1. Key: D Content Area: Human Development and Behavior.
Enmeshed family member relationships. Enmeshment tends to develop as a result of poor boundaries between family members. Permissive attitudes about sexuality is incorrect, as incest tends to occur more in families with rigid moral attitudes regarding sexuality. High-conflict relationships and chaotic lifestyles are not characteristics uniquely common to incestuous families.
2. Key: D Content Area: Human Development and Behavior.
Family members are deliberately destructive and deceitful. Family therapy is not recommended in such situations, as it generally requires honest and constructive efforts.
3. Key: B Content Area: Psychotherapy and Clinical Practice.
Call the girlfriend and disclose the potential for violence given his level of agitation when he left. Tarasoff regulations specify a “duty to warn” if: 1) a serious threat of physical violence is made; 2) the threat is made against a specifically named individual(s); and, 3) the threat is also made in the context of a clinician-patient relationship. The duty to warn stems from the 1976 legal case, “Tarasoff v. Regents of the University of California,” where a therapist heard a credible threat and only called law enforcement authorities (failing to notify the intended victim). In this case, the client’s extensive history, immediate behavior, and veiled verbiage appear to engage the duty to warn.
4. Key: C Content Area: Diagnosis and Assessment.
Substance abuse typically involves narcotics, while dependence typically involves non-narcotic drugs. In general, narcotics are more addictive than non-narcotic substances. Even relatively “benign” substances of abuse, such as marijuana, can produce dependence if used often enough, and mounting clinical and preclinical evidence suggests that a marijuana withdrawal syndrome also exists (however, it is not yet in the DSM; see Harvard study: Kouri, EM. Psychiatric Times. 2002;19). Common treatment medications include: Antabuse (disulfiram; for alcohol abuse); ReVia (naltrexone; for alcohol and narcotics); Trexan (naltrexone; for alcohol and opioid dependence).
5. Key: A Content Area: Diagnosis and Assessment.
Self-image. Self-expression in creating the drawing is one way for the social worker to understand how a client views him/herself. Elements such as the relative size of the figure, the proportions of the body, and even the order in which the parts of the body are drawn can be informative.
6. Key: B Content Area: Psychotherapy and Clinical Practice.
Cognitive-behavioral therapy. This modality uses a short-term intervention approach that is highly goal oriented, and draws upon principles of behavioral modification, task-centered treatment, and social learning theory. Thus, it is well suited for addressing phobias of many kinds. Ideally, the therapist will offer a specialized “Overcoming Fear of Flying” program.
7. Key: C Content Area: Human Development and Behavior in the Environment.
Client ambivalence about the need for treatment. Clients who are receiving involuntary treatment are often angry at being forced into the clinical setting. However, from a clinical perspective, client ambivalence about whether or not there is a need for treatment is often the greatest obstacle to be overcome. It is not possible to make meaningful improvement if a client does not see any need to change.
8. Key: B Content Area: Service Delivery.
Acknowledge her many challenges and ask which she wants to focus on. Clients often have multiple problems confronting them, and they may “spill” them out to the clinician in an intake interview. Pressing them to “specify one” can communicate indifference or impatience. Better to acknowledge the burdens they face and then help them prioritize their concerns.
9. Key: B Content Area: Diagnosis and Assessment.
Major depression with psychotic features. The precipitating event was his job loss, which led to depression. When the depression deepened he started “hearing voices,” and he drank to cope with the negative messages (and to cope with his depression). Therefore, while the alcohol use must be included in his diagnostic formulation, it would not be his primary diagnosis. Of note, the diagnosis of major depression with psychotic features is missed about 25% of the time in an Emergency Department, with only the depression typically identified (Arehart-Treichel J. Psychiatr News. 2008:43). Common treatment medications include: Celexa (citalopram), Elavil (amitriptyline), Eldepyl (selegiline), Marplan (isocarboxazid), Nardil (phenelzine), Paxil (paroxetine), Prozac (fluoxetine), Tofranil (imipramine), and Zoloft (sertraline).
10. Key: D Content Area: Professional Values and Ethics.
Clarify that even after a professional relationship ends, socializing is not appropriate. A relationship that involves as much personal divulging as exists in a therapeutic context should remain on a purely professional level. Socializing can result in a client devaluing the therapist, holding unrealized expectations, or engaging in problematic assumptions about the therapist’s presence, actions, verbalizations, etc.
11. Key: D Content Area: The Therapeutic Relationship.
Make an immediate effort to contact the boyfriend and warn him. The Duty to Protect as derived from the Tarasoff case has been rigorously debated in terms of other mechanisms of harm. A situation where a client is human immunodeficiency virus (HIV) positive and is known to be having unprotected sex with a victim who is not aware of the client’s HIV positive status is one. Given the deadly nature of the sexually and blood-to-blood transmitted HIV, it has been determined that a social worker or other clinician may be warranted in breaching confidentiality if education about the dangers and efforts at counseling have failed to alter the HIV positive client’s behavior. However, the following 5 specific criteria must be met: 1) The client must be known to be HIV positive. 2) The client must be engaging in unprotected sex or sharing drug injection paraphernalia. 3) The behavior must actually be unsafe. 4) The client must indicate an intent to continue the behavior even after counseling regarding potential harm. 5) HIV transmission must be likely to occur.
