1. Making effective referrals to mental health services

2. Think back to Oleg…  What would have been the challenges in making a referral?  What would an outreach worker’s goals have been?  What would Oleg’s view have been?

3.  Can you identify any shared concerns?

4. Case study - Mary  26 year old woman. She has been in the hostel system for three years, after being excluded from her home that she shared with her partner and child following an incident of severe self-harm by overdosing.  She had previously had other self-harm attempts including cutting, attempted self strangulation.  She entered the hostel system dependent on alcohol and was drinking between five and ten 2 litre bottles of strong lager a day. She would wake in the night to drink in order to ward off withdrawal symptoms. She has engaged with alcohol services sporadically and has been through detox once but relapsed. She had managed to have a period of sobriety for three months post detox but then relapsed back to original level of drinking.

5.  Despite a number of referrals via A and E, following her self harm attempts, she has not had a full mental health assessment, either due to non- attendance or non- engagement at interview. There is a suspicion that she has a personality disorder but this has not been formally assessed.  She periodically says that she would like to stop drinking, however her drinking is at such a level that she would find it impossible to cut down in order to show motivation for detox and rehab. Though the substance misuse services want to offer support they cannot see her when she is intoxicated and she cannot be sober without going into withdrawal.  Workers at the substance misuse service suspect she has a mental illness and have requested she be assessed by mental health services, but again it is difficult to assess her as she is always intoxicated and her behaviour is erratic.

6. What would the challenges be in making a referral for Mary?  When?  Who to?  What might she likely to feel about statutory services?

7. Does the person you are concerned about want to be referred to mental health services?  If not, what are the circumstances when you might consider this anyway?  How might you engage them in a discussion about this?  What are your motivations?

8. Re-framing the referral process…  Mental Health services are not always the answer – (despite the frustrations that exist for housing projects when they seem to be holding the chaos when highly qualified mental health professionals turn down referrals!)  They might be part of the answer. 1. When discussing a potential referral with a resident don’t over-sell. 2. When making a referral be specific about what is wanted.

9. Email 1  “His behaviour has become increasingly erratic, he was unable to sleep in his room last night, as he was convinced there was a snake under his bed – I had to show him this morning, it was not a snake, but a piece of plastic.”

10. Email 3  “He tells me that he has not slept the last few nights, and that he has been injecting crack nonstop”  Do not leave out “inconvenient” information!

11. It’s OK to say:  The person you are referring and you have different perspectives or priorities.  You don’t know what might be help but you are concerned.  Substance use may be playing a part.

12. Expertise  The real expert is the person being referred  A hostel keyworker – may well have an very good knowledge about the impact of that person’s mental health and about how they behave. - Value this – describe what you know and what your concerns are – but do not pretend to be a psychiatrist!

13. Language  When describing someone’s mental health presentation, your subjective impression is relevant and it is more important and helpful for you to record and describe this in your own descriptive language than it is to worry about having the right specialist vocabulary.  In most situations, discuss your impression with the person you are referring

14. Ask questions  Ask questions.  Involve primary care.  Understand the system but don’t over strategise!  Do think about timing.  Planning for crises (they can be opportunities).