PLAB 2 Alcohol Counselling Station: How to Approach, Mark Scheme & Free Practice

Hold these differentials in your head

Bracket the deadly causes first. If you fail to consider any of these in your reasoning out loud, the clinical-management domain will suffer.

• Lower-risk drinking
  At or below 14 units a week, spread over three or more days, with no binges and no CAGE positives. Your job here is reinforcement and accurate information, not intervention - do not pathologise a social drinker.
• Hazardous drinking
  Above 14 units a week or regular binges, but no harm has yet occurred and no dependence features. AUDIT-C picks this up. The ideal candidate for a brief intervention and a self-directed cutting-down plan.
• Harmful drinking
  Drinking that is already causing physical, mental or social damage - deranged LFTs, low mood, relationship breakdown, injuries - but without the dependence syndrome. Needs structured support and follow-up, not just advice.
• Alcohol dependence
  The discriminators are tolerance, withdrawal symptoms (morning shakes, sweats, anxiety, GI upset), eye-opener drinking, failed attempts to cut down and drinking taking priority over other activities. This diagnosis changes your entire management plan - supervised detox, never abrupt cessation.
• Alcohol-related liver disease presentation
  The station may open with abnormal LFTs, jaundice, or non-specific symptoms in a heavy drinker. Ask about right-upper-quadrant discomfort, appetite, weight and bruising, and offer baseline bloods - the alcohol history is the diagnostic test here.
• Withdrawal risk and delirium tremens history
  A dependent drinker who has previously had severe withdrawal - marked tremor, hallucinations, confusion or a seizure after stopping - is at high risk of it recurring, and worse. This history mandates medically supervised withdrawal and an explicit warning against stopping alone.
• Comorbid depression or anxiety driving the drinking
  Alcohol as self-medication. Screen mood and suicidal ideation in every alcohol station - low mood plus heavy drinking is a high-risk combination, and treating the drinking without addressing the mood rarely works.

Step-by-step approach

This is the structure that scores. You do not need to follow it verbatim, but every numbered block below maps to a cluster of marks in the rubric.

1. 1. Open without judgement

   How you open decides whether the next seven minutes are honest or defensive. Normalise the questions before you ask them.

   • Greet, introduce yourself with name and grade, confirm the patient's identity.
   • Explain sensitively why you are raising the subject - a nurse's concern, a blood result, a routine part of their care - without sounding accusatory.
   • Normalise: "These are questions we ask everyone - would it be alright if I asked you a bit about your drinking?"
   • If the patient bristles, acknowledge it: "I'm not here to judge - I just want to make sure we look after you properly."

2. 2. Quantify accurately in units

   "A few glasses" is not an answer. Expect underestimation and gently pin it down without accusing.

   • Ask what they drink, how much, and how often - type, container size and strength all matter.
   • Convert honestly: a bottle of 13% wine is roughly 10 units; a pint of strong lager is about 3; a large (250 ml) glass of wine is about 3.
   • Anchor with concrete questions: "On a typical day, how many glasses? How large? How many days a week?"
   • Ask about the heaviest recent day or weekend separately - binges hide inside averages.
   • Ask how long they have been drinking at this level.

3. 3. Weave in CAGE / AUDIT-C naturally

   Do not announce a questionnaire. Ask the four CAGE questions as conversation - each one is individually marked.

   • Cut down - "Have you ever felt you should cut down on your drinking?"
   • Annoyed - "Have people annoyed you by criticising your drinking?"
   • Guilty - "Have you ever felt guilty about your drinking?"
   • Eye-opener - "Do you ever need a drink first thing in the morning to steady your nerves?"
   • Two or more positives suggests a problem; the eye-opener question doubles as a dependence screen.

4. 4. Screen explicitly for dependence

   This is the fork in the road for your entire management plan. Miss it and everything downstream is wrong.

   • Withdrawal symptoms when they go without: shakes, sweats, anxiety, nausea, tummy pain, loose stools.
   • Tolerance - needing more over time to get the same effect.
   • Previous attempts to cut down or stop, and what happened - a failed attempt with withdrawal symptoms is near-diagnostic.
   • Whether they can get through a normal day without alcohol.
   • Any previous severe withdrawal - confusion, hallucinations or a fit after stopping.

