay for this mother was a burden that took a terrible toll on her as she coped the best she could with a very disturbed son and a mental health system that did not view her son as so ill that he could access treatment. This parent went from agency to agency and from advocacy group to advocacy group seeking help for her son. In time, that help came. But, during those eighteen months of anguish, she lost weight, slept fitfully and had crying bouts at work. 

Family members may have trouble understanding any difficulties the person is having, or they may tell themselves that the person will "snap out of it" if given time, support and encouragement. Families may become angry and frustrated as they struggle to get back to a routine that previously they have taken for granted. How much easier to believe everything will go on as before, rather than to focus on the changes and adjustments the person and the family must make. This behavior often results in the family going from crisis to crisis, without any plan to deal with the situation. They become more and more frustrated and bewildered because both the ill person and the family have no control and no understanding of what is happening. 

Obviously such constant stress and concern can create serious family problems. Family life can be unsettled and unpredictable. It becomes very difficult, often impossible, to plan for family outings or vacations or to have even the simplest gathering at home. The needs of the ill member become paramount. At the same time there remains the needs of other family members and the usual problems of everyday life. For siblings this can be very painful. It appears that their needs, their time to have the focus on them, are put off or ignored. In some cases the parents disagree on what should be done or find that caring for the ill person leaves them too exhausted to give much attention to their partner. This very draining experience can create an atmosphere of confusion and resentment, which can result in irreparable damage to the family. 

A pastor can be very helpful in working with the family to deal with frustration, helplessness and anxiety by giving each family member a place to share his/her distress without feeling guilty or disloyal. The pastor can also be most supportive by remembering the person who is ill in the prayer life of the congregation, in keeping in contact with the person and the family, and by encouraging others to do the same. The pastor, by learning about mental illness and community resources and by making a referral, can be a catalyst for the family to learn ways to work with the person who is ill and to identify resources for their loved one and themselves Understanding Exhaustion and Burnout

Often families become worn out and discouraged dealing with a loved one who has a mental illness. Having gone down many dead-end streets in an attempt to find assistance, they may be hesitant to try another approach for fear of another failure. They may begin to feel unable to cope with living with an ill person who must be constantly cared for. Hopefully they can develop a plan to allow each family member to take responsibility for different tasks and/or to trade off times of primary responsibility. But often, they feel trapped and exhausted by the stress of the daily struggle, especially if there is only one family member. Members of the congregation can alleviate the situation by offering to assist the family with some of the care responsibilities. This may mean taking the person out for a drive, getting the person to an appointment, bringing in a meal, offering to spend time with the person to relieve the family, etc. 

Families may feel completely out of control. They may be at their wit's end, believing that it is impossible to predict what will happen from day to day. This may happen because the ill person has had no limits set on his/her behavior. The person may rule the family as a tyrant who is demanding, threatening, and refusing all efforts to help him/her alter unacceptable behavior. This is especially likely to happen when the ill person is unable, because of the illness, to understand the effect of his/her destructive behavior. Families may say they can no longer stand the abusive behavior, the threats, the living in constant fear, and the constant talk of suicide. It is imperative that the family is referred to a mental health professional, such as a social worker, and a support group, such as the Alliance for the Mentally Ill or the Depressive and Manic Depression Association. These resources can assist the family in making a plan to manage a volatile situation and in setting limits. Families need to be reminded that in the light of all the pain they see around them, they are bound to feel helpless at times. They should be able to admit this without shame. They should know that in caring and in being there, they are doing something that is vital for their ill loved one. Understanding Grief

One of the greatest difficulties for families in accepting any life altering illness of a loved one is dealing with a changed future and expectations. The grief is particularly acute for families where a loved one has a mental illness. This illness impairs the person's ability to function and participate in the normal activities of daily life, and that impairment can be ongoing. Families struggle with accepting the realities of an illness that is treatable, but not curable. 

Imagine how it must feel watching others finish their education, get jobs, and have families while your child is struggling to obtain a G.E.D., barely holding on in a supported living arrangement, and having lost his friends, one by one, as their lives have less and less in common. Families grieve for what might have been and find it difficult to focus on the possibilities that remain for their loved one. Very often they see the person as having substantially diminished potential rather than as having a changed potential. Without a caring place, without someone to be with them through this grief process, they may never come to accept the illness. Of course the pain may never go away. But, working through their grief allows them to accept what has happened and to move on. In these situations a pastor can be a supportive listener who understands the need for this process and the presence of someone to help. 

