Last question of the bunch: barriers to treatment.
In your first meeting with Kevin, 47, he tells you that he’s been “feeling funny” lately, having trouble getting up in the morning, sleeping “too much.” Kevin says he has “occasionally” used crack cocaine in the past, but says “I haven’t hit the pipe in a week.” Kevin has been homeless in the past. He currently lives in a sober living house downtown. Kevin tells you he sometimes thinks people are talking about him and laughing about him, “but it doesn’t bother me much.” Kevin says he has not worked since being laid off two years ago.
4. What are some of the potential barriers to treatment in this case?
1. Client refuses to take medication as prescribed
Client comes to session intoxicated
Client not motivated for treatment
Client does not trust doctors and refuses to get physical exam
2. Client refuses to take medication as prescribed
Your urge to “rescue” client
Client does not believe you can help him
Client hearing voices
3. Client refuses to take medication as prescribed
Client refuses to enter an abstinence contract with you
Client not motivated for treatment
Client comes to session intoxicated
4. Class differences between you and client
Client not motivated for treatment
Client refuses to take medications as prescribed
Client refuses to enter an abstinence contract with you
MY ANSWER: #1. THIS ONE'S A CLOSE CALL. SETS 1, 3, AND 4 ARE "YES" FILLED. ALSO, MANY SOLID ANSWERS ARE REPEATED. WHAT TO DO: ELIMINATE REPEATED ANSWERS AND COMPARE WHAT REMAINS. THINK BASIC NEEDS AND RISK FIRST. IN THIS CASE, #1 INCLUDES THE MOST RISKY BARRIERS TO TREATMENT–NO PHYSICAL, NO MEDS, INTOXICATED IN SESSION–AND BEATS OUT OTHER VALID BARRIERS (CLASS DIFFERENCES, NO ABSTINENCE CONTRACT). BUT, AGAIN…VERY CLOSE CALL.
1. Client refuses to take medication as prescribed (YES)
Client comes to session intoxicated (YES)
Client not motivated for treatment (YES)
Client does not trust doctors and refuses to get physical exam (YES)
2. Client refuses to take medication as prescribed (YES)
Your urge to "rescue" client (YES – BUT NOT AN IMMEDIATE RISK)
Client does not believe you can help him (YES)
Client hearing voices (DEPENDS UPON WHAT THEY'RE SAYING)
3. Client refuses to take medication as prescribed (YES)
Client refuses to enter an abstinence contract with you (YES – BUT COMING TO SESSION INTOXICATED A BIGGER BARRIER)
Client not motivated for treatment (YES)
Client comes to session intoxicated (YES)
4. Class differences between you and client (YES)
Client not motivated for treatment (YES)
Client refuses to take medications as prescribed (YES)
Client refuses to enter an abstinence contract with you (YES – BUT COMING TO SESSION INTOXICATED A BIGGER BARRIER)
SWP, this is the first answer where I differed with you. I went with #4 over #1 for these reasons: All four answers in #1 are based on assumptions not supported by facts. Also, “doesn’t trust doctors…” is a stretch since other answers assume a willingness to engage w/ professionals…And, “comes to sessions intoxicated” assumes relapse/is at odds with a stated fact “hasn’t used in a week.”
In #4, class difference is a proven barrier to establishing therapeutic rapport so is based in fact, only three are assumptions. None of those three is directly at odds with a given fact.
Obviously all these answer groups include assumptions not included in facts but I went with what assumed the least.
JCB,
Well argued. Given that all the answers are filled with assumptions, this question asks that you shift gears a little bit and not rely upon evidence in the vignette. Without the gear shift, you’re right, #4 looks strong. With the shift, #1 wins out for the reasons stated above.
Will the real vignette exam require that kind of flexibility? Probably not. But wrestling with this stuff here is bound to be good exercise! Good luck with the exam!