5. 5. Screen the impact: mood, work, driving, relationships, liver

   The four Fs plus mood. Alcohol stations are psychiatry stations in disguise - always screen self-harm.

   • Family and home - relationships, friction over the drinking, who is at home.
   • Finance and work - job security, drinking at or before work, money worries. Address work safety directly if they operate machinery or care for others.
   • Friends and social life - does everything revolve around drinking?
   • Forensic - any trouble with the law, especially drink-driving. Ask whether they drive; if drinking affects their driving, discuss their responsibility and DVLA notification where relevant.
   • Mood, and always screen for thoughts of self-harm or suicide.
   • Physical health - appetite, weight, tummy pain, jaundice, memory. Ask about medications, allergies and recreational drugs.

6. 6. ICE and readiness to change

   Meet them where they are. Motivational interviewing scores; lecturing does not.

   • "How do you feel about your drinking yourself?" - many patients privately suspect a problem and will say so if asked without judgement.
   • Explore what has prompted any previous attempts to change, and what got in the way.
   • Reflect their own words back: "You mentioned you tried to cut down before - what made you want to?"
   • If they are not ready to change, do not push. Plant the information, keep the door open and arrange follow-up.

7. 7. Explain your findings and UK low-risk guidance in plain terms

   Translate their intake into something they can picture, then name the concern without moralising.

   • State the UK guidance: no more than 14 units a week, spread over three or more days, with some drink-free days - and put their intake next to it: "A bottle of wine a day is around 70 units a week, about five times that level."
   • Explain the risks in lay language - liver damage, stomach problems, low mood, sleep, blood pressure, and the link with several cancers.
   • If dependence features are present, say so kindly: "From what you've told me - the shakes when you stop, the failed attempt to cut down - your body has become dependent on alcohol. That's a medical condition we can treat, not a moral failing."
   • Check understanding before moving to the plan.

8. 8. Brief intervention, safe options, safety-net and follow-up

   The plan depends entirely on whether they are dependent. Get this fork wrong and the station collapses.

   • Not dependent: agree a realistic cutting-down plan - smaller glasses, weaker drinks, drink-free days, a drinking diary - and offer written information.
   • Dependent: refer to community alcohol services for a planned, medically supervised detox with medication and monitoring. Never advise a dependent drinker to stop suddenly - explain that abrupt withdrawal can cause seizures and a dangerous confusional state, so cutting down must be gradual and supported.
   • Offer baseline bloods including liver function tests, and mention thiamine (vitamin B1) supplementation and medical follow-up where intake is heavy.
   • Signpost support: local alcohol services, Alcoholics Anonymous, counselling, and involve the GP for ongoing care.
   • Safety-net explicitly: seek help urgently for severe shaking, confusion, hallucinations or a fit.
   • Book follow-up before they leave, invite questions and close warmly.

Common pitfalls

• Advising a dependent drinker to stop drinking immediately - this is the safety-critical fail. Abrupt withdrawal can cause seizures and delirium tremens; detox must be gradual and medically supervised.
• Accepting "a few glasses" as an answer. Pin down type, size, strength and frequency, and convert to units - the quantity question is one of the highest-weighted items.
• Lecturing instead of listening. The mark scheme rewards a motivational, patient-centred approach built on the patient's own wish to change, not a monologue about liver failure.
• Skipping the eye-opener and withdrawal questions - they are the dependence screen, and dependence changes the entire management plan.
• Forgetting to screen mood and self-harm. Heavy drinking and low mood travel together, and the suicide screen is separately marked.
• Sounding accusatory in the opening. "The nurses say you drink too much" poisons the consultation; "I'd like to make sure we're looking after you properly" does not.
• Not asking about previous attempts to cut down or stop - a failed attempt with withdrawal symptoms is the single most revealing question in the station.
• Closing without a concrete plan: no bloods offered, no referral, no follow-up booked, no safety-netting for severe withdrawal symptoms.

Frequently asked questions