Families may ask why mental illness has struck this family. They need to know that, just as with any serious illness, there may be no good answer. It is no one's fault, it is simply an illness that has struck just as cancer, diabetes, or heart disease can strike. In this situation, the pastor can assist the family to turn their questioning toward learning about the illness and how to handle it. The added assistance of a support group, such as the Alliance for the Mentally Ill or the Depressive and Manic Depressive Association can be most helpful to the family. They will find others in these groups who have experienced some of the same problems and concerns. They will be able to find that they are not alone, that others have found answers and that with sufficient resources things can improve for them just as they have for others. 

Family members may find that mental illness is so devastating that it is hard to bear. However, just as with multiple sclerosis, diabetes or a disabling accident that strikes young adults, the family must guard against pity or placing the ill person in the role of victim. The entire family, including the person who is ill, should be encouraged to look to the future with a plan for dealing with the illness. Certainly this can be difficult and time consuming, but it will lead to building on and strengthening the person's and the family's assets rather than concentrating on deficits. Again, a mental health professional and a support group can be very helpful in assisting with this process. Understanding the Need for Personal Time and to Develop Personal Resources

Clergy working with families should remember that often the family is the first line of defense for their ill loved one. If family members deteriorate due to stress and overwork, it can result in the ill family member having no ongoing support system. Therefore, families must be reminded that they should keep themselves physically, mentally and spiritually healthy. Granted this can be very difficult when coping with their ill family member. However, it can be a tremendous relief for families to realize that their needs should not be ignored. There may be no one else except the pastor who will help them to focus on their needs and their concerns. The pastor should continually remind them that it is necessary to take time for themselves, despite the demands of assisting their family member. For anyone living and/or working with a person who has a mental illness, one should: 

Develop Spiritual Resources: Understand that feelings of spiritual distress are a normal reaction to having a family member or friend struck by a life altering illness. Realize that other people of faith have feelings of abandonment, frustration, anger, anxiety, helplessness, isolation and hopelessness. Develop your spiritual identity and resources. Seek help from your pastor, a pastoral counselor, or a therapist who affirms the importance of spiritual resources. Continue your connectedness with your faith community. 

Avoid placing blame and guilt: Recognize that you are a loving family member and/or friend and not a magician. None of us can change anyone else, we can only be supportive of ourselves and our loved one as each of us attempts to find ways to manage mental illness. Focus on the good things that happened during each day. Realize that we all have physical and emotional limits. Do not blame yourself or others if that limit is reached. 

Look for support: Learn to give support, praise and encouragement and learn to accept it in return. Use a support network regularly for empathy, reassurance, affirmation and refocusing. Attend a support group (see listings in the "Community Resources" section). Accept practical, appropriate assistance from educated family members and friends. 

Seek relief from stress: Find a pleasurable place to go each day. Find a place where you can be alone. Use it whenever you need it. Be gentle with yourself. Spend some time away from the person with mental illness. Avoid activities that increase your levels of tension. Inject some humor in your life. 

Learn to gain control of your life: Learn to set limits and to make choices. Learn to say "no" and mean it. If you can't say "no," what is your "yes" worth? Use the expression "I choose to" rather than "I have to," or "I should." Learn to say "I won't" rather than "can't." Take care of your own nutritional and sleep needs. Establish short term and long term goals for yourself. You may find it helpful to keep a journal. 

Continue outside interests: Realize that you should continue your leisure activities, your church activities, your relationships with others, your hobbies, etc. Remember to find times every day, however brief, to enjoy life. Get plenty of physical exercise. 

Learn about the illness: Learn about resources. Learn what to do if a crisis occurs. Understanding the Effect of Inappropriate Professional Assistance

Many family members have had hurtful experiences with those in the helping professions. For example, a pastor who has a son with schizophrenia had a painful experience when he led an in service training session at a mental health center. One staff member stated categorically to the group, "Families are usually sicker than the patients," (Cannon, 1990, 216). This statement was inappropriate and not based on any accepted theory of causation. When clergy, from lack of knowledge, also articulate such myths, the family quite naturally recoils. This is not atypical because for many years psychotherapy was based on the mistaken theory that family patterns caused mental illness. One learned about poor parenting, pathological families, identified patients in the family, etc. One particularly destructive theory was that of the "schizophrenigenic" mother, and the "ineffectual" father, who both used parenting skills that caused schizophrenia in their children. None of these theories are any longer creditable. However, some are still believed by people who have not kept abreast of advances in the field over the last twenty-five years.
 
The following are some suggestions to help a pastor assist a person who may have a mental illness. Response to the pastor's actions and suggestions will vary depending upon the extent of the illness, whether the person has received or is currently receiving treatment, and if the person accepts that he/she has a mental illness and has an understanding of it. 

