Comments on: Vignette Exam Practice: Kevin, Question Four

By: Ray Brittain

Ray Brittain — Thu, 06 Oct 2011 23:31:50 +0000

Your vignettes with the potential barriers and the thoughtful responses appear quite helpful. I have supervisees who are looking for as much clinically valid vignette help as possible. Workshops are fine but the more opportunities available aside from workshops, the better.
Thank you for the service you provide.

By: SWTP

SWTP — Fri, 07 May 2010 20:33:10 +0000

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!

By: JCBlues

JCBlues — Fri, 07 May 2010 19:01:15 +0000

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.

By: SWP

SWP — Tue, 11 Aug 2009 20:03:03 +0000

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)