What scope of competence means
Scope of competence is the set of things you are actually qualified to do, as opposed to the set of things you feel able to do. The gap between the two is where most preventable harm in this field lives.
Facilitators are often capable, experienced, and genuinely helpful, and they are usually not clinicians. Sitting with someone through a difficult night is not the same as assessing whether that person is having a psychiatric emergency. Holding a supportive conversation is not the same as treating trauma. Both distinctions are routinely blurred, almost always with good intentions.
Writing your scope down is a good discipline. What you do. What you do not do. What you refer out. Then noticing when you drift past it.
What a facilitator is not qualified to do
- Diagnose a mental health condition.
- Advise anyone to start, stop, or change a prescribed medication.
- Decide that a medical symptom does not need a doctor.
- Treat trauma, unless separately qualified to do so.
- Manage a psychiatric emergency alone.
- Tell someone that a deterioration is part of their process rather than a clinical problem.
The last one deserves emphasis. Framing someone's decline as spiritual progress is the most common way that a treatable situation becomes a lasting one.
Referral thresholds
Refer promptly and without hedging when you see:
- Any suicidal thinking, intent, or planning. Immediately, and do not leave the person alone.
- Psychotic features: fixed beliefs not shifting with reality, hearing or seeing things persistently outside the experience itself, paranoia.
- Derealisation or depersonalisation persisting beyond a couple of weeks.
- Sleep that has not returned after two weeks.
- Loss of ability to function at work or at home.
- Escalating substance use.
- Any physical symptom you are not qualified to assess, particularly cardiac or neurological.
The error most people make is waiting. Referring early costs the person one appointment. Referring late costs considerably more.
Building the referral list first
A referral list assembled during a crisis is not a referral list. Build it in advance and keep it current: a psychiatrist who will take an urgent call, a therapist or two who will not dismiss an account of a ceremony, a doctor, local emergency numbers, and a crisis line for the participant's country rather than only your own.
For international participants this takes real work, and it is part of what preparation buys. Ask during screening who their doctor is and where they will be in the weeks afterward.
How to refer well
A referral that feels like rejection tends not to be taken up. Say plainly that you are recommending this because you take the situation seriously and want them to have someone properly qualified. Give a specific name rather than a category. Offer to help make the appointment. Confirm you are not disappearing, and then stay in contact in whatever way is appropriate.
Tell the person what to say. Many participants are frightened of disclosing a ceremony to a doctor and so give an incomplete account, which produces worse care. A short factual script helps: what they did, when, what has happened since.
The cost of doing it properly
Referring well costs money, reputation, and sometimes the relationship. It means telling someone the thing you offer is not what they need, in front of colleagues who may see it as a failure.
It is the clearest available test of whether an organisation's ethics are real. Ask any practitioner for the last time they referred someone out, and for the last time they returned a deposit. The specificity of the answer tells you most of what you need to know. See consent, power, and money.