People with an ongoing mental illness are often isolated. Very often their loss of self-esteem or the symptoms of the illness exacerbate the tendency to withdraw. A consumer describes her experience: 

When you say moving within ourselves, withdrawing, I don't think it's withdrawing. But sometimes what we are experiencing is terrifying. I think this is a key issue. Others are not experiencing what the ill person is. It is this experience, this reality to which we are reacting. And, understanding that, may lead to a pastor being able to reach someone. Or just sit, and just be, and just be present with that person.

For that person it is tremendously affirming to have a relationship with a pastor or someone in the congregation because all too often that person may have no other friends or support systems. The pastor should reassure the person that God knows, loves and understands the person's needs even if he/she is too ill to express them to God. 

When a pastor provides a referral to mental health resources, it does not imply that the individual's spiritual needs are not real. Neither does it imply that a mental health professional, agency or support group will necessarily deal with the person's spiritual concerns. What a referral CAN do is provide treatment for the person's mental illness. At the same time a pastor can provide care and support that focus on the religious and spiritual dimensions of the individual's situation. In many cases having the support and ongoing involvement of his/her pastor will enhance the prospects of a person having a positive experience with a psychotherapist and/or rehabilitation and support programs. 

Alienation: Often people with mental illnesses feel alienated and misunderstood. Many factors contribute to these feelings. People with the illness may have little awareness of the process of the disease. Their own thoughts and feelings may be disturbing and opposed to what they have learned to expect of themselves as persons of faith. They sometimes judge themselves as unacceptable to the faith community. Or, they project their own judgments on the congregation and perceive that people are condemning them for their lack of faith. As a result, they pull away from the congregation (Uken, 1986, 7). 

Punishment or Judgment: Individuals suffering from depression and feelings of hopelessness and helplessness because of their illness, may focus on religious themes of judgment. Some people believe that God must be punishing them or why would God have them in this situation. There is a strong feeling that the person is the guilty one, who has failed others and him/herself. The person believes that punishment from God is deserved. They may feel excessive guilt or shame, or believe themselves unworthy or incapable of accepting comfort and forgiveness for past failures. People who suffer from paranoid symptoms may focus on religious themes of persecution and the fear of being punished or abandoned by God and others (Weisinger, 1991, 32-33). 

Spiritual Isolation: In this situation, the person is cut off from or is very distant in his/her relationship to God. A consumer describes his feelings: 

When something like mental illness comes along, which is so incomprehensible to somebody who has otherwise had a reasonably solid life in terms of family background, schooling opportunities, professional opportunities, it's absolutely so devastating that it tends to severely shake faith. Why, if there's a providential God, which I believe there is, why does he allow things like this to happen to otherwise good people?

This issue has been voiced repeatedly by those who have experienced a close relationship to God in the past. Suddenly the person finds, in the midst of their emotional distress, when they sense very desperately a need to reach out to God for support, God is not there for him/her as before. Where before He was very close and involved in their lives in a meaningful way, now He is distant, removed and unmoving - or so it seems to some people undergoing the pain of mental illness (Wagner, 1985, 80-81). 

Physical Isolation: It may be that the illness makes it impossible for some people to tolerate the stimulation of being in a worshiping community. They may be unable to socialize and visit as often as is expected in church. Sometimes it is impossible to think clearly. Bible reading may be more confusing than helpful. Prayer may seem impossible. They may even feel they are losing faith. 

Loss: A consumer describes his sense of loss: 
My hope is often shaken by my periodic episodes of depression. It cost me my Air Force career. It cost me my marriage. It cost me, basically, my family. I only see my daughter once a year. This cost me every major romantic relationship I've had since it becomes too difficult for a loved one, a woman in my life, to put up with it for more than a year or two. I feel a social disparity between myself and my family members, because of my sense of deprivation and seeing them thriving. The same is true with friends, who are very achieving persons as I am when I'm well.

Delusions: Some people may have frightening experiences such as having delusions of being either Christ or the devil or hearing special messages or commands from God or demons. They may conclude they are evil, that God is abandoning or punishing them, or that they are lost. Just when these persons need to be reassured in concrete ways that God is with them, that the congregation is supporting them and praying for them when they cannot pray, they may feel threatened, judged or punished, abandoned and isolated (Uken, 1986, 7). 

Worthlessness: Willard Wagner (1985, 82) describes a case where a pastor's wife characterized her life prior to coming to the hospital as a life of giving to others. For years she had taken an active part in church programs. She taught, led bible study, called on shut-ins and was involved in the activities of the parish. What caused her the most distress and contributed to her sense of worthlessness was that although for many years she had taught others that they should trust in God, she now found that she had great difficulty in trusting in Him because she felt that she was totally cut off from Him. Along with the loneliness of being disconnected from God she also experienced the loneliness of being out of touch with other people and with herself. She believed that all she had attempted to contribute in the past was meaningless and worthless. She came to a point where she gave up going to church, one of the things she had previously enjoyed. 

