CASC: Supportive psychotherapy — demoralisation after job loss

Candidate instructions

You are the psychiatry registrar. Alex, 46, recurrent depression, lost a job three weeks ago. On sertraline 100 mg daily. PHQ-9 last week 16. No psychosis. Passive death wishes when most demoralised; no plan or intent today. CBT waitlist ~6 months. Feels "talking won't help" and that you will only "push antidepressants." Tasks in 10 minutes:[5][7]

1. Engage and set a collaborative agenda (mood, job stress, meds, what would help today).
2. Explain supportive work in plain language (not jargon, not "just chat").
3. Use at least three techniques: validation, praise of adaptive effort, collaborative problem-solving for one next step.
4. Screen suicide risk and safety-net.
5. Agree follow-up and what success looks like this week.
6. Maintain a professional frame if Alex tests for special after-hours dual-role help.

Actor brief (Alex)

• Soft-spoken, demoralised, slightly defensive about "just meds."
• Sustain talk: "Nothing will change until I have a job"; "Therapy is for weak people."
• Softens if validated and offered a concrete small step (update one CV line; message one former colleague; fixed morning routine).
• Admits passive death wishes when lying in bed midday; denies plan/intent; accepts crisis numbers.
• Tests frame once: "Can I just text you whenever I spiral tonight?" — should receive warm but clear contact boundaries and crisis alternatives.

Marking grid (domains)

Model process (time map)

0–2 min — Engage/focus. "We can talk about mood, the job loss, medication, sleep, or what feels most urgent — where shall we start?" Permission and agenda.[7]

2–5 min — Supportive model and techniques. "When life knocks confidence, people often withdraw; structured support helps you feel understood and take small workable steps while depression treatment continues." Validate loss; praise attending and taking sertraline; co-create one next step with day/time.[5][7]

5–8 min — Risk and frame. Ask ideation, intent, plans, protective factors; crisis contacts. If texting request: warm limit — clinic hours/process, crisis line for after-hours, emergency if safety threatened. Link alliance: working relationship is helped by clear boundaries.[11][12][14]

8–10 min — Close. Summarise plan, med adherence check, review date, what to do if worse tonight.[5][6]

Sample high-scoring utterances

• "Losing work would knock most people — and part of you still showed up here today."
• "If energy is low, what is one 15-minute step toward work or support that still counts this week?"
• "I want you to have help after hours — that is the crisis team/line, not unrestricted personal texting. That boundary keeps this treatment safe and reliable."
• "Passive death wishes matter; let's make a clear plan for if tonight feels worse."

Examiner keys

Supportive technique (validation, praise, collaborative next step), risk screen with safety-net, clear frame without dual-role texting, and no claim that support is "just chat" or placebo.[5][6][7][14]