12. Key: C Content Area: The Therapeutic Relationship.
Agree to the eviction and seek an alternate placement for the client. In this situation, the client is displaying very organized, planned, and goal-directed behavior. While problems with hallucinations and delusions can result in co-resident conflicts and problems, they would revolve around the client’s altered beliefs, confusion, and/or hallucinatory symptoms (i.e., fear that the other resident possesses “special powers” to harm him or her, and thus a conflict arises, etc). In this situation, the client made deliberate and carefully calculated plans to coerce another resident into a sexual experience. This is not due to his diagnosis, but arises from a specific anti-social propensity that will likely remain problematic in this setting. Further, the threatened resident has diminished capacity and is unlikely to feel safe with the client still in that residential setting. Restitution for the damaged property is an issue for the female resident’s guardian and administrative staff at the facility.
13. Key: A Content Area: The Therapeutic Relationship.
Provide the husband with a copy of his summary letter. While the social worker owns the psychiatric record, the information held within that record is generally viewed as belonging to the patient. Moreover, the summary letter was written by the husband and was merely shared with the social worker (as opposed to the clinical notes of the social worker). Just as either party may (in most states) view the clinical record and/or request copies, this information would not be deemed privileged and should be released. However, it would be appropriate to discuss the issue further in a follow-up session before restoring the husband’s copy to ensure that the wife understands the rationale behind restoring the husband’s written summary, and does not view it as a hostile act by the social worker. Further, the need the wife had to destroy the document should also be explored–particularly since all involved already knew of the content.
14. Key: C Content Area: Communication.
Explain to the physician that the patient has a right to remain uninformed. Many cultures defer to senior family members (often males) to make important decisions in their behalf. It is important that these cultural boundaries be respected where possible. In this situation, a physician has a duty to educate and inform. However, the physician’s duty does not translate into a patient’s obligation to hear and be taught. Patient’s have the right to remain in ignorance, provided it is a free and voluntary choice, and provided the available information has been genuinely offered.
15. Key: D Content Area: Diagnosis and Assessment.
Their overall relationship. The specific reference to sexual discord is not surprising, as this is often a measure of overall marital satisfaction. However, the couple does not describe sexual inadequacy as their primary issue. The other two response options may eventually be revealed to have an impact on their relationship, but they are also not in and of themselves primary sources of the discord being experienced (i.e., the couple does not cite arguments, resentment, etc, involving either their decision not to have children or career goals as the source of their disharmony).
16. Key: D Content Area: Diagnosis and Assessment.
Cluster D: Violent and/or Explosive Disorders (also referred to as “aggressive and intrusive conduct disorders”). There is no “Cluster D”–only A, B, and C. These cluster descriptions have been provided by authors in various academic sources, although they generally only loosely describe each cluster’s content. Cluster A includes: paranoid, schizoid, and schizotypal personality disorders. Cluster B includes: antisocial, borderline, histrionic, and narcissistic personality disorders. Finally Cluster C includes: obsessive/compulsive, avoidant, and dependent personality disorders. The additional category for indeterminate behaviors that appear to characteristic of a personality disorder is called: “personality disorder, NOS” (not otherwise specified). Clusters tend to run in families.
17. Key: C Content Area: Psychotherapy and Clinical Practice.
Allow the patient to move into his motor home. The patient has a plan sufficient to meet his needs for food, clothing, and shelter. He has the legal right to choose where he wishes to live, even if others are not comfortable with his choice. Calling the police will not help, as they cannot force him to return to the facility. Adult Protective Services may have a subsequent role, if the patient begins to exhibit marked self-neglect or cognitive changes, but they cannot force the patient, either. Finally, the patient is not eligible for an involuntary hold, as he is not placing himself or others in danger based upon a diagnosable mental illness, intoxication, or other substance abuse. Careful collateral planning, however, will be important (ensuring the daughter visits and checks in on him, etc), to try and maximize his potential for success. After coping with the hardships of independent living for a time, he may willingly return to assisted living.
18. Key: C Content Area: Issues of Diversity.
Evaluate the impact that the issue of ethnicity currently has on the relationship. Obtaining a meaningful understanding of the current scope of the problem is a prerequisite to addressing it.
19. Key: B Content Area: Human Development and Behavior.
Paradoxical directive. This technique involves directing the participant(s) to do the exact opposite of what is actually desired.
20. Key: B Content Area: Clinical Supervision, Consultation, and Staff Development.
Job-related stress. The social worker needs to change service areas, seek part-time work, or find some other way to reduce these stressful feelings if she is to preserve her health and remain effective in her work. By modeling successful coping skills, the supervisor may be able to help. Supervision experts indicate that supervisor-social worker interactions provide the strongest determinants for how the social worker copes and treats others.