NCMHCE Practice Test 15

Presenting Problem

You are a licensed mental health counselor working in an outpatient behavioral health agency. Raymond, a 47-year-old hospital maintenance foreman, was referred by the municipal court after his second arrest for driving under the influence two months ago. Completing an assessment and any recommended counseling is a condition of his probation, and the court referral form asks the agency to send his probation officer monthly reports. He opens the intake by saying, "I'm here because the judge said so. I don't have a drinking problem. I have a bad-luck problem."

Raymond reports drinking six to eight beers on most evenings for about three years, an amount that increased after his divorce. He says beer "takes the edge off" evenings alone in a quiet house. "I tell myself I'll have two, and then the twelve-pack is gone." He tried to stop twice in the past year; the longest stretch lasted four days. "I wasn't sick or shaky. I just wanted one." He describes thinking about "that first cold one" by midafternoon on most workdays and says it "takes a lot more now to feel anything than it used to."

Both arrests followed evenings at a bar, about two years apart, and Raymond acknowledges that he has driven after drinking "plenty of times I didn't get caught." His license is suspended, he has paid more than $4,000 in fines and fees, and he faces jail time if he violates probation. He says he has never missed a shift or been disciplined at work, and he still bowls in his Thursday league, where a teammate now drives him. He denies drinking in the morning, blackouts, or alcohol-related medical problems, and his primary care provider described his physical last month as unremarkable.

Raymond scored 18 on the AUDIT. His last drink was two beers three nights before the intake. He denies suicidal ideation, plans, or past attempts, and he denies homicidal ideation. "I'm not depressed. I'm annoyed." He asks how many sessions the court requires and adds, "If I have to come, I'll come, but I'm not going to sit here and confess."

Mental Status Exam

Raymond arrived on time in work clothes, with adequate grooming and hygiene. He was oriented to person, place, time, and situation. He described his mood as "annoyed"; his affect was irritable early in the interview and more relaxed as it progressed, and it was congruent with content. Eye contact was intermittent. Recent and remote memory were intact. Motor activity and gait were normal, with no tremor or sweating. His thought process was linear and goal-directed, and thought content centered on the court requirements and his job. He denied hallucinations, and none were observed. He denied suicidal and homicidal ideation and reported no history of mania or hypomania. Substance use: alcohol as described; he smokes about half a pack of cigarettes a day and denies other drug use.

Psychosocial and Family History

Raymond grew up in a small town, the second of three children. His father drank heavily and died of liver disease when Raymond was 30; Raymond says, "I'm nothing like him. He couldn't hold a job." Raymond was married for 19 years, and he describes the divorce three years ago as "we grew apart." His 22-year-old son is getting married later this year. Raymond has worked at the same hospital for 15 years and is proud of his attendance record. His older brother, who lives nearby and does not drink, has offered to drive him to work. Raymond was raised Catholic and attends Mass on holidays. A trauma screen was negative. Money is tight because of court costs. As he signs the intake forms, Raymond asks, "Does my probation officer get to read what I say in here?"