Elation: People experiencing mania or a delusion may feel euphoric and elated because of their condition. They may have an elevated sense of self-importance or an exaggerated opinion about their relationship to God. They may lack an appropriate sense of shame, guilt or self control. They may feel that they can behave inappropriately without suffering the consequences of their actions (Weisinger, 1991, 32-33). Pastor's Resistance to a Referral

Difficulty in completing a referral to a mental health professional and rehabilitation and support services is particularly unfortunate because in the majority of cases people with mental disorders can be substantially helped, and in some cases cured, with the assistance of a mental health professional. Difficulty in completing a referral can be due to a number of factors. First, as mentioned above, there is reluctance on the part of the person with a mental health problem. Second, there is reluctance to make a referral. This is often related to a lack of or no training about mental disorders. Third, some clergy have a pessimistic, negative orientation toward mental health professionals. This is reinforced by people who are unreceptive to the idea of working with a mental health professional. This gives rise to the perception that anyone is likely to reject such a referral. Fourth, some mental health professionals themselves have not facilitated the referral process. Their receptiveness, feedback, and understanding of spiritual issues are often disappointing. Finally, the mental health system can be remote and difficult to access, often due to inadequate staff and resources, further hindering the referral process.
 
To facilitate acceptance of a mental health referral, the pastor must first foster an open and trusting relationship. This allows the person to voice his/her concerns openly and honestly. The pastor should encourage the person to express feelings about the proposed referral. Once any objections or feelings of rejection are identified, the pastor should clarify why the referral is being made. And, the pastor should emphasize that he/she will continue to give spiritual support and guidance. This process does take some planning and takes enhanced listening skills (both verbal and nonverbal). But, the goal is very important - that of getting the person to accept the referral. Furthermore, simply getting the person to the door of a mental health resource is of little value if the person arrives too frightened, angry, confused or defensive to be able to listen or work at the therapy. The person who accepts the referral out of compliance, or simply to please the pastor, family or friends, may still be closed to any mental health therapy. The goal of the referral is not to force an unwilling person to spend a few minutes with a mental health professional or a support program. The goal is to help the person go to the mental health professional and/or program or agency with openness and hopefulness. a. Dealing with Objections

The fear of the stigma and the blow to the person's self-esteem can be confronted by using two interviewing techniques: empathy and addressing negative feelings. These are suggestions. When dealing with someone with a mental illness, do what is most comfortable for you. Use empathetic statements, acknowledge and validate the person's emotional experience. For example, "You might feel it is beside the point to be told to see a mental health professional when the pain you are feeling is spiritual. I will continue to work with you on the spiritual issues that are troubling you. But, I think you also need some additional help with some of these problems that may have another cause." 

Addressing negative feelings others may have about people needing mental health therapy is also a way to acknowledge and validate the person's perceptions. For example, what consequence does the person most fear when others learn about the referral? Does the person have a concern about negative feelings of people close to him/her, such as family members? This is especially so when family members are people with whom the pastor has contact. A solution can be to have them return with the person and jointly discuss the referral and what it means to the pastor, the person needing therapy and the family. 

Remember that feelings of depression can lead a person to believe that the illness is a punishment from God. If the person believes there is a theological connection between him/her and the illness, let that person know this is not the case. Reassure the person that God cares for him/her and the pastor will be there for the person. 

In addition if the person in need of help and/or those concerned about this person are in need of additional information about the importance of therapy and available mental health services in the community, that information should be made available quickly and in a short but in-depth form. b. People with Mental Illness

When the person's resistance is an integral part of a mental illness, it can be useful to point this out to that person. The pastor can explain that the person's resistance is part of the problem that needs treatment. And, that if the problem was less troublesome, the person would not feel the same way about a referral. 

Learning about the person's prior experiences, if there are any, with mental health care can help clarify objections and make it possible to satisfy or work around them. If the person displays inappropriate behavior the pastor may not be able to change it, but can respond appropriately. Remember, the pastor may be the only support that person has. c. Reassurance of Continuity

If a person is feeling rejected because of the referral, the pastor must counter this feeling. The person should be reassured that this referral is not a rejection and that the pastor will still be there to assist the person with theological and spiritual issues. This can be demonstrated by scheduling a follow up appointment shortly after the person's first visit to a mental health professional or program. If the person is hospitalized, ask for the person to give consent for the pastor to visit him/her in the hospital and to mention his/her name among those for special prayers due to being hospitalized. Affirm that the church is a place that will always be there to accept the person as they are. And, that if one is out of the congregational community for a period of time, an accepting, nonjudgmental congregation and pastor will continue as a caring community for that person. For example it is helpful for the pastor to tell the person he/she will be remembered in the regular prayer cycle.

updated December, 2007