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3

Making referrals for maternal mental illness

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Contents

Objectives

When you have completed this chapter you should be able to:

Referrals

3-1 What is a referral?

Referral is the act of directing a patient to another person, place or service for help or information. The word ‘referral’ is often used in medical settings. It is an active process that is more than simply recommending more specialised services to the mother. When making a referral, the type of problem, services available and how the mother feels about getting further help all need to be considered. A referral does not stop once a recommendation has been made. It also needs to be followed up to see whether the help was useful.

A referral is the process of directing a patient to another person or service for assistance.

3-2 Why would a mother need referral?

She may need additional help with medical, social or emotional problems. Therefore the reason for referral will help decide to whom she should be referred. She may need medical treatment or counselling and support. This could be provided by a single person or a service.

3-3 Are there different services to refer to?

If you have screened a mother for mental health problems, have identified risk factors that might make her vulnerable for mental health problems, and noted symptoms of possible mental illness, you may need to refer her to a service that can help her.

These may include:

Referral is a very important part of mental health care, but can only be made if there are appropriate resources available. These differ from place to place, so it is important to identify what is available in your community. There may be both governmental services and community-based services in your area. Below are examples of the types of services and resources which may be available.

3-4 What are community mental health nurses?

These nurses are usually based in clinics, community health centres or district hospitals. They have received special training and often work together with psychologists and psychiatrists. They are sometimes known as community psychiatric nurses. It would be important to refer all mothers with psychotic features, suicidal plans or severe mental health symptoms that affect functioning. If needed, the community mental health nurse will refer the mother to a psychologist or psychiatrist.

3-5 When do you refer to a social worker?

Social workers have different roles depending on where they work. If the mother has a problem related to social issues, like accessing social grants, housing or other social services, you could refer her to the social worker. Social workers may also provide assistance with family issues, such as domestic abuse or adoption.

3-6 When does a mother need emergency mental health care?

A mother’s condition can be considered an emergency if:

Contact the community mental health or psychiatric nurse, or the doctor in your ward or facility. They will need to urgently refer the mother to an emergency unit for assessment, or preferably to the nearest health facility offering psychiatric services.

Urgently refer any mother who is suicidal, has thoughts of harming herself or others or is psychotic.

3-7 How do you support families affected by substance misuse?

If a woman or her partner misuses alcohol or drugs, she can get psychological support and information from special organisations that will deal with addiction problems (see chapter 5 and the Resources section for more information). In some settings, the protocol is to refer these families to a social worker.

3-8 What other local resources may be available?

It may be useful to look for organisations in the area which could be able to assist. Non-governmental support services in the community may include:

In South Africa, some examples of social assistance are Maintenance Orders and the Child Support Grant. Mothers with mental illness may need social assistance.

3-9 What is a Maintenance Order?

If a woman’s partner has left her, she can report him to the Maintenance Office for child support. There are Maintenance Officers at Magistrates’ Courts who can help women apply for maintenance from their ex-partners. They also deal with applications to increase or reduce maintenance payments.

If the partner denies paternity, he can be forced to take a paternity test. This gives genetic information to say if he is the baby’s father. This is a complicated procedure, but it can be worth doing as it may provide some financial support for the mother.

Here are some facts about Maintenance Orders in South Africa:

For details on how to apply for a Maintenance Order and what to do when payment is not made, go to the Resources section.

3-10 Who can access the Child Support Grant?

The primary caregiver of a child (her own or someone else’s child) can apply for a Child Support Grant. Parents and primary caregivers do not have to pay school fees for children who are benefiting from a Child Support Grant.

The primary caregiver of a child can apply for a Child Support Grant.

Note
Details about these grants, as well as the process to follow to apply, are available in the Resources section.

3-11 Are there other forms of government support?

A woman can also apply for indigency status at her Municipal Office. This can allow her to get assistance with the cost of water, electricity and property rates. If a woman has applied for a grant, but has not yet received it, she can apply for urgent support. People in desperate need of support can apply for temporary assistance called Social Relief of Distress. This is normally issued as a food parcel but can also be a voucher or cash payment. If a woman receives cash, this will be deducted from the grant money she eventually receives.

