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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

A law and ethics question. My answer and explanation are in comments. On the exam (or at least on practice questions I've seen), questions may ask exclusively about law or ethics. Different answers, so heads up.

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.

3. What are the legal and ethical considerations in this case?

1. Get client's informed consent before beginning treatment
Terminate with Kevin if countertransference feelings emerge during treatment
Base your fee on client's ability to pay
Take steps to have client hospitalized if he is a danger to himself or others

2. Get client's written consent before making referrals
Work cooperatively with other professionals involved with this case
Bill more to client's insurance in order to reduce his co-pay
Take steps to have client hospitalized if he is a danger to himself or others

3. Get client's written consent before making referrals
Work cooperatively with other professionals involved with this case
Base your fee on client's ability to pay
Refer client to a specialist--case is out of LCSW's scope of practice

4. Seek consultation if countertransference emerges during course of treatment
Get client's written consent before making referrals
Work cooperatively with other professionals involved with this case
Base your fee on client's ability to pay

Next question. Worth noting: Groups of answers aren't in any particular order. Your task is to rate each item and choose the answer group that best answers the question. AATBS advocates using 2s, 1s, and 0s to mark each part of an answer (2s are good answers, 1s okay, 0s bad). Others push a + and - approach. Scratch paper helps. My answer and explanation (using "Yes" as a 2 or +) in comments.


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.

2. What referrals might are most likely to be useful in this case?

1. Physician for medical evaluation
Substance abuse detox
Physician for medical evaluation
A homeless shelter in the event that sober living is problematic for client

2. Physician for medical evaluation
Hospitalization till suicidal thoughts pass
Substance abuse detox
Psychiatrist to address symptoms of depression

3. Physician for medical evaluation
Psychiatrist to help stabilize symptoms
Government assistance program for financial and nutritional support
Alternative housing referrals

4. Vocational counselor
Psychiatrist to help stabilize psychotic symptoms
Outpatient drug program
Cocaine Anonymous

Some test materials for the vignette exam suggest writing questions yourself to get a behind-the-scenes view of the process. So I did. Here's the first of several questions for the following exhibit. Who knows what the test really looks like?--this is based on samples from AATBS and the BBS. Not studying for the vignette? Try this anyway--it's the same materials more-or-less, just tested in a different form. My answer and explanation are in comments.

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.

1. What are the major diagnostic considerations for this case?

1. Substance-induced psychosis
Major Depression
Schizoaffective Disorder
R/O Cocaine Dependence

2. Psychotic Disorder
R/O Substance induced psychosis
Major Depressive Disorder
Substance Abuse or Dependence

3. Schizophrenia, Paranoid Type
Depression NOS
PTSD
Substance abuse or dependence

4. Bipolar I Disorder
Brief Psychotic Disorder
Substance withdrawal delirium
R/O Cocaine Dependence