NCMHCE Practice Test 13

Presenting Problem

You are a licensed mental health counselor working in a community mental health agency. Mesfin, a 38-year-old man who moved to the United States from Ethiopia 14 months ago with his wife and two children, is referred by his primary care physician after several visits for neck pain, headaches and fatigue with no medical cause found. Mesfin speaks Amharic and some English, so the intake is conducted with a trained agency Amharic interpreter. "The doctor says my body is healthy, but my mind does not rest. I am thinking too much."

Mesfin taught secondary-school mathematics in Ethiopia and now works night shifts at a distribution warehouse. The worry began about two months after the family arrived and has been present "almost every day" for about a year. He worries about paying rent, his children's schooling, his parents in Ethiopia, his own health and being late for his shift. He also worries about things that are going well: his wife has steady work as a home health aide, yet he worries daily that she will be fired, and although both children earn good grades, he checks their school portal several times a day. "When one worry finishes, another one comes. I tell myself to stop, but I cannot."

He reports muscle tension in his neck and shoulders, tiring easily, trouble concentrating on training materials at work and irritability with his children. He falls asleep after his shift but wakes after three or four hours with his mind "already running." He denies any sudden surges of intense fear. "In my country I was a teacher. Here I am nobody." Mesfin says he feels he must not show weakness to his family and that his wife urged him to come.

When asked about safety, he denies suicidal ideation, intent or plan and any past attempts: "My faith does not allow it, and my children need me." He denies homicidal ideation.

Mental Status Exam

Mesfin arrived on time, neatly groomed and wearing a pressed shirt. He was oriented to person, place, time and situation. His affect was anxious and mildly restricted, congruent with his stated mood, "tired and worried." Recent and remote memory were intact. He sat rigidly and rubbed his neck often; gait was normal. Eye contact was intermittent, and he often looked toward the interpreter. Thought process was logical and goal directed; thought content centered on financial, family and health worries without delusional themes. He denied perceptual disturbances, suicidal or homicidal ideation, and any history of mania or hypomania. He reports drinking one or two beers after some shifts to help him sleep and denies tobacco or drug use.

Psychosocial and Family History

Mesfin and his wife have been married 15 years and have a 15-year-old daughter and a 10-year-old son. His younger brother, who sponsored the family's move, lives across town and works long hours; they see each other about once a month. Mesfin sends money to his parents monthly, and the family is one month behind on rent. He belongs to the Ethiopian Orthodox Tewahedo Church, prays daily and attends services when his schedule allows. He has not had his teaching credentials evaluated in the United States. A trauma screen was negative; he describes the move as planned and "chosen, but harder than I expected." At the end of the intake, Mesfin asks that his daughter interpret at future sessions instead of the agency interpreter: "She understands me, and I do not want to cost the clinic money."