Tips:

3-12 What is the aim of a good referral?

The aim of a good referral is:

3-13 How do you make a successful referral?

Express your concern to the mother

Do not attempt to deceive or manipulate her into getting help. Make it clear that this recommendation represents your best judgement based on your assessment of her particular problem. Be specific about her behaviours, symptoms or screening results that have raised your concerns.

Give information

Explain to the mother why she is being referred. She may be more accepting of your referral if you express concern for her wellbeing and the impact of her situation on her and her family.

Choose resources you know and trust

Your choice of the referral organisation or service makes all the difference. Make personal contact with a staff member there, and learn about what they do. This will make it easier for the mother and for you when you follow up on her.

See what is feasible for the mother

Explore the mother’s situation to work out whether she is able to use the referral:

Write a referral letter

Write a detailed referral letter and be sure to ask for a reply to you. Should the mother be referred to a counsellor, your referral letter should explain that the mother is experiencing mental distress or has symptoms of mental illness. If you don’t have much time, write in bullet points. Put your name and contact number on the letter. See the Resources section for an example of a referral letter.

Follow-up

Try to find out from the mother if she went to her appointment. If she did go, find out if the appointment was useful or not. If she was unable to keep her appointment, find out why. Try not to seem disapproving. You may need to make another referral, possibly to another place.

Have an open-door policy

You may feel frustrated when a mother defaults or refuses your referral, but it is important not to judge her, to be angry or to punish her.

It is important to keep an open-door policy. Quite often, at a later stage or in a crisis, the mother changes her mind and returns to a place or person where she felt supported. It is important that she has access to mental health care when she needs it. When a mother returns by choice, she is more likely to follow up on her appointments and treatment.

If you keep an open-door policy and allow the mother to come back when she is ready, she may be more compliant and benefit from a referral and the help you offer.

Note
In the Resources section, you can find an example of a referral letter and a referral evaluation form. The referral letter template can be used as a model for letters that you send with the mother to the new service. The referral evaluation form can be used when you have a follow-up appointment with the mother, after the referral.

Counselling

3-14 What is counselling?

Counselling is a process of education, communication and support by which a counsellor helps a person or people to cope with difficult situations in their lives so that they are able to make important decisions and find realistic ways to solve their problems. Counselling helps people to make their own informed decisions and supports their choices, rather than simply telling them what to do. Many mental health problems can be successfully managed through counselling.

Counselling helps people make the best decisions for themselves.

3-15 What is a counsellor?

A counsellor is someone who is professionally trained to educate, assist and give psychosocial support to people with problems. They offer relevant information and discuss options for people to manage their problems and better cope with their lives. This empowers peoples to make their own decisions and take the best course of action according to their personal circumstances, customs, and religious and moral beliefs.

3-16 What can a mother expect from a counselling referral?

It is a good idea to find out about the services offered in your area. When making a referral to a community mental health nurse, social worker or any other service for counselling, you will need to know what is offered and then describe this to the mother. You may explain the following:

3-17 What kind of problems can be dealt with in counselling?

In addition to mental distress, counselling can benefit the following problems:

Figures 3-1, 3-2 and 3-3 illustrate different types of care appropriate for different levels of distress.

Mild distress

Figure 3-1: Talking to a trusted friend

Figure 3-1: Talking to a trusted friend

Individual support:

Mild to moderate distress

Figure 3-2: Attending a support group

Figure 3-2: Attending a support group

Individual or group support:

Severe distress

Figure 3-3: Counselling.

Figure 3-3: Counselling.

Professional medical support:

3-18 What can counselling do?

Counselling can provide:

3-19 What happens when someone is referred for counselling?

The counselling process consists of: 

3-21 What are different types of counselling?

Some counsellors will use a combination of styles during therapy.

Note
There is research evidence that many of these types of therapies work well in developing countries and when delivered by trained non-mental health professionals.

