A 23-year-old man, Bob, comes to see you. He has not been able to work for the past few years. He reports having flashbacks ever since he got back from military duty in Iraq and drinking beer to get rid of the flashbacks. He is concerned that the relatives he is staying with may kick him out because he is spooking them with his problems.

1. What information presented in the vignette suggests that Bob is in crisis?

A. He is unemployable.
    He is having conflict with his relatives.
    He is bothered by flashbacks.
    He drinks beer to get rid of his flashbacks.

B. He is an Iraq War Veteran.
    He has PTSD.
    He is bothered by flashbacks.
    He drinks beer to get rid of his flashbacks.

C. He drinks beer to get rid of flashbacks.
    His relatives find his behavior spooky.
    He may lose his current living arrangement.
    He has not been able to work.

D. He is an Iraq War Veteran.
    He is having conflict with his relatives.
    He is unemployed.
    His relatives find his behavior spooky.

A. Interview with Bob’s relatives about his medical status.
    Bob’s medical records.
    Bob’s employment records.
    Past records of substance abuse treatment.

B. Interview with Bob’s relatives about his substance use.
    Interview with Bob’s relatives about his functioning before the war.
    Bob’s employment records.
    Past mental health treatment records.

C. Interview with Bob’s past employers.
    Interview with Bob’s relatives regarding the behavior they find spooky.
    Bob’s military and VA records.
    Bob’s past mental health records.

A. Stress inoculation training.
    Exposure.
    Motivational enhancement therapy.
    Relapse prevention.

B. Systematic desensitization.
    Psychological debriefing.
    Inpatient detoxification.
    12-step community groups.

C. Psychological debriefing.
    Exposure.
    Motivational enhancement therapy.
    Relapse prevention.

D. Eye movement desensitization and reprocessing.
    Interpersonal psychotherapy.
    Motivational enhancement therapy.
    12-step community groups.

1. C – This question is asking about the specific details which indicate that Bob is in crisis. Drinking in order to get rid of flashbacks, exhibiting behavior that disturbs others and threatens his current living arrangements, and an inability to work are all issues that may indicate Bob is in crisis. In contrast, the fact that Bob is an Iraqi War Veteran does not necessarily indicate that he is in crisis as many veterans are not in crisis (Response B). Similarly, the fact that Bob has not worked for a few years, does not indicate that he will never be able to work or that he is unemployable (Responses A and D). Finally, while a diagnosis of PTSD (Response B) may eventually be justified, this question is about crisis, not diagnosis.

2. D – Interviews with Bob’s relatives regarding his “spooky” behavior and his substance use are both helpful ways to get collateral information (Response D). In contrast, interviewing his relatives about his medical status (Response A) is less relevant when you can access his past mental health treatment records (Response D). Since Bob has not been employed for the past three years, inquiries into his employment (Responses A, B, and C) would not be helpful at the present time. Finally, although Bob is using substances, it is premature to assume that he is abusing them or that he has sought treatment in the past (Response A).

3. A – Stress inoculation training (Response A), developed by Meichenbaum, has demonstrated efficacy for PTSD. Once the client feels safe within the therapy and has reduced his fear of dealing with the past, he will be ready for exposure (Response A) to avoided stimuli. Motivation enhancement therapy (Response A) can be used at the outset of treatment to increase the client’s motivation to recognize his substance abuse issues. Marlatt’s Relapse Prevention treatment (Response A) is a comprehensive cognitive-behavioral intervention for substance abuse. Critical incident debriefing and the related intervention of psychological debriefing were originally hailed as treatments that could prevent PTSD from developing. The underlying theory was that immediate debriefing of people who had suffered a trauma would resolve their problems without the development of chronic symptoms. Further research has shown that these treatments are not effective in preventing PTSD, and, for a subset of people, actually worsens trauma-related symptoms (ruling out Responses B and C). EMDR (Response D), for all its controversy, has been shown to be effective in treating PTSD. However, it is no more effective than other exposure-based treatments. Finally, interpersonal therapy, based on the work of Harry Stack Sullivan, is a well-established treatment for depression, but has not been specifically applied to the treatment of PTSD (ruling out Response D).