JASON Your neighbor, Dave, asks if you want to join him to go duck hunting this weekend. You ask who else is going. He says, “Only Tim. Jason is acting out again, so I’m not taking him.” You know that Dave and his wife have had ongoing trouble with their 16 year old son, Jason, but not the details. “Do you want to talk about it?” you ask. “Well, his grades have gotten really bad this quarter and then he got into a fight at school. When he went to the school counselor, Jason said he should just make everybody happy and end it all. The school called us in saying they were worried about him. But my wife and I said that he says stuff like that all the time to manipulate us when he gets in trouble. I’m just not going to let him get away with that kind of stuff.” What do you say next?

HAROLD Harold, your favorite uncle, is 72 years old. Betty, his wife of 47 years died a year ago after a long fight with cancer. Harold was a devoted caregiver giving up almost all his previous activities to be with and care for his wife. In the past six months, he has told you that he is having trouble sleeping and that his appetite isn’t good. In the past three weeks, he has made and broken two dates with you, which is totally out of character. When you finally do see him, you ask him how he’s doing. “I don’t know. I just don’t feel myself,” he says. When you ask him, “What do you think would make you feel better?”, Harold replies, “Probably just a shot in the head from my trusty old .22” What would you say next?

TAMMY Tammy is a 17 year old, straight A student at your high school. You know that she has had some counseling for anxiety in the past, but is not currently in treatment. She struggles with perfectionism and is obsessed with getting into a top-notch school. Her SAT results came back much lower that she expected and her boyfriend has decided they should “have some time apart” Today after class, she asks if she can talk with you. Then she tells you that she is in “crisis” and that her “whole world is falling apart”. When you question her further, she says that she thinks that maybe she should just end all this pain. When you ask her what she means by that, she says that she could die by taking all the prescription pills that are in the medicine cabinet at home along with a whole lot of Tylenol. What do you say or do next.

MARYANN MaryAnn is a 30 year old who has recently given birth to her second son in less than two years. You are at her home doing the second of three new baby visits. Unlike at the first visit, MaryAnn seems somewhat disinterested in both her boys, the house is pretty dirty (stinky diapers under the coffee table) and she has trouble making eye contact. You know from her chart that she had been taking anti-depressants before this pregnancy and discontinued them when she learned she was pregnant. Her primary care provider has suggested that she go back on them and she resumed taking them two weeks ago. When you ask her whether she is getting any benefit from them, she replies, “I think the only way they’ll do me any good is if I take the whole three months supply at once and never wake up again.” Then she starts to cry. What do you do next?

TOM Tom is a 24 year old who has recently returned from deployment where he was in a motor vehicle crash, with significant injuries to his spinal cord. After spending time in both acute care and rehab facilities, he has moved back home with his parents and is now receiving physical therapy services at the VA clinic. He has been making excellent progress and has regained most of the function in his upper body though there has been almost no progress with his legs. You are a volunteer providing transportation services for the VA. Today, while driving him to his clinic appointment, you get the feeling that something is different. When you ask what is going on, he says, “What’s the point in all of this? I’m going to be stuck in this chair for the rest of my life. What kind of life is that for me or my parents who have to take care of me and most of my friends don’t know how to deal with a guy in a chair.” What do you do or say next?

STAN Your co-worker, Susan is worried about her husband, Stan. He is a 56 year-old, married man who has two daughters in college. He lost his job at a high-tech firm eighteen months ago due to downsizing. Though he has been actively searching for a job ever since, he has yet to find anything, other than a few consulting jobs. Today at lunch, Susan tells you that Stan has been having problems with sleep over the past two to three months, and he has seen his primary care provider for complaints of chronic back pain and headaches. She says that he has been very moody, and has said more than once, “You know that if something happens to me, you’ll have all the life insurance money.” What do you do next?