Defaulting

3-22 What stops women from taking up a referral?

You may have difficulties with setting up appointments for referral. For many reasons, women often do not attend appointments that were made for or by them. There can be practical or emotional reasons why women do not attend appointments.

3-23 What is defaulting?

Defaulting means that someone has stopped taking medication when it is still prescribed or has not attended an appointment that was made for or by them, and so does not benefit from the treatment programme.

Defaulting treatment or appointments means the mother does not fully benefit from the care provided.

3-24 Why do women default appointments?

There are many reasons why women do not attend appointments.

Practical obstacles

Many women affected by mental illness are often living in poverty or other difficult situations, which make it difficult to keep their appointments. For example, they may not have money for transport, they may not be able to get time off work, or they may not be able to arrange child care. Ways to overcome these need to be explored with the woman. These might include making appointments on the same day at the same facility (e.g. to see a social worker on the same day as her antenatal appointment as this would save transport costs and decrease the need for childcare arrangements), referring her for telephonic counselling if she has access to a phone, or sending her to a facility within walking distance of her house. If you are unaware of what the obstacles may be, then you can’t help her to look for solutions.

Myths and beliefs

Mothers may have certain beliefs about mental illness and its treatment, which can prevent them from taking up services. For instance, some women may be afraid that they will be judged as an unfit mother and have their baby taken away.

Stigma

Women may be scared to think and talk about their problems. They may worry that they will be seen as ‘crazy’. Many people think that a person with mental health problems is stupid or weak in some way. There is also a common misunderstanding that people with mental illness do not get better. Health and social workers can play an important role in addressing stigma, both with their patients and with their co-workers.

Lack of trust

Women may be concerned that the health or social worker or counsellor will tell other people about their problems. Creating a trusting environment and explaining confidentiality could help the mothers open up to you. Trust can also reduce the risk of mothers defaulting their appointments.

Depression and/or anxiety

Mental illnesses can impact on a woman’s ability to keep her appointments. A mother may not be able to make the necessary arrangements to get to her appointment because depression or anxiety:

By taking care to set up a referral appointment properly, and by bearing in mind these issues, you give the mother the best chance of getting the help she needs.

Practical obstacles, myths and beliefs, stigma, lack of trust and depression or anxiety can cause mothers to default their appointments.

3-25 What can you do if you cannot refer for counselling?

You may work in a place where the resources for referral do not exist or you may feel that the resources will not be enough. These are difficult situations, but there are other ways to assist a mother who is experiencing mental health problems.

Listen to the mother’s story

Many women may feel isolated and have no support. Having someone to talk to, even for a short time, has real and positive effects for women. While you are doing the booking procedures, taking the history and checking the physical health of the mother, you can listen to her story. Listening to the mother and showing empathy are the most important things you can do for her.

Often, health or social workers don’t ask women how they are feeling, because it takes too much time to listen properly. Health and social workers may also find it difficult to hear about other people’s feelings and problems. However, compassionate care does not need to take much more time than the routine engagement with the mother. The quality of care is as important as the quantity of care.

Provide basic counselling

Professional counselling can only be given after training. Identifying a registered training organisation to equip you and your colleagues with professional counselling skills can enhance the care you can provide for women. This can also increase your own job satisfaction and enable you to care for your own psychological wellbeing. (See chapter 4 for further details.)

Set up a support group

Support groups provide a useful space for women to share their experiences and to learn about mental health issues or other pregnancy-related matters. Support groups help people feel less alone with their problems. Feeling supported is particularly important for the recovery of women suffering from a maternal mental illness.

Help the mother to get a birth companion

If the mother is alone and has no partner or family support, you could help her to get a birth companion, also known as a doula.

If you cannot refer a mother for counselling, there are many other ways you can assist her.

Doulas

3-26 What is a doula?

The word ‘doula’ comes from the Greek language and means a ‘woman who helps other women’. Today a doula is another word for a birth companion.

A doula’s function is to care for and support a mother in labour. The doula offers emotional and physical support to a mother, and also to those who are with her during labour. A doula is not a midwife.

