A Guide for Step 2 vs Step 3 referral
This is a guide to help with the decision process. However, as people are all so diverse and
complex, it will never work for all people.
What is the diagnosis/ presenting problem?
Anxiety inc. panic attacks
Depression
Post natal depression
Stress
Anger (with underlying Anxiety,
depression or stress)
Insomnia
Mild OCD symptoms
Severe and
enduring
mental illness+
Is it usually
stable, but
difficulties caused
by an unrelated
situation?
Consider Step 2
referral
Have they had CBT/
Psychotherapy or Psychology
intervention’s in the past?
Does the patient have suicidal
thoughts with plans/ and or intent or
are they currently self-harming/ a
risk to others?
Has the patient experienced a
significant event e.g. relationship
breaks down, bereavement, abuse
etc
Obsessive Compulsive Disorder (OCD)
Post Traumatic Stress Disorder (PTSD)
Complex grief*
severe low self-esteem
Complex psychological history #
Consider step 3/3+
Consider step
3/3+/4 referral
Has an unrelated situation/ event happened
and the client wants a refresher?
Consider step 3/3+/4
referral
Consider low cost/ specific
counselling (see
www.firststepssurrey.nhs.uk for
signposting info
Do they want
someone to talk
things through
with?
Key
Yes
Consider a Step 2 referral
No
A Question
Consider Step 2
See overleaf for definitions
Consider another service type
* Complex grief
It is normal for all people to experience a grieving period after bereavement. Complex grief is an
intense and long-lasting form of grief that takes over a person’s life. Complex grief refers to factors
that interfere with the natural healing process. These factors might be related to characteristics of
the bereaved person, to the nature of the relationship with the deceased person, the circumstances
of the death, or to things that occurred after the death.
+ Severe and Enduring Mental illness
Is a generic term that describes a mental illness that has a profound effect on a person’s ability to
function over a long period of time. These long-term illnesses include schizophrenia, personality
disorders and bi-polar disorder but can also include the most severe forms of depression and anxiety
(most commonly Obsessive Compulsive Disorder (OCD) and Agoraphobia).
# Complex psychological history
Describes people who have had a significant or several significant experiences that have impacted
on their mental health. Examples could include past abuse, rape, traumatic experiences, severe
bullying, suicide or murder of a loved one etc.
Drugs/ Alcohol misuse
Talking Therapies are unlikely to be helpful if a person is misusing drugs/ alcohol and they do not
feel that they are able to control this. A general suggestion is that if the drugs or alcohol are causing
the depression/ anxiety the person needs a drugs/ alcohol service.
If the anxiety/ depression is causing the person to use drugs/alcohol to cope and the person feels
that they can control/ reduce/ stop their use to allow themselves to learn new ways of coping, then
an IAPT service would be most helpful.
Self harm
Includes any act where a person makes a deliberate effort/ choice with the aim of causing
themselves harm. This could include cutting, scratching, hitting, burning, poisoning, risk
taking, starving self etc.