Some circumstances may necessitate the consideration of referring a client to other clinicians or services. This may be to obtain additional services, or because the clinician feels that the client requires responses that are beyond their own level of skills and expertise [389]. As mentioned in Chapter A3, it is vital that AOD workers can appreciate their level of expertise and training but also have the ability to recognise their own limits and work within their own capacity. Referring a client to a more suitable clinician is an ethical practice that ensures appropriate treatment needs will be met, and requesting supervisor support can be useful in this process [389].
Referrals can involve transferring a client temporarily, permanently, or sharing client care [389]. Whenever possible, clients should be retained in AOD treatment whilst accessing other services, rather than excluded from AOD services and referred to others. For example, a client entering residential rehabilitation who has been identified as having a bipolar disorder may be retained in AOD treatment, but it may be useful to obtain an appointment with a psychiatrist who can undertake an assessment, provide a diagnosis, and prescribe medications; the client’s condition can then be managed while they are in the residential service. Increasingly, a number of employment, welfare, and medical services are providing consultation times within AOD services to facilitate client access to these services.
In some cases, however, it may be necessary to refer clients to external services. For example, in cases of acute psychosis and suicidality, it may be necessary to contact the local mental health crisis assessment and treatment service to come and assess the client for admission to appropriate mental health services. AOD workers should be aware that, in instances where the client needs to leave the AOD treatment setting to have more immediate needs met prior to addressing their AOD use (e.g., acute mental health or medical issues), their relationship with the client should not cease. The client will still require AOD treatment after these issues have been addressed and it is important to follow-up with the client and referral agency regarding the provision of this treatment.
One of the biggest risks in the referral of clients to external services is the potential for clients to ‘fall through the gaps’ and disappear from treatment altogether. People with co-occurring conditions in particular often have difficulty navigating their way through the available services, and many are lost during the referral process [389]. The act of trying to navigate the health care system has been likened to a roundabout with many points of entry and many options regarding the direction to be taken [85]. Therefore, it is crucial that the referral process focuses on linking the client with services as smoothly as possible. This process may be assisted by the development of formal links between services regarding consultation, referral pathways, and collaboration, such as a memorandum of understanding.
Where referral is non-urgent (e.g., not requiring urgent medical or psychiatric attention), the referral process may be passive, facilitated, or active (see Table 36). In the case of clients with co-occurring conditions, active referral is recommended over passive or facilitated referral. Active and timely referrals have been associated with improved AOD and mental health outcomes [639, 640], whereas passive referrals are considered to be one of the reasons for low engagement in continuing care [641].
When referring a client to an outside service, it is crucial that AOD workers consult with the referral agency to determine whether the client kept the appointment, whether assistance was provided and what progress was made. This process of assertive follow-up is particularly crucial in cases where the referral is related to a high-risk situation (e.g., suicidal intent). With clients’ permission, families and carers should be involved in the referral process wherever possible, as they will often need to facilitate clients’ access to other services. Families and carers should also be informed of services available to them in the form of advocacy and support groups (e.g., Family Drug Support, SMART Family and Friends).