To have another woman in constant attendance during birth and the weeks that follow is an old practice with many benefits. Traditionally, other women who had previously given birth would surround women in labour. These women would gather to support and encourage the labouring mother.

A doula is a trained birth companion.

3-27 What can a doula do?

All mothers need to be able to trust the people around them during the birthing process. The doula creates a safe environment where the mother feels protected and calm. A doula does not perform any medical tasks but can assist labour ward staff by calming and supporting mothers in labour.

Figure 3-4: A doula is a birth companion who calms and supports a mother in labour.

Figure 3-4: A doula is a birth companion who calms and supports a mother in labour.

3-28 What are the benefits of having a doula?

The benefits of having a doula during labour can include:

Chapter summary

Case study 1

A mother at your facility who has a 6-week-old baby seems to be very depressed. She complains of lack of sleep due to worry and says that she feels like crying all the time.

1. What can you do to help her to get help?

You need to make a referral to more specialised services.

2. How do you decide who to refer to?

In order to make a referral, you need to know what kind of problem she has, what resources are available in your area and whether she would like help.

After asking her to tell you a bit more about her problem, you find out that her husband has left her and is not providing any financial support. She is feeling worried about how she will support the baby, and she is feeling very lonely and isolated.

3. What kind of help would you like to be able to refer her to?

  1. For maintenance issues, a social worker may be able to help her with a Maintenance Order.
  2. A counsellor or support group may be able to help her with her emotional problems.

4. Does this mother need emergency mental health care?

In order to assess how urgently she needs the referral, you need to find out if:

The mother does not appear to be in any danger of harming herself or others and does not require emergency mental health care. There are a number of organisations in your area which offer services. These include a drug rehabilitation centre, a social worker, an HIV counsellor, a church choir and a group of mothers who grow vegetables.

5. Which of these do you think would be appropriate referrals for this mother?

The social worker may be able to assist her with a Maintenance Order, and the mothers’ group may be supportive and provide her with some food.

Case study 2

You are becoming frustrated that women are not going to appointments when you have made a referral to specialist services. You wonder whether they are just being lazy or whether you are not referring them correctly.

1. Why would you want a referral to be successful?

The aim of a good referral is:

2. Can you think of some practical examples of why some women default appointments?

Practical obstacles:

3. How can depression or anxiety stop women from taking up appointments?

Mental illnesses can impact on a woman’s ability to keep her appointments. A mother may not be able to make the necessary arrangements to get to her appointment because depression or anxiety:

4. What are some of the other emotional barriers that stop women from taking up referrals?

Some emotional barriers are:

5. How can you help the women to overcome some of the obstacles they face?

You need to discuss with the mother what obstacles she might face, and help her to find solutions. These might include making appointments on the same day at the same facility (e.g. to see a social worker on the same day as her antenatal appointment – this would save transport costs and decrease the need for childcare arrangements), referring her for telephonic counselling if she has access to a phone, or sending her to a facility within walking distance of her house. If you are unaware of what the obstacles may be, then you can’t help her to look for solutions.

Case study 3

A mother at your facility, who has very little financial support, has told you that her children are hungry. You would like to refer her to a local NGO that offers a soup kitchen on a weekday morning and provides food parcels on a Saturday. You have been in touch with this organisation before and know the supervisor of the programme.

1. What information do you need to give to the mother to make this a successful referral?

Explain to the mother why you would like to refer her. She may be more accepting of your referral if you express concern for her wellbeing and the effect that her situation has on her and her family. Give her information about what is being offered, when the soup kitchen is open, if there are any costs involved and who she needs to speak to when she is there.

2. What information do you need to find out from the mother in order to make this a successful referral?

Explore the mother’s situation to work out whether she is able to use the referral:

3. What else can you do to make this a successful referral?

Write a detailed referral letter and ask for a reply to you. Explain the woman’s situation, your involvement with her and why you feel that the organisation would be able to help her. Put your name and contact number on the letter. Give the letter to the woman and tell her who to take the letter to.

When you next meet with this mother, you follow up and find out that she did not go to the soup kitchen.

4. What do you need to do?

Try not to seem disapproving or upset. Follow up and ask her calmly what happened. Find out why she was not able to go.

The mother tells you that her circumstances have changed. Her aunt has come to stay and is able to contribute to the household expenses. Also, because the aunt is able to take care of the children sometimes, the mother is able to earn some money cleaning at a nearby factory. She is now able to feed her children and did not need to visit the organisation.

5. What do you think would have happened if you had been cross with her for not going to her appointment?

You would not have found out that her circumstances had changed for the better. Also, you would have closed the possibility of her coming back to you when or if she needed help at a later stage. By not judging her, you have been able to keep an ‘open door’. An open-door policy means that at a later stage or in a crisis, if the mother changes her mind, she can return to a place or person where she felt supported. It is important that she has access to care when she needs it. When a mother returns by choice, she is more likely to follow up on her appointments and treatment.

Case study 4

A pregnant mother at your facility has screened positive for anxiety. She says that she feels jumpy and shaky a lot of the time. She previously had a traumatic birth experience and is very scared about going into labour. You would like to refer her to a counsellor to get help with how she is feeling.

1. What information can you give this mother about the referral to counselling?

You may explain the following things to the mother:

2. The mother is very unsure about whether this is the right thing for her. She asks, what kind of problems can be dealt with in counselling?

Counselling can benefit the following problems:

As this mother is feeling very anxious, and has severe symptoms, it seems as if counselling could be of benefit to her. The counsellor can try to help her identify possible ways of coping, relaxing and getting support.

By talking to the mother about how she is feeling and what problems counselling can help with, it seems as if it would be the right kind of help for her.

3. The mother is still unsure about what happens during counselling and asks, what happens when someone is sent for professional counselling?

The counselling process consists of: 

The mother now understands what might go on during the time she is in counselling. She seems to be willing to meet with the counsellor.

4. What would you need to do to make this a successful referral?

Before meeting a mother for the first time, it is helpful for the counsellor to check the information that came with the referral. When referring someone for professional counselling, be sure to provide as much information as possible, such as mental health screening forms, notes on her background history or letters from other health workers.

5. What type (or types) of counselling may be best suited for this mother?

In a place where there are many resources and different counsellors, not all counsellors use the same styles for counselling. There are different types of counselling, such as:

As this mother has anxiety and a previous traumatic birth experience, these forms of counselling may help her:

Case study 5

A young pregnant mother at your facility screens positive for depression but does not want a referral to a counsellor. She is very withdrawn and you are worried about her. She seems to feel comfortable talking to you during her antenatal visit – but you are not a qualified counsellor. She tells you that she is lonely and does not have any friends here.

1. What can you do to help?

Listen to the mother’s story. Many women may feel isolated and have no support. Having someone to talk to, even for a short time, has real and positive effects for women. Listening to the mother and showing empathy is one of the most important things you can do for her. Compassionate care does not need to take much more time than the routine engagement with the mother.

When you listen to this mother, you understand that she is very lonely and isolated. She is not from this area, and does not trust her neighbours as they are rude to her. She finds it very difficult to make friends and worries that she will be alone during the birth of her baby as her husband travels a lot for his work.

2. What other supports or services might be useful for this mother?

Support groups provide a useful space for women to share their experiences and to learn about mental health issues or other pregnancy-related matters. Support groups help people feel less alone with their problems.

A very useful support to this mother would be a birth companion (doula). When trying to explain these options to the mother, she wants to know what a doula is and what she would do.

3. Can you explain what a doula is?

A doula is a woman who helps other women in labour. Today a doula is another word for a birth companion. A doula’s function is to care for and support the birthing mother. The doula offers emotional and physical support to the birthing mother, and also to those who are with her during labour. A doula is not a midwife.

The mother is interested in this, but wants more information.

4. Can you explain what a doula would do?

5. What are the benefits of having a doula?

The benefits of a doula during labour can include: