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101 | Initial Intake: Age: 18 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Community Residence Type of Counseling: Individual | Nadia was initially resistant to the interview. She stated that she had been seeing counselors her whole life and none of them ever helped. Nadia had limited insight regarding her risk-taking behaviors. The counselor assessed that Nadia’s cognitive functioning appeared low. She stated that although she had contemplated suicide in the past, she currently had no intention or plan.
| Nadia is an 18-year-old in a community residence for children in foster care. She was referred for counseling because she has been running away from the group home, often for days at a time. Currently she is not getting along with her peers and gets into fights when they make comments about her activities, which is starting to affect everyone in the house.
History:
Nadia is one of 10 children by her birth parents. She has an extensive history of abuse and sexual exploitation by her parents until the age of 14 when she was removed from her parent’s care. Her and her siblings were sent to various foster homes as they could not all stay together. This is a subject that Nadia does not like to talk about since she was the oldest and had the responsibility to care for the younger ones. She feels as if she let them down. Nadia is frequently truant from school. For the past 4 years Nadia was in and out of foster homes due to her risk-taking behaviors and disrespect for others. She does have a good relationship with two staff members in the group home. | null | Which of the following is a nonprojective test that can be administered to Nadia? | Achenbach tests | Thematic apperception test | Rorschach | Sentence completion test | (A): Achenbach tests
(B): Thematic apperception test
(C): Rorschach
(D): Sentence completion test | Achenbach tests | A | The Achenbach tests are a collection of question-based assessments for ages 1 ½ to 90, and are not projective. Achenbach tests look at several areas of functioning. Projective tests use ambiguous stimuli which are identified or completed by an individual and are said to bring forth unconscious feelings or desires. The thematic apperception test uses ambiguous scenes in which the individual tells a story of what they think is happening. The Rorschach uses inkblots in which the individual identifies what the object is. In the sentence completion test, a sentence stem is given which the individual completes. Therefore, the correct answer is (C) | intake, assessment, and diagnosis |
102 | Initial Intake: Age: 9 Gender: Female Sexual Orientation: Heterosexual Race/Ethnicity: Caucasian/Non-Hispanic Relationship Status: Single Counseling Setting: Private Practice Type of Counseling: Individual | Lottie presents as excited, over-stimulated and hyperactive, unable to sit still and does not take breaks from talking. Her appearance is highly disheveled with stained clothes and unbrushed hair. Lottie nervously walks around your office touching and commenting on everything. You ask her nicely to ask you before she touches your things, but she refuses and continues to do so. Lottie deflects from every question posed in your assessment. She denies SI/HI, hallucination, or delusion, which you were surprisingly able to find out from her. |
Diagnosis: Attention Deficit Hyperactivity Disorder, predominantly hyperactive type (F90.1), Oppositional defiant disorder (F91.3), Reaction to severe stress (F43.9)
Lottie is a 9-year-old girl in the fourth grade who has been referred to you by officials in her elementary school. You are a counseling intern of a private practice that specializes in adult personality disorders, but your supervisor accepted Lottie as a new client because Lottie’s mother is a former client of her agency, and she requested her daughter be seen by your practice as opposed to a school-based counselor. Lottie’s mother does not want Lottie’s peers to know she is in therapy. Lottie has been doing well in school academically but has not been able to behave appropriately for years, according to the referral report. Lottie bounces up and down in her chair constantly, makes impulsive noises throughout the day, and engages in inappropriate behaviors daily. Some of the behaviors listed include invading the personal space of her peers, licking and eating school supplies to garner reactions from fellow classmates, hiding on the playground and refusing to emerge, and many other behaviors. Lottie follows basic classroom directions but needs constant reminding or guiding that the teacher does not have time for. Lottie breaks down into hysterical emotional fits when she does not get her way and her behaviors have been spreading the school staff too thin to be capable of managing without intervention. This session is conducted with only Lottie in the room; her mother insists on waiting in the car outside so she can make some phone calls. She mentions her Medicaid has just been reactivated to pay for sessions. | Family History:
Lottie lives at home with her mother and mother’s boyfriend, as well as their 1-year-old son Davie who is her half-brother. You learned from speaking with her mother beforehand that Lottie’s biological father was a drug addict and homeless, and he was recently shot and killed, about four months ago. Lottie knows and understands what happened. During the intake session you ask her to draw a picture of something important to her. She likes this assignment and draws you a picture of her father’s homeless camp where she last saw him. She explains to you the details surrounding his murder and mature, intimate details of her mother’s broken relationship with him. “How do you know all of this, Lottie?” you ask her, concerned. “Oh, my mother told me. She tells me everything.” | Which objective is most efficient for addressing Lottie's behavior issues? | Discuss feelings about having ADHD and learn acceptance and coping. | Identify behaviors causing difficulty and list consequences of problem behaviors. | Teach replacement behaviors and practice using them. | Learn how ADHD affects behavior and verbalize understanding of symptoms. | (A): Discuss feelings about having ADHD and learn acceptance and coping.
(B): Identify behaviors causing difficulty and list consequences of problem behaviors.
(C): Teach replacement behaviors and practice using them.
(D): Learn how ADHD affects behavior and verbalize understanding of symptoms. | Identify behaviors causing difficulty and list consequences of problem behaviors. | B | With co-occurring ADHD and ODD, Lottie is going to have a hard time taking suggestions in treatment of her conditions. Cognitively she is impaired and behaviorally she is resistant to suggestions. Without an understanding of how or why some of her behaviors are problematic, Lottie may not develop the desire or motivation to modify her behaviors. With little insight into what is causing her difficulty, Lottie will also not be willing to make changes. Discussing feelings about her conditions, learning acceptance, and coping strategies, and better comprehending the clinical issues underlying her symptoms, are all healthy objectives in counseling with Lottie; however, the most efficient method to directly help affect positive change for her is to target what Lottie endorses she is struggling with and help her see the effect of her choices. She may then be more willing to work on interventions aimed towards modifying inappropriate actions or improving skills needed to compensate for deficits. Therefore, the correct answer is (D) | counseling skills and interventions |
103 | Client Age: 51 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Divorced and single Counseling Setting: Local government mental health agency Type of Counseling: Individual counseling Presenting Problem: The client is experiencing a recent separation from her last partner who was verbally and physically abusive, and she is currently living in a domestic violence home. Diagnosis: Major depressive disorder, recurrent episode, moderate (F33.1) and post-traumatic stress disorder (PTSD) (F43.10) | Mental Status Exam: The client’s affect is flat, and she is hunched over in the chair. The client is oriented to person, place, time, and situation. She reports no hallucinations, paranoia, or depersonalization/dissocia | You are a licensed counselor working for a local government mental health agency in the counseling clinic. The client was referred to receive case management and counseling after experiencing homelessness due to leaving a physically and verbally abusive relationship with her last partner. The client is experiencing the following depressive symptoms: sadness more often than not, mental fogginess, suicidal ideation, insomnia, significant weight loss, feelings of worthlessness, and fatigue. The client experiences PTSD symptoms due to having experienced several abusive relationships, including recurrent distressing intrusive thoughts regarding the physical abuse, distressing dreams related to abuse, and physiological reactions (difficulty breathing, heart racing) when she goes near certain places that remind her of the abuse. She also explains that she has been avoiding triggers, believes that no one can be trusted, has an exaggerated startle response, and has had difficulty experiencing positive emotions. The client says that she does not know if therapy can help because she feels like these events have changed her and that she cannot get back to “normal,” but that she would like to make friends so she doesn’t feel so alone. | Fourth Session, 3 Weeks After the Initial Intake The client comes into the session, sits down, and immediately begins to talk about one of her roommates in the domestic violence home that has been making her angry because the roommate comes into her room when the client is gone and borrows her personal hygiene items. The client continues to explain that she worries that the roommate might come in while she is sleeping, but that she has not done this yet. You process these feelings with the client and identify that when she was a child, her uncle would come into her room without her permission and sexually abuse her. The client also reported that one of her ex-husbands would enter their bedroom drunk at night and would often hit her while she was asleep. You and the client discuss how to make her environment feel safe and how to engage in cognitive reframing. You empathize with the client and validate her emotions | What kind of cognitive distortion is the client experiencing? | All-or-nothing thinking | Personalization | Labeling | Jumping to conclusions | (A): All-or-nothing thinking
(B): Personalization
(C): Labeling
(D): Jumping to conclusions | Jumping to conclusions | D | The client is experiencing the cognitive distortion of jumping to conclusions. The client is using past experiences regarding her trauma to infer that this present situation will end in the same way. Labeling is about assigning value or labels to ourselves or others. Personalization is about taking blame or responsibility for the situation and would not relate to this client’s thoughts during this session. All-or-nothing, or black-or-white, thinking implies that a situation is either one way or the complete opposite. This would not apply because the client is assuming results based on prior experiences rather than assigning an all-or-nothing quality to the situation. Therefore, the correct answer is (D) | counseling skills and interventions |
104 | Client Age: Client 1: Age 18 Client 2: Age 21 Client 3: Age 22 Client 4: Age 19 Client 5: Age 18 Sex: Male and female Gender: Male and female Sexuality: Heterosexual Ethnicity: Multiracial Relationship Status: All members are single Counseling Setting: Counseling clinicType of Counseling: Group and individual counseling Presenting Problem: All individuals are seeking support for struggles related to borderline personality disorder. Diagnosis: Borderline personality disorder (F60.3) | Mental Status Exam: All clients appear to be oriented to time, situation, location, and person. The clients are all dressed appropriately for the weather. No clients appear to experience any visual or auditory hallucinations. Most of the clients are presenting as friendly but gua | You are a licensed therapist running a dialectical behavior therapy (DBT) group for young adults. You also provide a weekly individual counseling session for each group member, which is common practice for DBT group therapy. During the first session, you provide psychoeducation on DBT and the group process. Most of the members seem closed off and sometimes aggressive in response to being asked to speak during the first session, which can be consistent with borderline personality disorder. Client 3 becomes upset about halfway through the session, stating that he does not need to participate because the group will eventually end, so he does not need to build relationships with the group members. You end the session by planning individual therapy sessions with each group member. | You meet with client 3 for his individual therapy session. The client continues to be resistant, stating that he does not need to meet with you. You spend the session trying to build rapport with the client and are successful in taking down some of his walls. The client says he knew client 2 from back when he was in high school and began telling you that she slept with a bunch of guys and did a lot of drugs. You redirect the client back to focusing on himself. The client starts to open up about his relationship with his parents growing up and how he thinks they did not really try to show him affection and this made him sad talking about it. The client concludes by saying “I feel overwhelmed sharing all of this because I’ve never talked about it before.” You thank the client for sharing and you empathize with him. Due to resistance, you choose to use motivational interviewing techniques with client 3 | Due to resistance, you choose to use motivational interviewing techniques with client 3. Which of the following would be an approach in engaging the client in treatment planning that uses motivational interviewing? | You realize that you are imposing your goals for engagement, so you support the client in identifying what is important to him. | You decide to support the client in reframing thoughts about counseling and its ability to improve his life. | You assess the client’s personality by discussing birth order and its effects on functioning. | You realize that the purpose of the client’s behavior is to escape counseling, so you continue to engage the client in order to prevent escape. | (A): You realize that you are imposing your goals for engagement, so you support the client in identifying what is important to him.
(B): You decide to support the client in reframing thoughts about counseling and its ability to improve his life.
(C): You assess the client’s personality by discussing birth order and its effects on functioning.
(D): You realize that the purpose of the client’s behavior is to escape counseling, so you continue to engage the client in order to prevent escape. | You realize that you are imposing your goals for engagement, so you support the client in identifying what is important to him. | A | Using the client’s motivation and focusing on what they want to work on may help in building rapport and would be using motivational interviewing techniques. Reframing thoughts uses CBT techniques. Focusing on addressing escape behaviors would be an example of a behavior therapy technique. Discussing birth order is related to Adlerian therapy. Therefore, the correct answer is (A) | counseling skills and interventions |
105 | Name: Gary Clinical Issues: Behavioral problems Diagnostic Category: Disruptive/Impulse-Control/Conduct Disorders Provisional Diagnosis: F91.3 Oppositional Defiant Disorder Age: 10 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Not Assessed Ethnicity: White Marital Status: Not Assessed Modality: Individual Therapy Location of Therapy : Agency | The client reluctantly enters the session accompanied by his mother. He is slightly overweight for his age and is wearing clothes that appear too small for his physique. He is sitting in the chair with his arms crossed, refusing to make eye contact with you. His mood is angry, and his affect is irritable. His attitude during the initial part of the examination is defiant. Speech characterized by short responses and refusal to engage in conversation. Client refuses to discuss feelings or issues. He appears to have difficulty focusing. He lacks insight into his behavior and impact on others. Judgment and impulse control are poor. He denies suicidal or homicidal ideation. | First session You are a mental health therapist in an agency, and a 10-year-old male is referred to you due to behavioral issues. The client and his mother arrive at your office, and you note that he has an irritable look on his face. The two are arguing with each other. His mother threatens him with punishment if he does not cooperate with you and says that this is his "last chance". He glares at her and then stares at the floor. You introduce yourself and explain what you do as a therapist. The client barely says a word and keeps his head down with his arms crossed over his chest. You ask the mother to describe the issues that prompted her to seek help and she begins to tell you the story. She explains that her son has difficulty listening to adults and gets into verbal altercations with his peers. She informs you that he got suspended again from school because he lost his temper in the cafeteria when the student in front of him in the lunch line "wasn't moving fast enough". When you ask about how often his temper outbursts occur, the mother pauses for a moment to think and says, "It seems like he's always losing it, but I guess maybe a few times a month? The rest of the time, he's just angry, mostly at me and other adults. No matter what I do, he seems like he hates me." As she tells you this, you notice that the client is not paying attention and continues to look down at the floor, appearing disinterested in the conversation. His mother goes on to say that the school is threatening expulsion if her son's behavior does not improve. After thanking the mother for sharing this information with you, you look toward the client who has been sitting quietly the entire time. You explain that you understand it must be hard for him to be here and that you are not here to judge or criticize him. He looks up at you with a surprised expression on his face. He slowly nods and mumbles something under his breath. You let him know that you want to help him find ways to better manage his emotions so he can get along better with the people in his life. He looks away again, but this time there is a hint of curiosity in his eyes. You sit in silence for a moment. The client finally looks up at you and says, "It's just...everyone's always telling me what to do and they never listen to me. They think they know everything, but they don't. I can't help it if I get angry, but then everyone looks at me like I'm a monster. It's not fair." His mother looks away, tears in her eyes. You thank the client for expressing his feelings and explain that it is normal to feel upset when things are unfair. You further emphasize that you are here to help him find positive ways to handle his anger and other emotions. You then address the mother, "Parenting can be challenging, especially when it feels like your child is angry or upset with you. I'd like to work with both of you to improve your communication and relationship. It might be helpful to schedule separate sessions for you and your son, as well as joint sessions, so we can address individual concerns and work on improving your relationship together." The mother agrees, and you proceed to discuss a plan of action, including setting up regular weekly therapy appointments and providing resources to help support the family. | The client's father left the family two years ago. The mother, still married to him, retains sole legal custody of the client. Since his father left, the client will not help out around the house, seems angry, and sometimes loses his temper when he does not get his way. The client receives frequent but inconsistent corporal punishment from his mother. His mother made the appointment with you but did not tell him where they were going. The relationship between the client and his mother has been strained as the mother does not know how to handle the abandonment of the father. The client is in fifth grade and has been skipping school for the last six months and refuses to do any homework. His school records were released to you and show A's and B's through third grade, but C's and D's during the past two years. His decline in grades coincides with his truancy. He is also known as a "bully" at school and has been suspended and given detention a few times due to his behavior. He has a history of walking out of classrooms, running down the hallways, refusing to sit in his chair, and running away from the school counselor or anyone in an authoritative position. Personal/Social Relationships: The client does not have friends his age in the neighborhood, and parents do not want their children playing with him because they believe he is a "troublemaker". In addition, children in school avoid him because they are afraid of upsetting him. He does not seem interested in making friends and does not care to engage in any play time with the neighborhood children. Instead, he spends most of his time alone playing video games. | Who is the identified client in this case? | The father as he is the established cause for the son's treatment | The son because his maladaptive behavior is compromising his wellbeing | The mother because she is the client seeking help for her son | The mother and the son | (A): The father as he is the established cause for the son's treatment
(B): The son because his maladaptive behavior is compromising his wellbeing
(C): The mother because she is the client seeking help for her son
(D): The mother and the son | The son because his maladaptive behavior is compromising his wellbeing | B | In this case, all treatment is tailored toward the son's wellbeing. All other parties would be considered support systems for this client. Therefore, the correct answer is (B) | intake, assessment, and diagnosis |
106 | Client Age: 32 Gender: Female Sexuality: Bisexual Ethnicity: Caucasian Counseling Setting: Agency Type of Counseling: Individual Presenting Problem: Binge-eating Diagnosis: Binge-Eating Disorder 307.51 (F50.8), Moderate | Mental Status Exam: The client presents as polite and cooperative. She was well-groomed and dressed appropriately for the situation. Her affect is blunted, and she is tearful when discussing episodes of binge eating. The client has poor eye contact and periodically bites her fingernails. Her thought content is clear. She does not endorse audiovisual hallucinations, and she is oriented to person, place, time, and situation. The client denies suicidal and homicidal ideations. She denies previous suicidal attempts but states that she used to engage in cutting when she was an adolescent | You are working at an agency serving clients from the metropolitan area. Your client is a 32-year-old bisexual female presenting with feelings of sadness, frustration, and shame due to increased episodes of binge eating. The client explains that she has tried unsuccessfully to manage her weight and control her eating. She states she is secretive when bingeing and feels “disgusted” afterward but “completely unable” to stop the compulsion. The client reports binge eating six times per week, with episodes worsening in the last two years. She identifies as bisexual and reports her binge eating increased after coming out to her family. She continues to struggle with depressive symptoms, including feelings of hopelessness, depressed mood, and anhedonia. The client’s weight places her in the category of obese, and she has recently been diagnosed with borderline diabetes. Towards the end of the session, the client states, “This is starting to affect my health. If I could change anything in my life, it would be to stop binge eating.” | The client has made steady progress toward reducing maladaptive eating. After several weeks of collecting self-monitoring data, you and the client successfully identify patterns that maintain the problem of binge eating. The client’s depressive symptoms have improved, and she is seeking interpersonal connections. She has set appropriate boundaries with her family and distanced herself from their church. The client briefly attended a more liberal church, experienced biphobia, and did not return. She explains, “In my parent’s church, I’m not straight enough. In the LGBTQ community, I’m not gay enough.” You have introduced her to dialectical behavioral therapy, and she attributes mindfulness to improved depressive symptoms | Using the Transtheoretical Model (TTM) of the Stages of Change Model (SOC), which technique helps move the client from the contemplation stage to the preparation stage? | Tipping the decisional balance | Flexible pacing | Commitment and activation | Rolling with resistance | (A): Tipping the decisional balance
(B): Flexible pacing
(C): Commitment and activation
(D): Rolling with resistance | Tipping the decisional balance | A | Tipping the decisional balance (DB) is essential for moving the client from the contemplation stage to the preparation stage of change. Prochaska and DiClemente (1984) developed the Transtheoretical Model (TTM) of the Stages of Change Model (SOC) that serves as the foundation for enhanced motivational interviewing (MI). The stages of change are precontemplation, contemplation, preparation, action, and maintenance. Tipping the decisional balance is used to move clients from ambivalence toward commitment and change. DB exercises include examining ambivalence and advocating for change talk. Commitment, activation, and taking steps (CAT) help move clients from preparation to action. Rolling with resistance is used to decrease sustain talk (ie, what is keeping them in the problem) and is mainly used in the earlier SOC. Flexible pacing is an MI strategy used to help the counselor stay with the client and resist the urge to jump ahead or push the client forward rather than move at their own pace. Therefore, the correct answer is (C) | intake, assessment, and diagnosis |
107 | Initial Intake: Age: 35 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Employee Assistance Program Type of Counseling: Individual | Harold comes into the office, visibly upset, stating, “I really don’t know why I am here, but I am sure you will see that too after some time together. And I am sure that anything I say here- you can’t report it to anyone anyway, right?” Harold did not display any self-awareness of his actions when speaking to the counselor. At times he showed defensiveness and irritability and other times he was making jokes and complimenting the counselor. | Harold, an accounting executive, was referred for counseling by his supervisor after Human Resources received several complaints about Harold’s attitude towards others.
History:
Harold has been successful in his career and is knowledgeable in his field. However, he stated that he is often not well liked. Harold attributes this to people being envious of him. Harold told the counselor that recently he was called to human resources because of complaints from his peers. Complaints included allegations of rude remarks, bullying, and Harold taking credit for work that others did. One coworker stated that Harold took frequent breaks and suspected he may be using drugs. | null | The counselor should respond? | "I have a colleague here, if you want to just see them?" | "All therapists abide by the same confidentiality laws and principals, but we can find you someplace where you feel most comfortable." | "I don't know if that is a good idea as we already started talking about goals, I can definitely help you." | "If that is what you want, I will gladly do that." | (A): "I have a colleague here, if you want to just see them?"
(B): "All therapists abide by the same confidentiality laws and principals, but we can find you someplace where you feel most comfortable."
(C): "I don't know if that is a good idea as we already started talking about goals, I can definitely help you."
(D): "If that is what you want, I will gladly do that." | "All therapists abide by the same confidentiality laws and principals, but we can find you someplace where you feel most comfortable." | B | Sometimes clients will ask for a referral out, for diverse reasons. Clients must be able to assert their freedom of choice of who conducts their treatment. Choice d respects Harold's autonomy but lets Harold know he should expect the same standards of confidentiality with whomever he sees. Although the counselor and Harold did start the work, this statement seems more about the counselor and his/her feelings about the rejection. Choice b seems a little cold, as if the counselor is relieved that Harold suggested this. Choice c dismisses why Harold is requesting a referral out. The counselor is obligated to make an appropriate referral. Therefore, the correct answer is (D) | professional practice and ethics |
108 | Name: Robin Clinical Issues: Substance use/addiction issues Diagnostic Category: Substance Use Disorders Provisional Diagnosis: F10.20 Alcohol Use Disorder, Moderate Age: 28 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: Black Marital Status: Not Married Modality: Individual Therapy Location of Therapy : Private Practice | The client is well-groomed. She reports her mood as depressed due to her relationship breakup and feeling that she is unable to talk to family members about her life. Her affect is characterized by anxiousness and difficulties in answering questions. Her overall speech is slow and soft, with little eye contact as she speaks. The client's insight is fair. She recognizes that alcohol has been a major factor in her life, and she is aware of the negative effects it has had on her relationships and work performance. She states that she is at a point where she feels like she needs help to make changes in her life. Though she presents as sober at the time of the interview, her judgment appears impaired due to her continued heavy drinking despite the negative consequences. | First session You are a clinical mental health counselor at a community mental health center. You see many clients who struggle with substance use issues. A 28-year-old female presents for outpatient services today. She is an attorney who works long hours, specializing in family law. She and her boyfriend of ten years recently ended their relationship due to the client's excessive drinking. She says, "I can't live with the pain of our separation much longer, and I don't know how to cope with it." She tells you she is devastated and does not know what to do next. The breakup has triggered her to drink even more lately, and she is currently facing a DUI charge. Her attorney recommended that she seek an assessment for substance use disorder treatment in an effort to avoid a criminal conviction. You administer an assessment to determine the severity of the client's alcohol use and further evaluate her statement about being unable to live with the pain of her breakup. She reports an urge to drink daily, and acknowledges she has lost control of her drinking on many occasions. She also states that she has increased her alcohol intake because "it helps numb the pain and I can forget about everything for a little while." The client discusses her father's death when she was 17 and how this affected her life. She states that his death hit her hard, and only made matters worse because of her family's lack of emotional support in the wake of his passing. Even though she was still in High School, she began drinking heavily to cope with the grief, a pattern which has been present ever since. She drinks alone, typically at home or in bars after work. When asked about the effects of alcohol on other areas of her life like her finances, she says, "One of the perks of my job is that I get paid pretty well, so at least I'm not in debt like my brother." She pauses for a moment, then says, "Well, not yet anyway. I've got some court costs coming up." You explain to the client that substance use disorder is treatable and that it is important to take an honest look at her relationship with alcohol, in order to make positive changes to her lifestyle. You discuss the effects of excessive drinking on physical health, mental health, and personal relationships. You review the various options for treatment available and encourage her to be proactive in seeking help. The client acknowledges your advice but expresses hesitancy about beginning treatment due to fear of the stigma associated with addiction. You empathize with her feelings while emphasizing the importance of taking action now rather than waiting until her issues become worse. You present evidence-based treatment modalities that have been shown effective in managing substance use disorders. You let the client know you are here for her to help develop healthy coping skills, explore the underlying causes of her drinking, and create a plan to avoid future drinking and driving offenses. Then, you both discuss a treatment plan with the goal of helping the client resolve her current crisis and developing a strategy to maintain sobriety and avoid future legal issues. She provides you with releases to speak with her mother and her attorney. You set up a follow-up appointment one week from now. | The client has a younger brother. Her father died when she was 17, and her mother never remarried. The client's family has a history of problematic alcohol use, with family members utilizing alcohol to mask underlying emotions and distress. This pattern can be seen in her mother and brother, as well as extended family. Her mother is particularly reliant on alcohol and uses it as a way to cope with negative feelings. This has been an ongoing issue for many years. The client was raised in an environment where emotions were not discussed openly. The client expresses she learned early that it was best not to bring attention to any discomfort or upset she may have felt because it would only be met with more criticism and judgments. She states, "My mother and brother 'don't believe in depression.' When I told my mom that my boyfriend broke up with me and I was feeling depressed, she told me to that I needed to 'get over it and move on.' It's like I'm talking to a wall when I try to tell her anything about how I'm feeling." Although the client does not feel that her family understands her problems, she does communicate with her mother weekly. The client has been using alcohol as a way to cope with stress for many years. She expresses she has "been through a lot" in her life and that going to bars after work is an escape. Alcohol has maintained a significant presence during various phases of her life. | The client presents as an outwardly successful professional who has a family history of substance abuse and emotional repression who has just experienced the end of a long-term relationship as result of her alcohol use. Which short-term objective is most appropriate to address at this time? | Participate in a medical evaluation to assess effects of long-term alcohol use | Attend a 12-step program for group support | Verbalize an understanding of alcoholism and the recovery process | Learn and implement coping strategies focused on loss | (A): Participate in a medical evaluation to assess effects of long-term alcohol use
(B): Attend a 12-step program for group support
(C): Verbalize an understanding of alcoholism and the recovery process
(D): Learn and implement coping strategies focused on loss | Participate in a medical evaluation to assess effects of long-term alcohol use | A | A full physical examination can help determine if there are any underlying medical conditions that are contributing to the client's mental health issues. It is important to rule out any potential physiological causes before beginning therapy. Additionally, a physical exam may also reveal effects of long-term alcohol abuse, such as jaundice or liver damage. Therefore, the correct answer is (C) | treatment planning |
109 | Name: Gary Clinical Issues: Behavioral problems Diagnostic Category: Disruptive/Impulse-Control/Conduct Disorders Provisional Diagnosis: F91.3 Oppositional Defiant Disorder Age: 10 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Not Assessed Ethnicity: White Marital Status: Not Assessed Modality: Individual Therapy Location of Therapy : Agency | The client reluctantly enters the session accompanied by his mother. He is slightly overweight for his age and is wearing clothes that appear too small for his physique. He is sitting in the chair with his arms crossed, refusing to make eye contact with you. His mood is angry, and his affect is irritable. His attitude during the initial part of the examination is defiant. Speech characterized by short responses and refusal to engage in conversation. Client refuses to discuss feelings or issues. He appears to have difficulty focusing. He lacks insight into his behavior and impact on others. Judgment and impulse control are poor. He denies suicidal or homicidal ideation. | First session You are a mental health therapist in an agency, and a 10-year-old male is referred to you due to behavioral issues. The client and his mother arrive at your office, and you note that he has an irritable look on his face. The two are arguing with each other. His mother threatens him with punishment if he does not cooperate with you and says that this is his "last chance". He glares at her and then stares at the floor. You introduce yourself and explain what you do as a therapist. The client barely says a word and keeps his head down with his arms crossed over his chest. You ask the mother to describe the issues that prompted her to seek help and she begins to tell you the story. She explains that her son has difficulty listening to adults and gets into verbal altercations with his peers. She informs you that he got suspended again from school because he lost his temper in the cafeteria when the student in front of him in the lunch line "wasn't moving fast enough". When you ask about how often his temper outbursts occur, the mother pauses for a moment to think and says, "It seems like he's always losing it, but I guess maybe a few times a month? The rest of the time, he's just angry, mostly at me and other adults. No matter what I do, he seems like he hates me." As she tells you this, you notice that the client is not paying attention and continues to look down at the floor, appearing disinterested in the conversation. His mother goes on to say that the school is threatening expulsion if her son's behavior does not improve. After thanking the mother for sharing this information with you, you look toward the client who has been sitting quietly the entire time. You explain that you understand it must be hard for him to be here and that you are not here to judge or criticize him. He looks up at you with a surprised expression on his face. He slowly nods and mumbles something under his breath. You let him know that you want to help him find ways to better manage his emotions so he can get along better with the people in his life. He looks away again, but this time there is a hint of curiosity in his eyes. You sit in silence for a moment. The client finally looks up at you and says, "It's just...everyone's always telling me what to do and they never listen to me. They think they know everything, but they don't. I can't help it if I get angry, but then everyone looks at me like I'm a monster. It's not fair." His mother looks away, tears in her eyes. You thank the client for expressing his feelings and explain that it is normal to feel upset when things are unfair. You further emphasize that you are here to help him find positive ways to handle his anger and other emotions. You then address the mother, "Parenting can be challenging, especially when it feels like your child is angry or upset with you. I'd like to work with both of you to improve your communication and relationship. It might be helpful to schedule separate sessions for you and your son, as well as joint sessions, so we can address individual concerns and work on improving your relationship together." The mother agrees, and you proceed to discuss a plan of action, including setting up regular weekly therapy appointments and providing resources to help support the family. Fifth session It has been over one month since you first began working with the client. You've been meeting with him for individual therapy and have implemented parent training with his mother. During previous counseling sessions, you focused on building rapport with the client and talked about different triggers for his outbursts. He said that he often gets angry when people do not listen to him or when they try to tell him what to do. You also discussed strategies for managing these triggers and the importance of communicating his needs in a respectful way. Last week, as part of your parent management training approach, you assigned the mother homework to read from a parent training handbook. When the client arrives for today's session, he is clearly upset, saying that he does not want to be here. His facial expression is one of anger and frustration. His mother is exasperated and apologetic. You calmly remind her that it is all right, that this is a normal part of the process. You ask if she would like to accompany them into your office, but she declines, saying that she needs some time to herself and she would like to wait in the waiting room for the first half of her son's session. Once inside your office, you start by asking the client why he does not want to be here. He says that he is tired of talking about his problems and he does not think it will make any difference. When you ask him to tell you more, he glares at you and says, "Why do you care? You're only asking because you want to get paid." You acknowledge how difficult it can be to keep coming back, but emphasize that whatever feelings he is having in this moment are valid and important. The client then looks away and sighs. He slowly says, "I don't know why I have to keep coming here...it feels like no matter what I do, nothing changes. I still get mad, my mom and teachers still get mad at me, and the school still threatens to kick me out." After a few moments of silence, you ask the client if he remembers what goals were set for the session today. He looks away and mumbles something under his breath. You gently remind him that you want to help him learn how to manage his emotions in a healthier way so he can get along better with the people in his life. He gradually relaxes and you ask him what strategies he has been using in the past week to work toward this goal. He thinks for a few moments before recounting an incident at school where instead of getting angry, he took a deep breath and walked away from the situation. You use behavioral modification techniques to encourage this positive behavior. You then move into today's activity, which is a role-play exercise. Once you have completed your planned tasks with the client, you invite his mother in to your office to provide her with feedback on her son's progress and discuss next steps with parent training. | The client's father left the family two years ago. The mother, still married to him, retains sole legal custody of the client. Since his father left, the client will not help out around the house, seems angry, and sometimes loses his temper when he does not get his way. The client receives frequent but inconsistent corporal punishment from his mother. His mother made the appointment with you but did not tell him where they were going. The relationship between the client and his mother has been strained as the mother does not know how to handle the abandonment of the father. The client is in fifth grade and has been skipping school for the last six months and refuses to do any homework. His school records were released to you and show A's and B's through third grade, but C's and D's during the past two years. His decline in grades coincides with his truancy. He is also known as a "bully" at school and has been suspended and given detention a few times due to his behavior. He has a history of walking out of classrooms, running down the hallways, refusing to sit in his chair, and running away from the school counselor or anyone in an authoritative position. Personal/Social Relationships: The client does not have friends his age in the neighborhood, and parents do not want their children playing with him because they believe he is a "troublemaker". In addition, children in school avoid him because they are afraid of upsetting him. He does not seem interested in making friends and does not care to engage in any play time with the neighborhood children. Instead, he spends most of his time alone playing video games. | How would you best reflect the client's feelings at the beginning of the session? | "It's okay to feel frustrated about coming here today. Can you tell what happened today that has caused you to feel this way?" | "I can see that you're feeling frustrated and angry right now. And maybe like you don't have any control over what's happening. Does that sound right?" | "It makes sense to me why you don't want to be here. You believe that no matter what you say or do, nothing changes." | "I hear what you're saying and I understand how it might feel like I don't care. Can you tell me more about why you think that?" | (A): "It's okay to feel frustrated about coming here today. Can you tell what happened today that has caused you to feel this way?"
(B): "I can see that you're feeling frustrated and angry right now. And maybe like you don't have any control over what's happening. Does that sound right?"
(C): "It makes sense to me why you don't want to be here. You believe that no matter what you say or do, nothing changes."
(D): "I hear what you're saying and I understand how it might feel like I don't care. Can you tell me more about why you think that?" | "I can see that you're feeling frustrated and angry right now. And maybe like you don't have any control over what's happening. Does that sound right?" | B | At the beginning of the session, the client is feeling angry and frustrated. He is tired of talking about his problems and doesn't think it will make any difference. He is also feeling a sense of hopelessness, thinking that no matter what he does, nothing changes. Ultimately, he feels like he has no control over his life or his emotions. Therefore, the correct answer is (C) | counseling skills and interventions |
110 | Name: Camron Clinical Issues: Worry and anxiety Diagnostic Category: Anxiety Disorders Provisional Diagnosis: F40.10 Social Anxiety Disorder Age: 20 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: White Marital Status: Never married Modality: Individual Therapy Location of Therapy : University Counseling Center | The client looks anxious and uneasy, presenting with a "nervous" laugh. He twirls his thumbs and shakes his legs while seated. Mood is anxious and frustrated. He feels isolated and misunderstood by his family and peers. Speech is soft and hesitant. Eye contact is sporadic. Thought process is concrete and linear. He has some difficulty with abstract concepts. Thought content reveals fear of social interactions, feeling judged by others, and feeling inadequate. He seems to recognize the negative consequences associated with his anxiety and behavior, but he has limited insight with regard to recognizing the source of his anxiety. He reports difficulty recalling past experiences or conversations due to anxiety levels. No suicidal or homicidal ideation noted. | First session Your client is a 20-year-old male who has been seeing your colleague at the university counseling center where you both work as mental health therapists. The client requested to be transferred to another therapist because his former therapist reminded him too much of his father and therapeutic progress could not be made. The client's former therapist contacted you as a referral, and you agreed to transfer the client to your caseload. When you meet with the client today, he seems very anxious and laughs nervously. You can see he is shaking his legs as he sits, twirling his thumbs, and making little eye contact with you. You explain the therapy process and that you need to go over some intake questions. You ask him who his ICE (in case of emergency) contact is, and he says it is his roommate. You continue with your assessment, gathering information about his presenting problem and what he would like to accomplish in counseling. He continues by telling you, "I thought that going to college would alleviate my social anxiety, but I'm not doing well here. I want to be social, but I can't." The client feels frustrated and overwhelmed by his fears of interacting with others. He tells you that when he is feeling anxious, he punches bathroom mirrors to try to distract himself from the anxiety. He notes that the anxiety is crippling, preventing him from doing the things he loves, and has resulted in him feeling isolated. He is afraid that others are judging him and is constantly worried that he will make a mistake and feel embarrassed. | The client grew up in an authoritarian house where all of his actions and behaviors were scrutinized by his father. His father demanded obedience from his son and would not accept anything but perfection from him. He graduated from high school at the top of his class and has been waiting to attend college to get out from "under the thumb" of his father. The client's parents are paying all of his college expenses. The client is experiencing difficulties adapting to college life. He states that he stays in his room because he believes he always says and does the wrong thing, and everyone can see what a "loser" he is. He further states that he rarely leaves his dorm room except to go to his work-study position. The client has experienced two panic attacks; one occurred when he was required to give a presentation in class, and the second happened when he was required to meet with a small group to discuss his input for their group project. The client has missed many classes in which he is expected to participate or present projects. He is currently failing three classes. The client is in danger of losing his work-study job on campus due to frequent absences. He is competent and conscientious when his job does not require customer interaction. Personal/Social Relationships: The client is interested in exploring social relationships but is anxious as his father never allowed him to interact with his peers. As a result, his level of social functioning is relatively low. He has talked with a few students in his dorm and classes when required, but he feels extremely uncomfortable and inept. The client has not developed any friendships because of his anxiety. | What assessment tool is most applicable to the client based on his presentation? | Connors Comprehensive Behavior Rating Scales (Conners CBRS) | Beck Anxiety Inventory (BAI) | CAGE Questionnaire | Columbia Mental Maturity Scale (CMMS) | (A): Connors Comprehensive Behavior Rating Scales (Conners CBRS)
(B): Beck Anxiety Inventory (BAI)
(C): CAGE Questionnaire
(D): Columbia Mental Maturity Scale (CMMS) | Beck Anxiety Inventory (BAI) | B | The Beck Anxiety Inventory gauges severity and distinguishes between anxiety and depression. This would be helpful for the client who experiences anxiety and tries to distract himself by such actions as punching mirrors. The first priority is to ascertain the severity of the anxiety. Therefore, the correct answer is (D) | intake, assessment, and diagnosis |
111 | Client Age: 32 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Counseling Setting: Community Mental Health Agency Type of Counseling: Individual Presenting Problem: Depressed Mood Diagnosis: Bipolar II 296.89 (F31.81), current episode depressed | Mental Status Exam: The client is dressed casually and is somewhat disheveled. She avoids eye contact and displays a flat affect. The client admits to having suicidal thoughts in the past but currently denies both suicidal and homicidal ideations. Her speech is soft in volume and tone. She tends to provide one-word responses but is cooperative when asked to elaborate. The client denies audio-visual hallucinations, and her thought content is coherent. The client’s mood is depressed, and her affect is flat. She appears tired and reports she has insomnia at night and is sleeping most of the day. The client has experienced depression off-and-on, beginning in late adolesc | You work at a community mental health agency providing outpatient services to adults. Today, you are meeting with a 32-year-old female who presents with her husband for an initial intake session. The client’s husband is concerned about his wife’s depressive symptoms. She is experiencing sadness, decreased appetite, and hypersomnolence. The client also expresses hopelessness and has lost interest in doing the things she once enjoyed. Until recently, the client worked at an art gallery. When employed, she reports that she, “just couldn’t get out of bed” and was eventually let go due to excessive absences. After her employment ended, her depressive symptoms worsened. The client was able to recall a time nearly one year ago when she felt “almost the opposite” of how she feels now. During this time, she experienced increased energy and felt more inspired and creative. The client explains that she and her husband used to travel selling their art at juried art exhibitions most weekends, but it has been awhile since she has joined him. | The client reports that she has been feeling less depressed. Her affect is full-range and appropriate to the situation. She continues to have sleeping difficulties that seem to worsen when experiencing unexpected stressors. The client explains that she has been arguing with her daughter’s father about financial matters, which developed after the client lost her job. The client believes her depressive symptoms are exacerbated after spending significant periods of time on social media. The client remarks, “My husband’s patience with me is growing thin. I don’t think I can ever live up to his expectations | Counselors practicing the ethical use of distance counseling, technology, and social media disclose to clients all of the following EXCEPT: | The lack of visual cues and voice intonations used with electronic communication may affect the counseling process. | The need to identify alternative methods of service delivery may occur, because of the possibility of technology failure. | Informed consent for distance counseling, technology, and social media is no different than the protocol used with face-to-face counseling. | There are some individuals who may have unauthorized access to their electronic health records. | (A): The lack of visual cues and voice intonations used with electronic communication may affect the counseling process.
(B): The need to identify alternative methods of service delivery may occur, because of the possibility of technology failure.
(C): Informed consent for distance counseling, technology, and social media is no different than the protocol used with face-to-face counseling.
(D): There are some individuals who may have unauthorized access to their electronic health records. | Informed consent for distance counseling, technology, and social media is no different than the protocol used with face-to-face counseling. | C | According to the ACA Code of Ethics (2014), “In addition to the usual and customary protocol of informed consent between counselor and client for face-to-face counseling, [there are] issues, unique to the use of distance counseling, technology, and/or social media, [that] are addressed in the informed consent process” Specifically, counselors must explain that “individuals might have authorized or unauthorized access to such records or transmissions (eg, colleagues, supervisors, employees, information technologists)” (ACA, 2014). Counselors acknowledge that the lack of visual cues and voice intonations used with electronic communication may affect the counseling process. Finally, counselors inform clients that there is a need to identify alternative methods of service delivery because of the possibility of technology failure. Therefore, the correct answer is (C) | professional practice and ethics |
112 | Initial Intake: Age: 48 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Divorced Counseling Setting: Acute Inpatient Psychiatric Hospital Type of Counseling: Individual | Sandy wandered into the ER waiting room asking for a police officer. After further conversation, it was clear that Sandy thought she was in a police station and repeatedly called once of the nurses Officer McKinney, as if she knew him.
During the intake, the nurse practitioner mentioned that she was running a temperature, had a rapid heartbeat and breath smelled foul. In addition, her hands were trembling as well as her tongue and lips. Sandy’s behavior was somewhat irritable and erratic. At one point she was seemed to be hallucinating and stated that that she saw rats.
| Sandy was sent to the inpatient psychiatric from the emergency department for symptoms of hallucinations, memory loss, and disorientation.
History:
Sandy currently lives alone and is unemployed. She has a history of alcohol abuse and has been admitted to the hospital before because of this. Sandy has gotten into trouble with the law and has alienated most of her family and friends because of her alcohol use. She currently attends alcoholics anonymous. | null | A necessary factor for Sandy to overcome alcohol abuse is? | Support from family | A sponsor | Medication to alleviate withdrawal symptoms | Motivation to change | (A): Support from family
(B): A sponsor
(C): Medication to alleviate withdrawal symptoms
(D): Motivation to change | Motivation to change | D | Sandy can have all the resources above available to her, but if she does not have the motivation to change, she will not be successful. Once she has the motivation to change, support from others will be important to prevent relapse. One example of support is a sponsor, someone who has been through the stages of recovery. Medication to relieve the symptoms of withdrawal also makes this process more bearable. Therefore, the correct answer is (B) | treatment planning |
113 | Client Age: 35 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Hispanic Relationship Status: Divorced Counseling Setting: Private Practice Clinic Type of Counseling: Individual Counseling Presenting Problem: Anxiety; Depressed Mood, Difficulty with Changing Relationship Roles Diagnosis: Adjustment Disorder with Mixed Anxiety and Depressed Mood (F43.23) | Mental Status Exam: The client presents as oriented to person, place, time, and situation. The client appears anxious because he avoids eye contact often and expresses that he has never been in counseling and is ner | You are a licensed counselor in Texas in a private practice. A 35-year-old male client comes to counseling for support during a recent divorce. The client says that he and his wife separated a year ago and had to wait a year for divorce per state law; therefore, they finalized the divorce recently. The client says that his wife decided she married him because she was lonely and that, after 8 years of being married, she wanted to find someone she loved. The client states that he still loves his ex-wife and that he has a hard time with his new relationship with her because he shares custody of his children and still has to communicate with her regularly. He continues saying that his wife often calls him for emotional support and he does not know how to respond when this happens because he loves her and wants to support her, but this is confusing for him. The client says that he knows he “shouldn’t be with someone who doesn’t want to be with him and that things won’t go back to how they were.” The client identifies that anxious and depressive symptoms are present and that they affect his ability to engage socially, engage with his children, and perform at work. The client wants to work on navigating his new relationship with his ex-wife, his relationship with his children, and being single again. | The client talks about when he went to see his daughter at a dance recital and how, afterward when he went to say hello to her, she ignored him. He called his ex-wife later that day, and she denied knowing what was wrong, but when he talked to his son, the boy said, “Mommy told us you didn’t want to live with us anymore and that is why you left.” The client expresses frustration and anger with his ex-wife because she chose to leave him, and he thinks that it is not fair that she is telling the children a lie and also that it is affecting his relationship with them. The client states that he wanted to talk to you before he confronted his wife about this. You and the client discuss conflict resolution skills. The client provides you with a gas gift card, and he expresses that he is appreciative of your support | The client provides you with a gas gift card, and he expresses that he is appreciative of your support. Which of the following would demonstrate the most appropriate response considering what you know about the client? | You deny the gift because you do not want to cause economic hardship. | You consider what the client wants in return for the gift. | You consider why you want to accept the gift. | You consider accepting the gift due to cultural considerations. | (A): You deny the gift because you do not want to cause economic hardship.
(B): You consider what the client wants in return for the gift.
(C): You consider why you want to accept the gift.
(D): You consider accepting the gift due to cultural considerations. | You consider accepting the gift due to cultural considerations. | D | Based on what you know about this client, you consider the cultural reasons for the gift because it could be considered offensive in Hispanic cultures to decline a gift. It is also important to consider economic hardship, what the client may want or expect in exchange for the gift, and why you want the gift; however, with what you know thus far about the client, the most important aspect to consider is his culture. Therefore, the correct answer is (A) | professional practice and ethics |
114 | Initial Intake: Age: 40 Sex: Female Gender: Female Sexuality: Lesbian Ethnicity: African American Relationship Status: Partnered Counseling Setting: Community Agency Type of Counseling: Individual | The client appears to be slightly older than stated and demonstrates positive signs of self-care in her hygiene and dress. She states her mood fluctuates between “sad and okay.” Her affect is labile and mirrors topics discussed in session. She smiles when describing her children and her relationship with her former oncology team. She cries easily when discussing cancer, moving, instability, and fears. The client is cooperative and forthcoming, with easily understood speech. She offers insight into her thoughts and behaviors, is attentive, and shows no difficulties with memory or judgement. She acknowledges one episode of suicidal ideation, without plan, during her adolescence when she desperately missed her mother while on a custodial visit with her father. She has had no thoughts of harming herself since then and has no thoughts of harming others. | You are a counselor in a community agency. Your client presents with concerns about her lifelong history of being “anxious and emotional” since her parent’s divorce when she was 12. She tells you her feelings of “anxiety and feeling badly about myself” intensified when she was diagnosed with breast cancer four years ago and then again when her family moved to the area last year. She tells you that she thinks she managed her emotions well during her treatment because her focus was on getting through the crisis. She also was taking Klonopin twice a day for anxiety. She says she feels that she has let her family down by having cancer because it costs them monetarily and emotionally; she wonders sometimes if her cancer is a punishment for something she’s done. She reports that she does not discuss these concerns and emotional fears with her partner because “she has become the breadwinner and I feel like I need to protect her from my negativity.” On intake forms, she endorses crying daily, trouble sleeping, concentrating on things, has been losing weight without trying, and constantly worrying about her health and the family’s finances. She tells you that her partner says she “runs around like a chicken with my head cut off because I start stuff like cleaning or cooking and then stop right in the middle of it. I just get restless and sometimes I just can’t stop fidgeting when I should be paying attention.” She notes that she is in menopause due to her cancer treatments, which included a removal of her ovaries three years ago and a hysterectomy one year ago. She tells you people often refer to her as a “cancer survivor” but she doesn’t feel like she has survived it because every surgery makes her feel like she “is losing another piece of me.” Additionally, she says that having to have body scans every six months and not being able to look in the mirror and see a “complete woman” makes her feel that she is still trying to survive, rather than putting it in the past. | Family History:
Your client reports a four-year history of treatment for breast cancer. She has had 16 months of chemotherapy and 27 rounds of radiation, as well as a double mastectomy three years ago. She has completed reconstructive surgery for her breasts but has not yet added nipple tattooing for a more realistic image. She reports that she has three close female relatives with breast cancer, but no relapses after treatment. She states that she has been in a relationship with her partner for 17 years and they share two children, ages 12 and 8. She describes her partner as a “good person” and the relationship as “good.” She tells you that they moved to the area one year ago when her partner had an unexpected promotion. She reports this has been good but that their oldest child is “anxious, emotional, and just angry sometimes.” | Which of the following interventions would be the most effective for helping the client and her partner develop better communication skills at home? | Role play having the client's partner clarify whether the client is asking for help | Have the client and her partner develop a list of practice topics for asking for help | Provide a list of ideas that the client and her partner can use to ask for help from each other | Identify which areas the client has the most difficulty asking for help | (A): Role play having the client's partner clarify whether the client is asking for help
(B): Have the client and her partner develop a list of practice topics for asking for help
(C): Provide a list of ideas that the client and her partner can use to ask for help from each other
(D): Identify which areas the client has the most difficulty asking for help | Identify which areas the client has the most difficulty asking for help | D | Identifying which areas the client struggles with in asking for help will guide the counselor and client to focus on the emotions that surround these specific situations. This allows the client and her partner to be aware that these trouble spots are important and need more attention when communicating. The counselor and client then can practice role-playing examples of these situations. Having the counselor provide, or the client and her partner develop, a list for practice topics is likely to include more superficial topics since these are seen as practice opportunities. No evidence has been shown that the client struggles to ask for help except with her cancer journey and its impact on the couple's intimacy. Having the counselor roleplay with the client's partner puts the partner in the position to have to "pull out" what the client is really asking for, rather than helping the client communicate her needs more openly. Therefore, the correct answer is (C) | counseling skills and interventions |
115 | Initial Intake: Age: 16 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Private Practice Type of Counseling: Individual | Molly muttered one-word answers during the intake session, made little eye contact and frequently rolled her eyes. She started to warm up towards the middle of the intake session, with some prompting from her mother. She reluctantly agreed to continue counseling sessions- only due to the fact her mother stated that she could not use the family car unless she went to counseling. | Molly is a 16-year-old female who was referred to an outpatient mental health clinic after a two-week admission at a local psychiatric hospital. Molly was brought to the hospital by ambulance after she disclosed to the school psychologist that she wanted to kill herself.
History:
When asked what brought the family to the session, Molly’s mother was tearful as she disclosed that her husband died in a car accident 11 months ago. Molly and her father had been close, spending time together as Molly played recreational softball and her father was the coach. Since her father’s death, she has been distant with her mother, and often picks fights with her. Additionally, Molly frequently complains of stomach aches, stating that the pain is so severe, she cannot go to school. Before her father’s death, Molly was in Advanced Placement classes and maintained a high average. Recently, Molly’s grades have been declining and she is no longer interested in softball. She states that when she goes to the softball field, she can almost hear her father speaking to her. | null | What assessment would be best to assess Molly's current functioning? | Beck Depression Inventory | Child and Adolescent Functional Assessment Scale | Conners Rating Scale | Vineland Adaptive Behavior Scales | (A): Beck Depression Inventory
(B): Child and Adolescent Functional Assessment Scale
(C): Conners Rating Scale
(D): Vineland Adaptive Behavior Scales | Beck Depression Inventory | A | The Beck Depression Inventory is a 21 question, self-scoring questionnaire to determine the severity of depression. This would be beneficial to use at this time to assess the presence and severity of depressive symptoms. The Child and Adolescent Functional Assessment Scale is an assessment that measures functioning in various domains such as cognitive functioning and issues at school, home and the community. Molly has not had difficulties prior to the death of her father and her school issues are the result of attendance issues. If she was having difficulty in other areas of her life, this assessment may be beneficial to help drive goals and treatment. The Vineland Adaptive Behavior Scales is a guided questionnaire used to identify developmental disabilities. This would not be appropriate to use with Molly as there is no indication of developmental issues. The Conners Rating Scale is used to measure the severity of symptoms of Attention Deficit Hyperactivity Disorder (ADHD). In addition, various domains are examined. This would not be an appropriate assessment to use with Molly as she is not exhibiting any symptoms of ADHD. Therefore, the correct answer is (A) | intake, assessment, and diagnosis |
116 | Client Age: Husband, 38; wife, 37 Sex: Husband,male; wife, female Gender: Husband,male; wife, female Sexuality: Husband,heterosexual; wife, bisexual Ethnicity: Caucasian Relationship Status: Married Counseling Setting: Counseling clinic Type of Counseling: Couples counseling Presenting Problem: The couple is experiencing distress because the wife has had a sexual affair with a woman. Diagnosis: Adjustment disorder, unspecified (F43.20) and relationship distress with spouse or intimate partner (Z63.0) | Mental Status Exam: The couple presents as withdrawn at the start of the session, but they open up as they talk about lighter subjects. Both individuals are oriented to person, place, time, and situa | You are a licensed counselor meeting with a couple in your private practice clinic. The couple comes in, and they both sit down at far ends of the couch and do not look at each other. After explaining informed consent and other intake policies, you begin to ask the couple what brought them to counseling, and they both sit silently. You ask the couple if it is hard to start this conversation because of why they came, and they both nod. You ask the couple if it might be easier to start with how they met and why they fell in love with each other, and they both nod in agreement that they can talk about that. The couple appears more comfortable after this and even say a few statements to each other about shared experiences during the conversation. You circle back to the reason why they came to therapy, and the wife says that she assumes that she should talk first. She states that about a week prior she told her husband that she had an affair with a woman a few months before. She continues that, at the time, she was curious and it occurred while she was drunk and insists that it meant nothing. The husband states that he still loves her, but he is not sure how he is going to move past this. He emphasizes that not only did she have an affair, but her action exposed an aspect of her that he did not know about, making him question whether she even finds him attractive. | tion. Family History: The husband and wife have been married for 13 years. They report that they met when friends introduced them and that they dated for about 2 years before getting married. The couple have two children: two daughters (ages 7 and 10). The couple reports that they have been in “parent mode” for the past few years and have not been emotionally connected to each other because their attention has been predominantly focused on their children. You supervise an intern in your clinic who is working with a couple that is in counseling for coparenting but is also in a legal battle for custody | You supervise an intern in your clinic who is working with a couple that is in counseling for coparenting but is also in a legal battle for custody. Which of the following is the most ethically sound indication to release information for legal purposes? | The husband’s lawyer requests records of sessions, so you provide them to the lawyer because they are a legal representative and you have written consent to release the information. | The court subpoenas the records, so you provide them without written consent from either individual. | The wife’s lawyer requests you to appear in court, so you attend and testify without written consent from either the wife or husband. | Both individuals can request and receive records because they are both the identified client, and you must provide records when they are subpoenaed. | (A): The husband’s lawyer requests records of sessions, so you provide them to the lawyer because they are a legal representative and you have written consent to release the information.
(B): The court subpoenas the records, so you provide them without written consent from either individual.
(C): The wife’s lawyer requests you to appear in court, so you attend and testify without written consent from either the wife or husband.
(D): Both individuals can request and receive records because they are both the identified client, and you must provide records when they are subpoenaed. | The court subpoenas the records, so you provide them without written consent from either individual. | B | You can release information to the court if the court provides an official subpoena for recordsThis is a situation in which you can release information without any ethical conflicts because it is a legal requirement. The husband’s lawyer may be his legal representative, but you do not have written consent from the wife to release records. The wife’s lawyer can request that you appear in court, but you still would not have the husband’s consent to do so. Although both individuals are the identified client, you can withhold records if it causes potential harm to the other client. In this case, harm may be likely if information is released to one of the individual clients because it may affect the couple’s relationships with their children. For that reason, ethically, it would not be sound judgment to release the requested records to the individuals at this time. Therefore, the correct answer is (B) | professional practice and ethics |
117 | Client Age: 19 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Private Practice Type of Counseling: Individual Presenting Problem: Suicidality related to body image Diagnosis: Body Dysmorphic Disorder 300.7 (F45.22), with absent insight/delusional beliefs | Mental Status Exam: The client’s mood is sad and irritable. His speech is pressured when discussing his appearance but is otherwise normal. He is appropriately groomed and wears a beanie covering his ears. He admits to repetitively dissecting his face in the mirror several hours a day. The client offers that he cannot hide his ears with his hair because “it is too thin.” He denies audio/visual hallucinations. The client’s thought content is organized and coherent, but he shows poor insight and delusional thinking about how he and others regard his appearance. The client avoids social settings and reports that sometimes, an entire week goes by where he doesn’t leave the house. He denies suicidality and currently does not have a plan or intent to harm himself or others. Appetite and sleep are fair. The client denies drug use and states he consumes alcohol occasionally. You provide an in-depth suicide assessment, and you and the client work together to create a suicide safety | You are working in private practice and conducting an initial intake session with a 19-year-old male who presents today with his mother. The client was recently admitted to a psychiatric hospital for suicidality and was discharged four days ago. His mother reports that the client tried to commit suicide by overdosing. The client reports feeling increasingly hopeless following a “failed” cosmetic surgery procedure. He explains that he had an otoplasty performed to change the proportion and position of his ears. He states he has always hated his ears and is convinced people are staring and laughing at his “deformity.” His mother reports that she reluctantly consented to the surgery a year and a half ago, despite believing it was unnecessary. The client does not leave the house without wearing a beanie or hoodie. He has completed high school with no interest in attending college. He is unemployed due to shame and embarrassment over his “defective” appearance. Two weeks ago, the hospital psychiatrist changed his medication and placed him on a selective serotonin reuptake inhibitor (SSRI). | plan. Family History: The client’s parents are divorced and he lives with his mother and two younger siblings. There is a history of child protective services (CPS) involvement due to reports of domestic violence between his parents. The client witnessed these incidents between that ages of 10 and 12. His parents subsequently divorced and the client has had minimal contact with this father since. The client’s maternal aunt is diagnosed with obsessive-compulsive disorder. His mother previously attended therapy for anxiety and other trauma-related symptoms. The client began experiencing symptoms of body dysmorphic disorder at age 13, with symptoms worsening after starting high school. The client states, “When I leave the house, everyone is staring at my ears and laughing at my deformity | The client states, “When I leave the house, everyone is staring at my ears and laughing at my deformity.” This is an example of which one of the following? | Black-and-white thinking | All-or-nothing thinking | Emotional reasoning | Personalization | (A): Black-and-white thinking
(B): All-or-nothing thinking
(C): Emotional reasoning
(D): Personalization | Personalization | D | This is an example of personalization. Personalization is a cognitive distortion that involves a person believing that they are being targeted by someone else’s behavior (eg, laughing) when it has nothing to do with that person. All-or-nothing thinking is synonymous with black-and-white thinking and polarized thinking (eg, “If I’m not perfect, then I’m nothing”). Emotional reasoning results from believing that one’s feelings are facts, despite contradictory evidence (eg, “I feel deformed and worthless, so I must be that way”). Therefore, the correct answer is (C) | intake, assessment, and diagnosis |
118 | Name: Jackson Clinical Issues: Behavioral problems Diagnostic Category: Depressive Disorders Provisional Diagnosis: F34.8 Disruptive Mood Dysregulation Disorder Age: 11 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Not Assessed Ethnicity: White Marital Status: Not Applicable Modality: Individual Therapy Location of Therapy : Private Practice | Appearance: The client is dressed in clothes associated with anime. He is well groomed and appears to be a few years younger than his chronological age. Orientation: The client is oriented X3. Mood: The client's mood is dysphoric. Affect: The client's affect is restricted. Speech: The client's speech is soft and hesitant. Thought Process: The client's thought process is slow and labored. Thought Content: The client's thought content is pessimistic and focused on negative themes. Perception: The client's perception is intact. Insight: The client's insight is poor. | First session You are a therapist in private practice specializing in working with children. The client is an 11-year-old male. His mother brought him to therapy because of the "latest incident at school," wherein he had an angry outburst and threatened to come to school with a gun and shoot everyone, including himself. The mother states that the police were notified, and the client was suspended from school for a week. The client was unwilling to discuss his emotions or the incident at school. He became agitated and defensive whenever the topic was brought up and now will not talk to you. He seemed to be in a state of denial, minimizing the impact of the incident at school. You observe a bald spot on the top of the client's head, indicating that the client has been pulling his hair out. The client was evasive when asked about the bald spot on his head and became increasingly anxious. He could not articulate why he was pulling his hair out and seemed embarrassed, avoiding the topic. He has difficulty identifying and expressing emotions outside of anger. His mother reports that he lashes out at home with family and classmates at school, aggressively arguing and making threats. He had difficulty engaging in self-reflection and could not make meaningful connections between his behavior and the consequences that may follow. His mother is extremely frustrated and worried that this school will also expel him. She is upset with the lack of progress his previous therapist made with her son and is now considering residential treatment options. The mother has been receiving conflicting diagnoses from previous therapists and is seeking a definitive diagnosis from you. Halfway through the session, you ask to speak with the client by himself for a few minutes. The mother exits the room, leaving you alone with the client. You take notice of his anime shirt and ask him more about anime. He quickly starts talking and making eye contact. Second session After your initial session with the client, the school performed a risk assessment and concluded that the client could return to school. You have requested to meet with the client and his mother every week. Today is your second session, during which time you spend the first thirty minutes talking with the mother and the second half talking with the client. During your conversation with his mother, she shared that she believes her son might have Autism. She says she has been debating whether to tell you this because she is "concerned about the stigma associated with Autism" and the possibility of her son being treated differently. She has been anxious about her son's issues and wants to have him tested to get him the "right help." Jackson's mother appeared very anxious during the session. She shared concerns that he may have Autism but has hesitated to disclose this for fear of stigma. She has been struggling with getting him properly assessed and finding adequate support. Her anxiety around Jackson's issues was evident in her tense body language and rapid speech. She is worried about her son's well-being and future. However, the stigma she associates with an Autism diagnosis seems to be preventing her from getting Jackson the help he likely needs. You recognize that Jackson's mother feels overwhelmed and alone trying to understand her son's difficulties. Her eagerness to have him tested indicates she believes an Autism diagnosis would provide answers and open up access to services. Yet she is torn about the potential labeling and discrimination Jackson could face. Her desire to protect her son's privacy competes with her need to get him help. This is causing Jackson's mother significant inner turmoil. She presented today as a caring parent under great strain. In the second part of the session with the client, you find him disinterested and bored until you start talking about gaming. Then, he appears to perk up and becomes talkative. When you ask why he thinks he is here, he tells you about an incident at school. A student in another room texted his entire class, saying he was "short." This angered him, and he left the classroom and started a fistfight with that student, resulting in disciplinary action. Jackson told this story with clenched fists, still visibly upset. He explained that the school was unfair and justified his violent reaction by stating he has Autism. This suggests Jackson feels his neurodiversity excuses poor behavior. Rather than take responsibility, he blamed external factors for the altercation. Jackson's body language and tone indicated he remained defensive and saw himself as the wronged party. Jackson believed his Autism diagnosis makes aggression an inevitable response in certain situations. By citing Autism as the cause of his actions, he abdicated any sense of personal responsibility. Without intervention, he may continue acting out when provoked and making excuses based on his diagnosis. There is a risk that Jackson will not develop appropriate coping skills or learn to navigate his interpersonal conflicts. He appears fixed in the view that others are at fault, while his neurodiversity pardons any misdeeds. | The client's biological father was diagnosed with Bipolar I Disorder. The biological father is unaware of the client's existence although the client knows that his step-father is not his biological father. The client has transitioned from school to school. Each time his behavioral problems have escalated. This is his third school. The client's issues have become so severe that his parents have been called to the school multiple times. They have been unable to get him to listen to them or follow directions. His outbursts are becoming more frequent and aggressive, and his refusal to do work or cooperate has become a problem for his teachers. The school has tried various approaches to try and help the client, but he has been resistant to them. He has been put on a behavior plan but has not followed through. The administration has also tried talking to him on multiple occasions to try and get him to open up, but he has been unresponsive. The administration has now exhausted all of its options and is at a loss as to what to do. They are willing to give him one more chance, but they will be forced to find another solution if he does not improve. Previous Counseling: The client has been seeing a pediatric psychiatric nurse twice a month for two years for his frequent temper outbursts at home and school. His irritable and angry mood is a daily occurrence, with verbal rages and physical aggression occurring three or more times a week. He is currently taking Respidol for emotional regulation. The medication affects his appetite and energy level. | You would like to collaborate with other providers for the treatment of the client. Who would be the most important person to discuss progress and monitoring with? | The school principal | The school psychologist | The school resource officer. | The client's teacher | (A): The school principal
(B): The school psychologist
(C): The school resource officer.
(D): The client's teacher | The school psychologist | B | School psychologists bridge the gap between teacher and parent. They assess children's needs and report to the principal to make final decisions. This is the most important professional with whom to collaborate. Therefore, the correct answer is (C) | treatment planning |
119 | Client Age: 18 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: University Counseling Center Type of Counseling: Individual and Group Presenting Problem: Interpersonal relationships Diagnosis: Autism Spectrum Disorder. 299.00 (F84.0) | Mental Status Exam: The client is sloppily dressed and appears his stated age. He exhibits pressured speech at times; otherwise, he speaks in a monotonous tone. The client becomes irritable when discussing the incident with campus police, and brightens when expressing his passion for snakes. He displays poor eye contact and there is difficulty with normal back-and-forth conversation. The client denies suicidal or homicidal ideation. He lives on campus in sober student housing and denies drug or alcohol use. History of th | You are a counselor a university counseling center. The university has a program providing limited assistance to students diagnosed with Autism Spectrum Disorder (ASD). The ASD program director has referred an 18-year-old white male enrolled in the program. She is concerned over his recent run-in with campus police. The client arrives to his scheduled counseling session today and explained that he has a girlfriend who “now apparently wants nothing to do with me.” Campus security has been involved due to the client showing up at his girlfriend’s dorm, yelling and creating a disturbance. The client explains that his peers told him he would have sex in college once he got a girlfriend. When his girlfriend refused to have sex, he said he didn’t understand and only wanted to talk. The client continues to express a desire to have sex now that he is in college by stating matter-of-factly, “I haven’t had much luck, but I’m going to keep trying.” When asked about interests, the client spoke at length about his love for snakes and knowledge of all 300 worldwide species. | e The client provides written consent for you to speak to his mother. His mother explains that the client was originally diagnosed with Asperger’s disorder and ADHD in early childhood. She acknowledges that the client has difficulty tolerating frustration, primarily when encountering changes in routine. She further explains that she worries “constantly” about him having clean clothes, staying organized, and waking up for class on time. She states she calls the client at 8:00 am every morning to help him wake up and stay on track. The mother also says the client finds noise in the cafeteria overstimulating, so he often skips meals. Family and Work History The client is a first-year student majoring in architectural engineering with a 3.6 GPA. He held a part-time job at a local grocery store while in high school. The client’s parents have been married for 15 years, and he has one younger sibling living at home. The mother takes an SSRI for depression and anxiety. The client’s father struggled with similar issues as the client growing up, but he was never formally diagnosed. His family’s home is 45 minutes from campus, and the client’s mother visits most weekends to check on the client and help him clean his room. Relationships: The mother states the client has always had difficulty with peer relationships. She explains that he has always wanted a girlfriend, but he could never find someone who appreciated his differences. However, the client did have a small group of friends in high school who all played Dungeons and Dragons together. She thanks you for calling and states she will encourage the client to return to you for counseling services. You discuss the case with your supervisor, who encourages you to use a structural family therapy approach to examine the relationship between the client and his mother | You discuss the case with your supervisor, who encourages you to use a structural family therapy approach to examine the relationship between the client and his mother. Which statement best reflects this approach? | The client and the mother’s maladaptive behavior is the result of misunderstandings and a lack of loyalty and trust. | The client and the mother belong to an enmeshed family subsystem. | The client and the mother’s dysfunctional communication is the result of a reinforced circular feedback loop. | The client and the mother are highly emotionally fused and undifferentiated. | (A): The client and the mother’s maladaptive behavior is the result of misunderstandings and a lack of loyalty and trust.
(B): The client and the mother belong to an enmeshed family subsystem.
(C): The client and the mother’s dysfunctional communication is the result of a reinforced circular feedback loop.
(D): The client and the mother are highly emotionally fused and undifferentiated. | The client and the mother belong to an enmeshed family subsystem. | B | Developed by Salvador Minuchin, structural family therapy is based on the premise that family subsystems and boundaries are either disengaged or enmeshed. The mother and the client are an enmeshed subsystem due to being overly dependent and close. Multigenerational (Extended) Family Systems therapists use the termundifferentiated family ego massto describe individuals in families with high levels of emotional fusion and low levels of differentiation. Contextual family therapists view maladaptive behavior as an imbalance in loyalty, trust, and mutual understanding. Strategic family therapists view maladaptive behavior as the result of circular communication. Circular communication occurs when a behaviorally reinforced feedback loop maintains the family’s homeostasis and dysfunction. Therefore, the correct answer is (B) | intake, assessment, and diagnosis |
120 | Name: Camron Clinical Issues: Worry and anxiety Diagnostic Category: Anxiety Disorders Provisional Diagnosis: F40.10 Social Anxiety Disorder Age: 20 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: White Marital Status: Never married Modality: Individual Therapy Location of Therapy : University Counseling Center | The client looks anxious and uneasy, presenting with a "nervous" laugh. He twirls his thumbs and shakes his legs while seated. Mood is anxious and frustrated. He feels isolated and misunderstood by his family and peers. Speech is soft and hesitant. Eye contact is sporadic. Thought process is concrete and linear. He has some difficulty with abstract concepts. Thought content reveals fear of social interactions, feeling judged by others, and feeling inadequate. He seems to recognize the negative consequences associated with his anxiety and behavior, but he has limited insight with regard to recognizing the source of his anxiety. He reports difficulty recalling past experiences or conversations due to anxiety levels. No suicidal or homicidal ideation noted. | First session Your client is a 20-year-old male who has been seeing your colleague at the university counseling center where you both work as mental health therapists. The client requested to be transferred to another therapist because his former therapist reminded him too much of his father and therapeutic progress could not be made. The client's former therapist contacted you as a referral, and you agreed to transfer the client to your caseload. When you meet with the client today, he seems very anxious and laughs nervously. You can see he is shaking his legs as he sits, twirling his thumbs, and making little eye contact with you. You explain the therapy process and that you need to go over some intake questions. You ask him who his ICE (in case of emergency) contact is, and he says it is his roommate. You continue with your assessment, gathering information about his presenting problem and what he would like to accomplish in counseling. He continues by telling you, "I thought that going to college would alleviate my social anxiety, but I'm not doing well here. I want to be social, but I can't." The client feels frustrated and overwhelmed by his fears of interacting with others. He tells you that when he is feeling anxious, he punches bathroom mirrors to try to distract himself from the anxiety. He notes that the anxiety is crippling, preventing him from doing the things he loves, and has resulted in him feeling isolated. He is afraid that others are judging him and is constantly worried that he will make a mistake and feel embarrassed. | The client grew up in an authoritarian house where all of his actions and behaviors were scrutinized by his father. His father demanded obedience from his son and would not accept anything but perfection from him. He graduated from high school at the top of his class and has been waiting to attend college to get out from "under the thumb" of his father. The client's parents are paying all of his college expenses. The client is experiencing difficulties adapting to college life. He states that he stays in his room because he believes he always says and does the wrong thing, and everyone can see what a "loser" he is. He further states that he rarely leaves his dorm room except to go to his work-study position. The client has experienced two panic attacks; one occurred when he was required to give a presentation in class, and the second happened when he was required to meet with a small group to discuss his input for their group project. The client has missed many classes in which he is expected to participate or present projects. He is currently failing three classes. The client is in danger of losing his work-study job on campus due to frequent absences. He is competent and conscientious when his job does not require customer interaction. Personal/Social Relationships: The client is interested in exploring social relationships but is anxious as his father never allowed him to interact with his peers. As a result, his level of social functioning is relatively low. He has talked with a few students in his dorm and classes when required, but he feels extremely uncomfortable and inept. The client has not developed any friendships because of his anxiety. | What is the most noteworthy reason you would need to break confidentiality with this client? | The client is engaging in behavior where he is at risk of harming himself | The client poses an imminent and violent threat to others | The client reports a history of emotional abuse from his father | The client is destroying property | (A): The client is engaging in behavior where he is at risk of harming himself
(B): The client poses an imminent and violent threat to others
(C): The client reports a history of emotional abuse from his father
(D): The client is destroying property | The client is engaging in behavior where he is at risk of harming himself | A | The client punches bathroom mirrors when he cannot distract from the anxious thoughts. He is not cutting or harming himself badly, but this is something to monitor. You need to reiterate to the client that you must break confidentiality if he is a danger to himself or others. Therefore, the correct answer is (D) | professional practice and ethics |
121 | Initial Intake: Age: 16 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Biracial Relationship Status: Single Counseling Setting: High School Social Worker Type of Counseling: Individual | Autumn came to intake session, during her lunch period. She appeared younger than her stated age because she was so underweight. The counselor greeted Autumn and told her that she was welcome to eat during their session if she wanted to. Autumn looked down and responded, “It’s okay- I don’t like to eat in front of anyone- I can just eat later.” Erin seemed tired during the interview but was cooperative and friendly. | History:
Autumn is a junior in high school. Her parents divorced about a month ago. Recently, the teacher noticed a change in Autumn’s mood. Autumn’s teacher also noticed that she was taking her lunch and eating it outside by herself. Oftentimes, she didn’t seem to eat much of it at all. When asked about it, Autumn seemed embarrassed and stated that she was fine. | null | Based on the first session notes, what should the counselor do next? | Refer client to inpatient treatment | Definitively state that trust and therapeutic alliance is established | Identify client driven goals and objectives | Discuss transferring to someone who specializes in eating disorders | (A): Refer client to inpatient treatment
(B): Definitively state that trust and therapeutic alliance is established
(C): Identify client driven goals and objectives
(D): Discuss transferring to someone who specializes in eating disorders | Identify client driven goals and objectives | C | Now that the diagnosis has been established, it is important to formulate a treatment plan that focuses on the needs and priorities of the client. Autumn is not currently a safety risk to herself or others, so hospitalization is not warranted. Throughout the counseling process, the quality of the therapeutic alliance should be monitored and addressed if any issues arise. There is no indication that the counselor cannot properly treat the client. Therefore, the correct answer is (B) | intake, assessment, and diagnosis |
122 | Client Age: 35 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Hispanic Relationship Status: Divorced Counseling Setting: Private Practice Clinic Type of Counseling: Individual Counseling Presenting Problem: Anxiety; Depressed Mood, Difficulty with Changing Relationship Roles Diagnosis: Adjustment Disorder with Mixed Anxiety and Depressed Mood (F43.23) | Mental Status Exam: The client presents as oriented to person, place, time, and situation. The client appears anxious because he avoids eye contact often and expresses that he has never been in counseling and is ner | You are a licensed counselor in Texas in a private practice. A 35-year-old male client comes to counseling for support during a recent divorce. The client says that he and his wife separated a year ago and had to wait a year for divorce per state law; therefore, they finalized the divorce recently. The client says that his wife decided she married him because she was lonely and that, after 8 years of being married, she wanted to find someone she loved. The client states that he still loves his ex-wife and that he has a hard time with his new relationship with her because he shares custody of his children and still has to communicate with her regularly. He continues saying that his wife often calls him for emotional support and he does not know how to respond when this happens because he loves her and wants to support her, but this is confusing for him. The client says that he knows he “shouldn’t be with someone who doesn’t want to be with him and that things won’t go back to how they were.” The client identifies that anxious and depressive symptoms are present and that they affect his ability to engage socially, engage with his children, and perform at work. The client wants to work on navigating his new relationship with his ex-wife, his relationship with his children, and being single again. | The client talks about when he went to see his daughter at a dance recital and how, afterward when he went to say hello to her, she ignored him. He called his ex-wife later that day, and she denied knowing what was wrong, but when he talked to his son, the boy said, “Mommy told us you didn’t want to live with us anymore and that is why you left.” The client expresses frustration and anger with his ex-wife because she chose to leave him, and he thinks that it is not fair that she is telling the children a lie and also that it is affecting his relationship with them. The client states that he wanted to talk to you before he confronted his wife about this. You and the client discuss conflict resolution skills. The client asks if his ex-wife can come into the next session so they could work on co-parenting skills | The client asks if his ex-wife can come into the next session so they could work on co-parenting skills. Which one of the following is the most ethical course of action? | Explain your role with the client and provide a family therapy or couples counseling referral. | Explain that if you are going to work with the client and his wife, then you would not be able to revert back to individual counseling because you can only work with him in one modality to avoid a conflict of interest. | Explain guidelines for how you can provide individual therapy for him and his family or couples therapy for him and his ex-wife. | Explain that you are unable to meet with both of them because you are his individual counselor. | (A): Explain your role with the client and provide a family therapy or couples counseling referral.
(B): Explain that if you are going to work with the client and his wife, then you would not be able to revert back to individual counseling because you can only work with him in one modality to avoid a conflict of interest.
(C): Explain guidelines for how you can provide individual therapy for him and his family or couples therapy for him and his ex-wife.
(D): Explain that you are unable to meet with both of them because you are his individual counselor. | Explain your role with the client and provide a family therapy or couples counseling referral. | A | You have had four sessions with this client and would likely already be too engaged, and therefore biased, to provide appropriate therapy to your client and his ex-wife at this point. It would be most ethical to refer the couple to another therapist if they would like to work on coparenting skills. Simply stating your inability to work with the couple without providing proper direction via a referral would not be the most ethical course of action because it does not support your client in seeking the additional help that he is requesting. If you provided individual and couples/family therapy, you would be risking bias toward this client because you work more directly with him and his needs. Therefore, the correct answer is (A) | professional practice and ethics |
123 | Initial Intake: Age: 32 Gender: Female Sexual Orientation: Heterosexual Ethnicity: Caucasian Relationship Status: Divorced Counseling Setting: Community Mental Health Agency, state-run Type of Counseling: Individual and family | Shania is disheveled, has tangential and fast rate speech and is fidgety with twitching in her motor movements. Shania makes consistent eye contact and leans in close when she becomes upset and begins to cry. Shania admits to having suicidal thoughts and attempt behaviors in her past, but says she no longer feels suicidal. Shania denies homicidal ideations, hallucinations, or delusions. She shares how when she was heavily using drugs and alcohol, she would become paranoid and frequently experience delusional thinking with manic presentation but only while actively on psychoactive substances. Shania has an extensive physical and emotional abuse history since childhood but is a poor historian with the timeline of events. She attributes her anxiety to her trauma as she remembers feeling anxious around her parents since she was a child. She tells you she has no desire to use drugs again but is frequently worried about her temptations to drink when she is stressed or around members of her extended family who drink. Shania’s depression and anxiety have increased more recently due to her family being evicted from their rental apartment and having to stay in a hotel room for the past few weeks. | Diagnosis: Major Depressive Disorder, recurrent, unspecified (F33.9), Anxiety Disorder, unspecified (F41.9), Alcohol dependence, uncomplicated, in early remission (F10.20), Cocaine Use Disorder, unspecified with cocaine-induced mood disorder, in remission (F14.94)
You are an intern providing mental health counseling sessions to adults and children struggling with economic and legal issues and are given a referral to conduct an evaluation for Shania, a 32-year-old woman with three children. Shania has temporary guardianship of her youngest two daughters but is undergoing a custody battle to win back full custody of all her kids. Her oldest, age 12, is under guardianship of her parents in another state. Shania tells you in the intake session that her father beats her 12-year-old with his belt and her mother verbally abuses her, but that she isn’t taken seriously when reporting. Shania says because of her legal and substance use history, and due to her reports often being vague on details and directly attempting to influence her court hearing results, officials do not follow through on investigations. Shania further shares that her youngest daughter is struggling with psychiatric and behavioral issues, has used violence against her when angry and cannot sit still, most nights only sleeping for two or three hours. She can no longer afford medications and no longer has health insurance. | Substance Use History:
Shania has been in long and short-term treatments several times in her 20s for alcohol dependency and cocaine use. She had all her children while under the influence or in remission from using substances and has had minimal contact with their fathers. The man she is currently living with is not the biological father of the children but has taken to caring for them as his own while he is in a relationship with Shania.
Work History:
Shania has never been able to keep a job for long because of her substance use, which has contributed to her depression and has caused suicidality in her past. Shania has worked in several retail, food and other merchandising chains but has just recently become unemployed again. This is what contributed to her inability to pay rent and eviction. She asks you for help with getting government assistance as she has no family she can rely upon for support. | While conducting a suicide assessment you learn Shania has a history of attempts using prescription medications. What precautions should you advise for her safety plan? | Dispose of all old Rx and lock up any active Rx for partner to administer as needed. | There's nothing she can reasonably do to prevent this from happening again. | File a caution alert on her medical records and mental health charts. | Have her sign a safety plan agreeing to call for help if she feels suicidal. | (A): Dispose of all old Rx and lock up any active Rx for partner to administer as needed.
(B): There's nothing she can reasonably do to prevent this from happening again.
(C): File a caution alert on her medical records and mental health charts.
(D): Have her sign a safety plan agreeing to call for help if she feels suicidal. | Dispose of all old Rx and lock up any active Rx for partner to administer as needed. | A | Signing a safety plan does not adequately support a client's high-risk behaviors if there is something that can be done to improve her physical safety. Alerts on her EMRs will not improve her safety when she's at home with access to harmful content. While there is no guarantee of a client's safety, making no advisements is irresponsible if there is something that can at least support her in the interim while you are providing her with services and can monitor her condition and progress. A reasonable suggestion would be to eliminate any inventory of prescription medications that are in her home that she no longer needs, and if she is on current medication, she can discuss safety precautions with her partner who can assist in administering medications daily while the remaining medications are kept in a locked safe. Therefore, the correct answer is (B) | professional practice and ethics |
124 | Client Age: 13 Sex Assigned at Birth: Male Gender: Transgender; Gender Nonconforming (TGNC) Ethnicity: Caucasian Counseling Setting: Child and Family Agency, School-Based Services Type of Counseling: Individual and Family Presenting Problem: Truancy; Gender Dysphoria Diagnosis: Gender Dysphoria, Provisional (F64.1); Social Exclusion or Rejection V62.4 (Z60.4) | Mental Status Exam: The client is dressed in age-appropriate clothing. They wear eye makeup and chipped black fingernail polish, and they have bitten most fingernails down to the quick. The client’s mood is irritable, and they are quick to show anger toward their mother when misgendered. Their thoughts are coherent, and they deny audio/visual hallucinations. The client acknowledges feeling sad and hopeless but denies suicidal ideation. They attribute increased levels of anxiety at school to bullying, particularly with select peers. They explain that a select group of students threaten the client and call them offensive and derogatory names. Family History and History of th | You are a school-based mental health counselor in a public middle school. Your client is a 13-year-old Caucasian 7th grader who presents for the initial intake with their mother. The mother says that the client has had several unexcused absences from school because “he is confused about his gender.” The client adamantly denies being confused and explains that they self-identify as transgender. The client’s preferred pronouns are “they/them.” The client further states that they have had a strong desire to be a different gender since early childhood, and this desire and their distress have recently intensified. The mother reports that the client is chronically irritable, spends a lot of time alone, and has “basically shut everyone out.”The client reports experiencingbullying—both verbal and physical—in school “nearly every day.” In addition to the bullying, the client says that certain teachers refuse to allow them to use the bathroom aligned with their identified gender. To prevent this conflict, the client does not eat breakfast or lunch at school. | e The client’s mother and father are both realtors. The mother states that she used to see a therapist for anxiety, which she now manages with medication. The father works long hours, and the mother returns home early to attend to the client’s needs. The mother states that she realized that the client wished to be another gender when they were younger, but she believed it was just a phase. She explains that the father is not supportive and refuses to discuss the issue. The mother is concerned about the client’s truancy and desires to be supportive but has mixed feelings about it. She says that she is fearful every day and believes that if she accepts the client’s truth, it will set the child up for “a lifetime of prejudice and discrimination.” Which of the following suggests that gender dysphoria is caused not only by external (distal) stressors (e\. g | Which of the following suggests that gender dysphoria is caused not only by external (distal) stressors (e.g., prejudice, discrimination) but also by internalized (proximal) stressors (transphobia, stigma)? | Social identity theory | Minority stress theory | Escape theory | Cognitive dissonance theory | (A): Social identity theory
(B): Minority stress theory
(C): Escape theory
(D): Cognitive dissonance theory | Minority stress theory | B | Minority stress theory posits that gender dysphoria is caused not only by external (distal) stressors (eg, prejudice, discrimination) but also by negatively internalized (proximal) stressors, including internalized transphobia and stigma. Proximal stressors also include anticipated rejection, hiding gender identity out of fear, and the cumulative experiences of being “othered” as a minority in a cisgender culture. Proximal stressors are linked to higher instances of behavioral health disparities and an increase in mental health symptoms. Cognitive dissonance theory asserts that individuals experience distress when faced with two or more incompatible cognitive elements (ie, choices). Social identity theory explains that individuals are influenced by fitting in and belonging to social groups. Alignment with one’s identified social group is likely to affect self-esteem, especially if the identification is strong (ie, an “in-group” versus an “out-group”). Escape theory states that individuals tend to avoid activities that are psychologically unpleasant. Therefore, the correct answer is (B) | counseling skills and interventions |
125 | Initial Intake: Age: 35 Gender: Male Sexual Orientation: Heterosexual Ethnicity: African American Relationship Status: Divorced Counseling Setting: Community Mental Health Center Type of Counseling: Individual | Davone presents as well-groomed, of fair hygiene and motor movements are within normal limits. Davone makes decent eye contact throughout session. Speech tone and rate are normal. Thought process unremarkable. Denies SI/HI. Davone becomes tearful when he recalls past family information, sharing that his father was never around for him for the same reasons he is not around for his family. Davone frequently refers to his racial background and where he grew up, becomes angry as evidenced by tense expression, furrowed brow, and clenched fists, and then self-soothes without prompting by taking a deep breath and moving forward in conversation. When asked, Davone tells you he learned those skills in past anger management classes he was mandated to take years ago. | Diagnosis: Adjustment disorder with mixed disturbance of emotions and conduct (F43.25) Provisional, Problems related to other legal circumstances (Z65.3)
Davone is referred to you by his probation officer after being mandated by the court to undergo weekly emotional and behavioral health counseling sessions for a minimum of 9 months or until his next court hearing is scheduled, whichever is sooner. Davone’s Medicaid insurance cover his sessions. The probation officer tells you Davone is undergoing sentencing for violating his probation and restraining orders put in place by his ex-wife, which render him unable to set foot on their property or visit with his children (twin boys, age 9, and girl, age 4). In the initial assessment, Davone shares that he has had run-ins with the criminal justice system for most of his life “just like his father” and that he fears a lifetime of being in prison and not being able to be there to watch his kids grow up. Davone tells you he will do anything to get out of his situation and return to having a life where he can continue going to work and providing for his children. | Legal and Work History:
You learn from Davone’s referral paperwork that Davone’s legal record extends back to age 9 when he was first beginning to show signs of conduct at school. Davone was often sent to the “recovery room” in elementary school for aggressive outbursts and defiance towards teachers. He has a record with the Juvenile Justice System for breaking rules and truancy in middle and high school. After age 18, he was arrested several times for misdemeanors of vandalism, shoplifting and reckless driving. He then married and became employed full-time by age 25, where he did not get into trouble with the law again until age 31 when he got fired for stealing from his company. This caused marital discord and led to Davone’s divorce two years ago. Davone has had a continued string of misbehavior, arrests, and short-term jail stays ever since. Davone adds that his ex-wife accused him of consistently endangering her and the kids without caring, which is why she got the restraining order. He disagrees with her, saying “I would never harm my kids.” | Your diagnostic impression includes disordered adjustment with “mixed disturbance of emotions and conduct.” Why was this diagnosis chosen over Antisocial Personality Disorder? | You would like to learn more about Davone prior to giving this diagnosis. | The root of Davone's conduct is unresolved emotions. | Davone does not meet criteria for Antisocial Personality Disorder. | Adjustment disorders are preferred for individuals with criminal backgrounds. | (A): You would like to learn more about Davone prior to giving this diagnosis.
(B): The root of Davone's conduct is unresolved emotions.
(C): Davone does not meet criteria for Antisocial Personality Disorder.
(D): Adjustment disorders are preferred for individuals with criminal backgrounds. | You would like to learn more about Davone prior to giving this diagnosis. | A | Learning more about Davone's pattern of behaviors, experience of remorse, underlying cognitive and emotional conditions and family history is best practice prior to assigning Davone a personality disorder. Answer a) is incorrect because Davone does meet 3 out of 15 prescribed criteria for APD but upon initial assessment you have not been given adequate time to rule out other possible contributing biopsychosocial factors including any other co-occurring conditions prior to assigning a personality disorder. Answer c) is not a qualifying reason for delaying a personality disorder diagnosis because diagnoses are given based on symptoms and behavioral criteria, not on underlying reasons. Answer d) is also incorrect; people with criminal backgrounds are not given adjustment disorder diagnoses automatically. Therefore, the correct answer is (B) | intake, assessment, and diagnosis |
126 | Initial Intake: Age: 29 Gender: Female Sexual Orientation: Heterosexual Ethnicity: Caucasian Relationship Status: In a relationship Counseling Setting: Private practice Type of Counseling: Individual | Taylor presents as well groomed, has good eye contact, and movements are within normal limits. Taylor appears anxious with tense affect and is occasionally tearful. Taylor has no history of suicidal thoughts or behaviors, no reported trauma history and has never been in counseling. | Diagnosis: Adjustment disorder with anxiety (F43.22)
You are a counseling intern working in a private practice with your supervisor and several other interns. Taylor is a 29-year-old college student who was referred to you by her university’s resource center for mental health counseling. Taylor went to them requesting someone to talk to about her family stress. Taylor’s 18-year-old brother has autism and is preparing to go to college in another state, and Taylor is feeling anxious about the transition since he will be leaving home for the first time and their family will not be around to help him. Taylor has been manifesting her anxiety in ways that are causing her difficulty in school and in her relationship, such as trouble concentrating, completing assignments, and lashing out with aggressive reactions towards her parents or her boyfriend whenever they bring up the topic of her brother’s college. She has even yelled at her brother once out of frustration. Taylor is hoping to find ways to cope with her stress and manage her emotions over her family’s decisions. | Family History:
Taylor lives at home with her parents and her brother, and commutes to University for her Bachelor studies. She stayed at home since graduating high school to help her parents with her brother with autism. Her parents had separated on and off for several years because of an affair her mother had, so the house has had tension and instability making Taylor feel responsible to keep her brother on a stable routine. Taylor comments that her brother’s challenges have always “taken up all her time” and that she used to complain about them, but now that he is going to be on his own, she is very upset she will not be able to be there for him. She complains her parents are “flaking out” on her and feels left out of their decision making but does not know what to do about it. | You recall her brother lives out of state and that Taylor will be in another state during the virtual visit. What should you consider doing prior to the session? | Explain that you will not be able to have session and reschedule. | Consult with your agency or state laws that govern interns offering out of state services. | Send Taylor a Telemedicine consent form via email and have her send proof she signed. | Because your client lives in your state and is just visiting out of state there is no problem. | (A): Explain that you will not be able to have session and reschedule.
(B): Consult with your agency or state laws that govern interns offering out of state services.
(C): Send Taylor a Telemedicine consent form via email and have her send proof she signed.
(D): Because your client lives in your state and is just visiting out of state there is no problem. | Consult with your agency or state laws that govern interns offering out of state services. | B | Each state or agency has specific guidelines for how counseling interns may deliver services in these circumstances, therefore it is best practice to check on the rules governing your specific location and situation prior to conducting session. If you are unable to verify the rules for your situation, it is then best to reschedule until you can do so or return to your counseling routine. Therefore, the correct answer is (B) | professional practice and ethics |
127 | Name: Timmy Clinical Issues: Developmental processes/tasks/issues Diagnostic Category: Neurodevelopmental Disorders Provisional Diagnosis: F84.0 Autism Spectrum Disorder, Level 2 Age: 13 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: Black Marital Status: Not Applicable Modality: Family Therapy Location of Therapy : School | The client speaks using only a few words. There is no report of echolalia or other repetitive or overly formal use of language. You ask him to say "hi," and he opens his mouth wide, smiles, and laughs. He sustains direct eye contact with you for about two seconds. When you ask him to show you where his mother is, he points to her, looks back at you, and begins to laugh again. There are no reported or observed preoccupations and no reported or observed sensory symptoms to date. | First session You are a mental health therapist in a school setting. The client is referred to you by your school district to complete an evaluation. The client and his mother enter the session. The mother is prompting the client in a "toddler-like" voice to sit in the seat. The mother tells you that the client is becoming increasingly "violent" in the home setting, and she and her husband are not equipped to teach their son the skills he needs to regulate his emotions. In addition, she states that he needs some social exposure to others. He is nonresponsive to subtle social cues and has difficulty when others cannot understand his needs. She states that they need professional help and requests assistance in getting him "the education he deserves". You listen carefully to the mother's concerns and ask additional questions about her son's behavior, both at home and in school, as well as any history of mental health treatment or diagnoses. You explain to the client’s mother that you will provide an assessment of her son’s social and emotional needs and use evidence-based interventions to help him develop effective strategies for regulating his emotions and interacting with others. You review your therapy procedures in detail, including your expectations regarding how often the client and family should come for sessions and what to expect in terms of treatment outcomes. You also discuss any potential risks associated with therapy and the importance of open communication between family members, the client, and yourself during treatment. The mother expresses her understanding of your expectations and agrees to follow through with treatment. You encourage her to ask questions if she has any concerns or needs clarification about any part of the therapy process. Fourth session You have arranged for the client to have a one-on-one aid at school. You review his progress with his team of teachers and give them necklaces with visual cues to help communicate with him. The aid brings the client in for his weekly session with you today. The client sits and stares. At times he will rock and make loud noises. You hand him a stress ball and model for him how to squeeze it. The client starts to giggle as he squeezes the stress ball. You show the client the picture of a person laughing. You clap for the client and tell him "good job." The client mimics you and starts to clap. You ask the client if he would like to try playing a game with you. He nods his head in agreement and looks at you with anticipation. You choose a simple matching game with different shapes, colors, and sizes. Through this game, you encourage him to take turns and practice communication skills. As the session progresses, you provide verbal praise for his efforts and watch as he slowly builds a sense of trust in you. You create opportunities for him to share small stories about himself and encourage him to express his feelings through drawings or writing exercises. Through these activities, you provide a safe and comfortable environment for him to explore his emotions and interact with others. Following your session with the client, you contact his mother with an update on his progress. You discuss the importance of continuing therapy on a regular basis and explain what kinds of progress she can expect to see as time goes on. You also provide her with resources such as books, websites, and support groups that she can use to help reinforce the skills her son is learning in therapy. Finally, you outline a plan for continuing treatment and develop a timeline for when the family should check back in for sessions. The client's mother expresses her appreciation for your assistance and her agreement to follow through with the treatment plan. | The client has a close-knit family, and his parents strive to support their son in any way they can. They have little outside support, however, and have been overwhelmed by their child's needs. The client has been home-schooled and lacks social skill development. Parents report that lately he refuses to do school work; as he gets older they will not have the skills to teach him what he needs to know academically. They feel it is now best for him to learn how to thrive socially and emotionally in a public school setting. | What would most influence your decision to suggest a one-on-one aid to support the client through his day? | To demonstrate follow-through on the Education Act of 1996 | To meet his Individual Educational Plan | To follow up on a neuropsychological assessment | To ensure his physical safety and the safety of those around him | (A): To demonstrate follow-through on the Education Act of 1996
(B): To meet his Individual Educational Plan
(C): To follow up on a neuropsychological assessment
(D): To ensure his physical safety and the safety of those around him | To meet his Individual Educational Plan | B | This is the best option for supporting consistency within this client's plan and would most influence your decision to assign a one-on-one aid. Therefore, the correct answer is (A) | treatment planning |
128 | Client Age: 38 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Married Counseling Setting: Private Practice Type of Counseling: Individual Presenting Problem: Marital Difficulties Diagnosis: Obsessive-Compulsive Personality Disorder 301.4 (F 60.5) | Mental Status Exam: The client is meticulously dressed and immaculately groomed. He frequently checks his watch and states he has owned his watch since adolescence and it “still works like new.” His speech is even, and his affect is blunted. At times, he is defensive and attempts to talk over you. He exhibits poor insight into his marital problems and is excessively preoccupied with perfectionism, structure, and order. Fam | You are a counselor working in private practice and meeting your client for the first time today. The client is here at his wife’s insistence, who has threatened divorce if he does not seek and comply with therapy. The client explains that he is swamped at work and has already lost an hour of productivity traveling to your office. He discloses that he has been married just over four years and has a daughter who is 3½. The couple dated briefly and married when the client’s wife discovered she was pregnant. The client believes that if he didn’t leave his wife a schedule and checklist, “things would never get done.” He states that they would be in “so much debt” if it weren’t for his detailed household budget. In his estimation, conflict occurs each time his wife tried to do things “her way” because “it is never the right way.” You paraphrase and clarify the client’s concerns. | ily and Work History: The client works as a web designer and developer. He allows you to obtain collateral information from his wife. You reach his wife by phone, who explains that the client has “an explosive temper when I don’t do things exactly how he asks.” The client’s wife states he can be controlling, overly critical, and irrational at times\. This is the client’s first marriage\. The client’s wife wants to participate in couples counseling but says the client is adamant about her not joining | You are use using acceptance and commitment therapy (ACT) with the client, which involves combining behavioral therapy with which one of the following? | Shaping | Developing discrepancy | Mindfulness | Unbalancing | (A): Shaping
(B): Developing discrepancy
(C): Mindfulness
(D): Unbalancing | Mindfulness | C | ACT combines mindfulness and behavioral therapy to assist individuals with accepting distressing thoughts and feelings rather than fighting against them. ACT is an evidence-based practice for OCPD because of its focus on increasing psychological flexibility (ie, reducing rigidity). The practice of mindfulness helps clients stay in the here-and-now and accept each thought and feeling without judgment. Shaping is used in operant conditioning and involves reinforcing successive approximations to a targeted behavior. Unbalancing is associated with structural family therapy and consists of the counselor aligning with a family member or subsystem to create disequilibrium. Developing discrepancy is used with MI to help the client explore the pros and cons of making a change. Therefore, the correct answer is (A) | counseling skills and interventions |
129 | Client Age: 51 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Divorced and single Counseling Setting: Local government mental health agency Type of Counseling: Individual counseling Presenting Problem: The client is experiencing a recent separation from her last partner who was verbally and physically abusive, and she is currently living in a domestic violence home. Diagnosis: Major depressive disorder, recurrent episode, moderate (F33.1) and post-traumatic stress disorder (PTSD) (F43.10) | Mental Status Exam: The client’s affect is flat, and she is hunched over in the chair. The client is oriented to person, place, time, and situation. She reports no hallucinations, paranoia, or depersonalization/dissocia | You are a licensed counselor working for a local government mental health agency in the counseling clinic. The client was referred to receive case management and counseling after experiencing homelessness due to leaving a physically and verbally abusive relationship with her last partner. The client is experiencing the following depressive symptoms: sadness more often than not, mental fogginess, suicidal ideation, insomnia, significant weight loss, feelings of worthlessness, and fatigue. The client experiences PTSD symptoms due to having experienced several abusive relationships, including recurrent distressing intrusive thoughts regarding the physical abuse, distressing dreams related to abuse, and physiological reactions (difficulty breathing, heart racing) when she goes near certain places that remind her of the abuse. She also explains that she has been avoiding triggers, believes that no one can be trusted, has an exaggerated startle response, and has had difficulty experiencing positive emotions. The client says that she does not know if therapy can help because she feels like these events have changed her and that she cannot get back to “normal,” but that she would like to make friends so she doesn’t feel so alone. | tion. Family History: The client has three adult children: a daughter(age 32), son (age 30), and a second daughter (age 28). The client reports on and off relationships with her children historically because they did not want to be around these men, but that they have rekindled their relationships recently. The client has been married twice, and, in addition to her most recent partner (unmarried), all three men have been physically and verbally abusive toward her | All of the following are possible risk factors for suicide, EXCEPT: | Hopelessness about one’s ability to change one’s situation | Recklessness with decision making | Substance use | The presence of depression | (A): Hopelessness about one’s ability to change one’s situation
(B): Recklessness with decision making
(C): Substance use
(D): The presence of depression | The presence of depression | D | Although depression can cause suicidal ideation, it has been shown that depression alone is often not the factor that leads to suicide attempts. Rather, a combination of other issues has been proven to correlate with suicidal ideation, including a history of trauma, hopelessness, anxiety, panic attacks, substance use, and self-harm (Sommers-Flanagan & Sommers Flanagan, 2015). Substance use, recklessness, and hopelessness can all attribute to a general disturbance in the client’s ability to make sound decisions, leading to possible suicide attempts. Therefore, the correct answer is (D) | intake, assessment, and diagnosis |
130 | Initial Intake: Age: 26 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Private Practice Type of Counseling: Individual | The client appears his stated age and is dressed appropriately for the circumstances in clean jeans and a t-shirt. He identifies his mood as “anxious but a little excited” because he “is hopeful that he can finally let his anger go.” He tells you he is tired because he has difficulty falling asleep and staying asleep most nights. His affect is pleasant with emotional lability evident. He demonstrates appropriate insight and judgment, memory, and orientation. He reports never “seriously” having considered suicide but acknowledges that there were times when he wondered “if dying would make this pain go away.” He has never attempted suicide and states he would never consider harming himself or anyone else. | You are a counselor in a private practice setting. Your client is a 26-year-old male who presents for counseling at the request of his family and his employer, with whom he is close and who knows his history. The client tells you that he has been angry for the past 15 years, beginning a year after the death of his father from a heart attack. He says that his anger is triggered very quickly when frustrated by people or situations and that his “fuse is very short these days.” He states that he has been in some “loud arguments” with his mother, and later his stepfather. He admits that there have been times in the past when he and his stepfather have “almost come to blows” but his mother stepped in and made them stop. He admits to having hit or kicked walls at times in his anger, but has never hit a person. He tells you that he doesn’t want to feel this way because it interferes with his relationships and his former girlfriends have never understood that when the anniversary of his dad’s death comes around, he just wants to be alone for a couple days and not have to talk to anyone. He tells you that he has never had a long-term relationship with a woman because either he gets “depressed” for a few days during certain times of the year (i.e., father’s birthdate and death date) or because he is too quick to get angry and then says things he doesn’t mean. He says that he has been in a relationship with a woman now for eight months and really wants to get himself together because he feels “she’s the one.” | Family History:
The client reports a family history of being the youngest of three siblings born to his mother and father. He reports a “great life” with his family and that they regularly spent time together playing, camping, traveling, and “just being a family.” He tells you that he is sure there were occasional arguments but that he doesn’t remember anything significant, except that he had been mad at his dad the night he died because his dad wouldn’t let him stay up late, but that before the client went to bed, he had come down, apologized to his dad, and they had both said “I love you.” He states his parents had been married for 15 years prior to his father’s death, which occurred when the client was 11 years old. He states his dad died of a heart attack while sleeping, so while he did not see it, he knew something had happened because his mother woke him and his siblings and rushed them over to the next door neighbors’ house. He said that his mother went to the hospital with his father in the ambulance and came home that night to tell him and his siblings that their father had died. He tells you that he and his siblings are still very close and that they now have three much younger siblings born after his mother married his stepfather. He says that he is very close to his mother and stepfather, although he lives three hours away from them. He tells you that he tries to get home for big family events, like birthdays. He states that his stepfather adopted him and his siblings after the wedding and the client loves him very much. He tells you that he and his stepfather have gotten in what the client thinks are “typical teenager/parent” conflicts but that they have often been made worse by the client’s anger that seems to always be inside and erupts quickly. | Which of the following assessments would be helpful before beginning therapy treating the client for PTSD? | All of the above | Multidimensional Inventory of Dissociation (MID) | Dissociative Experiences Scale II (DES-II) | Structured Clinical Interview for DSM - Revised (SCID-D-R) | (A): All of the above
(B): Multidimensional Inventory of Dissociation (MID)
(C): Dissociative Experiences Scale II (DES-II)
(D): Structured Clinical Interview for DSM - Revised (SCID-D-R) | All of the above | A | Prior to treating for PTSD, it is important to assess the client's level of dissociation and each of these assessments will help do this. Most people have some level of dissociation (ie, listening to someone talk but realizing that they did not hear part or all of what was said), however those who experience traumatic events may experience greater levels of dissociation. In the presence of high levels of dissociation, individuals with PTSD can experience further traumatic reactions during treatment. Therefore, the correct answer is (D) | intake, assessment, and diagnosis |
131 | Client Age: 14 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Asian-American (Karen) Grade: 8th Counseling Setting: Child and Family Services Agency Type of Counseling: Individual and Family Presenting Problem: Substance Misuse and Acculturation Difficulties Diagnosis: Substance Use Disorder, Moderate (F2.911 ); Acculturation difficulty (V62.4 Z60.3) | Mental Status Exam: The client is polite and cooperative. He is neatly dressed and is the only member of his family who is not wearing traditional Karen clothing. His affect is restricted, and his eye contact is poor. The client denies suicidal and homicidal ideation. He reports feeling anxious and sad frequently. He expresses that he is particularly worried at school and has had a difficult time adjusting. The client states that he lived in outdoor homes and buildings before coming to the United States. He explains, “Here, I feel like I’m trapped in a c | You are working as a counselor in a child and family mental health agency. A 14-year-old Asian-American male presents with family members who are concerned about the client’s drug use. The family is part of an ethnic population from Southeast Asia who resettled in the United States just under two years ago. The client is fluent in English and interprets for the family. The client goes to a public school specifically designed to improve English proficiency and has, until recently, done well academically. The parents have limited English proficiency (LEP). The parents provide a letter from his school stating the client was suspended after administrators found marijuana and amphetamines in the client’s locker. The client expresses remorse and says he became highly anxious and fearful when the school resource officer became involved. He explains, “Where I come from, the police are not there to protect or help.” The client willingly completes a substance use screening assessment, and the results indicate he is at risk for meeting the diagnostic criteria for substance use disorder. | The client is now attending family therapy with his parents and has made progress. His last four drug screens have been negative, and the client is beginning to show insight into his problem. The parents have improved with limit setting and are learning how to help the client achieve a healthy sense of identity. The parents are becoming better acclimated to the United States and have developed stronger connections within their church and community | According to the transtheoretical, or stages of change (SOC), model, in which stage would you currently classify this client? | Precontemplation | Action | Contemplation | Maintenance | (A): Precontemplation
(B): Action
(C): Contemplation
(D): Maintenance | Action | B | According to the SOC model, the client is in the action stage of change. This model, developed by Miller & Rollnick (2013), outlines the following stages: precontemplation, contemplation, preparation, action, and maintenance. This client has just entered the action stage. The client has been compliant with therapy and reports four negative drug screens. The SOC model is not always linear. The client has just entered the action phase and may regress toward earlier stages or may eventually reach the maintenance stage. Individuals in the precontemplation stage are not considering a change, whereas those in the contemplation stage are beginning to consider making a change. Those in the contemplation stage are still using substances but are weighing the pros and cons of cutting back or abstaining. Individuals in the action stage have a specific behavioral plan and are committed to the process of change. When individuals become more stable in their sobriety, they have reached the maintenance stage. Therefore, the correct answer is (D) | counseling skills and interventions |
132 | Initial Intake: Age: 48 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Divorced Counseling Setting: Acute Inpatient Psychiatric Hospital Type of Counseling: Individual | Sandy wandered into the ER waiting room asking for a police officer. After further conversation, it was clear that Sandy thought she was in a police station and repeatedly called once of the nurses Officer McKinney, as if she knew him.
During the intake, the nurse practitioner mentioned that she was running a temperature, had a rapid heartbeat and breath smelled foul. In addition, her hands were trembling as well as her tongue and lips. Sandy’s behavior was somewhat irritable and erratic. At one point she was seemed to be hallucinating and stated that that she saw rats.
| Sandy was sent to the inpatient psychiatric from the emergency department for symptoms of hallucinations, memory loss, and disorientation.
History:
Sandy currently lives alone and is unemployed. She has a history of alcohol abuse and has been admitted to the hospital before because of this. Sandy has gotten into trouble with the law and has alienated most of her family and friends because of her alcohol use. She currently attends alcoholics anonymous. | null | Which of the following can be ruled out based on the stated symptoms? | Ketoacidosis | Sedative, hypnotic or anxiolytic withdrawal | Alcohol withdrawal | Psychosis | (A): Ketoacidosis
(B): Sedative, hypnotic or anxiolytic withdrawal
(C): Alcohol withdrawal
(D): Psychosis | Ketoacidosis | A | Ketoacidosis is a diabetic complication in which the body over produces ketones and may cause hallucinations. However, one of the symptoms of ketoacidosis is sweet smelling breath. In the intake summary, it is noted that Sandy had foul smelling breath. Sandy may be showing symptoms of alcohol, sedative, hypnotic or anxiolytic withdrawal which can all cause hallucination or disorientation. Sandy may also be showing symptoms of psychosis. Therefore, the correct answer is (C) | intake, assessment, and diagnosis |
133 | Client Age: 19 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Private Practice Type of Counseling: Individual Presenting Problem: Suicidality related to body image Diagnosis: Body Dysmorphic Disorder 300.7 (F45.22), with absent insight/delusional beliefs | Mental Status Exam: The client’s mood is sad and irritable. His speech is pressured when discussing his appearance but is otherwise normal. He is appropriately groomed and wears a beanie covering his ears. He admits to repetitively dissecting his face in the mirror several hours a day. The client offers that he cannot hide his ears with his hair because “it is too thin.” He denies audio/visual hallucinations. The client’s thought content is organized and coherent, but he shows poor insight and delusional thinking about how he and others regard his appearance. The client avoids social settings and reports that sometimes, an entire week goes by where he doesn’t leave the house. He denies suicidality and currently does not have a plan or intent to harm himself or others. Appetite and sleep are fair. The client denies drug use and states he consumes alcohol occasionally. You provide an in-depth suicide assessment, and you and the client work together to create a suicide safety | You are working in private practice and conducting an initial intake session with a 19-year-old male who presents today with his mother. The client was recently admitted to a psychiatric hospital for suicidality and was discharged four days ago. His mother reports that the client tried to commit suicide by overdosing. The client reports feeling increasingly hopeless following a “failed” cosmetic surgery procedure. He explains that he had an otoplasty performed to change the proportion and position of his ears. He states he has always hated his ears and is convinced people are staring and laughing at his “deformity.” His mother reports that she reluctantly consented to the surgery a year and a half ago, despite believing it was unnecessary. The client does not leave the house without wearing a beanie or hoodie. He has completed high school with no interest in attending college. He is unemployed due to shame and embarrassment over his “defective” appearance. Two weeks ago, the hospital psychiatrist changed his medication and placed him on a selective serotonin reuptake inhibitor (SSRI). | The client has been free of suicidal ideation for four weeks now. Psychoeducation has helped him gain insight into BDD. Distance counseling has been effective in decreasing ritualistic behaviors, and you provide face-to-face sessions every other week to help decrease avoidance behaviors. The client has benefited from cognitive-behavioral therapy (CBT). He attended two social events this month and has decreased ritualistic “safety behaviors” once used to prevent a feared consequence. He would like to take two college courses in the fall and is nearing the termination stage of therapy | Which one of the following would qualify as the client’s ritualistic safety behaviors? | Wearing a beanie or hoodie while away from home | Agreeing to contact the counselor if he experiences suicidal ideations | Identifying core beliefs that contribute to anxiety in social situations | Complying with his selective serotonin reuptake inhibitor (SSRI) medication | (A): Wearing a beanie or hoodie while away from home
(B): Agreeing to contact the counselor if he experiences suicidal ideations
(C): Identifying core beliefs that contribute to anxiety in social situations
(D): Complying with his selective serotonin reuptake inhibitor (SSRI) medication | Wearing a beanie or hoodie while away from home | A | Wearing a beanie or hoodie while away from home is a safety behavior. Safety behaviors are used to prevent, diminish, or escape what is perceived as a feared catastrophe. Like other avoidance behaviors, safety behaviors create a positive feedback loop that reinforces anxiety due to cognitive misattributions of safety. Complying with his SSRI medication is not considered to be a safety behavior. Unlike fast-acting medications such as benzodiazepines, SSRIs do not provide immediate onset. Carrying a fast-acting medication such as a benzodiazepine would qualify as a safety behavior. Agreeing to contact the counselor if he is experiencing suicidal ideation is not classified as a ritualistic safety behavior. Core beliefs, which are generally long held, rigid, and pervasive, contribute to the client’s anxiety rather than ensuring safety. Therefore, the correct answer is (B) | intake, assessment, and diagnosis |
134 | Name: Logan Clinical Issues: Bullying Diagnostic Category: V-codes Provisional Diagnosis: Z60.4 Social Exclusion or Rejection Age: 11 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Not Assessed Ethnicity: Asian American Marital Status: Not Applicable Modality: Individual Therapy Location of Therapy : School | The client is wearing clean clothes appropriate to his age. Initially hesitant and withdrawn, he becomes more relaxed and responsive as the interview progresses. He is soft-spoken but articulates clearly. Mood is depressed, anxious, and irritable. Affect is euthymic with occasional sadness. Thought process is logical, goal-directed, and organized. No evidence of any cognitive deficits. Good insight into the impact the bullying has on his emotional well-being and his ability to make appropriate decisions is intact. No suicidal ideation was reported. | First session You are a school counselor seeing an 11-year-old male named Logan. He presents to your office with his mother. His mother reports that her son has been struggling in school and has been the target of bullying. She tells you that he recently started at a new school after their neighborhood was re-zoned. The bullying started a few weeks ago when he was sitting alone in class during lunch. A group of boys, whom Logan had never seen before, sat beside him and began teasing him about his clothes, shoes, and hair. When Logan tried to ignore them, they started calling him names. He went home that day feeling embarrassed and alone. Since then, the boys have devised new ways to make fun of Logan. They sneak behind him in the hallways, push him around when the teacher is not looking, and push him into the bathroom. Logan has been refusing to go to school, saying he has stomach aches. His mother says, "He used to love school. He even loved doing his homework. How many parents are lucky enough to have a child who likes doing homework?" When questioned, Logan says that he now hates school and wants to be home-schooled. He says he is being bullied throughout the day, and it does not stop until he leaves the bus. Logan's mother has been worried about him and wants to know how to stop the bullying. At first, she thought it was just "kids being kids" when they tease each other, but she is now concerned that it has gone too far. She also asks if you can help him to make friends in his new school. During today's session, you notice that Logan appears anxious and withdrawn. As you gently probe further, Logan shares that he feels overwhelmed by the constant bullying, which has begun to affect his self-esteem. You observe that he appears hesitant to discuss the specifics of his experiences, suggesting that he may fear rejection by you or be embarrassed by what was done to him. This indicates that the situation has caused significant distress and has started to erode his resilience. As you explore Logan's support network, he hesitantly reveals that he has been unable to make new friends since starting at the new school. The fear of being targeted by bullies has made it challenging for him to approach other students or engage in extracurricular activities. Consequently, Logan feels increasingly isolated and struggles to see a way out of his current situation. This lack of social connection exacerbates his feelings of loneliness and despair. As part of his treatment plan, you include developing and maintaining positive relationships with peers to work on his tendency to isolate himself. Toward the end of the session, Logan's mother inquires about possible strategies to address the bullying. You acknowledge her concerns and emphasize the importance of a collaborative approach involving the school, family, and community. You suggest initiating communication with Logan's teachers and school administrators to create a safe and supportive environment for him. Additionally, you recommend Logan's mother encourage her son's interests and hobbies outside of school to help him build self-esteem and form new friendships. Meanwhile, you will continue to work with Logan on developing coping strategies and strengthening his emotional resilience in future sessions. | The client has a large supportive family. The extended family often gathers together for Sunday dinners. The client says that he has fun playing games with his cousins. The client's mother states that their family is very close, and she and her husband make a concerted effort to prioritize shared time with the extended family. | What is the best response to Logan's mother's request for you to help him make friends at school? | Reassure her that you will talk to his teachers to encourage positive interactions at school | Provide empathy and understanding | Assign him a mentor to help him make social connections | Discuss your role as a school therapist | (A): Reassure her that you will talk to his teachers to encourage positive interactions at school
(B): Provide empathy and understanding
(C): Assign him a mentor to help him make social connections
(D): Discuss your role as a school therapist | Discuss your role as a school therapist | D | As a school therapist, it is important to emphasize that you are not in a position to help Logan directly make friends at the new school. However, you can provide him with skills and strategies that will help him better manage his emotions, build self-confidence, and develop social interaction skills that may help him find other students who have similar interests and who he can connect with. Additionally, you can provide Logan's mother with resources and guidance to help her facilitate social connections for her son in the new school. Together, you can work on developing an action plan that will give Logan the tools he needs to be successful at his new school. Therefore, the correct answer is (C) | professional practice and ethics |
135 | Client Age: 27 Sex: Female Gender: Female Sexual Orientation: Heterosexual Ethnicity: Caucasian Relationship Status: Married Counseling Setting: Career Counseling Center Type of Counseling: Individual Presenting Problem: Employment-related Stress; Anxiety Diagnosis: Adjustment Disorder with Anxiety 309.24 (F43.22) | Mental Status: The client was well-groomed and dressed appropriately. She appears nervous and jittery and quickly places her hands under the table when she notices them shaking. The client states that she is not sleeping well and says it is difficult making it to work each day knowing that “things rarely go as planned.” She explains that she has irritable bowel syndrome, which is exacerbated by stress. The client reports that there are no known medical conditions that would cause her chronic headaches. The client denies homicidal or suicidal ideations but remarks that she has felt like this in the past. Wor | You work in a career counseling center, and your intake is a 27-year-old white female employed as a fourth-grade elementary schoolteacher. The client has been a teacher for 3.5 years and has become increasingly dissatisfied with her job. The client explains that she is “at her breaking point” and relays that her stress level has increased sharply within the past 3 months. This is her first school year with a newly hired principal who has been “unreasonably demanding and unsupportive.” The client states that she was already second-guessing her career choice and explains that disruptive students and a lack of parental involvement have made teaching incredibly challenging. She reports “stress-induced physical symptoms,” which include acute stomach distress and chronic headaches. She worries that her skill set is nontransferable. | The client reports that she and her husband have separated and she is now living with her parents. She is tearful and says that the past few days have been challenging. She reports an increase in headaches and stomachaches. The client has interviewed for a teaching position at a private school but doesn’t think she can afford a pay cut. Nevertheless, the client continues to be motivated to continue with counseling and believes that she will find a good career fit, but it may take some time. You discuss using a cognitive information processing approach with the client, and she is receptive. You explain that this approach will enable you to examine the communication, analysis, synthesis, valuing, and execution (CASVE) cycle of career decision-making skills. The client is prioritizing career options and assessing how her choices might impact her community, her significant relationships, and herself | The client is prioritizing career options and assessing how her choices might impact her community, her significant relationships, and herself. The client is in which of the following CASVE decision-making phases? | Synthesis | Communication | Valuing | Analysis | (A): Synthesis
(B): Communication
(C): Valuing
(D): Analysis | Valuing | C | The client is in the valuing phase of the CASVE decision-making model. The CASVE decision-making model uses a cognitive information processing approach (CIP) based on Frank Parsons’ three-factor model. When individuals are in the valuing phase, they prioritize career options and construct a cost-benefit analysis of how a new career path fits into their values. The CASVE phases are communication, analysis, synthesis, valuing, and execution. In the communication phase, a career concern is identified by examining the gap between where one sees themselves and where one would like to be. In the analysis phase, there is an acknowledgment of a career problem and an investigation into how the problem can be resolved. This generally includes obtaining an understanding of oneself and one’s viable career options. The synthesis phase involves elaborating on potential solutions and identifying areas consistent with one’s values, abilities, interests, and knowledge. The execution phase is where one determines an action plan. Therefore, the correct answer is (A) | counseling skills and interventions |
136 | Initial Intake: Age: 9 Gender: Female Sexual Orientation: Heterosexual Race/Ethnicity: Caucasian/Non-Hispanic Relationship Status: Single Counseling Setting: Private Practice Type of Counseling: Individual | Lottie presents as excited, over-stimulated and hyperactive, unable to sit still and does not take breaks from talking. Her appearance is highly disheveled with stained clothes and unbrushed hair. Lottie nervously walks around your office touching and commenting on everything. You ask her nicely to ask you before she touches your things, but she refuses and continues to do so. Lottie deflects from every question posed in your assessment. She denies SI/HI, hallucination, or delusion, which you were surprisingly able to find out from her. |
Diagnosis: Attention Deficit Hyperactivity Disorder, predominantly hyperactive type (F90.1), Oppositional defiant disorder (F91.3), Reaction to severe stress (F43.9)
Lottie is a 9-year-old girl in the fourth grade who has been referred to you by officials in her elementary school. You are a counseling intern of a private practice that specializes in adult personality disorders, but your supervisor accepted Lottie as a new client because Lottie’s mother is a former client of her agency, and she requested her daughter be seen by your practice as opposed to a school-based counselor. Lottie’s mother does not want Lottie’s peers to know she is in therapy. Lottie has been doing well in school academically but has not been able to behave appropriately for years, according to the referral report. Lottie bounces up and down in her chair constantly, makes impulsive noises throughout the day, and engages in inappropriate behaviors daily. Some of the behaviors listed include invading the personal space of her peers, licking and eating school supplies to garner reactions from fellow classmates, hiding on the playground and refusing to emerge, and many other behaviors. Lottie follows basic classroom directions but needs constant reminding or guiding that the teacher does not have time for. Lottie breaks down into hysterical emotional fits when she does not get her way and her behaviors have been spreading the school staff too thin to be capable of managing without intervention. This session is conducted with only Lottie in the room; her mother insists on waiting in the car outside so she can make some phone calls. She mentions her Medicaid has just been reactivated to pay for sessions. | Family History:
Lottie lives at home with her mother and mother’s boyfriend, as well as their 1-year-old son Davie who is her half-brother. You learned from speaking with her mother beforehand that Lottie’s biological father was a drug addict and homeless, and he was recently shot and killed, about four months ago. Lottie knows and understands what happened. During the intake session you ask her to draw a picture of something important to her. She likes this assignment and draws you a picture of her father’s homeless camp where she last saw him. She explains to you the details surrounding his murder and mature, intimate details of her mother’s broken relationship with him. “How do you know all of this, Lottie?” you ask her, concerned. “Oh, my mother told me. She tells me everything.” | What are the three types of patterns identifiable as ODD criteria? | angry mood, aggressiveness, criminal behavior | irritable mood, argumentative behavior, vindictiveness | depression, disagreeableness, defensiveness | sensitive, resentfulness, lawlessness | (A): angry mood, aggressiveness, criminal behavior
(B): irritable mood, argumentative behavior, vindictiveness
(C): depression, disagreeableness, defensiveness
(D): sensitive, resentfulness, lawlessness | irritable mood, argumentative behavior, vindictiveness | B | According to the DSM-5, ODD is characterized by a pattern of angry or irritable mood, argumentative or defiant behavior, or vindictiveness lasting at least six months as evidenced by at least four symptoms from any of these categories. Therefore, the correct answer is (B) | intake, assessment, and diagnosis |
137 | Initial Intake: Age: 16 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: African American Relationship Status: Single Counseling Setting: Community Health Type of Counseling: Individual | The client appears older than his stated age, with weight appropriate for height. He demonstrates positive signs of self-care in his hygiene and dress. He appears to be open and cooperative, with some hesitancy noted in his speech pattern, due to age or possible alcohol use. The client endorsed several positive responses to alcohol dependence but states he has not used alcohol prior to this session. He states he does not take any medication. He identifies his mood as ambivalent and his affect is congruent with little lability. His responses to questions demonstrate appropriate insight, judgement, memory, concentration, and orientation. He does state that he has never considered harming himself, but acknowledges passive ideas such as, “what’s the point,” he would be “better off dead,” or he should “drink a lot of wine and go to sleep.” He acknowledges these as previously unrecognized suicidal ideations and states he does not have a wish or plan to follow through or harm himself. | You are a counselor in a private practice setting. Your client is a 68-year old male who presents with difficulties stemming from his role as a caregiver to his wife of 26 years and who now has Parkinson’s disease and requires his full attention. He tells you that he has been providing care for the past 40 years, first for his parents and now for his wife. The client endorses feelings of sadness, anger, guilt, irritability, and being overwhelmed. He states that he has difficulty concentrating, anxious, losing things, and having unwanted thoughts like that he might be better off dead. He tells you also that he has difficulty sleeping and can’t enjoy any hobbies or social activities because of caring for his spouse. The client states that he distracted himself from his negative feelings last year by preparing for the move to their new home and then getting settled in. The client and his wife moved into an assisted living facility, but live in independent housing. The client endorsed a history of alcohol use that includes drinking more than he intends, feeling the need to cut down, being preoccupied with drinking, and using alcohol to relieve emotional pain. He states he drinks one to two bottles of wine daily and has done so for the past 6 years. He acknowledges that he has not admitted the extent of his alcohol use to others and works diligently to hide it. He reports he is unwilling to attend AA or other alcohol support groups, but “lurks” on an online support group for alcoholics. The client tells you that he attended counseling twice: 15 years ago, related to depression about his wife’s diagnosis and 10 years ago related to depression and anxiety related to caregiving. On both occasions, he was prescribed antidepressants but said he refused to fill the prescriptions because he doesn’t like to take medicine. | Family History:
The client describes his family history as containing a significant number of family members who use alcohol in great quantities and multiple, maternal, close relatives diagnosed with schizophrenia. Client states that two of his aunts have male children with schizophrenia and that one of these aunts has been diagnosed with Bipolar I disorder. The client’s father was diagnosed with Parkinson’s disease and was in an assisted living facility prior to his death while the client’s mother remained in their family home. The client was the main caregiver for both of his parents until their deaths. The client reports two siblings, one with an alcohol and drug use history who is a paraplegic following a motorcycle accident and one who identifies as “gay” with a history of alcohol dependence and hospitalizations for “nerves.” | Which of the following circumstances is most likely to negatively impact the counselor's work with this client? | All of the above | The client continues to refuse medication for depression | The counselor is in recovery from their own substance history | The counselor seeks weekly supervision related to treating this client | (A): All of the above
(B): The client continues to refuse medication for depression
(C): The counselor is in recovery from their own substance history
(D): The counselor seeks weekly supervision related to treating this client | The counselor is in recovery from their own substance history | C | Counselors who have their own history of substance use and recovery are often good addictions counselors, but it is also true that to some degree, all counselors have personal issues that influence their work with clients. It is possible that counselors with a history of recovery may be influenced by and may impose their personal recovery experiences and beliefs on their client. Supervision would be a helpful practice to avoid this potentially negative influence on the counselor's work with the client. The client's refusal to use medication for depression must be honored by the counselor under one of the ethical principles of counseling, autonomy. A client's determination to be autonomous should not impact the counselor's work with the client as the counselor should collaborate with the client to find ways to support his decision. Finally, b and c are not negative impacts so choice d is not correct. Therefore, the correct answer is (A) | intake, assessment, and diagnosis |
138 | Initial Intake: Age: 16 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: African American Relationship Status: Single Counseling Setting: Community Health Type of Counseling: Individual | The client presents as a thin young woman, whose weight is appropriate for her age. Her clothing is appropriate for her age and to the situation. She identifies her mood as happy and her affect is congruent. The client shows some retardation in movement but no spasticity or physical or abnormal movements. The client appears open and honest in her responses, though responses are short. She responds to closed questions without pause but appears to struggle to answer open-ended questions as evidenced by staring and smiling without speaking or saying “I don’t know.” On examination, the client shows little insight into her mother’s concerns and uses childlike judgement when responding to hypothetical questions. The client denies suicidal or homicidal ideations or intent, delusions, or hallucinations, but does admit to playing a game with children at her maternal grandmother’s house where they attempt to see ghosts in the bathroom mirror. | You are a counselor in a community health setting which includes in-office sessions as well as home visits. Your client is a 16 year-old female who presents with a history of academic difficulties, problems following rules at home, and fighting with her sister, which recently included threatening to cut her sister with a kitchen knife. Her mother tells you that the client has always had some problems in school but they are getting worse. Her teachers say that she doesn’t pay attention and struggles with simple concepts, but is always polite and friendly to others. When asked to tell you how she thinks things are going, she answers “good” and smiles. You notice that she often smiles while her mother is talking but when her mother talks about the problems at home, the client looks away from both of you and stares out the window. The client’s mother reports that the client does not clean her room, has to be told to attend to her hygiene, and does not complete chores when they are assigned, such as cleaning out the refrigerator or vacuuming the living room. Mother reports that the client stays at home alone or with her two younger sisters when her mother or mother’s boyfriend are at work or away from home during the day. | Family History:
The client is the oldest of three children born to her mother. Her siblings have different fathers and her youngest sister’s father currently lives in the home and is identified as “mom’s boyfriend” or “Robert.” Client’s mother reports no family history of mental health disorder or substance abuse. The client reports that she often spends several nights a week with her grandmother “to give Mom a break” and plays games and spends time with the neighborhood children. The client states that her grandmother “makes me sit and she reads the Bible to me” for several hours each day. She reports that she likes spending time at her grandmother’s house because she and her sister watch “scary movies” including movies about monsters, murders, and witchcraft. | Using the information provided, which of the following steps should be taken first? | Setting up initial boundaries for client and her behavior at home. | Working with mother to determine if client should stay with grandmother. | Asking client and mother if they are willing to work together to help client. | Discussing mother's thoughts and feelings about services and home visits. | (A): Setting up initial boundaries for client and her behavior at home.
(B): Working with mother to determine if client should stay with grandmother.
(C): Asking client and mother if they are willing to work together to help client.
(D): Discussing mother's thoughts and feelings about services and home visits. | Discussing mother's thoughts and feelings about services and home visits. | D | Addressing the parent's thoughts and feelings about needing or choosing to access services, which includes home visits, is critical to building a therapeutic relationship with both client and her parent. Depending on the mother's cultural history and beliefs, having a stranger in the home, who is acting as an authority figure, may feel demeaning, intrusive, or frightening. Building the therapeutic relationship with the client's mother is equally as important as building it with the client. Asking the client and mother if they are willing to work together may be received as a judgment that mother has not been working for her child up to this point and may be perceived as insulting. Setting up initial boundaries for the client and determining whether the client should stay with her maternal grandmother are choices made by the client's mother and the relationship may be too fragile at this first meeting for the counselor to begin making suggestions for changes for parenting. Therefore, the correct answer is (B) | counseling skills and interventions |
139 | Initial Intake: Age: 16 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: African American Relationship Status: Single Counseling Setting: Community Health Type of Counseling: Individual | The client presents as a thin young woman, whose weight is appropriate for her age. Her clothing is appropriate for her age and to the situation. She identifies her mood as happy and her affect is congruent. The client shows some retardation in movement but no spasticity or physical or abnormal movements. The client appears open and honest in her responses, though responses are short. She responds to closed questions without pause but appears to struggle to answer open-ended questions as evidenced by staring and smiling without speaking or saying “I don’t know.” On examination, the client shows little insight into her mother’s concerns and uses childlike judgement when responding to hypothetical questions. The client denies suicidal or homicidal ideations or intent, delusions, or hallucinations, but does admit to playing a game with children at her maternal grandmother’s house where they attempt to see ghosts in the bathroom mirror. | You are a counselor in a community health setting which includes in-office sessions as well as home visits. Your client is a 16 year-old female who presents with a history of academic difficulties, problems following rules at home, and fighting with her sister, which recently included threatening to cut her sister with a kitchen knife. Her mother tells you that the client has always had some problems in school but they are getting worse. Her teachers say that she doesn’t pay attention and struggles with simple concepts, but is always polite and friendly to others. When asked to tell you how she thinks things are going, she answers “good” and smiles. You notice that she often smiles while her mother is talking but when her mother talks about the problems at home, the client looks away from both of you and stares out the window. The client’s mother reports that the client does not clean her room, has to be told to attend to her hygiene, and does not complete chores when they are assigned, such as cleaning out the refrigerator or vacuuming the living room. Mother reports that the client stays at home alone or with her two younger sisters when her mother or mother’s boyfriend are at work or away from home during the day. | Family History:
The client is the oldest of three children born to her mother. Her siblings have different fathers and her youngest sister’s father currently lives in the home and is identified as “mom’s boyfriend” or “Robert.” Client’s mother reports no family history of mental health disorder or substance abuse. The client reports that she often spends several nights a week with her grandmother “to give Mom a break” and plays games and spends time with the neighborhood children. The client states that her grandmother “makes me sit and she reads the Bible to me” for several hours each day. She reports that she likes spending time at her grandmother’s house because she and her sister watch “scary movies” including movies about monsters, murders, and witchcraft. | Given the information provided, which diagnosis is most likely to be accurate for this client? | Schizoaffective Disorder | Autism Spectrum Disorder | Bipolar I Disorder | Major Depressive Disorder | (A): Schizoaffective Disorder
(B): Autism Spectrum Disorder
(C): Bipolar I Disorder
(D): Major Depressive Disorder | Schizoaffective Disorder | A | The client is diagnosed with Schizoaffective Disorder. She meets criteria for a major depressive disorder including sadness, loss of appetite, fatigue, irritability, and psychomotor retardation over the past two weeks. Concurrently, the client has been experiencing delusions and hallucinations for over one year during times when she is and is not experiencing a depressive episode. Thus, she meets the criteria for the disorder. While the client is experiencing a major depressive episode, it is within the context of and better explained by the Schizoaffective diagnosis. The client exhibits no deficits in communication that are not explained through her IQ scores and does not demonstrate restricted or repetitive patterns so she does not qualify for an Autism Spectrum disorder. The client does not show symptoms of Bipolar I disorder as she has not experienced manic episodes, including pressured speech, psychomotor agitation, racing thoughts, or high-risk activities. Therefore, the correct answer is (C) | treatment planning |
140 | Initial Intake: Age: 4 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: African American Relationship Status: Single Counseling Setting: Community Clinic Type of Counseling: Individual | Destiny was engaging with the counselor throughout the interview although her affect was flat. She played by herself while the counselor spoke to Darlene and Tony. She did not look up at her parents or engage with them during the entire session. | Destiny is a 4-year-old who was referred for therapy by her preschool teacher. Destiny arrived at the intake session with her adoptive parents, Darlene and Tony Mase. Darlene and Tony shared that they were concerned about Destiny because she never wants to interact with other children, rarely smiles or laughs, and has mood fluctuations with little or no pattern or trigger. Reactions include irritability, sadness, and tearfulness.
History:
Destiny arrived at the Mases’ when she was two years old and was nonverbal at the time. Destiny also showed cognitive delays in her early intervention screening. Darlene and Tony noticed Destiny’s lack of interest in playing with other children when Destiny arrived and she did not want to interact with the other children in the home. The irritability and mood fluctuations began over a year ago. Darlene and Tony were hopeful that once Destiny started preschool that she would start interacting with others, however this is not the case. | null | To further explore relationships, the counselor should use the following technique? | Ask the child to write a story | Ask the caregiver to ask the child why she doesn't want to live with them anymore | Ask the child numerous questions about the quality of her relationship with caregivers | Explore the child's memories of their caregivers through role-play with puppets | (A): Ask the child to write a story
(B): Ask the caregiver to ask the child why she doesn't want to live with them anymore
(C): Ask the child numerous questions about the quality of her relationship with caregivers
(D): Explore the child's memories of their caregivers through role-play with puppets | Explore the child's memories of their caregivers through role-play with puppets | D | The best way at this point to explore the relationships Destiny has with others is by the counselor exploring Destiny's memories. This can be done through play, such as using puppets. Feelings may come out organically as opposed to through direct questions. Asking numerous questions may cause Destiny to shut down. Looking at the child's age, as well as their past trauma, Destiny may not comprehend, let alone verbalize her feelings about living with her foster parents. Additionally, she may not want to be asked this question by Ms Maze. Having the child write a story may be too difficult for Destiny at such a young age. Therefore, the correct answer is (A) | intake, assessment, and diagnosis |
141 | Client Age: 12 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Private Practice Type of Counseling: Individual Counseling Presenting Problem: Withdrawn and Avoidant Behavior Diagnosis: Undetermined | Mental Status Exam: The client appears oriented to person, place, time, and situation. The client is dressed appropriately for the weather and appears to be maintaining appropriate hygiene. The client was withdrawn for most of the session but was able to open up slightly about what was going on with | You are a licensed therapist working in private practice. A 12-year-old female client comes into your office for the intake session and is accompanied by her parents. The client’s parents report that their daughter has been withdrawn and has refused to return to school for the past 6 school days. The client is avoiding eye contact with anyone and is slouching with her arms crossed. You try to engage the client in open questions to initiate the intake session with her, and she does not answer you or look at you. You ask her if privacy would make her more comfortable, and she nods, so you ask her parents if they would mind waiting in the lobby, and they agree. The client continues to refuse to talk about school, but she does engage in conversation with you about other topics. | The client reports that a worker from the local child protective services office met with her and that she is worried about what the coach will do in response when he finds out that she reported him. The client says that she has not returned to school but that the school has provided the classwork and homework needed to keep up; she feels like the school is supporting her well enough to not fall behind. The client confirms that all of the symptoms that she described during her last session are still present | If you are having trouble empathizing with a client, what would be the most beneficial tactic to understanding the client experience? | Research more about experiences that you do not relate to in order to try to understand the client’s experience. | Be open with the client in that you do not understand what it was like for her to experience these circumstances. | Accept that you cannot empathize with every client experience and that is fine. | Try to relate to the core feelings associated with the client’s experience. | (A): Research more about experiences that you do not relate to in order to try to understand the client’s experience.
(B): Be open with the client in that you do not understand what it was like for her to experience these circumstances.
(C): Accept that you cannot empathize with every client experience and that is fine.
(D): Try to relate to the core feelings associated with the client’s experience. | Try to relate to the core feelings associated with the client’s experience. | D | Although you will not always have shared life experiences with clients, you can try to understand the core feelings related to their experiences. Although you may have never experienced sexual assault, most people can understand the feelings of fear, violation, and possibly shame. Even though you cannot understand every client’s experience the way the client does, you can still provide empathetic statements to the client based on your own experiences of those core feelings. Being open about your inexperience with the client situation can be helpful, but it does not promote an empathetic response. Research may provide more insight, but it would not help during this immediate session in terms of understanding the client’s experience. Therefore, the correct answer is (B) | counseling skills and interventions |
142 | Client Age: 19 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Private Practice Type of Counseling: Individual Presenting Problem: Suicidality related to body image Diagnosis: Body Dysmorphic Disorder 300.7 (F45.22), with absent insight/delusional beliefs | Mental Status Exam: The client’s mood is sad and irritable. His speech is pressured when discussing his appearance but is otherwise normal. He is appropriately groomed and wears a beanie covering his ears. He admits to repetitively dissecting his face in the mirror several hours a day. The client offers that he cannot hide his ears with his hair because “it is too thin.” He denies audio/visual hallucinations. The client’s thought content is organized and coherent, but he shows poor insight and delusional thinking about how he and others regard his appearance. The client avoids social settings and reports that sometimes, an entire week goes by where he doesn’t leave the house. He denies suicidality and currently does not have a plan or intent to harm himself or others. Appetite and sleep are fair. The client denies drug use and states he consumes alcohol occasionally. You provide an in-depth suicide assessment, and you and the client work together to create a suicide safety | You are working in private practice and conducting an initial intake session with a 19-year-old male who presents today with his mother. The client was recently admitted to a psychiatric hospital for suicidality and was discharged four days ago. His mother reports that the client tried to commit suicide by overdosing. The client reports feeling increasingly hopeless following a “failed” cosmetic surgery procedure. He explains that he had an otoplasty performed to change the proportion and position of his ears. He states he has always hated his ears and is convinced people are staring and laughing at his “deformity.” His mother reports that she reluctantly consented to the surgery a year and a half ago, despite believing it was unnecessary. The client does not leave the house without wearing a beanie or hoodie. He has completed high school with no interest in attending college. He is unemployed due to shame and embarrassment over his “defective” appearance. Two weeks ago, the hospital psychiatrist changed his medication and placed him on a selective serotonin reuptake inhibitor (SSRI). | The client has been free of suicidal ideation for four weeks now. Psychoeducation has helped him gain insight into BDD. Distance counseling has been effective in decreasing ritualistic behaviors, and you provide face-to-face sessions every other week to help decrease avoidance behaviors. The client has benefited from cognitive-behavioral therapy (CBT). He attended two social events this month and has decreased ritualistic “safety behaviors” once used to prevent a feared consequence. He would like to take two college courses in the fall and is nearing the termination stage of therapy. During a CBT exercise, you discover that the client believes his “defective” appearance makes him unworthy of love | During a CBT exercise, you discover that the client believes his “defective” appearance makes him unworthy of love. This is an example of which of the following? | Automatic thought | Core belief | Intermediate belief | Hot thought | (A): Automatic thought
(B): Core belief
(C): Intermediate belief
(D): Hot thought | Core belief | B | This is an example of a core belief. Core beliefs are generally long-held, rigid, and pervasive beliefs that are often formed in childhood. The client equates his external attributes, which are distorted perceptions, with being unworthy or unloved. Cognitive restructuring is one mode of CBT used to address core beliefs. Intermediate beliefs occur between automatic thoughts and core beliefs. When an automatic thought (ie, an immediate internal reaction) is generated, there is an intermediate process involving conditions and rules. For example, “If my appearance were not defective, I would be successful and worthy” Intermediate thoughts categorize these assumptions and are driven by core beliefs. Automatic thoughts are immediate, knee-jerk reactions to events or situations. Not all automatic thoughts are negative. It is the unhelpful automatic thoughts that counselors must help clients identify when using cognitive restructuring and other CBT techniques. Hot thoughts are automatic thoughts that happen along with an emotional change. Therefore, the correct answer is (C) | counseling skills and interventions |
143 | Age: 9 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Private practice Type of Counseling: Individual counseling Presenting Problem: The client has been engaging in behavior that has gotten him suspended from school several times over the past year, which also causes significant distress for the client’s family at home. Diagnosis: Conduct disorder, childhood-onset type, with limited prosocial emotions, severe (F91.1) | Mental Status Exam: The client was minimally engaged in the session. The client’s behavior was withdrawn, argumentative, and la | You are a professional counselor, and you specialize in working with children and adolescents. The client comes to this session with his parents. You review informed consent with the client and his parents and begin to ask the client about what brings him to counseling. The client responds by saying “shut the hell up” and leaves the room to go to the lobby. The client’s father gets up and follows him out, and after a few minutes they return. The client sits down and faces away from you. The client does not engage in the intake session aside from cursing at his parents when they report specific behavioral incidents and he disagrees with them about the facts of the events. The client’s parents say that he has had “bad behavior” over the past 2 years and that his behavior has “gotten worse” over the past 5 months. The parents outline the following behavioral problems that the client engages in, in all settings: bullying, physical fighting, kicking and throwing items at his dog, intentionally breaking others’ property, lying to others to get items or have access to activities, stealing items from others, truancy, and leaving the house at night without permission or supervision. | You meet with the client alone, and he appears to be more comfortable with you because he comes in and starts talking about a video game that he plays. You share that you have played that video game before. During the session, the client mentions that his parents got his first report card of the year and found out that he was failing most of his classes. He started to say that he was worried that his dad was going to hit him because of his grades. You ask if his father hits him often, and he replies that he does several times a week. You try to inquire about the manner of hitting his father uses because a certain level of corporal punishment is legal in the state that you work in. The client says that he is not going to talk any more about this. You remind the client that you likely will need to report this to child protective services and he says, “I don’t care” in response. You spend the rest of this session processing his relationship with his parents, and he discloses that he does love them, but that they are not his real parents. You meet with the client’s parents near the end of the session, and, while talking with them, they report that he was neglected while in foster care because the foster parent was “just in it for the money.” The client becomes upset at the end of this session after talking about the alleged physical abuse, and he begins to throw toys and any items within arm’s reach | The client becomes upset at the end of this session after talking about the alleged physical abuse, and he begins to throw toys and any items within arm’s reach. Which one of the following would be the LEAST helpful response when considering the client’s current emotional state? | Use an open body posture and a calm voice | Use the 5-4-3-2-1 grounding technique | Attempt to process the client’s present thoughts and emotions | Disengage with the client with regard to the subject at hand | (A): Use an open body posture and a calm voice
(B): Use the 5-4-3-2-1 grounding technique
(C): Attempt to process the client’s present thoughts and emotions
(D): Disengage with the client with regard to the subject at hand | Attempt to process the client’s present thoughts and emotions | C | When the client escalates to using physical aggression, he is likely not able to engage in processing his thoughts and emotions. It may escalate the behavior further if you attempt to have a conversation with the client. Using the 5-4-3-2-1 grounding technique is helpful because it focuses on engaging the senses and it can help the client calm his body down. Using an open body posture and a calm voice supports the client in not feeling threatened. When the client’s level of intensity is not matched, he is more likely to reduce the level of intensity of his emotions to match the counselor’s. It can be assumed that the client’s behavior is an attempt to avoid talking about a difficult topic. In behavior therapy, you would not want to allow the avoidance to occur; however, this might be related to a trauma response because it is about a physical abuse allegation. Therefore, you should strive to be understanding and sensitive about possible trauma. Therefore, the correct answer is (A) | counseling skills and interventions |
144 | Client Age: 13 Sex Assigned at Birth: Male Gender: Transgender; Gender Nonconforming (TGNC) Ethnicity: Caucasian Counseling Setting: Child and Family Agency, School-Based Services Type of Counseling: Individual and Family Presenting Problem: Truancy; Gender Dysphoria Diagnosis: Gender Dysphoria, Provisional (F64.1); Social Exclusion or Rejection V62.4 (Z60.4) | Mental Status Exam: The client is dressed in age-appropriate clothing. They wear eye makeup and chipped black fingernail polish, and they have bitten most fingernails down to the quick. The client’s mood is irritable, and they are quick to show anger toward their mother when misgendered. Their thoughts are coherent, and they deny audio/visual hallucinations. The client acknowledges feeling sad and hopeless but denies suicidal ideation. They attribute increased levels of anxiety at school to bullying, particularly with select peers. They explain that a select group of students threaten the client and call them offensive and derogatory names. Family History and History of th | You are a school-based mental health counselor in a public middle school. Your client is a 13-year-old Caucasian 7th grader who presents for the initial intake with their mother. The mother says that the client has had several unexcused absences from school because “he is confused about his gender.” The client adamantly denies being confused and explains that they self-identify as transgender. The client’s preferred pronouns are “they/them.” The client further states that they have had a strong desire to be a different gender since early childhood, and this desire and their distress have recently intensified. The mother reports that the client is chronically irritable, spends a lot of time alone, and has “basically shut everyone out.”The client reports experiencingbullying—both verbal and physical—in school “nearly every day.” In addition to the bullying, the client says that certain teachers refuse to allow them to use the bathroom aligned with their identified gender. To prevent this conflict, the client does not eat breakfast or lunch at school. | The client arrives for the session without her husband. Her affect is flat, and she presents as more subdued. The client explains that she has been in bed for the last 4 days, which has caused escalated conflict and tension with her husband. She says that her husband believes that they are at an impasse and threatened to leave during their fight last night. When processing the details of their altercation, the client states that her fear of being alone has become unbearable. She denies any suicidal plans but says she feels hopeless and void of purpose and is in significant levels of physical pain due to intractable migraines. You conduct a suicide risk assessment to determine the client’s level of safety | The National Action Alliance for Suicide Prevention (2018) evidence-based standard care for people with suicide risk includes all of the following elements EXCEPT: | Supervision | Caring contacts | Safety planning | Means reduction | (A): Supervision
(B): Caring contacts
(C): Safety planning
(D): Means reduction | Supervision | A | The National Action Alliance for Suicide Prevention: Transforming Health Systems Initiative Work Group’sRecommended Standard Care for People with Suicide Risk: Making Health Care Suicide Safe(2018) contains recommendations for treating suicidality. All of the elements (safety planning, means reduction, and caring contacts) except supervision are included in the recommended standard care. EBPs for outpatient behavioral health include conducting a safety plan intervention during sessions when the concern for suicide risk is high. Safety planning includes frequently assessing suicidal risk and updating the safety plan during each visit until the risk subsides. Means reduction involves assessing for lethal means and arranging for their removal or reduction. Caring contacts is another evidence-based standard and practice. Caring contacts are staff members or other individuals who provide brief support to clients during high-risk periods, such as transitioning from hospitalization to a lower level of care or for missed appointments. Contacts are made via phone, texts, or letters to help prevent isolation and reduce the risk for suicide. Therefore, the correct answer is (C) | professional practice and ethics |
145 | Client Age: Husband, 38; wife, 37 Sex: Husband,male; wife, female Gender: Husband,male; wife, female Sexuality: Husband,heterosexual; wife, bisexual Ethnicity: Caucasian Relationship Status: Married Counseling Setting: Counseling clinic Type of Counseling: Couples counseling Presenting Problem: The couple is experiencing distress because the wife has had a sexual affair with a woman. Diagnosis: Adjustment disorder, unspecified (F43.20) and relationship distress with spouse or intimate partner (Z63.0) | Mental Status Exam: The couple presents as withdrawn at the start of the session, but they open up as they talk about lighter subjects. Both individuals are oriented to person, place, time, and situa | You are a licensed counselor meeting with a couple in your private practice clinic. The couple comes in, and they both sit down at far ends of the couch and do not look at each other. After explaining informed consent and other intake policies, you begin to ask the couple what brought them to counseling, and they both sit silently. You ask the couple if it is hard to start this conversation because of why they came, and they both nod. You ask the couple if it might be easier to start with how they met and why they fell in love with each other, and they both nod in agreement that they can talk about that. The couple appears more comfortable after this and even say a few statements to each other about shared experiences during the conversation. You circle back to the reason why they came to therapy, and the wife says that she assumes that she should talk first. She states that about a week prior she told her husband that she had an affair with a woman a few months before. She continues that, at the time, she was curious and it occurred while she was drunk and insists that it meant nothing. The husband states that he still loves her, but he is not sure how he is going to move past this. He emphasizes that not only did she have an affair, but her action exposed an aspect of her that he did not know about, making him question whether she even finds him attractive. | The couple comes into the session and continues to appear more comfortable with each other. Both individuals report that they have been intentional about spending more quality time with one another. The husband says that his wife made sure that he had time to go fishing with his father last weekend, which meant a lot to him. During the session, you discuss events leading up to the affair and both agree that they have spent the majority of the last few years neglecting their relationship. The wife begins to speak but expresses that she knows she is the one who hurt her husband so she should not explain why it happened. You ask the husband if he wants to know how she is feeling and he nods. The wife explains that she felt he was not interested in her anymore, and although she knows what she did was not okay, she felt validated and cared for by the woman. The husband begins to cry. You continue to support the couple’s exploration of this area of their marriage and provide empathetic listening. The wife states that she felt her husband was not interested in her anymore and refers to this feeling returning when she tried to have sexual intercourse with him, which was not successful | The wife states that she felt her husband was not interested in her anymore and refers to this feeling returning when she tried to have sexual intercourse with him, which was not successful. Which of the following cognitive distortions best describes this thought process? | Emotional reasoning | Jumping to conclusions | “Should” statements/beliefs | Catastrophizing | (A): Emotional reasoning
(B): Jumping to conclusions
(C): “Should” statements/beliefs
(D): Catastrophizing | Jumping to conclusions | B | By assuming that her husband is not interested in her based on a failed attempt at a sexual interaction, the wife is jumping to conclusions in making a generalization based on a single situation. Catastrophizing is when a situation is blown out of proportion based on what occurred, and a conclusion is anticipated to be the worst possible outcome. Emotional reasoning is when an individual feels a certain way and assumes that their feelings are solely emotional and without rational justification. “Should” statements involve assuming that things should be a certain way and, when they are not, feeling a sense of distress. Therefore, the correct answer is (B) | counseling skills and interventions |
146 | Initial Intake: Age: 43 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Married Counseling Setting: Private Practice Type of Counseling: Individual | The client presents appropriately dressed in a long-sleeved t-shirt and jeans and is well-groomed. Her weight appears appropriate to height and frame. Her movements and speech demonstrate no retardation and she is cooperative and engaged. The client reports her mood as anxious, however you note her to be relaxed in speech and appearance. She reports no recent suicidal ideations and demonstrates no evidence of hallucinations or delusions. The client reports that she is in good health and takes no medication except birth control. She reports she has difficulty falling asleep at night because she worries whether her husband finds her attractive. She states she also frequently worries about the children or situations that have happened during the day, but is often able to dismiss these after a few minutes. | You are a counselor in a private practice setting. During the intake session, you learn that your client has been married for 15 years and has four children and is currently struggling with her marital relationship. She states her husband does not want to attend counseling with her. Your client complains of occasional feelings of unhappiness, irritation, difficulty sleeping, as well as worrying. These have been present for the past 8 to 10 months, with the worry being almost daily. She states she feels alone in the marriage because her husband is an introvert and is often too tired after work to engage emotionally with her. She views the marriage as “good” and they engage in sex at least 5 times per week, where she is often the initiator. She reports that she repeatedly asks her husband and best friend to reassure her that she is still attractive. She tells you that her best friend is encouraging, but her husband tells her he is tired of her constant, daily questioning and says she must be in a midlife crisis. She confides that her husband frequently looks at pornography and sometimes they watch pornographic movies together prior to sex. | Family History:
Approximately 6 years ago, the client’s family doctor prescribed a short course of Valium, while she and her husband were building their house. She also was diagnosed with postpartum depression after her first child was born. She reports she did not seek counseling at the time but her obstetrician prescribed antidepressants, which she took for 10 months with good results. Her doctor then prescribed the same antidepressants for 12 months as a preventative against postpartum depression prior to each of her subsequent births. | Considering the client's likely diagnosis, which of the following assessment instruments should be used when planning treatment? | Columbia Suicide Severity Rating Scale (C-SSRS) | Minnesota-Multiphasic Personality Inventory-2 (MMPI-2) | Beck Depression Inventory-II (BDI-II) | Beck Anxiety Inventory (BAI) | (A): Columbia Suicide Severity Rating Scale (C-SSRS)
(B): Minnesota-Multiphasic Personality Inventory-2 (MMPI-2)
(C): Beck Depression Inventory-II (BDI-II)
(D): Beck Anxiety Inventory (BAI) | Columbia Suicide Severity Rating Scale (C-SSRS) | A | Adults with body dysmorphic disorder exhibit high rates of suicidal ideation and suicidal attempts, and a large proportion of suicidal ideation has been attributed to concerns about appearance. There is little clinical evidence of depression in this client, however the BAI may be useful for evaluation of therapy not for planning. The MMPI-2 provides assessment of a broad range of diagnostic disorders, not treatment. Therefore, the correct answer is (D) | intake, assessment, and diagnosis |
147 | Client Age: 20 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Asian Relationship Status: Single Counseling Setting: College counseling clinic Type of Counseling: Individual counseling Presenting Problem: Panic attacks Diagnosis: Provisional diagnosis: panic disorder (F41.0) | Mental Status Exam: The client is oriented to person, place, time, and situation. The client does not appear anxious or depressed and was friendly and eng | You are a counselor working in a college counseling department. The client comes in after being late to class several times over the last month due to reported “freak-outs” in the morning. The client experiences the following panic symptoms: accelerated heart rate, sweating, shaking, shortness of breath, and a feeling of impending doom. The client reports a feeling of impending doom when she wakes up on days when she has classes, and this anxiety tends to escalate into fear of having a panic attack on a daily basis, often making her late to her first class. The client is worried that she will have panic attacks every day for the rest of her life. She says that her parents have put a lot of pressure on her to get a high grade point average at college. The client is worried about how this pressure and the panic attacks are going to affect her doing well at college and engaging socially. | aged. Family History: The client reports that she is close with her parents but that they often have high expectations of her and that she worries about disappointing them. The client has an older brother who is 25 and is a lawyer. The client says some of the pressure is wanting to be as successful as her brother because she thinks her parents are really proud of him | Based on Shawn Shea’s model for the clinical interview, which of the following statements is part of closing the intake session? | “It was great meeting with you today! I think we can do some good work together. I’ll walk you out to the lobby.” | “It seems like your panic attacks are unexpected, but there are some things you can do to improve your management of them. I want you to read this literature on coping skills for panic symptoms.” | “Let’s talk about panic disorder so you understand more about what’s happening to you.” | “You’ve made a great choice for yourself by deciding to start therapy. I think that if we make a good plan together, we can improve management of your panic attacks.” | (A): “It was great meeting with you today! I think we can do some good work together. I’ll walk you out to the lobby.”
(B): “It seems like your panic attacks are unexpected, but there are some things you can do to improve your management of them. I want you to read this literature on coping skills for panic symptoms.”
(C): “Let’s talk about panic disorder so you understand more about what’s happening to you.”
(D): “You’ve made a great choice for yourself by deciding to start therapy. I think that if we make a good plan together, we can improve management of your panic attacks.” | “You’ve made a great choice for yourself by deciding to start therapy. I think that if we make a good plan together, we can improve management of your panic attacks.” | D | Validating the client’s choice to be in therapy and instilling hope that you believe that you can improve things are parts of the closing phase of the intake session according to Shea’s model. Stating that you can help is part of closing, but coupling this with recommending interventions is part of the body of the intake session. Providing psychoeducation on the diagnosis is also part of the body of the intake session. The termination phase of the intake session is when you say goodbye to the client for that current session. Therefore, the correct answer is (A) | counseling skills and interventions |
148 | Initial Intake: Age: 26 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Private Practice Type of Counseling: Individual | The client appears his stated age and is dressed appropriately for the circumstances in clean jeans and a t-shirt. He identifies his mood as “anxious but a little excited” because he “is hopeful that he can finally let his anger go.” He tells you he is tired because he has difficulty falling asleep and staying asleep most nights. His affect is pleasant with emotional lability evident. He demonstrates appropriate insight and judgment, memory, and orientation. He reports never “seriously” having considered suicide but acknowledges that there were times when he wondered “if dying would make this pain go away.” He has never attempted suicide and states he would never consider harming himself or anyone else. | You are a counselor in a private practice setting. Your client is a 26-year-old male who presents for counseling at the request of his family and his employer, with whom he is close and who knows his history. The client tells you that he has been angry for the past 15 years, beginning a year after the death of his father from a heart attack. He says that his anger is triggered very quickly when frustrated by people or situations and that his “fuse is very short these days.” He states that he has been in some “loud arguments” with his mother, and later his stepfather. He admits that there have been times in the past when he and his stepfather have “almost come to blows” but his mother stepped in and made them stop. He admits to having hit or kicked walls at times in his anger, but has never hit a person. He tells you that he doesn’t want to feel this way because it interferes with his relationships and his former girlfriends have never understood that when the anniversary of his dad’s death comes around, he just wants to be alone for a couple days and not have to talk to anyone. He tells you that he has never had a long-term relationship with a woman because either he gets “depressed” for a few days during certain times of the year (i.e., father’s birthdate and death date) or because he is too quick to get angry and then says things he doesn’t mean. He says that he has been in a relationship with a woman now for eight months and really wants to get himself together because he feels “she’s the one.” | Family History:
The client reports a family history of being the youngest of three siblings born to his mother and father. He reports a “great life” with his family and that they regularly spent time together playing, camping, traveling, and “just being a family.” He tells you that he is sure there were occasional arguments but that he doesn’t remember anything significant, except that he had been mad at his dad the night he died because his dad wouldn’t let him stay up late, but that before the client went to bed, he had come down, apologized to his dad, and they had both said “I love you.” He states his parents had been married for 15 years prior to his father’s death, which occurred when the client was 11 years old. He states his dad died of a heart attack while sleeping, so while he did not see it, he knew something had happened because his mother woke him and his siblings and rushed them over to the next door neighbors’ house. He said that his mother went to the hospital with his father in the ambulance and came home that night to tell him and his siblings that their father had died. He tells you that he and his siblings are still very close and that they now have three much younger siblings born after his mother married his stepfather. He says that he is very close to his mother and stepfather, although he lives three hours away from them. He tells you that he tries to get home for big family events, like birthdays. He states that his stepfather adopted him and his siblings after the wedding and the client loves him very much. He tells you that he and his stepfather have gotten in what the client thinks are “typical teenager/parent” conflicts but that they have often been made worse by the client’s anger that seems to always be inside and erupts quickly. | Which of the following statements would best help the client understand his sadness and crying? | The effects of trauma can prevent the client from experiencing normal grief. | As the client tries to reduce his anger, his limbic system creates new defense mechanisms. | As the client works on his trauma, he is beginning to showing symptoms of depression. | Trauma is a neurological and emotional reaction and crying is an expected symptom. | (A): The effects of trauma can prevent the client from experiencing normal grief.
(B): As the client tries to reduce his anger, his limbic system creates new defense mechanisms.
(C): As the client works on his trauma, he is beginning to showing symptoms of depression.
(D): Trauma is a neurological and emotional reaction and crying is an expected symptom. | As the client tries to reduce his anger, his limbic system creates new defense mechanisms. | B | The effects of trauma include the development of persistent negative emotional states including fear, guilt, anger, etc, (Criterion D4) and significant alterations in arousal and reactivity, including angry outbursts with little provocation (Criterion E1). As the client's symptoms of PTSD subside, he will be better able to connect with normal emotions of grief and loss. PTSD can be associated with MDD, however, the client has described not feeling sad most days, which is a requirement (Criterion A) for an MDD diagnosis. The limbic system is controlled by hormone release and as the client works through his anger, hormones that control "fight or flight" such as cortisol, will be released less often into the system inducing normal function, rather than creating new defense mechanisms. While crying can certainly be a reaction to trauma, this client has not experienced that reaction and is reporting crying more now that he is beginning to feel better and less angry. These facts suggest that crying is not a symptom of his PTSD and is occurring as a result of working through his trauma. Therefore, the correct answer is (C) | counseling skills and interventions |
149 | Initial Intake: Age: 40 Sex: Female Gender: Female Sexuality: Lesbian Ethnicity: African American Relationship Status: Partnered Counseling Setting: Community Agency Type of Counseling: Individual | The client appears to be slightly older than stated and demonstrates positive signs of self-care in her hygiene and dress. She states her mood fluctuates between “sad and okay.” Her affect is labile and mirrors topics discussed in session. She smiles when describing her children and her relationship with her former oncology team. She cries easily when discussing cancer, moving, instability, and fears. The client is cooperative and forthcoming, with easily understood speech. She offers insight into her thoughts and behaviors, is attentive, and shows no difficulties with memory or judgement. She acknowledges one episode of suicidal ideation, without plan, during her adolescence when she desperately missed her mother while on a custodial visit with her father. She has had no thoughts of harming herself since then and has no thoughts of harming others. | You are a counselor in a community agency. Your client presents with concerns about her lifelong history of being “anxious and emotional” since her parent’s divorce when she was 12. She tells you her feelings of “anxiety and feeling badly about myself” intensified when she was diagnosed with breast cancer four years ago and then again when her family moved to the area last year. She tells you that she thinks she managed her emotions well during her treatment because her focus was on getting through the crisis. She also was taking Klonopin twice a day for anxiety. She says she feels that she has let her family down by having cancer because it costs them monetarily and emotionally; she wonders sometimes if her cancer is a punishment for something she’s done. She reports that she does not discuss these concerns and emotional fears with her partner because “she has become the breadwinner and I feel like I need to protect her from my negativity.” On intake forms, she endorses crying daily, trouble sleeping, concentrating on things, has been losing weight without trying, and constantly worrying about her health and the family’s finances. She tells you that her partner says she “runs around like a chicken with my head cut off because I start stuff like cleaning or cooking and then stop right in the middle of it. I just get restless and sometimes I just can’t stop fidgeting when I should be paying attention.” She notes that she is in menopause due to her cancer treatments, which included a removal of her ovaries three years ago and a hysterectomy one year ago. She tells you people often refer to her as a “cancer survivor” but she doesn’t feel like she has survived it because every surgery makes her feel like she “is losing another piece of me.” Additionally, she says that having to have body scans every six months and not being able to look in the mirror and see a “complete woman” makes her feel that she is still trying to survive, rather than putting it in the past. | Family History:
Your client reports a four-year history of treatment for breast cancer. She has had 16 months of chemotherapy and 27 rounds of radiation, as well as a double mastectomy three years ago. She has completed reconstructive surgery for her breasts but has not yet added nipple tattooing for a more realistic image. She reports that she has three close female relatives with breast cancer, but no relapses after treatment. She states that she has been in a relationship with her partner for 17 years and they share two children, ages 12 and 8. She describes her partner as a “good person” and the relationship as “good.” She tells you that they moved to the area one year ago when her partner had an unexpected promotion. She reports this has been good but that their oldest child is “anxious, emotional, and just angry sometimes.” | Which of the following should the client work on during this session? | Exploring solutions increasing intimacy | Exploring how the client and her partner learned to identify the needs of others | Exploring why the client's partner didn't attend the client's treatment sessions | Exploring when the client first started feeling angry at her partner | (A): Exploring solutions increasing intimacy
(B): Exploring how the client and her partner learned to identify the needs of others
(C): Exploring why the client's partner didn't attend the client's treatment sessions
(D): Exploring when the client first started feeling angry at her partner | Exploring how the client and her partner learned to identify the needs of others | B | The client has relied on subtle messages and reverse messaging (ie, "you don't have to go") with the hope that her partner would "read her mind" and meet the client's unspoken needs. Exploring how the client and her partner learned to identify other people's needs will be helpful in showing the client and her partner that they need to communicate in a way that each can understand. Exploring solutions to their intimacy issues is a symptom of the greater communication issue and resolving their communication should help them regain some intimacy. Exploring when the client first became angry focuses on situations rather than overall communication patterns, and the patterns appear to be causing the problems for the couple. Exploring "why" the partner didn't attend circles back to the client's communication style of not expressing her needs and focuses more on blame than on learning new communication styles. Therefore, the correct answer is (D) | counseling skills and interventions |
150 | Initial Intake: Age: 16 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Private Practice Type of Counseling: Individual | Molly muttered one-word answers during the intake session, made little eye contact and frequently rolled her eyes. She started to warm up towards the middle of the intake session, with some prompting from her mother. She reluctantly agreed to continue counseling sessions- only due to the fact her mother stated that she could not use the family car unless she went to counseling. | Molly is a 16-year-old female who was referred to an outpatient mental health clinic after a two-week admission at a local psychiatric hospital. Molly was brought to the hospital by ambulance after she disclosed to the school psychologist that she wanted to kill herself.
History:
When asked what brought the family to the session, Molly’s mother was tearful as she disclosed that her husband died in a car accident 11 months ago. Molly and her father had been close, spending time together as Molly played recreational softball and her father was the coach. Since her father’s death, she has been distant with her mother, and often picks fights with her. Additionally, Molly frequently complains of stomach aches, stating that the pain is so severe, she cannot go to school. Before her father’s death, Molly was in Advanced Placement classes and maintained a high average. Recently, Molly’s grades have been declining and she is no longer interested in softball. She states that when she goes to the softball field, she can almost hear her father speaking to her. | null | Molly's symptoms are indicative of? | Persistent Complex Bereavement Disorder | Adjustment Disorder | Major Depressive Disorder | Post-Traumatic Stress Disorder | (A): Persistent Complex Bereavement Disorder
(B): Adjustment Disorder
(C): Major Depressive Disorder
(D): Post-Traumatic Stress Disorder | Persistent Complex Bereavement Disorder | A | Persistent Complex Bereavement Disorder is a diagnosis used for those who have experienced the death of someone close to them, with other specific criteria. These include longing for the deceased, preoccupation with the deceased of circumstances of the death, marked difficulty in acceptance, emotional numbness, a desire to join the deceased, and a distrust of other individuals. Molly is showing symptoms consistent with this diagnosis and symptoms have persisted for more than 6 months. Although Molly is exhibiting distress and impairment in functioning after an indefinable stressor (her father's death), it has lasted longer than 6 months. Additionally, Molly's symptoms are more severe than the diagnostic criteria for Adjustment Disorder with Depressed Mood which includes, low mood, tearfulness and feelings of hopelessness. Post-Traumatic Stress Disorder can be diagnosed after someone experiences the sudden death of a close family member. Although Molly is experiencing some symptoms of PTSD such as intrusive thoughts, Molly does not meet the criteria of persistent avoidance of stimuli that remind her of the event. In fact, she is preoccupied with the event and perseverates on details of the accident and similar events. Finally, although Molly is showing many symptoms of Major Depressive Disorder, she is focused on the loss of her father. Her symptoms are more consistent with Persistent Complex Bereavement Disorder. Due to the precipitating factor of her symptoms, Major Depressive Disorder is not the best diagnosis at this time. Therefore, the correct answer is (B) | professional practice and ethics |
151 | Name: Jack and Diane Clinical Issues: Marital/partner communication problems Diagnostic Category: V-codes Provisional Diagnosis: Z63.0 Relationship Distress with Spouse Age: 35 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: White Marital Status: Married Modality: Couples Therapy Location of Therapy : Community-based mental health facility | The clients are a couple in their mid-30s. The husband is tall and healthy. The wife is petite and well-groomed. As they enter, you make note that though they came in the same vehicle, they enter with no contact between them. They sit far away from one another and do not look at each other but maintain excellent eye contact with you. The husband's movements seem to be more agitated; the wife appears subdued. He speaks quickly and loudly and often fidgets in his chair, rarely sitting still; in contrast, her speech is low and soft, and she remains still and moves very little. They both seem guarded. They both identify their son's diagnosis of Autism Spectrum as being a significant strssor. | First session Your clients are in their mid-30s and present to the community agency where you are employed as both a licensed mental health therapist and a marriage and family therapist. You begin by introducing yourself and telling the couple about your professional experience and explain the types of therapies that you provide for couples. When asked why the couple made an appointment to meet with you, the husband takes the lead and tells you that he and his wife have been "serious problems" with their relationship for a few years. The husband shares that his wife does not trust him since his alcohol use "got out of control." Although he has been able to maintain sobriety for two years, he says that his wife is "paranoid" that he is using again and insists on knowing where he is "every minute of the day." He further reports that his wife is "too dependent" on him, and he feels "suffocated." He says, "I just can't keep doing this" and puts his head in his hands. You thank him for sharing his perspective of the problem and encourage the wife to share her thoughts about what is going on with their relationship. She tells you, "Truthfully? I'm scared to death that he's going to start drinking again and leave me alone with our children. I don't know what I would do if I lost him." She wipes a tear away from her face. After taking a deep breath, she says that when she tries to approach him to talk about how she feels, "he just gets mad and leaves the room." Using open-ended questions, you ask about each person's expectations for the counseling process and inquire about past experiences in therapy that may inform the current situation. Both partners look at each other, then back at you and share that they would like to re-establish trust and respect in their marriage. This is their first time seeking counseling. You also invite them to share the story of how they first met each other, memories of their relationship prior to getting married, and how they felt when they became parents. The husband shares that they first met when they were teenagers and have been together ever since. He talks about how their relationship was full of passion, respect, and trust. Even during the difficult times, they felt like nothing could tear them apart. He also shares that when their son was diagnosed with Autism Spectrum Disorder, they felt like the world had come to a standstill, but they were determined to get him the best care possible. He pauses. The husband and wife look at each other before the wife speaks. She explains that after their son's diagnosis, her husband began to drink more heavily as a way of dealing with his own stress and anxiety. He denied it for a long time, but eventually admitted he needed help and sought treatment. Although she was relieved that he got help, she is still struggling to trust him again. | The husband used to have severe issues with alcohol. He went to rehab three years ago and has maintained sobriety for two years. He continues to attend weekly meetings. As a result of his alcohol misuse, he has some medical issues with his liver, but they are not currently life-threatening as long as he continues to abstain from alcohol. The husband has worked hard to rebuild his relationships with his family and friends. He is actively trying to repair the damage that was done due to his alcohol misuse. He has been attending AA meetings and is focusing on rebuilding trust and communication. He has also been making an effort to be more present in his family life and to be a better husband and father. | The wife says to you, "I'm still scared that he's going to start drinking again. I just don't know how to trust him after all the hurt and pain he caused us. I need him to understand that if we're ever going to rebuild our relationship, he needs to be honest with me and take responsibility for his actions." What would you do to encourage a collaborative alliance between the wife and her husband? | Reframe the wife's fear as concern for her husband's well-being | Invite the wife to look at her husband and express her feelings directly to him | Ask the husband to share how he feels in response to his wife's disclosure | Ask the wife to expand on her thoughts about the husband as a means to encourage her further openness. | (A): Reframe the wife's fear as concern for her husband's well-being
(B): Invite the wife to look at her husband and express her feelings directly to him
(C): Ask the husband to share how he feels in response to his wife's disclosure
(D): Ask the wife to expand on her thoughts about the husband as a means to encourage her further openness. | Invite the wife to look at her husband and express her feelings directly to him | B | By encouraging direct communication with each other (instead of using you as a mediator or interpreter), you are nurturing a collaborative alliance between the wife and husband. Therefore, the correct answer is (D) | counseling skills and interventions |
152 | Initial Intake: Age: 12 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: School Counselor Type of Counseling: Individual | Michael came to the office and looked upset as he sat down. When asked about how he felt about what happened, Michael respectfully stated that he was sorry but that he did not want to talk about it.
| Michael came to the counselor’s office after he was suspended for fighting with one of the other students.
History:
Michael, who was a new student this year, did not typically get in trouble. Michael has excelled academically since his arrival and joined several school clubs. When the teacher was questioned regarding what happened, she stated that the other student made a gesture to Michael that could not see. Suddenly, she stated that they were both throwing punches. Michael’s teacher stated that now that she thought about it, she recently noticed Michael exhibiting some repetitive movements that she never witnessed before. | null | Which of the following, if recommended by the counselor, would likely worsen Michael's tics? | Engage in sports and hobbies | Identify and challenge his irrational thoughts | Monitor sleep | Increase the consumption of energy drinks | (A): Engage in sports and hobbies
(B): Identify and challenge his irrational thoughts
(C): Monitor sleep
(D): Increase the consumption of energy drinks | Increase the consumption of energy drinks | D | Energy drinks and increased consumption of caffeine may worsen tics. Ways to alleviate or suppress tics can be through monitoring sleep to ensure the individual is well rested. Engaging in sports and hobbies can also reduce tics as it gives the individual something to focus on. Also, by identifying and challenging Michael's irrational thoughts, this can help to reduce stressful situations. Therefore, the correct answer is (D) | counseling skills and interventions |
153 | Initial Intake: Age: 48 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Married Counseling Setting: Counselor Private Practice Type of Counseling: Marital | null | Kathleen and Tony came in for marital counseling because of arguing due to recent events in their relationship.
History:
Kathleen and Tony have been married for two years and had a generally positive relationship. They have no children. Kathleen, who works in travel, is frequently away from home. Recently, when Kathleen came home early from a work trip, she found her husband in their bedroom with one of her nightgowns on. Kathleen was convinced that there was another man in their house, and they must have heard her at the door and snuck out of the back
Kathleen started the initial session by stating that she feels that her husband is lying to her. At this comment, Tony threw his hands up in the air and stated, “It doesn’t matter what I say- you are not going to believe me anyway!” | null | If the counselor responds, "It sounds like you feel hurt that your wife does not believe you." This may make the client feel? | Validated | Annoyed | Vindicated | Confused | (A): Validated
(B): Annoyed
(C): Vindicated
(D): Confused | Validated | A | By using the intervention of reflection of feelings, a client is aware that they are heard, and their feelings are validated. Tony would likely not feel annoyed as the counselor is reflecting what he stated. Nor would he feel vindicated as that denotes some sort of feeling of satisfaction. Although the client seems conflicted about his wanting to be with his wife, the question is asking how the counselor's comments make him feel. Therefore, the correct answer is (A) | professional practice and ethics |
154 | Name: Robin Clinical Issues: Substance use/addiction issues Diagnostic Category: Substance Use Disorders Provisional Diagnosis: F10.20 Alcohol Use Disorder, Moderate Age: 28 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: Black Marital Status: Not Married Modality: Individual Therapy Location of Therapy : Private Practice | The client is well-groomed. She reports her mood as depressed due to her relationship breakup and feeling that she is unable to talk to family members about her life. Her affect is characterized by anxiousness and difficulties in answering questions. Her overall speech is slow and soft, with little eye contact as she speaks. The client's insight is fair. She recognizes that alcohol has been a major factor in her life, and she is aware of the negative effects it has had on her relationships and work performance. She states that she is at a point where she feels like she needs help to make changes in her life. Though she presents as sober at the time of the interview, her judgment appears impaired due to her continued heavy drinking despite the negative consequences. | First session You are a clinical mental health counselor at a community mental health center. You see many clients who struggle with substance use issues. A 28-year-old female presents for outpatient services today. She is an attorney who works long hours, specializing in family law. She and her boyfriend of ten years recently ended their relationship due to the client's excessive drinking. She says, "I can't live with the pain of our separation much longer, and I don't know how to cope with it." She tells you she is devastated and does not know what to do next. The breakup has triggered her to drink even more lately, and she is currently facing a DUI charge. Her attorney recommended that she seek an assessment for substance use disorder treatment in an effort to avoid a criminal conviction. You administer an assessment to determine the severity of the client's alcohol use and further evaluate her statement about being unable to live with the pain of her breakup. She reports an urge to drink daily, and acknowledges she has lost control of her drinking on many occasions. She also states that she has increased her alcohol intake because "it helps numb the pain and I can forget about everything for a little while." The client discusses her father's death when she was 17 and how this affected her life. She states that his death hit her hard, and only made matters worse because of her family's lack of emotional support in the wake of his passing. Even though she was still in High School, she began drinking heavily to cope with the grief, a pattern which has been present ever since. She drinks alone, typically at home or in bars after work. When asked about the effects of alcohol on other areas of her life like her finances, she says, "One of the perks of my job is that I get paid pretty well, so at least I'm not in debt like my brother." She pauses for a moment, then says, "Well, not yet anyway. I've got some court costs coming up." You explain to the client that substance use disorder is treatable and that it is important to take an honest look at her relationship with alcohol, in order to make positive changes to her lifestyle. You discuss the effects of excessive drinking on physical health, mental health, and personal relationships. You review the various options for treatment available and encourage her to be proactive in seeking help. The client acknowledges your advice but expresses hesitancy about beginning treatment due to fear of the stigma associated with addiction. You empathize with her feelings while emphasizing the importance of taking action now rather than waiting until her issues become worse. You present evidence-based treatment modalities that have been shown effective in managing substance use disorders. You let the client know you are here for her to help develop healthy coping skills, explore the underlying causes of her drinking, and create a plan to avoid future drinking and driving offenses. Then, you both discuss a treatment plan with the goal of helping the client resolve her current crisis and developing a strategy to maintain sobriety and avoid future legal issues. She provides you with releases to speak with her mother and her attorney. You set up a follow-up appointment one week from now. Second session The client had an appointment to meet with you two weeks ago, but she called to reschedule twice, citing a busy work schedule. The client shows up 10 minutes late for her second counseling session today, looking slightly disheveled. She starts off by telling you that "this morning has been a mess." She overslept and missed two appointments with clients. She contacted her secretary to reschedule the appointments, but she is still feeling stressed and overwhelmed. She tells you she was up late last night talking to her ex-boyfriend. You ask what motivated her to talk with her ex-boyfriend and she tells you, "It felt like the only way I could make sense of what had happened between us." She is not forthcoming with any additional details about their conversation. You then ask if anything else has been on her mind lately. She reports that her mother told her that she should be focusing more on finding someone new to date instead of worrying about getting back together with her ex. The client becomes distant and quiet during the session. She makes minimal eye contact and her responses are brief, often giving a one-word response to your questions. You can tell that something has shifted in her since last week's session as she presented to the intake as more talkative and open. You decide to address her change in behavior directly, saying "I notice that you seem more closed off today compared to the last session we had. Is there something specific that is causing you to feel this way?" The client responds, "I don't know, I'm just so tired of it all." When you ask her to elaborate, she closes her eyes and takes a deep breath before responding. She says that she feels emotionally drained. She is overwhelmed with the weight of all that has been happening and feels like she is a "total failure" for allowing things with her ex-boyfriend to come this far. She describes feelings of guilt for "treating him like dirt" the entire time they were together and sad that "I messed things up so badly." She also shares that she is feeling ashamed about being charged with a DUI. She says, "I'm an attorney, not a criminal. People like me don't get DUIs, yet here I am. What's wrong with me?" The client expresses both a desire and a fear of change. She often talks about wanting to make changes in her life, but is also uncertain about how to go about it, feeling overwhelmed by the idea of taking action. Her tone reveals a sense of hopelessness as she talks about where her life is headed. You empathize with her, acknowledging the difficulty of changing deeply-rooted patterns. You provide her with psychoeducation about the nature of addictions and the biological and environmental factors that can contribute to substance abuse. | The client has a younger brother. Her father died when she was 17, and her mother never remarried. The client's family has a history of problematic alcohol use, with family members utilizing alcohol to mask underlying emotions and distress. This pattern can be seen in her mother and brother, as well as extended family. Her mother is particularly reliant on alcohol and uses it as a way to cope with negative feelings. This has been an ongoing issue for many years. The client was raised in an environment where emotions were not discussed openly. The client expresses she learned early that it was best not to bring attention to any discomfort or upset she may have felt because it would only be met with more criticism and judgments. She states, "My mother and brother 'don't believe in depression.' When I told my mom that my boyfriend broke up with me and I was feeling depressed, she told me to that I needed to 'get over it and move on.' It's like I'm talking to a wall when I try to tell her anything about how I'm feeling." Although the client does not feel that her family understands her problems, she does communicate with her mother weekly. The client has been using alcohol as a way to cope with stress for many years. She expresses she has "been through a lot" in her life and that going to bars after work is an escape. Alcohol has maintained a significant presence during various phases of her life. | The client has shown a flattened affect and a lack of engagement in the initial part of the session. Of the following, which evidence-based practice would be most helpful? | Person-centered therapy | Solution-focused therapy | Reality therapy | Motivational interviewing | (A): Person-centered therapy
(B): Solution-focused therapy
(C): Reality therapy
(D): Motivational interviewing | Motivational interviewing | D | Motivational interviewing is an evidence-based practice that focuses on identifying a person's motivation to change their behavior. It helps clients explore and resolve ambivalence, which can be beneficial in helping them overcome resistance or blocks to progress. In this case, the client's lack of engagement suggests there may be ambivalence about addressing her issues. Motivational interviewing (MI) is a technique used to evaluate the client's readiness for change. When using motivational interviewing, the therapist determines which stage of change the client is currently in. These stages include: 1) pre-contemplation, 2) contemplation, 3) preparation, 4) action, or 5) maintenance. Therefore, the correct answer is (B) | treatment planning |
155 | Name: Anxiety Group Therapy Clinical Issues: Worry and anxiety Diagnostic Category: Anxiety Disorders Provisional Diagnosis: F41.1 Generalized Anxiety Disorder Age: 0 Sex Assigned at Birth: Female Gender and Sexual Orientation: Not applicable, Ethnicity: Various Marital Status: Not Applicable Modality: Group Therapy Location of Therapy : Agency | The group members appear to be insightful about their illness. Clients ages are 25 and older. All members are well-groomed and present with clean hygiene. | First session You are a therapist in an agency starting a group for clients with anxiety. The group will consist of seven participants. It is a homogeneous, closed group which will meet once a week on Wednesday evenings for an hour and a half for twelve weeks. The group's goal is to help clients diagnosed with Generalized Anxiety Disorders and other anxiety-related issues. An intern will co-facilitate the group with you. You are forming an outline for the group's goals, screening questions, and termination process. You will be observing candidates for the group to facilitate participant selection. Fourth session All seven members have been coming to your group for three weeks. The group is made up of married, single, and divorced females. Some have children and some do not. Ages range from 25 to 33 years old. It is multiculturally diverse. As group sessions progress, you note that some group members are starting to take risks, while others are still not fully trusting you and the group's co-facilitator. Most of the clients generally worry about their family and loved ones. Some are more afraid of getting ill and dying because of COVID-19. You lead the group in a guided meditation before you start making the rounds to calm everyone down and have them feel centered. | null | Which therapeutic factor is most often linked with healthy, well-functioning groups? | Transparency | Universality | Stonewalling | Structure and Framework of the group | (A): Transparency
(B): Universality
(C): Stonewalling
(D): Structure and Framework of the group | Universality | B | Universality means members recognize that others share similar feelings, thoughts and problems. Therefore, the correct answer is (C) | counseling skills and interventions |
156 | Name: Rick Clinical Issues: Referred for emotional and behavior issues Diagnostic Category: No Diagnosis Provisional Diagnosis: No Diagnosis Age: 18 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: Korean Marital Status: Single Modality: Group Therapy Location of Therapy : Community Center | The client is slouched over in his seat and appears withdrawn with a flat affect. He keeps his head down. The client plays with his shirt sleeve, twisting the material and pulling at it. You cannot see any cuts on his arms as reported by the mother. He does not appear to be angry at this time, which was also a symptom reported by his mother. He responds to your questions with one-word answers. He seems uninterested. The client denies any suicidal and homicidal ideation. The client mumbles, "I don't want to talk about anything here." | First session You work as both an individual and group therapist at a community center that primarily sees adolescents with emotional and behavioral issues. Rick is a senior in high school and lives with his mother and two sisters. Rick does not want to participate in individual or group therapy, but his mother insists that he get help. During the intake, you work to establish rapport with Rick. You also gather information to determine if he is an appropriate candidate for one of the groups you are preparing to start, along with a co-facilitator. You suspect he may have trouble trusting females as he expresses anger when talking about his mother, sister, and ex-girlfriend. Since his father left, Rick says that his mother has been "in his business" all the time, and he does not feel like he has any real privacy. You remain patient with Rick, listening to his story and validating his feelings. You empathize with him, letting him know it is understandable to feel frustrated about not having much privacy. You explain that you are here to help him, not to control him and that you are interested in learning more about him. You explain to Rick that you are planning to start a group therapy session with a co-facilitator and that you would like to see if it would be a good fit for him. You explain that the group will provide an opportunity for him to talk about his experiences in a safe space with others who may have gone through similar situations In addition, you share that it could be an excellent way for him to practice expressing himself and developing trust in others. You also explain to Rick that individual therapy sessions could be beneficial in addition to group therapy. You discuss the possibility of one-on-one sessions that would give him a chance to talk more deeply about his experiences in a safe, private setting You emphasize that this could be an excellent way for him to explore his feelings and learn how to cope with them in a healthy way. | The client is a first-generation American whose parents immigrated from Korea. He has an old sister who, based on Korean culture, is his superior whom he must obey and be subservient to. His parents have high expectations for him and are very controlling, expecting him to study every night and attend tutoring sessions on the weekend. They have arranged for him to marry a daughter of a prestigious family in Korea after he completes medical school eight years from now, with the intention that he and his wife will live with them and provide financial support. However, this plan has drastically changed. Seven months ago, the client's father moved out after his mother had an affair. The client became sullen, angry, and withdrawn after this event. Four months ago, while doing laundry, the client's mother saw dried blood on his shirt sleeve. She also noticed that he was wearing long-sleeved shirts all the time. She waited until he was getting dressed, walked in on him, and found he had cuts up and down his arms. The client does not speak to his father much since his parents separated. The client expresses a lot of anger toward the women in his life, specifically his mother, sister and ex-girlfriend. The client is a senior in high school. His grades have been suffering lately, and he is currently failing his math and science classes. Personal/Social Relationships: The client had been concealing his romantic relationship with a girl from his Saturday tutoring class, but following his father's abrupt departure from the family, he chose to discontinue the relationship and cease attending the class. He has since refrained from any communication or contact with her. His mother's affair has caused him to feel overwhelmed with anger, leading him to develop a dislike of all women. | Which type of group is most likely to benefit Rick? | Grief/loss group | Assertiveness training skills group | Self-help group | Psychotherapy group | (A): Grief/loss group
(B): Assertiveness training skills group
(C): Self-help group
(D): Psychotherapy group | Psychotherapy group | D | This is the correct answer because psychotherapy would be beneficial in treating the client's presenting problem. This collaborative form of healing can focus on interpersonal relationships or particular concerns shared by group members. Numerous psychological and emotional issues are treated in group therapy, ranging from addiction and abuse to anxiety and depression. Therefore, the correct answer is (C) | treatment planning |
157 | Name: Bianca Clinical Issues: Difficulty adjusting to life changes Diagnostic Category: V-codes Provisional Diagnosis: Z60.0 Phase of Life Problem Age: 62 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: Black Marital Status: Separated Modality: Individual Therapy Location of Therapy : Agency | The client is a 62-year-old female, wearing work attire. She appears to be in good hygiene and her dress is neat and appropriate for the situation. Her facial expression is sad and she has tear tracks on her cheeks. Her mood is noticeably depressed, anxious, and tearful. Her affect is constricted. She has coherent thought processes with appropriate content. She expresses feelings of sadness over her failed marriage and overwhelm about being alone. The client has intact memory and concentration. She has fair insight into her current situation and is able to verbalize her feelings in a coherent manner. | First session The client comes to the agency practice where you currently work as a licensed mental health therapist. She is a 62-year-old female who recently retired from an accounting firm employment. She is seeking treatment after her marriage recently failed. A few months ago, he husband filed for a legal separation and is currently romantically involved with another woman. The client looks at you tearfully and says, "I can't believe this is happening at my age. I am all alone. What am I going to do?" She continues to cry uncontrollably. You focus on providing a safe and secure environment. You assure her that she will not be judged or criticized in any way, and all of the conversations during the session will remain confidential. You gently let her know that it is okay to cry, and you are there to listen without judgement. You also tell the client that it is natural to feel lost and alone after a separation, especially since she and her husband have been together for such a long time. She says, "I just feel like such a fool. He cheated on me once before - that I know of - and now he's done it again. I stayed with him for over 30 years, and now I have nothing." She describes having mixed feelings of anger, sadness, fear, and confusion. She states, "There are moments where I'm so mad at him for leaving. Mad enough that I could break something! Our marriage wasn't perfect, but I thought he was committed to me. Well, obviously he wasn't. Then I start to question what's wrong with me that made him leave. And then I think about the future and how I'm going to live by myself. It's all so overwhelming." She further discloses that she is worried about having panic attacks again because "that's what happened the last time something of this magnitude happened to me." You reinforce the idea that it is important to focus on the fact that she is not alone and many people in similar situations feel overwhelmed and uncertain about their future. You let her know she is in a safe space to explore her feelings, work through her loss, and develop a plan for moving forward. You encourage her to reach out for support during this challenging time rather than isolate herself as she goes through this difficult change. Fifth session The client has been seeing you for individual therapy sessions every week. You have developed a strong rapport with her and collaborated on treatment goals, with her overall goal being to have a positive outlook on her life. During the last session, you gave her a homework assignment to begin keeping a journal, using the ABC model of rational emotive behavior therapy to identify self-defeating beliefs and understand how they are contributing to her emotional distress. You have also been working with her to process her feelings about her separation and develop coping skills. During today's session, she seems depressed, as she tells you her husband met with an attorney and officially filed for divorce. You explore her journal entries, noting one in particular in which she describes an experience in which she was driving and saw her husband sitting outside a café with "the other woman." She circled back a few times in her car, hoping he would see her. In her mind, she fantasized that he would leave his new girlfriend and drive away with her, and everything would return to normal. You ask her to tell you more about what "normal" means to her. She says, "I guess I just want things to go back to how it was before. When I mattered, when I felt loved, and when he was committed to our marriage." You acknowledge her feelings and explain that while it may not be possible to go back to exactly how things were, there is still hope for the future. You express compassion and understanding, emphasizing that there is no right or wrong way to feel. She states, "I just have mixed feelings about everything! I feel angry and betrayed by my husband, but sometimes I want him to come back. I start to feel lonely and realize the reality of my situation and that I have no purpose anymore and am alone. What's the point? My kids don't care; I have nothing in my life now. Things are so painful I'd be better off dead." You reassure her that you are here to support her as she works through all of her difficult emotions. | null | Which technique would you use with the client to help her process her feelings about her husband filing for a divorce? | Free association | Confrontation | Positive reinforcement | Reflection | (A): Free association
(B): Confrontation
(C): Positive reinforcement
(D): Reflection | Reflection | D | Reflection can be used to accomplish the validation she needs when it comes to her feelings. Therefore, the correct answer is (D) | counseling skills and interventions |
158 | Client Age: 45 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Divorced, single Counseling Setting: Private practice Type of Counseling: Individual counseling Presenting Problem: The client is experiencing difficulty in functioning in all areas of his life due to inhalant use. Diagnosis: Inhalant use disorder, severe (F18.20) | Mental Status Exam: The client is oriented to person, place, time, and situation. The client does not appear to be under the influence of inhalants because he does not display any symptoms of use. The client is friendly and engaged in the ses | You are a licensed counselor working in a private practice. You specialize in substance use disorders. The client comes into the session, is very friendly, and states that although his sessions are court ordered, he wants to get help with his inhalant use. The client spent the first half of the session explaining what happened to lead to him getting his third charge of driving under the influence of inhalants. The client says that he had twin sons 13 years ago and they both were in the ICU; one of his sons died after about a month. The client began drinking alcohol to excess daily for about 6 months, which then transitioned to inhalant use. The client says that he uses contact cement, model glue, paint, and permanent markers to become intoxicated. The client identified the following symptoms of inhalant use disorder: increase in frequency and amount of use over the past 5 years, several failed attempts at cessation of inhalant use, craving inhalants throughout every day, losing several jobs because of his inability to get to work on time due to inhalant use, use that has affected his ability to have visits with his children and maintain employment, use that increases the risk of harm to himself and others such as driving under the influence, increased tolerance, and continued use even when he knows it is negatively affecting his life. The client wants to become sober, improve his relationship with his children, and maintain employment. | sion. Family History: The client has three sons that are 11, 13, and 16 years old. The client is divorced as of 3 years prior and reports a contentious relationship with his ex-wife due to his difficulty following through with visits with their children. The client and his ex-wife were married for 17 years and dated for about 5 years before they were married. The client states that he loves his ex-wife but that she has currently been dating another man for the past 2 years and he knows they likely will not reconcile. He says that he understands why she does not want to be with him, and he thinks that he is not good for her or his children at this time. When discussing the informed consent form, you cover the risks of counseling | When discussing the informed consent form, you cover the risks of counseling. Which one of the following is NOT an expected risk of counseling? | The client may need to meet with multiple counselors prior to finding a match. | The client might choose to discontinue therapy earlier than recommended. | Therapy can make the client feel worse initially. | The counselor might not have the skill set needed to best provide benefit for the client. | (A): The client may need to meet with multiple counselors prior to finding a match.
(B): The client might choose to discontinue therapy earlier than recommended.
(C): Therapy can make the client feel worse initially.
(D): The counselor might not have the skill set needed to best provide benefit for the client. | The client might choose to discontinue therapy earlier than recommended. | B | The client may choose to discontinue therapy early; however, this is not a risk of the counseling process, rather, a decision on the part of the client. Therapy can make things worse initially because the client may have to discuss or confront situations, thoughts, and feelings that may cause distress. This is an expected part of the therapeutic process. The client may need to meet with multiple counselors prior to finding a match who meets his needs for building rapport and who also has the skill set needed to best support the client. Therefore, the correct answer is (D) | professional practice and ethics |
159 | Name: Sierra Clinical Issues: Adjustment related to physical loss/injury/medical condition Diagnostic Category: Trauma and Stressor Related Disorders Provisional Diagnosis: F43.23 Adjustment Disorder with Mixed Anxiety and Depressed Mood Age: 16 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: Native American (Cherokee) Marital Status: Not Applicable Modality: Individual Therapy Location of Therapy : Private Practice | The client's appearance is slightly disheveled. Her behavior is withdrawn. She has her arms crossed throughout the session. The client's affect is congruent. Her mood is depressed during the initial intake. She reports that she sometimes "doesn't feel like existing" when thinking about her injury. She shares that the thought of not being able to dance ever again is "too much to bear." Exploration of thought content reveals that she has considered how she might harm herself. She reports that her father has guns locked in a safe, but she knows the passcode. The client denies she would ever act on this impulse and identifies three friends she could contact for support. | First session You are a mental health therapist in a rural private practice setting. A 16-year-old female is referred to you by her pediatrician for concerns about her mood, behavior, and low appetite. She is accompanied by her mother and father. You begin by speaking with all three family members, reviewing the informed consent process and how confidentiality will be handled with the daughter. They all acknowledge and sign the appropriate paperwork. Next you meet one-on-one with the parents to understand their concerns. They are extremely concerned about their daughter's mental health and wellbeing. They share that their daughter has been crying more often lately and she has become incredibly sensitive to criticism. She is often irritable and "snaps" at them over minor issues. She withdraws from social interaction with friends, which is out of character for her. She appears increasingly withdrawn from activities she used to enjoy like drawing and playing the piano. She is also sleeping more and eating less than usual, resulting in weight loss. The parents confirm that they have limited insight into their daughter's actual feelings, as she often refuses to discuss them. The mother tells you, "She had a ballet injury a couple of months ago, and she seems to be struggling with it. We've been trying to stay positive and supportive, but she's just not getting better. Her physical therapist said that keeping up a positive attitude is really important in the recovery process, but our daughter doesn't seem to care." After you feel you have obtained a thorough understanding of the parents' concerns, you ask the parents to wait in your waiting room and invite the daughter back into your office. You begin by expressing your understanding of the situation that lead her parents to bring her in for therapy. You state, “From what your parents have told me, I understand you have been going through a difficult time lately with your physical injury and the changes that it has caused in your life.” After establishing this understanding, you ask her to tell you about her experience with the injury, how it has impacted her life, and how she has been feeling since it occurred. She tells you she has a hard time concentrating at school because she is unable to dance. She becomes tearful when you attempt to find out about how her ballet injury is affecting her. She says her "life is ruined now" and "I will likely never dance again. I'll never be able to fulfill my dream of being a ballet dancer. I hate it. All of my dreams are crushed." She begins sobbing uncontrollably. You take a moment to de-escalate her intense emotional reaction. You explain that it is common to feel overwhelmed in the aftermath of a major injury, and there are strategies she can use to cope with her feelings. You discuss the importance of staying connected to friends, family, and supportive people during this difficult time. After completing your mental status examination of the client, you note suicidal ideation as an issue to discuss with her parents. | The client reports that she is doing "okay" in school. Her parents report that she used to make straight A's but is now making C's and D's. She is failing history because she did not complete a project. They share that her teachers have tried to reach out to her, but she has not responded to any of them. The client reports that she smokes cigarettes. She used to smoke once every couple of months while out with friends. Her use has become more frequent, and she is now smoking several times a week. She has tried alcohol (three beers) and smoked a joint at a friend's party, but she reports that she did not like how they made her feel. Pre-existing Conditions: The client fell in dance class two months ago and broke her ankle. There were complications during surgery to repair the break. The client is currently in intense rehabilitation planned for at least one year, but it may take longer. Doctors are unsure if she will ever regain full mobility of her ankle. | Which of the following are physical indicators that the current issue is causing the client distress? | Substance use history | Her statements regarding suicidality | Difficulty concentrating at school | Her behavior and affect | (A): Substance use history
(B): Her statements regarding suicidality
(C): Difficulty concentrating at school
(D): Her behavior and affect | Her behavior and affect | D | The client's behavior and affect are physical indicators that the client may be in a state of distress. Therefore, the correct answer is (A) | intake, assessment, and diagnosis |
160 | Initial Intake: Age: 28 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Married Counseling Setting: Private Practice Type of Counseling: Couple | The couple appear to be their stated ages with positive signs of self-care related to hygiene and dress. Both individuals appear overweight for height, and John appears to visually be categorizable as obese. Both individuals presented with congruent affect to their stated moods. Neither demonstrated retardation, spasticity, or hyperactivity of motor activity. The couple present as cooperative, open, and forthcoming, though each frequently looks at the other and confirms that the information they are presenting individually is accurate. Jane is noted to be caregiving of and highly empathetic to John. John is noted to respond appropriately to Jane’s statements. Neither presents with reports of suicidal ideations, thoughts of harm to self or others, or difficulties with memory, judgement, or concentration. | You are a counselor in a private practice setting. Your client, Jane, is 28 years old and presents with her spouse, John, a 24 year-old Hispanic male for “problems communicating.” The couple report that they have been married for one year after cohabitating for one year prior to marriage. Immediately after their marriage they began trying to become pregnant. They state they sought help from a specialist after several months and on learning that some degree of infertility existed, Jane began hormone therapy. Jane notes that it was soon after this time that the communication problems between them began. She tells you that it was at this point that she and John realized that they may not be able to have a biological child together. John acknowledges that Jane has tried many times over the last year to bring up this topic for discussion, but he chooses not to engage her. He tells you that he tends to believe that “if I don’t think about it, it will probably go away.” Jane agrees with John and reports that over time, the couple have talked less and spend much less time together. John agrees and says that sometimes “I may not say more than five words to Jane in a day.” Jane reports that they have not been intimate in over two months. When completing the intake paperwork, John endorsed no problems on any symptom criteria. Jane reported “serious” problems with “feeling sad, loss of interest in things she previously enjoyed, crying spells, and stress. She reported “moderate” problems with “feelings of worthlessness, anxiety, loss of appetite, and sleep disturbance. The couple states they were to sign divorce papers last week but made the decision to try counseling first. Neither has participated in counseling previously. | Family History:
The couple currently live with Jane’s 10 year-old son from her previous marriage and Jane’s 75 year-old grandfather, for whom the couple provide care. Jane owns and operates a small shop, is completing her bachelor’s degree, cares for her grandfather, and parents her son, who is heavily involved in baseball. She describes a history of hypothyroid disease though is no longer taking medication as her disease is now controlled with diet and exercise. She reports taking an antidepressant for two years, approximately seven years ago. She currently is taking Provera and Clomid for infertility and states these have had a noticeable effect on her mood. John reports this is his first marriage and he has no children from prior relationships. He was laid off two years ago and has been working in his uncle’s business, but the family has no insurance. He is actively involved in caring for Jane’s son and grandfather. He reports a history of high blood pressure. Prior to their wedding, John states he experienced irritability, agitation, difficulty sleeping due to “thinking about things” and worry. He was prescribed an SSRI and took this for six months. He tells you it seemed to help but he discontinued it 8 to 9 months ago. He reports that his doctor said his anxiety might have been because of his high blood pressure. | Which of the following will best help you understand the needs and concerns of the couple? | Completing a role-play exercise using infertility issues to observe how they communicate | Completing a separate, in-depth, biopsychosocial interview with each individual | Completing a Beck's Depression Inventory (BDI) with each individual | Completing a communication exercise to increase John's skills in responding to Jane | (A): Completing a role-play exercise using infertility issues to observe how they communicate
(B): Completing a separate, in-depth, biopsychosocial interview with each individual
(C): Completing a Beck's Depression Inventory (BDI) with each individual
(D): Completing a communication exercise to increase John's skills in responding to Jane | Completing a separate, in-depth, biopsychosocial interview with each individual | B | When working with couples, especially couples who seek confirmation from their partner before answering, it is helpful to have one meeting with each individual to complete an in-depth, biopsychosocial interview where each individual feels safe to disclose their own thoughts and feelings without their spouse present. This process allows the counselor to better understand the unique perspectives and needs of each member of the couple, which helps formulate an effective treatment plan for the couple. Using role-play and communication exercises provide the counselor with information about the couple's skills in communicating, but do not provide a holistic picture of the couple's needs and concerns. The BDI is limited to helping the counselor determine if either of the individuals is experiencing a depressive episode. This is important information but does not provide a holistic view of each individual. Therefore, the correct answer is (D) | intake, assessment, and diagnosis |
161 | Initial Intake: Age: 82 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Widowed Counseling Setting: Community Clinic Type of Counseling: Individual | Theodore is tearful most days and has dropped a significant amount of weight. He has not been sleeping and stays up watching videos of his deceased wife. | Theodore is an 82-year-old who was referred for grief counseling by his son, Nate. Theodore’s wife, Nancy died one month ago after a 4-year battle with cancer.
History:
Theodore was the primary caretaker for Nancy and has not paid attention to his own health in years. Nate would like his father to move in with him and his family and sell the house his parents lived in to pay off their debt. However, Theodore refuses to sell the house and stated that he will not give away or sell anything that they owned. Nate drove Theodore to the initial session and sat in for the intake, with Theodore’s consent.
Once everyone sat down, Theodore looked at the counselor and stated, “I am only here so my son stops bugging me about selling the house. I am not getting rid of anything in that house- and especially not the house itself!” Nate explained that his father cannot maintain the house on his own and is worried about him being lonely. Theodore insists that he has other options and thinks that living with Nate would put a burden on him. | null | Using Erikson's stages of psychosocial development, what stage is Theodore in? | Intimacy vs. isolation | Immortality vs extinction | Integrity vs. despair | Generativity vs stagnation | (A): Intimacy vs. isolation
(B): Immortality vs extinction
(C): Integrity vs. despair
(D): Generativity vs stagnation | Immortality vs extinction | B | Theodore seems to be in Erikson's stage of Immortality vs. Extinction in which a person is accepting of death and believes that they have led a satisfying and meaningful life. Intimacy vs isolation occurs around the age of early adulthood when an individual is developing true autonomy from their parents and establishes their own values and ideals. Integrity vs despair occurs in later adulthood when the individual has not yet accepted death but is beginning to develop a point of view about it. Generativity vs stagnation is a stage that occurs in middle adulthood. Developmental tasks include parenting, nurturing of adult relationships and the management of career and householdThe immortality vs extinction stage was added by Joan Erikson for persons over 75 years of age. Therefore, the correct answer is (D) | intake, assessment, and diagnosis |
162 | Initial Intake: Age: 45 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Asian Relationship Status: Single Counseling Setting: Community outpatient clinic Type of Counseling: Individual | During the intake she looked visibly anxious. She appeared jumpy and kept looking at her watch. Although hesitated at times when she was asked a question. The counselor was concerned when Li paused for a long time when asked if she ever thought of hurting herself. Li eventually responded no. The counselor noticed that Li’s clothes looked disheveled and soiled. Li was not forthcoming with information about her past.
| Li is a self-referral. She walked into the clinic and stated that she had been experiencing feelings of anxiety.
History:
Li came into the community outpatient clinic asking to pay a sliding scale fee in cash. When asked for identifying information, Li asked if she had to give that information. She explained that she was undocumented and was weary of leaving any information that may lead government officials to her. Li did not want to give the counselor much of her history and cut the intake session short, stating that she had to get back to work. | null | Which of the following steps should the counselor take? | Tell her she needs to find another place to live. | Suggest finding another job. | Give Li a referral to a shelter. | Encourage Li to go to the police. | (A): Tell her she needs to find another place to live.
(B): Suggest finding another job.
(C): Give Li a referral to a shelter.
(D): Encourage Li to go to the police. | Encourage Li to go to the police. | D | Li is a victim of human trafficking and exploitation, and the police should be involved. The counselor should encourage Li to go to the police. If she does not, the counselor must consider the level of risk there is. Ethical Code B2a. Serious and Foreseeable Harm and Legal Requirements states that "The general requirement that counselors keep information confidential does not apply when disclosure is required to protect clients or identified others from serious and foreseeable harm or when legal requirements demand that confidential information must be revealed. Counselors consult with other professionals when in doubt as to the validity of an exception". A referral to a shelter, would be beneficial after the authorities are contacted. Telling Li she needs to find another place to live would not be the appropriate choice. Although this must be done, simply stating that without calling the authorities or giving her resources would not be appropriate. Li will also have to find another job eventually but the priority is keeping her safe and reporting what happened to authorities. Therefore, the correct answer is (D) | intake, assessment, and diagnosis |
163 | Name: Andie Clinical Issues: Gender identity development Diagnostic Category: Gender Dysphoria Provisional Diagnosis: F64.1 Gender Dysphoria Age: 12 Sex Assigned at Birth: Male Gender and Sexual Orientation: Female, Questioning Ethnicity: Caucasian Marital Status: Never married Modality: Individual Therapy Location of Therapy : Agency | The client is quiet in the session and clingy toward his mother. His head is bent down, and he refuses to make any eye contact. When an attempt is made to engage the client in conversation, he responds with short statements such as, "I guess; I don't know." | First session You are a mental health therapist for an agency where two parents and their 12-year-old child named Andie present for their first counseling session with you. The father looks irritated, and the mother seems depressed. She expresses that they have been concerned for some years regarding their son's confusion around his gender identity. They feel he is too young to make any decisions that will affect the rest of his life. The father speaks up, saying, "He's getting all of this nonsense from school just to fit in, and it needs to stop." The mother expresses that Andie always likes to dress up in his sister's clothes and believes that one day he will become a girl. Andie appears anxious and is afraid of the father as evidenced by his withdrawing behavior. You discuss your role as therapist and tell Andie that your job is to help make people feel better. You also provide the parents with your initial observations and make a recommendation to start therapy with weekly appointments. Fourth session During the previous two sessions, you focused on making Andie feel comfortable and spent time learning about his interests and strengths. You have established a strong rapport with Andie. Today, he is quiet and reluctant to speak. He tells you about his family and that his dad is always yelling at him and calling him a "sissy boy." He states feeling sad and does not understand why his dad will not love him if he wants to be a girl. he also states that he feels confused by his mother's seeming acceptance of him, but her unwillingness or inability to "be on his side" when his father berates him. He admits that he feels happy when he thinks of himself as a girl, especially when he is free to express himself in that way. He said all the boys at school are mean to him and call him names. he feels most at ease with the girls in his class, or with the teacher. You work with the client on how to express his thoughts and feelings appropriately to his father rather than holding them in. Tenth session The family arrives to today's session to review Andie's progress. The mother states that she is happy to see that the conflict between her husband and son is decreasing. She states that they are all utilizing "I statements" in order to express their feelings. The father states that he is trying to just let him go through this "phase" and find himself. You continue to explore with the family any other contributing factors that could be hindering family dynamics. You also explore an array of interventions that would be appropriate when behavior disturbances occur. | The client has three sisters, loves his mother but has difficulties with his father. His parents differ in child-rearing styles. The client is the youngest and has three older sisters and wishes that he had been born a girl. He acts out at home when he feels that he's not being "understood" by his parents. He withdraws from his family quite often (will not leave his room) and usually has "screaming matches" with his father in regard to his expression of his preferred gender. The client does not get along with the other boys in his class but relates to the girls without difficulty. Before the initial interview with the client, his father related that he is concerned about his son's long-standing "girlish ways." His son avoids contact sports but has expressed an interest in ballet. | As a therapist, how can you best create a therapeutic environment that is inclusive and welcoming to members of the LGBTQIA+ community? | State that you are an LGBTQIA+ Friendly practice in all forms and never discriminate against a client who is a part of that community | Join LGBTQIA+ Community organizations, add preferred pronouns on all administrative paperwork, and be aware of your own unconscious biases. | At a minimum, therapists should fully familiarize themselves with the APA guidelines, the ALGBTIC competencies, and the WPATH standards of care. Therapy sessions should be affirmative in nature. In addition, all intake forms should include a section for preferred pronouns. | Attend PRIDE organization events, hire an LGBTQIA+ consultant, and align all practice policies with inclusive language | (A): State that you are an LGBTQIA+ Friendly practice in all forms and never discriminate against a client who is a part of that community
(B): Join LGBTQIA+ Community organizations, add preferred pronouns on all administrative paperwork, and be aware of your own unconscious biases.
(C): At a minimum, therapists should fully familiarize themselves with the APA guidelines, the ALGBTIC competencies, and the WPATH standards of care. Therapy sessions should be affirmative in nature. In addition, all intake forms should include a section for preferred pronouns.
(D): Attend PRIDE organization events, hire an LGBTQIA+ consultant, and align all practice policies with inclusive language | At a minimum, therapists should fully familiarize themselves with the APA guidelines, the ALGBTIC competencies, and the WPATH standards of care. Therapy sessions should be affirmative in nature. In addition, all intake forms should include a section for preferred pronouns. | C | To create an inclusive environment as a therapist, it is imperative to familiarize yourself with the current research and be cognizant of the language used in all administrative paperwork, informed consents, and therapy sessions. Therefore, the correct answer is (D) | professional practice and ethics |
164 | Initial Intake: Age: 15 Gender: Female Sexual Orientation: Unknown Ethnicity: Hispanic Relationship Status: Unknown Counseling Setting: School-based through a counseling agency Type of Counseling: Individual | Maria is slightly unkempt with a flat expression and normal rate and tone of voice. Maria is highly tense, hypervigilant, and anxious, flinching in response to loud noises and intermittently darting eye contact. She appears to “veer off” mentally while you are speaking with her, then realizes she is doing so and returns her attention to you by nodding her head and reconnecting with her gaze. She denies history of trauma, prior to this event, has no prior experience in counseling, and denies SI/HI. Maria maintains the position that she does not need counseling for herself but is willing to talk to someone about how she can better help her siblings. | Diagnosis: Acute Stress Reaction (F43.0), Provisional
You are a mental health counseling intern providing sessions for students inside of a high school. Maria enters the conference room that you use to meet with students and sits down to tell you that she needs help for her siblings. You have no referral for Maria and were not scheduled to meet with anyone during this hour of the day. Maria shares that two days ago, her and her two younger elementary school siblings witnessed their father take a gun to their mother, shoot and kill her, and then use the gun on himself. She tells you she is fine and does not need counseling, but she wants her brother, age 7, and sister, age 4, to receive counseling because it was likely “very traumatic for them.” Identifying that Maria is clearly in shock, you offer your sincere condolences, followed by recommending Maria have counseling as well. She declines at first, insisting she is doing okay and has nothing to talk about. After inviting the school counselor and assistant principal to the discussion, with Maria’s permission, they help convince her that it would be healthy for her and her siblings if she was also being seen by a counselor. The principal adds that some of the school staff, including herself, responded to the incident the following day by going to the neighbor’s house to assess for the children’s safety and let them know they had permission to take a leave of absence from school. Maria insisted on coming to school the next day, saying she was “fine” and “needed the distraction.” Maria consents to meeting with you, but only because she believes it will help her family stick together. Due to the nature of the trauma and obvious client need, you receive permission from your supervisor to provide services pro bono until insurance or payment can be established. | Family History:
Maria is the oldest child of three children, and to her knowledge her siblings were born of the same two parents as herself; but she was unable to confirm this with absolute certainty during the initial assessment. She has difficulty providing historical information on her parents but can tell you in her own words she knows her dad was “sick” with “mental problems” and that her parents fought often. She tells you after the incident occurred her neighbors rushed to their aid and were able to take them in until they can establish a more permanent living situation with their grandmother, who lives across town and is preparing to have them move in soon. You ask if she can have her grandmother sign your company’s consent paperwork, but she replies that she has no transportation and does not speak English. She adds that her mother always told her she would want her to “go to her grandmother” if something ever happened to her and her father. | Maria tells you she will not be needing more counseling after today. You assess she is retreating with avoidance after having opened up to you emotionally. How should you respond? | Use strategies to convince her to continue | Respect her decision but with disclaimers | Tell her she is a safety risk and insist she continue | Use reverse psychology | (A): Use strategies to convince her to continue
(B): Respect her decision but with disclaimers
(C): Tell her she is a safety risk and insist she continue
(D): Use reverse psychology | Respect her decision but with disclaimers | B | You cannot force any client to engage in counseling. Using motivational interviewing and other strategies can be helpful to support your client in making healthy decisions for themselves but attempting to convince someone to do something they have declared they do not want to do can backfire in strengthening their resistance. Intentionally using a "reverse psychology" strategy to "trick" or "entice" them into following your agenda is unethical and unprofessional. Respecting Maria's decision is the best choice, while also providing her with your clinical advisement that she remains in counseling. You can provide education useful to her decision-making process such as how having a counselor as an advocate can be more helpful to her and her family than if she were to be alone, or how the counseling relationship may increase her sense of safety and help reduce mood disturbances. Therefore, the correct answer is (A) | counseling skills and interventions |
165 | Client Age: 41 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Divorced Counseling Setting: Behavioral Health Type of Counseling: Outpatient Presenting Problem: Fear and Panic Diagnosis: Agoraphobia 300.22 (F40.00) | Mental Status Exam: The client appears her stated age, and she is dressed in casual attire. Her affect and mood are anxious. She is tearful and seems extremely distressed when recounting her panic attacks. The client denies suicidal or homicidal ideations but does endorse feeling hopeless about her condition. She is unsure if she will benefit from counseling and expresses mixed feelings about seeking help. The client denies audio and visual hallucinations. Fam | You work in a behavioral health outpatient center. Your client is a 41-year-old Caucasian female presenting with symptoms of fear and panic. The client has a history of anxiety and depression but explains that her anxiety has worsened within the last year and that she has begun to experience panic attacks. She states that she has an “overwhelming fear” of elevators and stairwells. When exposed to these situations, she has trouble breathing, begins to feel dizzy, and hyperventilates. The client remembers having her first panic attack while staying at a hotel one weekend. She was taking the stairs and suddenly felt intense fear and panic. On the same trip, she had a similar experience when taking the elevator. The client quit her last job due to travel requirements, and she is currently unemployed. She stays away from stairwells and elevators as much as she possibly can. When unable to do so, she asks her son to accompany her. | ily and Work History: The client was married for 15 years before she divorced. She and her ex-husband share custody of their 16-year-old son. The client is an only child and reports that her parents were strict and overbearing when she was growing up. She works as a travel photographer and, until recently, worked for a large national publication. She enjoyed her job but cannot envision a time when she would feel comfortable staying in hotels again. This fear has prevented her from exploring other travel accommodations while on assignment. She states, “There are too many unknowns with travel, and I just don’t think I can do it any longer | Which of the following is a risk and prognostic factor for agoraphobia? | Interpersonal physical and sexual abuse | Neglect and/or lack of supervision | Negative events in childhood (e.g., separation, death of a parent) | Serious social neglect | (A): Interpersonal physical and sexual abuse
(B): Neglect and/or lack of supervision
(C): Negative events in childhood (e.g., separation, death of a parent)
(D): Serious social neglect | Negative events in childhood (e.g., separation, death of a parent) | C | The DSM-5-TR lists negative events in childhood (eg, the separation or death of a parent) as an environmental risk and prognostic factor for agoraphobia. Serious social neglect is associated with disinhibited social engagement disorder. Interpersonal physical and sexual abuse are environmental risk and prognostic factors for dissociative identity disorder. Lastly, neglect or lack of supervision is a risk and prognostic factor for pica. Therefore, the correct answer is (A) | intake, assessment, and diagnosis |
166 | Client Age: 41 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Divorced Counseling Setting: Behavioral Health Type of Counseling: Outpatient Presenting Problem: Fear and Panic Diagnosis: Agoraphobia 300.22 (F40.00) | Mental Status Exam: The client appears her stated age, and she is dressed in casual attire. Her affect and mood are anxious. She is tearful and seems extremely distressed when recounting her panic attacks. The client denies suicidal or homicidal ideations but does endorse feeling hopeless about her condition. She is unsure if she will benefit from counseling and expresses mixed feelings about seeking help. The client denies audio and visual hallucinations. Fam | You work in a behavioral health outpatient center. Your client is a 41-year-old Caucasian female presenting with symptoms of fear and panic. The client has a history of anxiety and depression but explains that her anxiety has worsened within the last year and that she has begun to experience panic attacks. She states that she has an “overwhelming fear” of elevators and stairwells. When exposed to these situations, she has trouble breathing, begins to feel dizzy, and hyperventilates. The client remembers having her first panic attack while staying at a hotel one weekend. She was taking the stairs and suddenly felt intense fear and panic. On the same trip, she had a similar experience when taking the elevator. The client quit her last job due to travel requirements, and she is currently unemployed. She stays away from stairwells and elevators as much as she possibly can. When unable to do so, she asks her son to accompany her. | The client’s son accompanies her to her appointment today. Since the initial intake, COVID-19 has become a global pandemic and has greatly impacted the client’s anxiety and fear. The client was visibly trembling when she spoke and requested that her son remain nearby. She explained that complying with the statewide mask mandate has been difficult, stating, “Wearing this mask makes me feel like I can’t breathe. It’s the same feeling I get when I’m walking up stairs or taking the elevator.” The client’s internist prescribes alprazolam (Xanax), which she has been taking for years. However, she thinks that it is no longer effective and asks if you can help her discontinue the medication. Given the COVID-19 outbreak, you discuss providing distance counseling to the client | Informed consent for distance counseling addresses issues unique to telehealth EXCEPT which of the following? | Interjurisdictional practice | Risks and benefits of telehealth | Time zone differences | Emergency procedures | (A): Interjurisdictional practice
(B): Risks and benefits of telehealth
(C): Time zone differences
(D): Emergency procedures | Interjurisdictional practice | A | Interjurisdictional practice is not a part of informed consent for distance counseling or telehealth. Informed consent involves sharing clear and sufficient information with the client to make an informed decision about treatment participation. Interjurisdictional practice occurs when a counselor provides services to a client across state lines. This is a legal issue that counselors must rectify before providing distance counseling. Although temporary permission for interjurisdictional practice may exist, it is rare and far less likely to be included in informed consent. All other answer items can be found in Section H2 of the ACA Code of Ethics, which outlines guidelines for informed consent and disclosure. Therefore, the correct answer is (C) | professional practice and ethics |
167 | Client Age: 30 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Married Counseling Setting: Counseling clinic Type of Counseling: Individual counseling Presenting Problem: The client is engaging in restrictive eating daily. The client engages in bingeing when her husband is away for business trips and engages in exercise as compensatory behavior. Diagnosis: Anorexia nervosa, binge eating/purging type, moderate (F50.02) | Mental Status Exam: The client is oriented to person, place, time, and situation. She reports no hallucinations or paranoia. The client was engaged in the session, but she had trouble accepting that her weight and self-talk were problem | You are a licensed counselor working in your own private practice, and you specialize in eating disorders. The client comes to counseling after her primary care physician (PCP) provided a referral to counseling due to restrictive eating that has led to a low body mass index of 16.5. The client says that she has lost about 30 pounds over the past 6 months and that she still feels that she is overweight. The client says that she usually consumes about 500 calories each day and that she fears that if she eats more, she will gain weight. The client’s mother, who was overweight, passed away at age 46 due to an aneurysm, which has contributed to the client’s perception that her mother’s death was weight related. The client expresses that she also has a fear that if she gains weight, then her husband will not love her. She describes experiencing anxiety resulting from the belief that she is currently overweight and is therefore already at risk of both her husband not loving her and of dying. The client says that she generally restricts eating when her husband is home, but when he is on business trips she binges and then forces herself to throw up. | atic. Family History: The client has two siblings: a younger brother (29) and an older sister (32). The client says that her older sister is obese and she is worried that her body would deal with food similarly, causing her to gain weight easily if she ate more. The client has been married for about 1 month at this point and has lived with her husband for about 6 months total. She says that she feels pressure from her husband to be thin, and although he places this expectation on her, she says that she has felt this way prior to meeting him, but has lost more weight since they have been living together. You are focusing on building a therapeutic relationship with the client | You are focusing on building a therapeutic relationship with the client. Which of the following terms focuses on viewing the client as the expert of herself and responding warmly with acceptance of where the client is in her life? | Congruence | Mutuality | Identification and internalization | Unconditional positive regard | (A): Congruence
(B): Mutuality
(C): Identification and internalization
(D): Unconditional positive regard | Unconditional positive regard | D | This approach to building rapport is called unconditional positive regard. This is used to demonstrate to the client that you accept her as she is and are genuinely interested in understanding what she is experiencing. Congruence is about being a genuine honest person and matching your external expressions to how you internally feel. It is not related to the concept of recognizing the client as the expert of herself. Congruence provides the client with the insight that the therapist is also a human and requires the management of counselor and client boundaries because self-disclosure and being openly emotional may cause the client to want to support the counselor. Mutuality involves sharing decision making, treatment planning, and power, while the therapist and client are both learning as they go. The identification and internalization process is about modeling behaviors or skills and internalizing them. Therefore, the correct answer is (B) | counseling skills and interventions |
168 | Client Age: 13 Sex Assigned at Birth: Male Gender: Transgender; Gender Nonconforming (TGNC) Ethnicity: Caucasian Counseling Setting: Child and Family Agency, School-Based Services Type of Counseling: Individual and Family Presenting Problem: Truancy; Gender Dysphoria Diagnosis: Gender Dysphoria, Provisional (F64.1); Social Exclusion or Rejection V62.4 (Z60.4) | Mental Status Exam: The client is dressed in age-appropriate clothing. They wear eye makeup and chipped black fingernail polish, and they have bitten most fingernails down to the quick. The client’s mood is irritable, and they are quick to show anger toward their mother when misgendered. Their thoughts are coherent, and they deny audio/visual hallucinations. The client acknowledges feeling sad and hopeless but denies suicidal ideation. They attribute increased levels of anxiety at school to bullying, particularly with select peers. They explain that a select group of students threaten the client and call them offensive and derogatory names. Family History and History of th | You are a school-based mental health counselor in a public middle school. Your client is a 13-year-old Caucasian 7th grader who presents for the initial intake with their mother. The mother says that the client has had several unexcused absences from school because “he is confused about his gender.” The client adamantly denies being confused and explains that they self-identify as transgender. The client’s preferred pronouns are “they/them.” The client further states that they have had a strong desire to be a different gender since early childhood, and this desire and their distress have recently intensified. The mother reports that the client is chronically irritable, spends a lot of time alone, and has “basically shut everyone out.”The client reports experiencingbullying—both verbal and physical—in school “nearly every day.” In addition to the bullying, the client says that certain teachers refuse to allow them to use the bathroom aligned with their identified gender. To prevent this conflict, the client does not eat breakfast or lunch at school. | Since the intake, you have provided professional development training for school staff on transgender and gender nonconforming (TGNC) individuals. The administration supports your recommendations for keeping the client and others safe at school. The client continues to miss school, but they have had fewer absences this month. You learn that the client’s desire to be rid of their male secondary sex characteristics has become more persistent. They say that they have seen media coverage of individuals who have undergone sex reassignment surgeries and wondered what that would be like. The client also states they are confused about their sexual orientation. The client appreciates being an active participant in their treatment, and together you create relevant treatment plan goals. You discuss the upcoming family session with the client’s parents. The client articulates appropriate topics for this session and reports increased anxiety concerning their father’s participation | What is the primary purpose for inviting the client to be an active participant in their treatment? | To validate presenting concerns and establish hope | To model active listening and express empathy | To help the client gain confidence in self-advocacy | To present as a united front during the upcoming family session | (A): To validate presenting concerns and establish hope
(B): To model active listening and express empathy
(C): To help the client gain confidence in self-advocacy
(D): To present as a united front during the upcoming family session | To validate presenting concerns and establish hope | A | The primary purpose for collaboration with the client is to validate presenting concerns and establish hope. The therapeutic alliance consists of shared tasks, goals, and bonds (Bordin, 1978). Goals outline agreed-upon measures to alleviate the client’s symptoms. Seeking the client’s input on these measures helps instill hope and improve confidence in the therapeutic process. Presenting as a united front is incorrect. Although the counselor is an advocate for the client, family sessions value input from all members. Modeling active listening and empathy is not the primary purpose for collaborating with the client. Gaining confidence in self-advocacy is an appropriate treatment plan goal; however, the purpose of collaboration at this time is to strengthen the bond with the client to promote therapeutic change. Therefore, the correct answer is (B) | treatment planning |
169 | Name: Carter Clinical Issues: Developmental processes/tasks/issues Diagnostic Category: Neurodevelopmental Disorders Provisional Diagnosis: F90.0 Attention-Deficit/Hyperactivity Disorder, Predominately Inattentive Presentation; F81.2 Specific Learning Disorder with Impairment in Mathematics Age: 11 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Not Assessed Ethnicity: White Marital Status: Not Applicable Modality: Individual Therapy Location of Therapy : School | The client is of average build. He is dressed in a neat and appropriate manner for school. He is reluctant to engage in the conversation but does not display any hostility or aggression. The client displays a flat affect with occasional brief moments of animation which appear to be fueled by fleeting interests. His mood appears to be somewhat dysphoric as he often responds with a shrug or a one-word answer. The client’s thought process is non-linear and circumstantial. He is able to answer questions in a straightforward manner once he understands the topic being discussed. The client’s speech is of normal rate and volume for his age but it does contain some articulation errors due to his speech disorder. His memory appears intact as he can recall details from previous conversations with ease. | First session You are a mental health therapist in a public school. The client, an 11-year-old male, and his parents arrive at your office for the intake appointment per a referral from the committee on special education. The parents express concerns with their son's ongoing lack of concentration, being easily distracted, requiring multiple prompts and redirection throughout his day, and not following multi-step processes. The mother states that he tends to "drift off and is fidgety." He has trouble sitting still and cannot focus on anything for more than a few minutes. According to the parents, this behavior is present at both school and at home. As you progress with the intake session, you ask the parents to describe their current goals and any treatment barriers they have experienced up to this point. They state that they would like their son to be more focused throughout the day and be better able to follow instructions. They also mention that so far their efforts in trying to help him have been unsuccessful and he is still struggling. After gathering more insight into the client's home life, school performance, and developmental history from the parents, you turn your attention to the client. He has been looking around the room and has not been actively engaged in the conversation. When asked directly about his feelings about school, he shrugs and says, "It's okay." You ask him if there is anything that makes it hard for him to stay focused in class, and after a few seconds of reflection he admits that it is sometimes difficult because "there are too many things happening at the same time." He states that he cannot keep up with all of the activity going on around him and it is distracting. You inquire further as to what else may be contributing to his difficulty maintaining attention in school and he admits that sometimes he gets frustrated when tasks are too challenging for him. While he is answering your questions, he is looking at the small tabletop clock sitting on the corner of your desk. Once you feel that you have an accurate understanding of the current presenting issues, you discuss next steps with the parents. You discuss meeting with the client for individual weekly sessions to help him develop effective coping skills, build self-esteem, and manage emotions associated with frustration, failure, and low self-worth. You also suggest collateral sessions with the parents to check in with them about their son's progress and discuss strategies they can use at home to help him. They agree to this arrangement and ask if there are any tools or techniques they can try between now and the next time they meet with you. You suggest they start by creating a daily routine that will provide a sense of predictability and help to reduce chaos, and having a set time for homework, meals, and bedtime. You also mention that stimulant medication is often prescribed for children with ADHD, which can help to improve focus and concentration. Lastly, you let the parents know there is some evidence that certain foods can trigger or worsen ADHD symptoms, such as sugary, processed, or artificial foods. | The client is currently a fifth grader participating in the general education curriculum. He has a disability classification with his school district as learning disabled. He receives consultant teacher services via classroom support aide for English Language Arts (ELA) and Math. In addition, he attends the resource room daily for added support. The client arrives to class prepared with necessary materials and homework assignments but requires prompts throughout his day to stay on track. He is conscientious about his grades and doing well academically but is easily distracted by environmental factors surrounding him. Three years ago, the client's triennial evaluation report indicated a classification of Speech Language Disorder. To date, staff suggests that the client's speech deficits manifesting as notably impaired speech do not seem to cause concern in social situations. Additional Characteristics: The client is a very pleasant, quiet, shy, reserved boy. He tends to lack confidence in his academic abilities, which seems to cause him stress. Small glimpses of the client's good sense of humor can often be seen in small group settings. | Given the client's age, what level of involvement is appropriate for him to have in his treatment plan? | Every client has the right to be included in treatment planning, except those under the age of 16, who do not have that right because of their age. | Every client has the right to be included in treatment planning in a manner consistent with his or her age and level of understanding. | Every client has the right to be included in treatment planning, except for those in a school setting who have a limited expectation of inclusion in the treatment process. | Every client has the right to be included in treatment planning regardless of age or educational status. | (A): Every client has the right to be included in treatment planning, except those under the age of 16, who do not have that right because of their age.
(B): Every client has the right to be included in treatment planning in a manner consistent with his or her age and level of understanding.
(C): Every client has the right to be included in treatment planning, except for those in a school setting who have a limited expectation of inclusion in the treatment process.
(D): Every client has the right to be included in treatment planning regardless of age or educational status. | Every client has the right to be included in treatment planning in a manner consistent with his or her age and level of understanding. | B | Every client should be involved in his or her own treatment. Therefore, the correct answer is (A) | treatment planning |
170 | Client Age: 60 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Married Counseling Setting: Private Practice Clinic Type of Counseling: Individual Counseling Presenting Problem: Unemployment; Anxiety; Depressed Mood Diagnosis: Adjustment Disorder with Mixed Anxiety and Depressed Mood (F43.23) | Mental Status Exam: The client appears to have a depressed mood as evidenced by his affect, slow speech pattern, and body posture. The client is dressed appropriately for the season and is in clean clothing. The client is oriented to person, place, time, and situa | You are a private practice therapist working in an outpatient clinic. Your 60-year-old male client comes into the intake session, sits down, and sighs deeply. You verbally acknowledge that the client looks as though he is carrying a big mental weight, and he nods. The client begins to talk about how he was let go from his job at an assembly plant a month prior due to budget cuts. The client says that he worked there for about 30 years and that he was most recently a plant manager for the past 10 years. The client states that the plant shut down because the automotive company moved their manufacturing to another country. The client expresses anxiety surrounding what he is going to do for work next. The client states that he worries that he does not have much to offer other employers due to the extent of time he spent at his last job and also that his age will make him unemployable. The client says that he has been isolating himself, feels down more often than not, and often worries about making ends meet. The client states that his wife is currently receiving cancer treatment and, because of this, they have significant, regular medical bills. | The client comes into the session and reports that he and his wife have been getting along better since the last session following some conversations about what they can do to get through this situation together. The client says that he wants to work on figuring out what he is going to do for work next. You and the client discuss possible options, and he says a friend offered him a job at his restaurant. The client says that he is considering it just for the money but that he has never been a server before and has some reservations. You conduct a career interest assessment and discuss the results. The client has not been applying to jobs due to anxiety that he will not get a job due to his age | The client has not been applying to jobs due to anxiety that he will not get a job due to his age. Which of the following would be an appropriate intervention to improve his motivation to apply to jobs? | Use of a CBT thought log to process during sessions | Progressive muscle relaxation | Role-playing | Psychoeducation on relaxation techniques | (A): Use of a CBT thought log to process during sessions
(B): Progressive muscle relaxation
(C): Role-playing
(D): Psychoeducation on relaxation techniques | Use of a CBT thought log to process during sessions | A | CBT thought log can capture unhelpful thinking that is a barrier to applying to jobs and can be used in counseling sessions to process these thoughts in order to improve self-talk. It will be helpful to provide psychoeducation on relaxation techniques, such as progressive muscle relaxation, in order to manage anxiety when he is experiencing it; however, this would not improve motivation because it focuses on symptoms rather than on cognitive barriers. Role-playing might be helpful when it comes to interviewing, but it does not help the client with applying to jobs. Therefore, the correct answer is (C) | counseling skills and interventions |
171 | Initial Intake: Age: 35 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Employee Assistance Program Type of Counseling: Individual | Harold comes into the office, visibly upset, stating, “I really don’t know why I am here, but I am sure you will see that too after some time together. And I am sure that anything I say here- you can’t report it to anyone anyway, right?” Harold did not display any self-awareness of his actions when speaking to the counselor. At times he showed defensiveness and irritability and other times he was making jokes and complimenting the counselor. | Harold, an accounting executive, was referred for counseling by his supervisor after Human Resources received several complaints about Harold’s attitude towards others.
History:
Harold has been successful in his career and is knowledgeable in his field. However, he stated that he is often not well liked. Harold attributes this to people being envious of him. Harold told the counselor that recently he was called to human resources because of complaints from his peers. Complaints included allegations of rude remarks, bullying, and Harold taking credit for work that others did. One coworker stated that Harold took frequent breaks and suspected he may be using drugs. | null | The counselor states, "It sounds like you are wondering about the reason you were referred to me. Perhaps we should review this together and discuss the details of our what our time together will consist of. I can then address any questions or concerns you may have." This is an example of? | Paraphrasing and structuring | Paraphrasing and informed consent | Confrontation and structuring | Confrontation and informed consent | (A): Paraphrasing and structuring
(B): Paraphrasing and informed consent
(C): Confrontation and structuring
(D): Confrontation and informed consent | Paraphrasing and structuring | A | Paraphrasing is rewording the client's words to convey understanding. It can also be used for clarification. The counselor reiterates what the client stated and demonstrates that she is listening. Structuring is when the counselor reviews what will be reviewed in the session. The counselor does this by outlining the different things the session will cover. Confrontation is not the counselor confronting the client but rather the client confronting something within themselves. Informed consent is the review of the counseling process including payment, procedure, risks, and benefits. Therefore, the correct answer is (D) | counseling skills and interventions |
172 | Name: Rick Clinical Issues: Referred for emotional and behavior issues Diagnostic Category: No Diagnosis Provisional Diagnosis: No Diagnosis Age: 18 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: Korean Marital Status: Single Modality: Group Therapy Location of Therapy : Community Center | The client is slouched over in his seat and appears withdrawn with a flat affect. He keeps his head down. The client plays with his shirt sleeve, twisting the material and pulling at it. You cannot see any cuts on his arms as reported by the mother. He does not appear to be angry at this time, which was also a symptom reported by his mother. He responds to your questions with one-word answers. He seems uninterested. The client denies any suicidal and homicidal ideation. The client mumbles, "I don't want to talk about anything here." | First session You work as both an individual and group therapist at a community center that primarily sees adolescents with emotional and behavioral issues. Rick is a senior in high school and lives with his mother and two sisters. Rick does not want to participate in individual or group therapy, but his mother insists that he get help. During the intake, you work to establish rapport with Rick. You also gather information to determine if he is an appropriate candidate for one of the groups you are preparing to start, along with a co-facilitator. You suspect he may have trouble trusting females as he expresses anger when talking about his mother, sister, and ex-girlfriend. Since his father left, Rick says that his mother has been "in his business" all the time, and he does not feel like he has any real privacy. You remain patient with Rick, listening to his story and validating his feelings. You empathize with him, letting him know it is understandable to feel frustrated about not having much privacy. You explain that you are here to help him, not to control him and that you are interested in learning more about him. You explain to Rick that you are planning to start a group therapy session with a co-facilitator and that you would like to see if it would be a good fit for him. You explain that the group will provide an opportunity for him to talk about his experiences in a safe space with others who may have gone through similar situations In addition, you share that it could be an excellent way for him to practice expressing himself and developing trust in others. You also explain to Rick that individual therapy sessions could be beneficial in addition to group therapy. You discuss the possibility of one-on-one sessions that would give him a chance to talk more deeply about his experiences in a safe, private setting You emphasize that this could be an excellent way for him to explore his feelings and learn how to cope with them in a healthy way. Sixth session Rick has been attending group therapy weekly. He continues to wear long sleeves to the session but appears engaged and involved in the group process. The group exhibits high cohesion, and all members participate in group activities. The focus is on continued productivity and problem-solving. You ask the members to reflect on the skills they have been practicing in the group and share an experience in which they have applied those skills outside the session. Rick's experience in the group has further helped him to identify and understand his feelings. He has been able to recognize his anger and express it in a healthier way. He has also been able to recognize his need for connection. He says he recently called his ex-girlfriend to apologize for being angry about his parents and "taking it out on her" by withdrawing from her. This has enabled him to develop a more constructive approach to conflict. The group members have provided Rick with a safe space to practice his new skills, giving him the confidence to try them in his real-life relationships. The other members have shown Rick support and encouraged him to take risks and to be open to opportunities for growth. Rick's active engagement in the group has been instrumental in his progress. He has become more aware of his emotions, and he can express himself in a way that is respectful and appropriate. His newfound ability to communicate effectively has been a significant step towards strengthening his relationships both inside and outside of the group. | The client is a first-generation American whose parents immigrated from Korea. He has an old sister who, based on Korean culture, is his superior whom he must obey and be subservient to. His parents have high expectations for him and are very controlling, expecting him to study every night and attend tutoring sessions on the weekend. They have arranged for him to marry a daughter of a prestigious family in Korea after he completes medical school eight years from now, with the intention that he and his wife will live with them and provide financial support. However, this plan has drastically changed. Seven months ago, the client's father moved out after his mother had an affair. The client became sullen, angry, and withdrawn after this event. Four months ago, while doing laundry, the client's mother saw dried blood on his shirt sleeve. She also noticed that he was wearing long-sleeved shirts all the time. She waited until he was getting dressed, walked in on him, and found he had cuts up and down his arms. The client does not speak to his father much since his parents separated. The client expresses a lot of anger toward the women in his life, specifically his mother, sister and ex-girlfriend. The client is a senior in high school. His grades have been suffering lately, and he is currently failing his math and science classes. Personal/Social Relationships: The client had been concealing his romantic relationship with a girl from his Saturday tutoring class, but following his father's abrupt departure from the family, he chose to discontinue the relationship and cease attending the class. He has since refrained from any communication or contact with her. His mother's affair has caused him to feel overwhelmed with anger, leading him to develop a dislike of all women. | In this session, the client discloses that he recently apologized to his ex-girlfriend for being angry at her and ending their relationship. What statement would you make to the client regarding his past and current behavior from an REBT perspective? | "Acknowledging your actions and taking responsibility for them by apologizing is a sign of growth and maturity. You are taking ownership of your life and are realizing that you can make positive changes." | "I get angry sometimes, too. It's okay to be angry, but it's important to try to recognize when you are projecting your anger on others." | "I want to commend you for having the courage to apologize and express yourself in a respectful way. It takes a lot of emotional maturity to be able to do this, and I'm proud of you." | "Though it's better late than never, in what way could your apology have been more effective?" | (A): "Acknowledging your actions and taking responsibility for them by apologizing is a sign of growth and maturity. You are taking ownership of your life and are realizing that you can make positive changes."
(B): "I get angry sometimes, too. It's okay to be angry, but it's important to try to recognize when you are projecting your anger on others."
(C): "I want to commend you for having the courage to apologize and express yourself in a respectful way. It takes a lot of emotional maturity to be able to do this, and I'm proud of you."
(D): "Though it's better late than never, in what way could your apology have been more effective?" | "Acknowledging your actions and taking responsibility for them by apologizing is a sign of growth and maturity. You are taking ownership of your life and are realizing that you can make positive changes." | A | From a REBT perspective, the client is taking responsibility for his own actions and emotions by apologizing. This type of behavior indicates that he has taken ownership of his life and realizes that no one else can make him happy; only he can create his own happiness. This shift in perspective is an example of how REBT helps individuals take control of their lives and make positive changes. By recognizing his own role in the situation and apologizing for it, the client is demonstrating a commitment to personal growth and development. Therefore, the correct answer is (D) | counseling skills and interventions |
173 | Client Age: Husband, 38; wife, 37 Sex: Husband,male; wife, female Gender: Husband,male; wife, female Sexuality: Husband,heterosexual; wife, bisexual Ethnicity: Caucasian Relationship Status: Married Counseling Setting: Counseling clinic Type of Counseling: Couples counseling Presenting Problem: The couple is experiencing distress because the wife has had a sexual affair with a woman. Diagnosis: Adjustment disorder, unspecified (F43.20) and relationship distress with spouse or intimate partner (Z63.0) | Mental Status Exam: The couple presents as withdrawn at the start of the session, but they open up as they talk about lighter subjects. Both individuals are oriented to person, place, time, and situa | You are a licensed counselor meeting with a couple in your private practice clinic. The couple comes in, and they both sit down at far ends of the couch and do not look at each other. After explaining informed consent and other intake policies, you begin to ask the couple what brought them to counseling, and they both sit silently. You ask the couple if it is hard to start this conversation because of why they came, and they both nod. You ask the couple if it might be easier to start with how they met and why they fell in love with each other, and they both nod in agreement that they can talk about that. The couple appears more comfortable after this and even say a few statements to each other about shared experiences during the conversation. You circle back to the reason why they came to therapy, and the wife says that she assumes that she should talk first. She states that about a week prior she told her husband that she had an affair with a woman a few months before. She continues that, at the time, she was curious and it occurred while she was drunk and insists that it meant nothing. The husband states that he still loves her, but he is not sure how he is going to move past this. He emphasizes that not only did she have an affair, but her action exposed an aspect of her that he did not know about, making him question whether she even finds him attractive. | The couple comes into the session and sits down. Their body language does not appear as uncomfortable as it has in previous sessions because they are sitting a little closer together. You ask both individuals what they need to work on. The wife says that she knows that she needs to rebuild trust, and the husband says that he wants to know more about what happened in the affair before they move forward. The couple report that they tried to engage in sex, but that the husband stopped during intercourse. The husband states that he could not get the idea out of his mind that his wife does not find him attractive because she was with a woman. You ask the husband what it means for their marriage if his wife does not find him attractive, and he states that it means he will not be able to please her. You then ask him what it means for the relationship if he cannot please her, and he responds that it means he cannot be a good husband. You follow up asking what it means if he cannot be a good husband, and he says that they will have a miserable marriage. You support effective communication strategies and empathize with the couple. After the session, the wife comes back to get her coffee that she left and says that she knows that she hurt her husband and is in the wrong, so she will do whatever her husband needs to rebuild trust. In order for you to assist in stabilizing this relationship, you must focus on building trust between the individuals | In order for you to assist in stabilizing this relationship, you must focus on building trust between the individuals. All of the following will help build this trust, EXCEPT: | Increasing positive interactions | Improving conflict resolution skills | Creating a safe environment for the wife to express her feelings | Increasing empathy | (A): Increasing positive interactions
(B): Improving conflict resolution skills
(C): Creating a safe environment for the wife to express her feelings
(D): Increasing empathy | Improving conflict resolution skills | B | Improving conflict resolution skills is not currently indicated because you do not have indications that the clients are having difficulty managing conflict in the general sense. Creating a safe environment for the wife to express feelings is important because she feels like she cannot do so, demonstrated by her private expression to you outside of the session. Although the wife caused harm to her husband, her feelings and thoughts matter because the success of the couple requires both individuals to be able to communicate freely. Increasing positive interactions is a small step toward building a more positive relationship overall and can lead to rebuilding trust as both individuals begin to feel united again in their relationship. Increasing empathy skills is important because it helps each individual see the other’s point of view, which creates a space for trust, understanding, and possible forgiveness. Therefore, the correct answer is (A) | core counseling attributes |
174 | Initial Intake: Age: 48 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Private Practice Type of Counseling: Individual | The client appears to be his stated age and overweight for his height. He is dressed professionally and appropriately to the circumstances as he tells you he will see clients after your appointment. The client lays on the office couch with his hands behind his head and his feet on a cushion. He answers questions without pauses and often replies very casually with “sure” or “I don’t know,” demonstrating little insight into his thoughts, behaviors, and emotions. He estimates his mood as dissatisfied and unhappy though his affect suggests ambivalence. He presents with some complaints of forgetfulness but is oriented to time and place, and endorses no delusions or hallucinations. He acknowledges frequently feeling suspicious, especially when he’s feeling really stressed. He says he questions other people’s motives and what they are doing or saying when he’s not present. The client acknowledges using alcohol on weekends, and has used marijuana and cocaine regularly over the past ten years but admits it has increased over the last two years. He assures you he only drinks and uses drugs when not seeing clients. He has a prescription for pain medicine and states he uses it appropriately. | You are a counselor in a private practice setting. Your client presents with complaints of not meeting his own expectations in his licensed, health care profession, and dealing with the business aspect of his work, difficulty meeting financial obligations, difficulty getting along with others, and problems with his ability to concentrate. He says his business partner used to be his best friend but now he can’t stand him because he sees the clients more often and leaves your client to do all the work. He tells you his concentration issues have always been present but have become progressively worse over the past eighteen months, as have his feelings of irritability, failure, fatigue, and lately he has pains in his chest and shoulder. He tells you that he thinks sometimes about what would happen if he died, but only as far as wondering how others would react. Later in the session, he says he is not suicidal and does not have a plan, but occasionally he just “gets tired of it all.” He tells you that sometimes he feels like “ending it” and has said that to women when the relationship isn’t going well and once or twice during breakups. He asserts that he has not actually tried to kill himself. He summarizes his relationships with others as “if they like me, they lose interest” and says that he finds himself “almost being manipulative” in how he chooses his words in his relationships with women and sometimes takes them on spontaneous “wildly expensive vacations” so they will not lose interest in him. The client tells you he has been in several relationships with women over the years, beginning with his high school sweetheart, then with his college sweetheart, but none of them have “worked out.” He states he was engaged to his college sweetheart at 24 for 6 months and then she married someone else. He tells you that another girlfriend was married and didn’t tell him, one “went crazy and threatened him with a gun,” and one broke up with him saying that he was “too needy” and “almost obsessive” in wanting to see her every day. He tells you that “all in all, I’m unhappy with how things are going and I need to make changes, but I just have no motivation to do it and I don’t know why I should have to.” | Family History:
He states he is close to his sister who has never married but “always likes the deadbeat guys.” He tells you his father and mother never showed affection to him while growing up, were always bickering, and his mother was always obsessive about saving money and always complaining. He acknowledges loving his parents but sometimes getting so angry at them that he wishes he could just ignore them forever. He tells you both his maternal and paternal grandfathers were “mean as snakes,” while his paternal grandmother was a “saint.” He reports that one of his uncles committed suicide several years ago and that his cousin, whom he was very close to, committed suicide last year. He also says his best friend died five years ago due to a drug overdose. | Based on the information provided, which of the following would be most appropriate to state to the client? | I want to hear how and what you are feeling but I'm uncomfortable when you raise your voice. | Why does that feel uncomfortable for you? | You are angry and feel a physical reaction to my words, but you are still able to tell me how and what you are feeling. | Can you tell me about the physical reaction you feel? | (A): I want to hear how and what you are feeling but I'm uncomfortable when you raise your voice.
(B): Why does that feel uncomfortable for you?
(C): You are angry and feel a physical reaction to my words, but you are still able to tell me how and what you are feeling.
(D): Can you tell me about the physical reaction you feel? | You are angry and feel a physical reaction to my words, but you are still able to tell me how and what you are feeling. | C | Summarizing the client's feelings and acknowledging that in spite of these, he is able to communicate honestly and openly with you, demonstrates you recognize his progress in addressing his emotions rather than sitting with ambivalence. This opens space for him to see that he can feel and express negative emotions without being abandoned. This will strengthen the therapeutic relationship. Asking him to tell you about the physical reaction changes the focus of the session to the mind-body connection, which is not as important right now as allowing him to express himself and feel safe in the relationship. "Why" questions are not used in counseling as they tend to make clients feel defensive. Counselors work to meet clients where they are and while setting boundaries for respect is important, clients often express negative emotions and should not be limited unless the manner of expressing is dangerous or clearly disrespectful to the counselor. In the case of clients with BPD, clients may test the strength of the therapeutic relationship to see if they will be abandoned. Therefore, the correct answer is (A) | counseling skills and interventions |
175 | Name: Bianca Clinical Issues: Difficulty adjusting to life changes Diagnostic Category: V-codes Provisional Diagnosis: Z60.0 Phase of Life Problem Age: 62 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: Black Marital Status: Separated Modality: Individual Therapy Location of Therapy : Agency | The client is a 62-year-old female, wearing work attire. She appears to be in good hygiene and her dress is neat and appropriate for the situation. Her facial expression is sad and she has tear tracks on her cheeks. Her mood is noticeably depressed, anxious, and tearful. Her affect is constricted. She has coherent thought processes with appropriate content. She expresses feelings of sadness over her failed marriage and overwhelm about being alone. The client has intact memory and concentration. She has fair insight into her current situation and is able to verbalize her feelings in a coherent manner. | First session The client comes to the agency practice where you currently work as a licensed mental health therapist. She is a 62-year-old female who recently retired from an accounting firm employment. She is seeking treatment after her marriage recently failed. A few months ago, he husband filed for a legal separation and is currently romantically involved with another woman. The client looks at you tearfully and says, "I can't believe this is happening at my age. I am all alone. What am I going to do?" She continues to cry uncontrollably. You focus on providing a safe and secure environment. You assure her that she will not be judged or criticized in any way, and all of the conversations during the session will remain confidential. You gently let her know that it is okay to cry, and you are there to listen without judgement. You also tell the client that it is natural to feel lost and alone after a separation, especially since she and her husband have been together for such a long time. She says, "I just feel like such a fool. He cheated on me once before - that I know of - and now he's done it again. I stayed with him for over 30 years, and now I have nothing." She describes having mixed feelings of anger, sadness, fear, and confusion. She states, "There are moments where I'm so mad at him for leaving. Mad enough that I could break something! Our marriage wasn't perfect, but I thought he was committed to me. Well, obviously he wasn't. Then I start to question what's wrong with me that made him leave. And then I think about the future and how I'm going to live by myself. It's all so overwhelming." She further discloses that she is worried about having panic attacks again because "that's what happened the last time something of this magnitude happened to me." You reinforce the idea that it is important to focus on the fact that she is not alone and many people in similar situations feel overwhelmed and uncertain about their future. You let her know she is in a safe space to explore her feelings, work through her loss, and develop a plan for moving forward. You encourage her to reach out for support during this challenging time rather than isolate herself as she goes through this difficult change. Fifth session The client has been seeing you for individual therapy sessions every week. You have developed a strong rapport with her and collaborated on treatment goals, with her overall goal being to have a positive outlook on her life. During the last session, you gave her a homework assignment to begin keeping a journal, using the ABC model of rational emotive behavior therapy to identify self-defeating beliefs and understand how they are contributing to her emotional distress. You have also been working with her to process her feelings about her separation and develop coping skills. During today's session, she seems depressed, as she tells you her husband met with an attorney and officially filed for divorce. You explore her journal entries, noting one in particular in which she describes an experience in which she was driving and saw her husband sitting outside a café with "the other woman." She circled back a few times in her car, hoping he would see her. In her mind, she fantasized that he would leave his new girlfriend and drive away with her, and everything would return to normal. You ask her to tell you more about what "normal" means to her. She says, "I guess I just want things to go back to how it was before. When I mattered, when I felt loved, and when he was committed to our marriage." You acknowledge her feelings and explain that while it may not be possible to go back to exactly how things were, there is still hope for the future. You express compassion and understanding, emphasizing that there is no right or wrong way to feel. She states, "I just have mixed feelings about everything! I feel angry and betrayed by my husband, but sometimes I want him to come back. I start to feel lonely and realize the reality of my situation and that I have no purpose anymore and am alone. What's the point? My kids don't care; I have nothing in my life now. Things are so painful I'd be better off dead." You reassure her that you are here to support her as she works through all of her difficult emotions. | null | What is the best way to reflect the client's feelings? | "You've experienced a lot of major changes lately, and it's understandable that you would like things to return to how they were before the separation." | "It's normal to feel like you have no purpose in life, especially when your children no longer need you like they did when they were growing up. Let's talk about what you can do to find your purpose again." | "It seems like you're experiencing a lot of difficult and confusing emotions. You're feeling stressed about your marriage, alone, and uncertain about your future." | "I can understand how difficult it must be to go through such a huge change in your life and see the person you once shared so much with now spending time with someone else." | (A): "You've experienced a lot of major changes lately, and it's understandable that you would like things to return to how they were before the separation."
(B): "It's normal to feel like you have no purpose in life, especially when your children no longer need you like they did when they were growing up. Let's talk about what you can do to find your purpose again."
(C): "It seems like you're experiencing a lot of difficult and confusing emotions. You're feeling stressed about your marriage, alone, and uncertain about your future."
(D): "I can understand how difficult it must be to go through such a huge change in your life and see the person you once shared so much with now spending time with someone else." | "It seems like you're experiencing a lot of difficult and confusing emotions. You're feeling stressed about your marriage, alone, and uncertain about your future." | C | Reflection of feelings is the process of deeply considering and understanding the emotions of another person and articulating those emotions back to them in a supportive and non-judgmental way. Therefore, the correct answer is (D) | counseling skills and interventions |
176 | Initial Intake: Age: 20 Gender: Male Sexual Orientation: Homosexual Race/Ethnicity: African American Relationship Status: Single Counseling Setting: University counseling center Type of Counseling: Individual | Jonathan presents as anxious with congruent affect, evidenced by client self-report and therapist observations of fidgeting, inability to sit still, tearfulness and shallow breathing with rapid paced speech. Jonathan occasionally closes his eyes and takes deep breaths when he begins to cry in attempt to slow himself down and prevent what he calls “another emotional breakdown.” He has prior inpatient treatment history of a one-week episode where he was involuntarily committed at 17 for making comments about planning to kill himself in response to his stress over finishing high school. He admits to passive suicidal ideations in the past few weeks while studying for exams but does not report considering a method or plan. He reports that he has been losing sleep because of long study hours and feeling too keyed up to calm down. You assess him as having distress primarily associated with anxiety, which at times of abundant stress turns to episodes of depression and hopelessness. | Diagnosis: Anxiety disorder, unspecified (F41.9), Major depressive disorder, single episode, unspecified (F32.9)
You are a brand-new counseling intern in the counseling resource center of a local university. Jonathan is a junior in college and comes to speak with you, as you are his newly assigned college university counselor. Jonathan is concerned about finals that he feels unprepared for, stating he is “overwhelmed” and “under too much pressure” from his family to “allow himself” to fail. He is making disparaging, negative remarks about himself and his abilities, often repeating himself and talking in circles using emotional reasoning. He asks you for help in getting his teachers to modify his deadlines so that he can have enough time to accomplish all his assignments, mentioning that his last counselor did that and called it “playing the mental health card”. There are no previous records on file for this student, but when you ask him who he met with he just changes the subject and continues to express his worry that he will “never amount to anything or graduate” if he fails these exams. | Education and Work History:
Jonathan has a high academic performance history, despite short periods of time where he experiences heightened stress. Jonathan has never gotten in trouble in school or had any infractions at part-time jobs later as a teenager. He has worked after-school jobs at the grocery store, bowling alley, and local town library. Jonathan had only one work-related incident where he broke down emotionally when feeling overwhelmed and left work in the middle of his shift, but his supervisor was supportive and helped him.
Current Living Situation:
Jonathan lives in the college dormitory with a peer and is supported by his mother. His mother is a single mom who works full-time in Jonathan’s hometown, which is almost a full day’s worth of driving from where Jonathan goes to college. Jonathan mentions that his friends call him “Jonny.” He adds that the food available to him is not very healthy and he has poor eating habits due to prioritizing studying and his involvement in extra-curricular activities. | What are you assessing when you are evaluating Jonny's current presentation and ability to cope? | hallucinations or delusions | adult skills of daily living | depression history | here and now functioning | (A): hallucinations or delusions
(B): adult skills of daily living
(C): depression history
(D): here and now functioning | here and now functioning | D | Evaluating Jonny's here and now functioning is part of a mental status exam and addresses how Jonny is coping and surviving his current situation. Jonny reported not eating well, and being too stressed to sleep, which now seems to be manifesting in overwhelming emotions and the development of cognitive distortions. Conducting measurement examinations or interviewing as well as reviewing any previous charts or notes available concerning Jonny's depression diagnosis would be what you are looking for in terms of learning about his depression history. Regardless of depression history, here and now functioning can be evaluated on its own. Jonny may not be doing a great job of self-care but living alone is a good sign that he has mastered enough ADL's to be living alone at college. Hallucinations and delusions may be present during an assessment, which would change the details of the here and now functioning results. Therefore, the correct answer is (A) | intake, assessment, and diagnosis |
177 | Client Age: 15 Sex: Female Gender: Female Sexual Orientation: Heterosexual Ethnicity: African American Counseling Setting: Agency Type of Counseling: Individual and Group Presenting Problem: Anxiety Diagnosis: Generalized Anxiety Disorder (GAD) 300.02 (F41.1) | Mental Status Exam: The client is dressed in age-appropriate clothing and is neat in appearance. She is cooperative and, at times, overly compliant with the interview questions, which is exemplified by apologizing unnecessarily for “not answering questions in the right way.” Her eye contact is poor, but she is engaged in the interview process. The client is restless and fidgety, and her tone of voice is soft. She states that she gets between 5 and 6 hours of sleep each night, which makes her irritable at times. Her affect is anxious, and she reports poor concentration. Her excessive worry has resulted in exhaustion and feeling like she is “always playing catch-up” with sleep and schoolwork. She denies any suicidal or homicidal ideations. The client also denies drug or alcohol use. Family History and History of th | You are a counselor working in a child and family outpatient mental health center. Your client is a 15-year-old African American female enrolled in the 10th grade at a predominately white private high school. She presents today with her father, who says she “has not been herself lately.” The client reports that she is under an enormous amount of pressure to excel academically and athletically. She is the number-one ranked player on the varsity tennis team and is in the school’s honors program. The client states that she perseverates the night before a tennis match and worries that her performance will be subpar. She reports excessively practicing her serves and backhands in her spare time because she is constantly dissatisfied with her less-than-perfect performance. The client says that she feels like she doesn’t fit in with her peers, which she attributes to being the only person of color on her tennis team, and one of few in the student body. | The client attends group therapy and is making therapeutic gains. Her overall anxiety has decreased, and she is engaging in more constructive thinking. Today is week 6 out of the 12 scheduled weekly group sessions. The client continues to work on increasing her assertiveness and has become less tentative with self-disclosures. She is pleasant and cooperative but remains eager to please others. Three group participants have formed a subgroup (i\. e., clique) and have excluded others. The client has begun to take social risks, and today she shares about a time when she felt most anxious. You notice the subgroup whispering and laughing after her disclosure. She nervously turns to you to gauge your response. Three of the subgroup participants are exhibiting negative behaviors | Three of the subgroup participants are exhibiting negative behaviors. Which one of the following observations would most likely indicate that the client’s group has successfully moved on to the next stage of development? | Avoidance of controversy | Acceptance of all group members | Group momentum slows down | Members vying for leadership roles | (A): Avoidance of controversy
(B): Acceptance of all group members
(C): Group momentum slows down
(D): Members vying for leadership roles | Acceptance of all group members | B | Acceptance of all group members would most likely indicate that the group has successfully moved to the next stage of development. The group is currently in the middle, or storming, stage of group development. The storming stage is characterized by conflict among members, challenges toward group leaders, and the formation of alliances or subgroups. During this phase, members vie for leadership roles as the desire for power and control becomes more pronounced. According to Tuckman (1984), there are five phases of group development: (1) the forming stage is marked by avoidance of controversy, apprehension, and tentative exploration, (2) the aforementioned storming phase, (3) the norming stage, in which structure and trust evolve and all members are accepted as the group begins to bond together, (4) the performing stage, in which the group functions as a unit working toward common goals,and (5) the final stage, adjourning, in which the group’s momentum slows as the group prepares to separate and say goodbye. Therefore, the correct answer is (C) | counseling skills and interventions |
178 | Name: Jack and Diane Clinical Issues: Marital/partner communication problems Diagnostic Category: V-codes Provisional Diagnosis: Z63.0 Relationship Distress with Spouse Age: 35 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: White Marital Status: Married Modality: Couples Therapy Location of Therapy : Community-based mental health facility | The clients are a couple in their mid-30s. The husband is tall and healthy. The wife is petite and well-groomed. As they enter, you make note that though they came in the same vehicle, they enter with no contact between them. They sit far away from one another and do not look at each other but maintain excellent eye contact with you. The husband's movements seem to be more agitated; the wife appears subdued. He speaks quickly and loudly and often fidgets in his chair, rarely sitting still; in contrast, her speech is low and soft, and she remains still and moves very little. They both seem guarded. They both identify their son's diagnosis of Autism Spectrum as being a significant strssor. | First session Your clients are in their mid-30s and present to the community agency where you are employed as both a licensed mental health therapist and a marriage and family therapist. You begin by introducing yourself and telling the couple about your professional experience and explain the types of therapies that you provide for couples. When asked why the couple made an appointment to meet with you, the husband takes the lead and tells you that he and his wife have been "serious problems" with their relationship for a few years. The husband shares that his wife does not trust him since his alcohol use "got out of control." Although he has been able to maintain sobriety for two years, he says that his wife is "paranoid" that he is using again and insists on knowing where he is "every minute of the day." He further reports that his wife is "too dependent" on him, and he feels "suffocated." He says, "I just can't keep doing this" and puts his head in his hands. You thank him for sharing his perspective of the problem and encourage the wife to share her thoughts about what is going on with their relationship. She tells you, "Truthfully? I'm scared to death that he's going to start drinking again and leave me alone with our children. I don't know what I would do if I lost him." She wipes a tear away from her face. After taking a deep breath, she says that when she tries to approach him to talk about how she feels, "he just gets mad and leaves the room." Using open-ended questions, you ask about each person's expectations for the counseling process and inquire about past experiences in therapy that may inform the current situation. Both partners look at each other, then back at you and share that they would like to re-establish trust and respect in their marriage. This is their first time seeking counseling. You also invite them to share the story of how they first met each other, memories of their relationship prior to getting married, and how they felt when they became parents. The husband shares that they first met when they were teenagers and have been together ever since. He talks about how their relationship was full of passion, respect, and trust. Even during the difficult times, they felt like nothing could tear them apart. He also shares that when their son was diagnosed with Autism Spectrum Disorder, they felt like the world had come to a standstill, but they were determined to get him the best care possible. He pauses. The husband and wife look at each other before the wife speaks. She explains that after their son's diagnosis, her husband began to drink more heavily as a way of dealing with his own stress and anxiety. He denied it for a long time, but eventually admitted he needed help and sought treatment. Although she was relieved that he got help, she is still struggling to trust him again. | The husband used to have severe issues with alcohol. He went to rehab three years ago and has maintained sobriety for two years. He continues to attend weekly meetings. As a result of his alcohol misuse, he has some medical issues with his liver, but they are not currently life-threatening as long as he continues to abstain from alcohol. The husband has worked hard to rebuild his relationships with his family and friends. He is actively trying to repair the damage that was done due to his alcohol misuse. He has been attending AA meetings and is focusing on rebuilding trust and communication. He has also been making an effort to be more present in his family life and to be a better husband and father. | Which is the quickest way for you to understand the nature and severity of the conflict within the couple's relationship? | The Relationship Assessment Scale | MMPI-3 | Making the conflict the focus of the sessions. | Marital Satisfaction Survey | (A): The Relationship Assessment Scale
(B): MMPI-3
(C): Making the conflict the focus of the sessions.
(D): Marital Satisfaction Survey | Marital Satisfaction Survey | D | The Marital Satisfaction Survey assesses conflict within the relationship. It would be most appropriate given the presenting problems. Therefore, the correct answer is (D) | intake, assessment, and diagnosis |
179 | Client Age: 4 Sex: Female Gender: Female Sexuality: Unknown Ethnicity: Caucasian Relationship Status: Not applicable Counseling Setting: Private Practice Clinic Type of Counseling: Family Therapy Presenting Problem: Foster Care; Disengaged Child; Behavioral Problems Diagnosis: Provisional Diagnosis of Reactive Attachment Disorder (F94.1) | Mental Status Exam: The client is disengaged, and when the foster parents prompt her to answer questions, she ignores them and continues playing. The client appears oriented to person, place, time, and situation because she answered questions about these topics. The client appeared more responsive to your questions than her foster par | You are a private practice counselor specializing in working with children with developmental disorders. The 4-year-old female client is referred to you by her PCP and arrives with her foster parents, who join her in the first session. The client has been with her foster parents for the last 13 months after being removed from the care of her biological parents due to their incarceration for drug trafficking and attempted armed robbery. The foster parents are worried because the client exhibits minimal positive mood, irritability without an obvious trigger, and behaviors that appear to be clearly connected to attachment with caregivers. She experienced emotional and physical neglect from the birth parents and changes in primary caregivers. The foster parents also report that the client does not seek comfort when something happens that upsets her. The client did not engage very much in the intake session and was instead playing with the toys provided by the counselor. During the session, the client becomes upset with her foster parents when they prompt her to answer some questions. She hits the foster father, runs out to the lobby, and sits down with the toys. You leave the office and meet her in the lobby. | ents. Family History: The client entered foster care 1 year ago when her parents were arrested on charges of drug trafficking and armed robbery. The client has been with the same foster parents for the past year. The client experienced emotional and physical neglect by her birth parents and was separated from her 5-year-old brother and 2-year-old sister when she entered foster care. He appears to have had trouble with attachment to the foster parents per the foster parents’ report. Following the first session, the birth mother calls you from jail asking about her daughter’s treatment, and you are able to verify that this is indeed the birth mother | Following the first session, the birth mother calls you from jail asking about her daughter’s treatment, and you are able to verify that this is indeed the birth mother. Which of the following is true regarding the birth parents’ right to access information regarding their biological daughter? | Only the foster parents have access to all of the information because they are the caregivers. | The birth parents still have a right to access information if their parental rights have not been terminated. | Regardless of whether the birth parents’ rights have been terminated, they still have access to your client’s information. | Because social services took over care of the child, they can decide if the birth parents have access to treatment information. | (A): Only the foster parents have access to all of the information because they are the caregivers.
(B): The birth parents still have a right to access information if their parental rights have not been terminated.
(C): Regardless of whether the birth parents’ rights have been terminated, they still have access to your client’s information.
(D): Because social services took over care of the child, they can decide if the birth parents have access to treatment information. | The birth parents still have a right to access information if their parental rights have not been terminated. | B | Unless parental rights are terminated, the birth parents have rights to PHI. The foster parents are able to provide reasonable medical and mental health care for the child that they are taking care of; therefore, because they are part of the therapeutic process, they also have access to this information. Therefore, the correct answer is (C) | professional practice and ethics |
180 | Client Age: 9 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Private practice clinic Type of Counseling: Individual counseling with family involvement Presenting Problem: Behavioral problems and social skills issues Diagnosis: Autism spectrum disorder, without accompanying intellectual impairment (F84.0) | Mental Status Exam: The client is oriented to person, place, situation, and time. The client appears clean and is wearing season-appropriate clothing; however, his parents report that he often wears the same outfit for several days because he gets frustrated with having to change his clothes and showering. The client was minimally involved in the intake session and was instead focused on reading a video game walk-through | You are a private practice, licensed counselor. The client is 9 years old and comes to the first session with his parents. The client has been previously diagnosed with autism via use of the Autism Diagnostic Observation Schedule-Second Edition by a psychologist, and you receive supporting documentation for this diagnosis. The client demonstrates difficulties with normal back-and-forth communication with peers, difficulty maintaining eye contact during the session, and difficulty with imaginative play with peers as reported by his parents. The client and his parents also report what they call “OCD behavior”—for example, he often lines up toys and insists that they “have to be this way”—and that he has trouble with changes in schedule, often becoming aggressive toward the parents if changes occur. The parents report that he is very rigid and that certain activities and play have to be done a certain way or he becomes upset, which affect the home, social, and school settings. The client’s intellectual quotient is above average for his age per the supportive testing provided. The parents report that the client’s difficulty with changing plans or daily changes causes him to become angry and confrontational. | This session is occurring in the client’s home in order to observe behaviors in his natural environment. The client’s parents and 8-year-old brother are present. You are observing during this session in order to gather information and then to provide psychoeducation at the end of the session to the parents. The client and his brother are sitting on the floor playing with a building toy, which the client’s parents report is often a toy that causes him frustration because he plays very specifically with it and his brother does not want to play how he does. After about 5 minutes, the client becomes visibly frustrated as he is telling his brother to put a brick in a certain place because it is the same color and his brother says he is not going to and goes to build on his own. The client continues to build and asks for the piece repeatedly over a few minutes. The client then picks up what he is building and throws it against the wall and leaves the room. During the session, the parents leave to answer a phone call, and the client’s uncle comes into the room | During the session, the parents leave to answer a phone call, and the client’s uncle comes into the room. When the client’s uncle asks who you are and why you are in the home, which one of the following would be the most ethical response? | “I’m a friend of the family; my name is (state your name).” | “I’m (state your name), your nephew’s counselor.” | “I’m (state your name); it’s nice to meet you. I can’t answer that question, but you’re welcome to ask your brother.” | “I’m a counselor, but I can’t say who I’m here to work with.” | (A): “I’m a friend of the family; my name is (state your name).”
(B): “I’m (state your name), your nephew’s counselor.”
(C): “I’m (state your name); it’s nice to meet you. I can’t answer that question, but you’re welcome to ask your brother.”
(D): “I’m a counselor, but I can’t say who I’m here to work with.” | “I’m (state your name); it’s nice to meet you. I can’t answer that question, but you’re welcome to ask your brother.” | C | Working in the community provides opportunities for situations like this. You are not able to tell anyone other than the client (or who you have a release of information to talk to) why you are present and who you are working with. It is most appropriate to redirect the uncle to the client’s parents because the client is a minor and he may not be able to appropriately choose whether to reveal who you are. Telling the uncle that you are there as a friend of the family is not true and would not assist in developing trust with the client’s uncle if you end up having to coordinate services with him also. Telling the uncle that you are the nephew’s counselor would breach confidentiality, as would telling him that you are a counselor but cannot say who you are working with. Therefore, the correct answer is (D) | professional practice and ethics |
181 | Client Age: 32 Gender: Female Sexuality: Bisexual Ethnicity: Caucasian Counseling Setting: Agency Type of Counseling: Individual Presenting Problem: Binge-eating Diagnosis: Binge-Eating Disorder 307.51 (F50.8), Moderate | Mental Status Exam: The client presents as polite and cooperative. She was well-groomed and dressed appropriately for the situation. Her affect is blunted, and she is tearful when discussing episodes of binge eating. The client has poor eye contact and periodically bites her fingernails. Her thought content is clear. She does not endorse audiovisual hallucinations, and she is oriented to person, place, time, and situation. The client denies suicidal and homicidal ideations. She denies previous suicidal attempts but states that she used to engage in cutting when she was an adolescent | You are working at an agency serving clients from the metropolitan area. Your client is a 32-year-old bisexual female presenting with feelings of sadness, frustration, and shame due to increased episodes of binge eating. The client explains that she has tried unsuccessfully to manage her weight and control her eating. She states she is secretive when bingeing and feels “disgusted” afterward but “completely unable” to stop the compulsion. The client reports binge eating six times per week, with episodes worsening in the last two years. She identifies as bisexual and reports her binge eating increased after coming out to her family. She continues to struggle with depressive symptoms, including feelings of hopelessness, depressed mood, and anhedonia. The client’s weight places her in the category of obese, and she has recently been diagnosed with borderline diabetes. Towards the end of the session, the client states, “This is starting to affect my health. If I could change anything in my life, it would be to stop binge eating.” | The client has made steady progress toward reducing maladaptive eating. After several weeks of collecting self-monitoring data, you and the client successfully identify patterns that maintain the problem of binge eating. The client’s depressive symptoms have improved, and she is seeking interpersonal connections. She has set appropriate boundaries with her family and distanced herself from their church. The client briefly attended a more liberal church, experienced biphobia, and did not return. She explains, “In my parent’s church, I’m not straight enough. In the LGBTQ community, I’m not gay enough.” You have introduced her to dialectical behavioral therapy, and she attributes mindfulness to improved depressive symptoms. The client’s depression has lifted, and she is seeking interpersonal connections | The client’s depression has lifted, and she is seeking interpersonal connections. Which one of the following theorizes that the client’s intrinsic desire for connection is driven by competence, relatedness, and autonomy? | Self-actualization process | Self-reflection method | Self-fulfilling prophecy | Self-determination theory | (A): Self-actualization process
(B): Self-reflection method
(C): Self-fulfilling prophecy
(D): Self-determination theory | Self-determination theory | D | Self-determination theory is based on the assumption that people are motivated by competence, connection, and autonomy, which are all required to achieve psychological growth. Self-actualization is a term used by Abraham Maslow that refers to a person’s highest level of personal fulfillment. Self-reflection is used in many approaches and is not specifically tied to a desire to have close personal relationships. A self-fulfilling prophecy is used when making future predictions and then acting in ways that guarantee that the prediction comes true. Therefore, the correct answer is (B) | counseling skills and interventions |
182 | Name: Rick Clinical Issues: Referred for emotional and behavior issues Diagnostic Category: No Diagnosis Provisional Diagnosis: No Diagnosis Age: 18 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: Korean Marital Status: Single Modality: Group Therapy Location of Therapy : Community Center | The client is slouched over in his seat and appears withdrawn with a flat affect. He keeps his head down. The client plays with his shirt sleeve, twisting the material and pulling at it. You cannot see any cuts on his arms as reported by the mother. He does not appear to be angry at this time, which was also a symptom reported by his mother. He responds to your questions with one-word answers. He seems uninterested. The client denies any suicidal and homicidal ideation. The client mumbles, "I don't want to talk about anything here." | First session You work as both an individual and group therapist at a community center that primarily sees adolescents with emotional and behavioral issues. Rick is a senior in high school and lives with his mother and two sisters. Rick does not want to participate in individual or group therapy, but his mother insists that he get help. During the intake, you work to establish rapport with Rick. You also gather information to determine if he is an appropriate candidate for one of the groups you are preparing to start, along with a co-facilitator. You suspect he may have trouble trusting females as he expresses anger when talking about his mother, sister, and ex-girlfriend. Since his father left, Rick says that his mother has been "in his business" all the time, and he does not feel like he has any real privacy. You remain patient with Rick, listening to his story and validating his feelings. You empathize with him, letting him know it is understandable to feel frustrated about not having much privacy. You explain that you are here to help him, not to control him and that you are interested in learning more about him. You explain to Rick that you are planning to start a group therapy session with a co-facilitator and that you would like to see if it would be a good fit for him. You explain that the group will provide an opportunity for him to talk about his experiences in a safe space with others who may have gone through similar situations In addition, you share that it could be an excellent way for him to practice expressing himself and developing trust in others. You also explain to Rick that individual therapy sessions could be beneficial in addition to group therapy. You discuss the possibility of one-on-one sessions that would give him a chance to talk more deeply about his experiences in a safe, private setting You emphasize that this could be an excellent way for him to explore his feelings and learn how to cope with them in a healthy way. Sixth session Rick has been attending group therapy weekly. He continues to wear long sleeves to the session but appears engaged and involved in the group process. The group exhibits high cohesion, and all members participate in group activities. The focus is on continued productivity and problem-solving. You ask the members to reflect on the skills they have been practicing in the group and share an experience in which they have applied those skills outside the session. Rick's experience in the group has further helped him to identify and understand his feelings. He has been able to recognize his anger and express it in a healthier way. He has also been able to recognize his need for connection. He says he recently called his ex-girlfriend to apologize for being angry about his parents and "taking it out on her" by withdrawing from her. This has enabled him to develop a more constructive approach to conflict. The group members have provided Rick with a safe space to practice his new skills, giving him the confidence to try them in his real-life relationships. The other members have shown Rick support and encouraged him to take risks and to be open to opportunities for growth. Rick's active engagement in the group has been instrumental in his progress. He has become more aware of his emotions, and he can express himself in a way that is respectful and appropriate. His newfound ability to communicate effectively has been a significant step towards strengthening his relationships both inside and outside of the group. | The client is a first-generation American whose parents immigrated from Korea. He has an old sister who, based on Korean culture, is his superior whom he must obey and be subservient to. His parents have high expectations for him and are very controlling, expecting him to study every night and attend tutoring sessions on the weekend. They have arranged for him to marry a daughter of a prestigious family in Korea after he completes medical school eight years from now, with the intention that he and his wife will live with them and provide financial support. However, this plan has drastically changed. Seven months ago, the client's father moved out after his mother had an affair. The client became sullen, angry, and withdrawn after this event. Four months ago, while doing laundry, the client's mother saw dried blood on his shirt sleeve. She also noticed that he was wearing long-sleeved shirts all the time. She waited until he was getting dressed, walked in on him, and found he had cuts up and down his arms. The client does not speak to his father much since his parents separated. The client expresses a lot of anger toward the women in his life, specifically his mother, sister and ex-girlfriend. The client is a senior in high school. His grades have been suffering lately, and he is currently failing his math and science classes. Personal/Social Relationships: The client had been concealing his romantic relationship with a girl from his Saturday tutoring class, but following his father's abrupt departure from the family, he chose to discontinue the relationship and cease attending the class. He has since refrained from any communication or contact with her. His mother's affair has caused him to feel overwhelmed with anger, leading him to develop a dislike of all women. | Based on Yalom's eleven therapeutic factors of group therapy, which is most efficacious for the client? | Interpersonal Learning | Imitative Behavior | Catharsis | Existential Factors | (A): Interpersonal Learning
(B): Imitative Behavior
(C): Catharsis
(D): Existential Factors | Interpersonal Learning | A | The client has shown an affinity for learning from his fellow group members. Therefore, the correct answer is (C) | counseling skills and interventions |
183 | Name: Becky Clinical Issues: Behavioral problems Diagnostic Category: Disruptive/Impulse-Control/Conduct Disorders Provisional Diagnosis: F91.1 Conduct Disorder, Childhood-onset Type Age: 10 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Not Assessed Ethnicity: White Marital Status: Not Applicable Modality: Family Therapy Location of Therapy : School | Appearance: Female with crossed arms, avoiding eye contact, and a blank expression. Affect: Flat affect. Speech: Responses are brief and monotone, lacking emotion. Thought Process: Poor focus, easily distracted, and unable to maintain a cohesive conversation. Thought Content: Negativity-focused on herself, blaming others for her difficulties; no suicidal or homicidal ideation reported. Perception: No evidence of hallucinations or delusions. Cognition: Difficulty with problem solving, difficulty shifting focus between tasks, and poor organization skills. Insight/Judgment: Poor insight into her situation; judgment impaired due to her inability to see the consequences of her actions. | First session You are a school counselor and often work with families whose children are having behavioral issues. A 10-year-old female student named Becky comes to your office with her parents. Becky's teacher notified you of behavioral problems she noticed in the classroom. You arranged to meet with Becky and her parents to discuss the teacher's concerns and determine how you can best support Becky's needs. You explain your role as a school counselor, providing short-term counseling for students and making referrals if long-term therapy is deemed appropriate. Becky's parents tell you that "it wasn't a surprise to get your phone call," as their daughter's behavior is poor at home, too. They are at their "wit's end" due to their daughter's constant "back talking" and "arguing" with them and any other authority figures in her life. Becky blames others when confronted at school and has become physically aggressive toward her classmates and teacher. You attempt to build rapport with Becky, but this proves challenging as she is not responsive to your efforts. Becky seemed to be quite guarded and disconnected during the initial assessment. She demonstrated defensive behaviors, such as crossed arms, avoiding eye contact, and evasive responses. She appeared to be dissociated from her current environment and seemingly uninterested in the conversation. However, she did demonstrate a certain level of compliance when her parents attempted to redirect her focus. Her parents reported that Becky has been displaying these behaviors for months, escalating in intensity as time has passed. She has been increasingly defiant and aggressive both at home and at school. They are concerned that her behavior could pose a risk to her safety and have already attempted different strategies to help her, such as removing privileges and providing additional structure. Still, she continues to be uncooperative and argumentative. Clearly, the family was feeling overwhelmed and needed help managing Becky's behaviors. Fourth session You have been meeting with Becky for 30-minute sessions once a week for the past three weeks. You have been collaborating with her parents and sharing strategies for how they can support their daughter at home. You have also been communicating with Becky's teacher to monitor Becky's behavior in the classroom. Today is your fourth session with Becky, and she is accompanied by her mother. The mother reveals that her daughter has stolen money from her purse. The mother has also received a call from Becky's teacher informing the parent that Becky was seen removing items from the teacher's desk. When confronted with this information during the session, Becky loudly denies stealing anything, calls her mother a liar, grabs a coffee cup from your desk, and throws it on the floor. You respond to the situation by remaining calm and utilizing a nonjudgmental approach. You remind Becky and her mother that it was a safe space to discuss their feelings and that it was important to express them appropriately. You then explored Becky's feelings about her mother's accusation to understand her perspective and encourage Becky to take ownership of her behavior. Finally, before Becky and her mother leave, you provide them with tools to practice at home to manage their emotions, suggesting they focus on communication, problem-solving, and finding healthy ways to express their feelings. | The client is currently failing in school. Her teacher has called for a conference to begin the process of making an individualized education plan (IEP) to address the client's disruptive behavior. The client has been referred to you for therapy. She has a history of aggressive behavior toward peers and teachers, including physical attacks and verbal aggression. She has also been observed to demonstrate non-compliant behavior, such as refusing to wear a face mask when interacting with other students. Additionally, she has been observed to demonstrate oppositional behavior, such as sticking her tongue out at the teacher. These behaviors have been consistently reported by the teacher and other school staff and have been increasing in frequency and intensity. These behaviors have significantly impacted the client's academic performance and have resulted in her current failure in school. Her teacher has called for a conference to begin the process of making an individualized education plan (IEP) to address the client's disruptive behavior. | How does the current revelation of the client's engaging in petty theft behavior affect your treatment plan? | An effective therapist does not need to feel shackled to a plan but remains flexible and addresses the client's here-and-now behaviors. | The therapist might want to change the collaborative treatment plan but must have the parent's written consent to make any alterations. | Given the new information regarding the client's behavior, it is appropriate to modify the treatment plan. | Consistency and structure are necessary for a successful therapeutic outcome. Once the treatment plan has been finalized, it should be changed only minimally. | (A): An effective therapist does not need to feel shackled to a plan but remains flexible and addresses the client's here-and-now behaviors.
(B): The therapist might want to change the collaborative treatment plan but must have the parent's written consent to make any alterations.
(C): Given the new information regarding the client's behavior, it is appropriate to modify the treatment plan.
(D): Consistency and structure are necessary for a successful therapeutic outcome. Once the treatment plan has been finalized, it should be changed only minimally. | Given the new information regarding the client's behavior, it is appropriate to modify the treatment plan. | C | The treatment plan is most useful when it deals with the whole of the client's behaviors. The treatment plan needs to be flexible to meet the client's ever-changing needs. Therefore, the correct answer is (D) | treatment planning |
184 | Initial Intake: Age: 40 Sex: Female Gender: Female Sexuality: Lesbian Ethnicity: African American Relationship Status: Partnered Counseling Setting: Community Agency Type of Counseling: Individual | The client appears to be slightly older than stated and demonstrates positive signs of self-care in her hygiene and dress. She states her mood fluctuates between “sad and okay.” Her affect is labile and mirrors topics discussed in session. She smiles when describing her children and her relationship with her former oncology team. She cries easily when discussing cancer, moving, instability, and fears. The client is cooperative and forthcoming, with easily understood speech. She offers insight into her thoughts and behaviors, is attentive, and shows no difficulties with memory or judgement. She acknowledges one episode of suicidal ideation, without plan, during her adolescence when she desperately missed her mother while on a custodial visit with her father. She has had no thoughts of harming herself since then and has no thoughts of harming others. | You are a counselor in a community agency. Your client presents with concerns about her lifelong history of being “anxious and emotional” since her parent’s divorce when she was 12. She tells you her feelings of “anxiety and feeling badly about myself” intensified when she was diagnosed with breast cancer four years ago and then again when her family moved to the area last year. She tells you that she thinks she managed her emotions well during her treatment because her focus was on getting through the crisis. She also was taking Klonopin twice a day for anxiety. She says she feels that she has let her family down by having cancer because it costs them monetarily and emotionally; she wonders sometimes if her cancer is a punishment for something she’s done. She reports that she does not discuss these concerns and emotional fears with her partner because “she has become the breadwinner and I feel like I need to protect her from my negativity.” On intake forms, she endorses crying daily, trouble sleeping, concentrating on things, has been losing weight without trying, and constantly worrying about her health and the family’s finances. She tells you that her partner says she “runs around like a chicken with my head cut off because I start stuff like cleaning or cooking and then stop right in the middle of it. I just get restless and sometimes I just can’t stop fidgeting when I should be paying attention.” She notes that she is in menopause due to her cancer treatments, which included a removal of her ovaries three years ago and a hysterectomy one year ago. She tells you people often refer to her as a “cancer survivor” but she doesn’t feel like she has survived it because every surgery makes her feel like she “is losing another piece of me.” Additionally, she says that having to have body scans every six months and not being able to look in the mirror and see a “complete woman” makes her feel that she is still trying to survive, rather than putting it in the past. | Family History:
Your client reports a four-year history of treatment for breast cancer. She has had 16 months of chemotherapy and 27 rounds of radiation, as well as a double mastectomy three years ago. She has completed reconstructive surgery for her breasts but has not yet added nipple tattooing for a more realistic image. She reports that she has three close female relatives with breast cancer, but no relapses after treatment. She states that she has been in a relationship with her partner for 17 years and they share two children, ages 12 and 8. She describes her partner as a “good person” and the relationship as “good.” She tells you that they moved to the area one year ago when her partner had an unexpected promotion. She reports this has been good but that their oldest child is “anxious, emotional, and just angry sometimes.” | Using the information you have learned, which of the following is the most appropriate next step? | Help the client develop goals that can be accomplished related to her body image | Teach the client relaxation skills to be used when she puts on a bathing suit | Teach the client that this is common post-cancer and most people get better with time | Help the client begin imagining herself undressed in front of a mirror | (A): Help the client develop goals that can be accomplished related to her body image
(B): Teach the client relaxation skills to be used when she puts on a bathing suit
(C): Teach the client that this is common post-cancer and most people get better with time
(D): Help the client begin imagining herself undressed in front of a mirror | Help the client develop goals that can be accomplished related to her body image | A | Before beginning therapy on this area of the client's concerns, outcome goals should be developed in collaboration with the client. This helps the client identify her ideal image as well as her realistic image so the counselor and client can focus on the changes she would like to make in her body, thoughts, and emotions. Setting goals builds hope and lets clients know they are not alone. Research does show that body image concerns are normal post cancer and they do tend to get better with time. While normalizing her concerns may be helpful, it is not likely to lower the level of distress she is currently feeling. Systematic desensitization (SE) is a helpful practice in post-cancer body image counseling; however, SE is approached slowly so beginning with having the client imagine herself undressed or putting on a bathing suit at this time is likely moving too quickly. Clients often stop therapy when SE is rushed, as it increases their level of anxiety. Therefore, the correct answer is (D) | treatment planning |
185 | Client Age: 30 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Pacific Islander Relationship Status: Single Counseling Setting: Private practice counseling clinic Type of Counseling: Individual counseling Presenting Problem: The client and her boyfriend recently broke up, and she is “tired of being with the wrong guys.” She admits that she will often stay in relationships even if she knows they are wrong for her. Diagnosis: Provisional diagnosis: Dependent personality disorder (F60.7), personal history (past history) of spouse or partner violence, physical (Z69.11), and personal history (past history) of spouse or partner psychological abuse (Z91.411) | Mental Status Exam: The client is oriented to person, place, time, and situation. No hallucinations, delusions, or paranoia are reported. The client was anxious at the start of the session, but she was able to calm herself down by easing into the counseling relation | You are a professional counselor working in a private practice clinic. The client comes in and sits quietly. The client appears nervous because she avoids eye contact and waits for you to initiate conversation. You ask why she is in counseling, and she responds that she is just tired. You ask more about this, and she says that she is not ready to talk about it yet. You decide to cover demographics and other less intimidating topics and then ask if she is comfortable talking yet. The client says that she feels a little more comfortable. She begins to state that she and her boyfriend broke up the previous week and that she was with him for 2 years. She explains that she has been “in this type of relationship before,” continually finds the “wrong guy,” and that she always goes “all in” with her relationships. Through processing, she identifies the following behaviors and beliefs: difficulty making daily decisions without the input of her partner, doing anything to gain support and affection even if she does not want to do the task or activity, quickly moving on to another relationship when a relationship ends, feeling that she cannot care for herself when she is not with someone else, and acknowledging that she needs others to take responsibility for major areas of her life. The client says that she has experienced physical and psychological abuse from partners, but that she is not ready to discuss this. The client identifies that her most important goal is to not end up in “the same relationship” again or rush into a relationship that is not right for her. Throughout the session, you provide empathetic and active listening. You suspect that the client has dependent personality disorder. | You meet with the client, and she reports that she started dating someone. You and the client spend some time talking about the man who she is dating and agree that he sounds like a nice person that is not taking advantage of her personality. You and the client discuss her having an increased awareness of the behaviors that she has engaged in in the past that she did not like. The client identifies that she has engaged in behavior that worries her with this boyfriend. She went out for lunch and felt compelled to buy him lunch also, even though he was not there. After exploring why the client feels an obligation to buy her boyfriend lunch when he is not present with her, it becomes clear that it is motivated by the fear that he will be offended that she bought herself lunch without thinking of him. You support the client in identifying more helpful thoughts related to this and ask her to complete a behavioral experiment regarding this situation. The client becomes frustrated that she is still struggling with relationships and says, “I think I’ll just date who I want and how I want from here on out. It’s definitely the easiest choice instead of doing all of this.” You remind the client that therapy takes some time but can be really beneficial and you praise her for engaging fully so far. Using the psychoanalytic approach to analyze the client’s statement about doing what she wants, you want to determine the influence of the id, ego, and superego | Using the psychoanalytic approach to analyze the client’s statement about doing what she wants, you want to determine the influence of the id, ego, and superego. Which one of the following is the best definition of the Freudian concept of the id? | Focus on unconscious basic impulses of aggression and sex | Focus on the balance between morals/ideals and basic impulses | Focus on morals and ideals | Focus on beliefs about the client’s own functioning | (A): Focus on unconscious basic impulses of aggression and sex
(B): Focus on the balance between morals/ideals and basic impulses
(C): Focus on morals and ideals
(D): Focus on beliefs about the client’s own functioning | Focus on unconscious basic impulses of aggression and sex | A | Sigmund Freud’s psychoanalytic theory states that there are three parts of the individual’s personality: the id, ego, and superego. The id focuses on basic impulses such as aggression and sex. Morals and ideals are part of the superego, and the balance between the two is the ego. The client’s own beliefs about functioning are not a part of Freud’s view of the human personality. Therefore, the correct answer is (A) | intake, assessment, and diagnosis |
186 | Client Age: 14 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Asian-American (Karen) Grade: 8th Counseling Setting: Child and Family Services Agency Type of Counseling: Individual and Family Presenting Problem: Substance Misuse and Acculturation Difficulties Diagnosis: Substance Use Disorder, Moderate (F2.911 ); Acculturation difficulty (V62.4 Z60.3) | Mental Status Exam: The client is polite and cooperative. He is neatly dressed and is the only member of his family who is not wearing traditional Karen clothing. His affect is restricted, and his eye contact is poor. The client denies suicidal and homicidal ideation. He reports feeling anxious and sad frequently. He expresses that he is particularly worried at school and has had a difficult time adjusting. The client states that he lived in outdoor homes and buildings before coming to the United States. He explains, “Here, I feel like I’m trapped in a c | You are working as a counselor in a child and family mental health agency. A 14-year-old Asian-American male presents with family members who are concerned about the client’s drug use. The family is part of an ethnic population from Southeast Asia who resettled in the United States just under two years ago. The client is fluent in English and interprets for the family. The client goes to a public school specifically designed to improve English proficiency and has, until recently, done well academically. The parents have limited English proficiency (LEP). The parents provide a letter from his school stating the client was suspended after administrators found marijuana and amphetamines in the client’s locker. The client expresses remorse and says he became highly anxious and fearful when the school resource officer became involved. He explains, “Where I come from, the police are not there to protect or help.” The client willingly completes a substance use screening assessment, and the results indicate he is at risk for meeting the diagnostic criteria for substance use disorder. | The client continues to be compliant with therapy but is having difficulty discontinuing his drug use. He states he uses because it changes his mood and helps him forget about not fitting in at home or school. He explains that when he speaks English or dresses in non-traditional clothing, his family says they feel like, “I’ll forget where I came from. But when I leave the house, all I hear is, ‘Go back to where you came from.’” The client states he began using at the end of 7th grade and started using daily approximately four months ago. He admits to feeling guilty about how his use affects his family but claims, “It’s not like I’m an addict or anything.” His parents arrive today with an interpreter and attend a concurrent parenting group with a psychoeducational component that addresses adolescent substance abuse | Using a motivational interviewing (MI) approach, how would you respond to the client’s uncertainty regarding his problematic drug use? | “Your disease affects your rational thinking. Can you identify and challenge those thoughts?” | “Your screening assessment tells a different story. What role is denial playing for you in this present moment?” | “You may not be ready to stop. What is it about using that you really need to hold onto?” | “Your addiction continues to harm your parents. What is the payoff for you today?” | (A): “Your disease affects your rational thinking. Can you identify and challenge those thoughts?”
(B): “Your screening assessment tells a different story. What role is denial playing for you in this present moment?”
(C): “You may not be ready to stop. What is it about using that you really need to hold onto?”
(D): “Your addiction continues to harm your parents. What is the payoff for you today?” | “You may not be ready to stop. What is it about using that you really need to hold onto?” | C | The use of MI is reflected in the following: “You may not be ready to stop. What is it about using that you really need to hold onto?” This statement stands apart from the other choices because it is non-confrontational, and the question appropriately addresses the client’s ambivalence. MI is used to address ambivalence and promote change. One aspect of this approach is to avoid argumentation. Avoiding argumentation is accomplished by refraining from accusations of denial or using terms like disease or addict. The idea is to roll with resistance by allowing the client to discover discrepancies between where they see currently see themselves and where they’d like to be in the future. Therefore, the correct answer is (B) | counseling skills and interventions |
187 | Initial Intake: Age: 12 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Hispanic Relationship Status: Single Counseling Setting: Outpatient Clinic Type of Counseling: Individual | Carlos came to the intake with his mother, Claudia. Claudia did most of the talking during the intake while Carlos sat in his chair, slumped down low and avoiding eye contact. | Carlos is a 12-year-old male referred to an outpatient community clinic by the court after he was caught breaking into several cars on his block.
History:
Claudia reported that she and Carlos’ father separated two years ago. Since then, Carlos has had frequent suspensions in school for bullying others and fighting. Carlos often threatens students on social media prior to the altercations. Claudia reported that she no longer knows what to do anymore and she hoped that the counselor can fix him or at least report to her what he is thinking when he does these things. | null | In coming up with treatment plan goals, the following is least important? | Consideration of other service providers | Treatment planning should be a collaborative process with Carlos | Prior history of success with similar goals | Discussion of termination | (A): Consideration of other service providers
(B): Treatment planning should be a collaborative process with Carlos
(C): Prior history of success with similar goals
(D): Discussion of termination | Prior history of success with similar goals | C | One of the goals of therapy is to change patterns of behavior and one of the beliefs in therapy is that people are capable of change. Although Carlos may not have been successful in the past with some goals, he may be successful if he tries again with additional support. The treatment planning process should always be client driven, with the client establishing the priorities. Termination should be discussed in the beginning of the therapeutic relationship, so the client is aware of the expectation that the goal is for them to be self-sufficient. When treatment planning, it is important to include formal and natural supports. It is also beneficial to understand the goals that the client may be working on with others to ensure that goals do not overlap or contradict one another. Therefore, the correct answer is (D) | counseling skills and interventions |
188 | Name: Becky Clinical Issues: Behavioral problems Diagnostic Category: Disruptive/Impulse-Control/Conduct Disorders Provisional Diagnosis: F91.1 Conduct Disorder, Childhood-onset Type Age: 10 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Not Assessed Ethnicity: White Marital Status: Not Applicable Modality: Family Therapy Location of Therapy : School | Appearance: Female with crossed arms, avoiding eye contact, and a blank expression. Affect: Flat affect. Speech: Responses are brief and monotone, lacking emotion. Thought Process: Poor focus, easily distracted, and unable to maintain a cohesive conversation. Thought Content: Negativity-focused on herself, blaming others for her difficulties; no suicidal or homicidal ideation reported. Perception: No evidence of hallucinations or delusions. Cognition: Difficulty with problem solving, difficulty shifting focus between tasks, and poor organization skills. Insight/Judgment: Poor insight into her situation; judgment impaired due to her inability to see the consequences of her actions. | First session You are a school counselor and often work with families whose children are having behavioral issues. A 10-year-old female student named Becky comes to your office with her parents. Becky's teacher notified you of behavioral problems she noticed in the classroom. You arranged to meet with Becky and her parents to discuss the teacher's concerns and determine how you can best support Becky's needs. You explain your role as a school counselor, providing short-term counseling for students and making referrals if long-term therapy is deemed appropriate. Becky's parents tell you that "it wasn't a surprise to get your phone call," as their daughter's behavior is poor at home, too. They are at their "wit's end" due to their daughter's constant "back talking" and "arguing" with them and any other authority figures in her life. Becky blames others when confronted at school and has become physically aggressive toward her classmates and teacher. You attempt to build rapport with Becky, but this proves challenging as she is not responsive to your efforts. Becky seemed to be quite guarded and disconnected during the initial assessment. She demonstrated defensive behaviors, such as crossed arms, avoiding eye contact, and evasive responses. She appeared to be dissociated from her current environment and seemingly uninterested in the conversation. However, she did demonstrate a certain level of compliance when her parents attempted to redirect her focus. Her parents reported that Becky has been displaying these behaviors for months, escalating in intensity as time has passed. She has been increasingly defiant and aggressive both at home and at school. They are concerned that her behavior could pose a risk to her safety and have already attempted different strategies to help her, such as removing privileges and providing additional structure. Still, she continues to be uncooperative and argumentative. Clearly, the family was feeling overwhelmed and needed help managing Becky's behaviors. | The client is currently failing in school. Her teacher has called for a conference to begin the process of making an individualized education plan (IEP) to address the client's disruptive behavior. The client has been referred to you for therapy. She has a history of aggressive behavior toward peers and teachers, including physical attacks and verbal aggression. She has also been observed to demonstrate non-compliant behavior, such as refusing to wear a face mask when interacting with other students. Additionally, she has been observed to demonstrate oppositional behavior, such as sticking her tongue out at the teacher. These behaviors have been consistently reported by the teacher and other school staff and have been increasing in frequency and intensity. These behaviors have significantly impacted the client's academic performance and have resulted in her current failure in school. Her teacher has called for a conference to begin the process of making an individualized education plan (IEP) to address the client's disruptive behavior. | Which assessment would provide the best method for assessing the client's behavioral issues? | The Conners 3rd Edition | The Early Childhood Inventory-4 | Autism Screening Instrument for Educational Planning | The Wechsler Intelligence Scale for Children | (A): The Conners 3rd Edition
(B): The Early Childhood Inventory-4
(C): Autism Screening Instrument for Educational Planning
(D): The Wechsler Intelligence Scale for Children | The Conners 3rd Edition | A | The Conners 3rd Edition is used to measure various behaviors in children from 6-18 years of age. It would be appropriate for this client. Therefore, the correct answer is (C) | intake, assessment, and diagnosis |
189 | Client Age: 12 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Private Practice Type of Counseling: Individual Counseling Presenting Problem: Withdrawn and Avoidant Behavior Diagnosis: Undetermined | Mental Status Exam: The client appears oriented to person, place, time, and situation. The client is dressed appropriately for the weather and appears to be maintaining appropriate hygiene. The client was withdrawn for most of the session but was able to open up slightly about what was going on with | You are a licensed therapist working in private practice. A 12-year-old female client comes into your office for the intake session and is accompanied by her parents. The client’s parents report that their daughter has been withdrawn and has refused to return to school for the past 6 school days. The client is avoiding eye contact with anyone and is slouching with her arms crossed. You try to engage the client in open questions to initiate the intake session with her, and she does not answer you or look at you. You ask her if privacy would make her more comfortable, and she nods, so you ask her parents if they would mind waiting in the lobby, and they agree. The client continues to refuse to talk about school, but she does engage in conversation with you about other topics. | You and the client meet 4 days after the initial intake session due to truancy because she has missed several days of school. For about half of the session, the client seems to be withdrawn. She asks you what you are required to report, and you remind her of the limits of confidentiality. The client says that she understands, and then says she is going to talk about what happened anyway. She says that her volleyball coach asked to meet with her after practice about 7 months ago and when she entered his office, he asked to look at her right thigh following a fall during practice. She continues to state that when she showed him, he started to touch her genital area from the outside of her pants. She states that she ran out of the room and went home. She explains that after this event she quit the team and told her parents that she did not want to play anymore, but recently she has started to experience distressing memories of the sexual abuse; she refuses to go to school because she would see the man daily; she has difficulty feeling happiness; and she is experiencing feelings of shame, insomnia, and difficulty concentrating. You praise the client for disclosing this information and empathize with her about how hard it must have been to share this experience | All of the following are general guidelines for mandated reporting EXCEPT: | To follow state regulations regarding time between learning of abuse or neglect and reporting the abuse or neglect | To consult with your agency prior to reporting | If you are unsure of whether the abuse or neglect is real or if anything will come of reporting, you must submit the report anyway | If your supervisor disagrees with reporting, report the abuse or neglect anyway | (A): To follow state regulations regarding time between learning of abuse or neglect and reporting the abuse or neglect
(B): To consult with your agency prior to reporting
(C): If you are unsure of whether the abuse or neglect is real or if anything will come of reporting, you must submit the report anyway
(D): If your supervisor disagrees with reporting, report the abuse or neglect anyway | To consult with your agency prior to reporting | B | Consulting with your agency might be the agency’s protocol, but it is not required. It is up to each individual therapist to report suspected abuse or neglect. You should report the abuse or neglect even if your supervisor or agency disagrees with you because it is not your or your agency’s responsibility to determine if a threat is credible. Each state has different regulations surrounding the amount of time that can pass between learning of abuse or neglect and reporting it, so it is important to know your state’s regulations and adhere to them. Therefore, the correct answer is (B) | intake, assessment, and diagnosis |
190 | Name: Ethan & Cindy Clinical Issues: Sexual functioning concerns Diagnostic Category: V-codes Provisional Diagnosis: Z63.0 Relationship Distress with Spouse Age: 69 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: White Marital Status: Married Modality: Couples Therapy Location of Therapy : Private Practice | The husband appears to be of average build. His dress is appropriate for the occasion, but his facial expression is blank and he keeps staring off into space. He has difficulty maintaining eye contact and speaks in an aimless monotone. His affect is blunted, and he appears to be emotionally detached from the situation. He reports feelings of worthlessness and emptiness that have been ongoing for many years. He has had recurrent suicidal ideations but is not currently making any plans to act on them. His thought process is disorganized, concrete and circumstantial in nature. The wife is slightly overweight and dressed in loose clothing. She appears agitated and tense but is able to maintain good eye contact throughout the conversation. She speaks in a clear, consistent manner and expresses her thoughts in an organized fashion. Her thought content is focused on her current difficulties with her husband, and she expresses feelings of disappointment, rejection, and anger. She acknowledges feeling a sense of hopelessness in the situation and shares concerns about her future. Her mood reflects her thoughts and is generally pessimistic. Insight is intact as she is able to recognize the impact of her own actions on the current state of affairs. Her judgment is also intact as she recognizes that her current behavior and attitude are not helping the situation. | First session You are a mental health therapist in a private practice setting. A couple, a 69-year-old male and a 65-year-old female, enters your office together. The couple has been married for over 40 years and have two grown children. Their second child age 31 is currently living at home. When you ask what brings them to therapy, the wife immediately states that her husband is not attracted to her anymore. She tells you that he never wants to be in a situation where they are romantic together. She is feeling unwanted, unattractive, and as if they are "roommates" who just cohabitate together. When you ask the husband how feels, he says that he has a sense of disgust toward his wife when he thinks of having an intimate encounter with her. The wife believes that her husband is repulsed by her physical appearance as she is overweight. The husband confesses to feeling guilty for his lack of interest in his wife, but he is unable to pinpoint why he feels this way or understand why it has become an issue now after 40 years of marriage. Exploring further, you ask the couple about their family of origin. The wife states that her parents were highly critical and demanding, while the husband's parents were more passive and removed when it came to expressing affection or showing disapproval. She also expresses concern over possible sexual abuse in the husband's past, though he is not sure if anything happened or simply cannot remember due to its traumatic nature. With these additional pieces of information, you begin to develop a comprehensive picture of their situation and focus on working with the couple towards a positive outcome. Fourth session You have seen the couple for three therapy sessions so far. Today is your fourth session with the couple. The wife tells you that she is "officially sleeping in the spare bedroom" and is considering a trial separation. Last week she bought lingerie to entice her husband, and he responded by ridiculing her, then turning away from her and going to sleep. The wife begins to cry as she says, "We don't talk anymore. He just berates me all the time, and that hurts a lot." As the wife tells you about the incident, the husband sighs audibly and shakes his head. He looks at you and states, "She's a mess. I don't know what to say." You empathize with the couple's emotional struggles, and you acknowledge their pain. You explain to them that it can be helpful for couples to explore personal issues in an individual therapy setting before coming together as a couple to make progress on their relationship challenges. You let them know that they may find it easier to express themselves when one partner is not present, and that individual counseling can give them each the space to address their own personal issues in a safe environment. You encourage them to take some time to reflect further on whether they believe individual therapy would be useful for them at this time, and you offer to provide further information about the process if needed. Finally, you let them know that you are here to support them as they make decisions about how best to move forward. You assure them that while their relationship may be in a difficult place right now, it is possible to heal and strengthen their connection with one another. You remind them that relationship issues are often complex and that it is important to be patient with each other as they work together to find solutions. You encourage them to stay committed to the process, even when things feel difficult, and you offer your ongoing support in helping them build a more fulfilling relationship. | The wife states that she had an emotionally distant relationship with her parents growing up and never felt truly accepted by them. She also reveals that her father was often angry and verbally abusive, which left her feeling anxious and fearful in his presence. When asked about his family of origin, the husband speaks of his parents as being cold and unapproachable; they showed acceptance or rejection based on whether he met their expectations. He expresses difficulty in determining how he is supposed to act around them. Stressors & Trauma: When asked about how the family of origin showed acceptance or rejection, the husband states, “My parents ignored me when they were displeased. I got to sleep in their bed when they were pleased with the way I acted.” When asked about sexual abuse, the client states, “I'm not sure. It seems like something bad happened with my mother and uncle. There might be something more than that, too. I can't really remember.” Previous Counseling: The husband has been struggling with depression for the past few months after he lost his job in an economic downturn. He has been struggling with feelings of worthlessness and emptiness for many years, even when he was employed. He has had multiple periods of suicidal ideation, but never acted on them. The client also states that it is difficult for him to focus and stay motivated. He is currently taking Wellbutrin that was prescribed by his primary care physician and states that it helps "take the edge off." The client states he would rather deal with the pain than be emotionally blunted. | What would be least important to consider when meeting with partners individually? | Discussing how to handle disclosure of secrets | Clarifying issues of confidentiality | Setting boundaries to avoid unproductive alliances | Explaining limits of using social media | (A): Discussing how to handle disclosure of secrets
(B): Clarifying issues of confidentiality
(C): Setting boundaries to avoid unproductive alliances
(D): Explaining limits of using social media | Explaining limits of using social media | D | This would be important to go over during intake with clients as part of their initial paperwork; however, it is not particularly important to consider when meeting with partners individually. Therefore, the correct answer is (C) | professional practice and ethics |
191 | Name: Luna Clinical Issues: Developmental processes/tasks/issues Diagnostic Category: Neurodevelopmental Disorders Provisional Diagnosis: F81.0 Specific Learning Disorder, with Impairment in Reading Age: 13 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: Hispanic Marital Status: Not Applicable Modality: Individual Therapy Location of Therapy : School | The client is an average-built individual who is alert. The client is casually dressed and adequately groomed. Speech volume is quiet, and speech flow is slow. She has difficulty maintaining eye contact for extended periods and often looks down at her feet. She demonstrates irritability at times during the interview and sighs several times. Her thought process is logical. Her estimated level of intelligence is in the low average range, with limited abstract thinking. Concentration is intact. The client shows no problems with memory impairment. | First session As the mental health therapist working in a school setting, you welcomed your new client and her parents into your office. They explained their daughter's struggle with reading and how it caused her to freeze when faced with a spelling or math test. After listening to them closely, you asked the client why she did not enjoy reading. She said that words confused her and made no sense, so she found it difficult to remember what she read. You consider possible solutions for your client, who was having difficulty with schooling due to a lack of literacy skills. You proposed an idea: "Let's try incorporating creative activities as part of our therapy sessions." Doing so, we can develop strategies for improving written language comprehension and expression while making learning fun for your daughter." The parents were hesitant but agreed to try it after seeing their daughter's enthusiasm about trying something different than traditional methods like instruction books or worksheets, as those have not been effective in the past. During the session, you brainstormed ideas around stories, role-playing games, and drawing activities focusing on using everyday experiences as inspiration for creating unique narratives within each session – not only reinforcing literacy skills but also providing an opportunity for emotional growth through storytelling exercises. | The client says she is only poor at reading and "good at everything else." She says that she feels stressed when she has to read. The client's IQ is 89. A reading specialist assessed her, and her reading skills are abnormally low. Throughout elementary school, teachers noted the client has difficulty reading and that, in turn, it has adversely affected the client's academic achievement. As a result, special needs are implemented in the client's school setting. The client has an active Individualized Education Plan (IEP). Pre-existing Conditions: The client has also been diagnosed with epilepsy and is on medication for seizures. The client had frequent seizures for many years until a medication that lessened the occurrence of her symptoms was prescribed. The client fell when she was eight, hit her head, and fractured her skull. She was not diagnosed with any traumatic brain injury, but she did need stitches. Additional Characteristics: The client portrays positive interactions with both staff and peers at school. The client does state she feels she is "stupid" when it comes to reading and wishes she could get better. The client's family is supportive and values education. They are hands-on in supporting the client in any way they can. | What would lead you to assess for a comorbid mental health condition? | Client's negative self-talk and mood during intake | Client's limited abstract reasoning ability | Client's medical history | Client's interactions with students and teachers | (A): Client's negative self-talk and mood during intake
(B): Client's limited abstract reasoning ability
(C): Client's medical history
(D): Client's interactions with students and teachers | Client's negative self-talk and mood during intake | A | The client says that she feels "stupid" when it comes to reading. Additionally, she presents with low speech volume and slow speech flow. She often looks down at her feet, demonstrates irritability, and sighs several times during the intake. It's possible that she has depression or is at risk of developing depression if her symptoms are left untreated. Therefore, the correct answer is (D) | intake, assessment, and diagnosis |
192 | Initial Intake: Age: 54 Gender: Male Sexual Orientation: Heterosexual Ethnicity: African American Relationship Status: Divorced, In a relationship Counseling Setting: Private Practice Type of Counseling: Individual | John presents as well-groomed with good hygiene and is dressed professionally. Motor movements are slightly fidgety, indicating nervousness or moderate anxiety. Eye contact is intermittent. Denies suicidal or homicidal ideation, no evidence of hallucinations or delusions. John tightens his fists when elaborating on situational issues between him and his ex-wife, with the same controlled expression and tense disposition when sharing about his girlfriend. John mentioned that his girlfriend is also unreasonable for complaining about how often John comes home smelling of alcohol, saying that meeting people for drinks is part of his job. He added the comment “I need to drink to deal with her attitude all the time.” | Diagnosis: Adjustment disorder with mixed disturbance of emotions and conduct (F43.25), provisional
John calls your practice asking to speak to a counselor to help him with his relationship. John tells you he’s never been to a counselor before and does not want anyone to know that he is seeing one, mentioning he will pay for sessions privately using cash. John admits to struggling with anger, specifically with his ex-wife of 15 years whom he divorced three years ago. John asks for availability in the evening hours and demonstrates hesitancy and reluctance to commit to more than a handful of sessions. In the initial assessment session, you notice he has difficulty making eye contact and is uncomfortable talking about his situation. After some rapport building, he begins to share that he is only seeing you because his girlfriend Sherry told him she would break up with him if he did not get his “anger issues under control.” John denied physically hitting Sherry, but alluded to several interactions that he stated, “got so heated I lost it on her, and she wouldn’t stop crying.” John complained of women he gets involved with being overly controlling of him and that he doesn’t understand why they are so “needy.” John works a demanding job in the sports marketing industry where he takes frequent trips out of state and spends long nights out, entertaining clients. He wishes he had the freedom to “do what he has to do” without “being treated like a child” by his romantic partners. | Family History:
John tells you he has two children, a 34-year-old son he had with a one-night stand in college and an 18-year-old daughter with his ex-wife the first year they were married. He has a decent relationship with his son and provides him and his family occasional financial support, visiting with his grandchild over social media video once a month. He reports once being close with his daughter but that their relationship became strained as she got older and that now they hardly speak, saying “she took her mother’s side during the divorce, so she doesn’t want anything to do with me right now.” While conducting further interviewing about John’s family health you learn that John’s father passed away at 56 after several heart attacks and his mother died of heart failure and diabetes complications at 49. John has no other living relatives besides an uncle in another state and his cousins who live near him. He tells you growing up he used to go to church with his mother every Sunday until she got sick and has not been to church since.
Work History:
John has a master’s degree in Business Marketing and made his connections with his current position through contacts he made while playing on collegiate basketball teams. John has always worked busy jobs with which he becomes heavily engaged in and puts in overtime hours. John prefers work that keeps him on the road and traveling often, as he does not like to engage in the same routine every day. He mentions when he was younger, he could not keep a 9-5 office job or at any place that did not encourage individuality, saying he “butted heads” with all his managers and bosses until he was older.
Legal History:
John has had two arrests made for domestic disturbances in his home that his wife called in after heated arguments that left his wife afraid for her life. He was always able to make bail and was never tried or sentenced as charges were usually dropped thereafter. John admits to one drinking and driving accident when he was 19 where he served community service and fines as punishment. | Which diagnosis can be ruled out based on the initial assessment of John? | Anxiety Disorder | Borderline Personality Disorder | Intermittent Explosive Disorder | Alcohol Use Disorder | (A): Anxiety Disorder
(B): Borderline Personality Disorder
(C): Intermittent Explosive Disorder
(D): Alcohol Use Disorder | Borderline Personality Disorder | B | The diagnostic criteria of borderline personality disorder as per the DSM-5 must be indicated by five or more out of nine listed criteria, by which at this phase in care John only qualifies for three (impulsivity in at least two areas that are potentially self-damaging, affective instability due to a marked reactivity of mood and inappropriate, intense anger or difficulty controlling anger). It is plausible or reasonable to consider that John can still meet criteria for the other listed diagnoses, with further assessment. Therefore, the correct answer is (C) | intake, assessment, and diagnosis |
193 | Initial Intake: Age: 16 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Private Practice Type of Counseling: Individual | Molly muttered one-word answers during the intake session, made little eye contact and frequently rolled her eyes. She started to warm up towards the middle of the intake session, with some prompting from her mother. She reluctantly agreed to continue counseling sessions- only due to the fact her mother stated that she could not use the family car unless she went to counseling. | Molly is a 16-year-old female who was referred to an outpatient mental health clinic after a two-week admission at a local psychiatric hospital. Molly was brought to the hospital by ambulance after she disclosed to the school psychologist that she wanted to kill herself.
History:
When asked what brought the family to the session, Molly’s mother was tearful as she disclosed that her husband died in a car accident 11 months ago. Molly and her father had been close, spending time together as Molly played recreational softball and her father was the coach. Since her father’s death, she has been distant with her mother, and often picks fights with her. Additionally, Molly frequently complains of stomach aches, stating that the pain is so severe, she cannot go to school. Before her father’s death, Molly was in Advanced Placement classes and maintained a high average. Recently, Molly’s grades have been declining and she is no longer interested in softball. She states that when she goes to the softball field, she can almost hear her father speaking to her. | null | What other sources of information would be the most helpful at this time? | A collateral meeting with the school guidance counselor who called 911 | A collateral meeting with her friend who is engaging in cutting | A family session with Molly and her mother to discuss her consideration of cutting | Past evaluations for developmental history | (A): A collateral meeting with the school guidance counselor who called 911
(B): A collateral meeting with her friend who is engaging in cutting
(C): A family session with Molly and her mother to discuss her consideration of cutting
(D): Past evaluations for developmental history | A collateral meeting with the school guidance counselor who called 911 | A | With Molly's permission, meeting with the school guidance counselor would provide more information about what led to the recent hospitalization, especially since Molly does not want to speak about it. Also, one of the areas that Molly has shown decreased functioning in is school. By collaborating with the school social worker, strategies can be discussed to help support Molly in school. The meeting with her friend does not seem warranted at this time. However, her friend is one of her only supports. Molly has alienated herself from her softball team friends and has a tenuous relationship with her mother, so the counselor may want to bring the friend in at a later time. Although a family session may be something to explore at a further time, the question asks about sources of information that would be important at this time. Additionally, she does not seem to have a good relationship with her mother currently and she may not want to speak to her mother about this. If Molly is still considering cutting after she is provided psychoeducation, this may be warranted as an intervention. There is no indication that there are any developmental delays or history of delays. Molly was doing well in school prior to the death of her father and was in Advanced Placement classes. There are no issues with cognitive functioning. Therefore, the correct answer is (A) | professional practice and ethics |
194 | Name: Ruth and Dale Clinical Issues: Parenting/co-parenting conflicts Diagnostic Category: V-codes Provisional Diagnosis: Z63.0 Relationship Distress with Spouse or Intimate Partner Age: 41 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: White Marital Status: Married Modality: Couples Therapy Location of Therapy : Agency | Appearance: The client is casually dressed and adequately groomed. She appears healthy, and her age is consistent with her stated age. Behavior: The client's behavior is tense and purposeful. She is cooperative with adequate rapport. Speech: Speech volume is normal, and speech flow is normal and spontaneous. Mood: The client's mood is dysphoric and anxious. Thought Process: Thought process is logical. Thoughts are negative. Affect: The client's affect is broad and appropriate to the discussion. Cognition: The estimated level of intelligence is within average range with abstract thinking. Concentration is intact. The client shows no problems with memory impairment. Insight and Judgment: Insight is fair. Impulse control and judgment appear to be below average. | First session You are a therapist working at a marriage counseling agency. Ruth is a 41-year-old female who comes to your office with her husband. The couple has been married for seven years and have two children, ages five and one. The husband also has a 16-year-old daughter from a previous marriage who lives in the home. The client is a stay-at-home mom, and her husband works at a correctional institution. Their five-year-old has been removed from three separate daycare facilities because of her defiant behavior. In addition, the 16-year-old was recently arrested for shoplifting. At the end of the session, the client turns to her husband and says, "I'm the one who has to stay home with the kids all day. You just don't get it. You don't know what it's like having no time for yourself and no quiet place to relax. You think all this stuff with the kids is a normal phase and everyone will grow out of it. Well, I don't think it's normal, and I'm tired of it! I've been talking to my ex-husband lately because he listens to me, and I feel better after I talk to him." Ruth demonstrates elevated stress and anxiety levels, as evidenced by her verbalization of feeling overwhelmed by the demands of caring for their children and lack of personal time. She also expresses feelings of frustration with her husband, who she perceives as not understanding her struggles. Her husband's absence during the day and the children's challenging behaviors have likely contributed to the client's feelings of isolation and burnout. Ruth's decision to reach out to her ex-husband for emotional support may indicate that she is not receiving adequate support from her current partner. Third session In accordance with Ruth's decision at the last session, she ceased communication with her ex-husband. After affirming this, she turns to her husband and says, "He called twice last week, but I didn't answer. At least someone wants to talk with me!" Dale gives her an exasperated look, folds his arms over his chest, and shakes his head in disgust, at which Ruth says, "See? That's all I ever get! Nothing!" and begins to cry. Dale seems angry but remains quiet. Dale sighs and rubs his temples. "This is why I don't talk about it," he says. "You always make it about you. Do you think I don't want to talk to you? Do you think I don't care?" Ruth sniffs and wipes her eyes. "Of course not, but it feels like you don't want to talk to me. Like you don't care. You never talk to me, and then you get quiet when I try to talk to you." Dale rolls his eyes. "That's because you don't listen when I try to talk to you. You just jump to your own conclusions and then get mad at me when I don't do what you think I should do. I'm tired of it. I'm tired of trying to talk to you, but you never listen." Ruth bristles, tears streaming down her face. "Well, what am I supposed to do? You never tell me what you want me to do, so how am I supposed to know?" Dale throws his hands and walks away in frustration. "I don't know, Ruth. I really don't know." | Ruth's parents died in a boating accident while she was in college. She has two brothers and one sister, but they are not close, partially due to the strain of losing their parents. Her husband's first wife left him soon after their daughter was born. She does not discuss her place in the family's dysfunction but talks about other family members who need help. Ruth has been unable to heal her relationship with her sister and feels guilty about it. She also expresses concern for her husband's well-being after his first wife's divorce, which she was partly responsible for. Additionally, Ruth struggles with depression and anxiety due to trauma related to the death of her parents. Personal/Social Relationships: Ruth feels that her husband minimizes their children's problems and is to blame for their lack of improvement. Ruth feels her marriage is "on the rocks.'" Her husband knows his wife is unhappy but does not know what to do. Finally, you learn that Ruth recently reconnected with her ex-husband and is seriously considering having an affair. Previous Counseling: The client has been working on her low self-esteem through therapy but says she is not getting any better. Her husband says, "I know Ruth is unhappy. That much is obvious. She's stressed out all the time, and she's stopped talking to me. She gets in the car, is gone for hours, and isn't home when I arrive after work. I'm worried I will lose her, but I don't know what to do." | Which of the following is an example of Gottman's concept of stonewalling? | Dale's exasperated look, folded arms, looking shaking his head in disgust | Dale rolling his eyes in response to Ruth's comment | Dale's frustration, throwing up his hands and walking away | Dale's statement that Ruth does not listen to him | (A): Dale's exasperated look, folded arms, looking shaking his head in disgust
(B): Dale rolling his eyes in response to Ruth's comment
(C): Dale's frustration, throwing up his hands and walking away
(D): Dale's statement that Ruth does not listen to him | Dale's frustration, throwing up his hands and walking away | C | This is an example of stonewalling according to Gottman's 4 Horseman model. Stonewalling is a form of disengagement in which one person withdraws from the conversation and shuts down communication. Therefore, the correct answer is (C) | counseling skills and interventions |
195 | Initial Intake: Age: 14 Gender: Female Sexual Orientation: Heterosexual Ethnicity: Hawaiian American Relationship Status: Single Counseling Setting: School-based mental health counseling Type of Counseling: Individual | Malik presents as well groomed, good hygiene and behavior within normal limits. She is highly anxious, evidenced by limited eye contact, tense expressions and fidgeting with her hands. Malik admits to having suicidal thoughts and has self-harmed by cutting herself in the past. She reluctantly shares that she had a traumatic event in Hawaii right before leaving but is unwilling to discuss it and begins crying. She then changes the subject and tells you moving out of Hawaii has been painful because “everything is different here, including how they do school and how people talk about each other.” She adds that she experiences at least one nightmare a week since moving. | Diagnosis: Major depressive disorder, single episode, unspecified (F32.9), Anxiety disorder, unspecified (F41.9)
Malik, a 14-year-old girl entering High School is referred to you for mental health counseling by her school counselor for reports of her leaving the classroom in tears and because of calls received by her mother stating that she has crying spells at home. After speaking with Malik’s mother, you learn her mother, stepfather and sisters have recently moved with her to the mainland states from the Hawaiian Islands and that she has been missing her father, friends, school, and other family members left behind. Malik spends most of her time in her room, appears depressed often, gets upset easily and is constantly on her phone. Her mother asks that you meet with her during school hours and help her understand what is going on. She says Malik has been crying since just before leaving Hawaii. | Family History:
Malik’s parents divorced while she was young but had always lived in Hawaii, making it easy for her to see both sides of her family at will. Malik has several siblings, cousins, and all her grandparents are still alive. Malik has a strained relationship with her father and stepmother and feels heavily influenced by her father’s opinion of her, stating “he just wants what is best for me, but he’s really harsh about it and it sometimes hurts my feelings and stresses me out.” She is struggling to connect with her mother now because she is working full-time, and she feels “doesn’t have time for her anymore.” Malik is also forced to do most of the household chores and care for her younger siblings on top of managing her schoolwork. All of this has made her feel overwhelmed. | It is clear to you that Malik has returned to engaging with the boy that was involved in her traumatic experience. Which is the most direct and ethical approach for responding to this presentation? | Present your observations of her changes in behavior and ask for her perspective on what has contributed to these changes. | Gather the data mentally and inquire more information from her mother next time you speak. | Lovingly confront her obvious behaviors and gently question the wisdom of her choices. | Have Malik write down a timeline of events from before leaving Hawaii until now. | (A): Present your observations of her changes in behavior and ask for her perspective on what has contributed to these changes.
(B): Gather the data mentally and inquire more information from her mother next time you speak.
(C): Lovingly confront her obvious behaviors and gently question the wisdom of her choices.
(D): Have Malik write down a timeline of events from before leaving Hawaii until now. | Present your observations of her changes in behavior and ask for her perspective on what has contributed to these changes. | A | Giving your client feedback and soliciting their perspective on contributing factors is the most ethical way to guide discussion of their own development of insight. Although d is clearly the most direct approach, it is not the most ethical choice as you are pointing out observations that might be assumptions or involve content that has not yet reached her level of understanding. Answer d could also damage your rapport as you may come across as judgmental and cause her to become defensive. Answer a is indirect because you would be deriving information from a parent, and unethical if Malik did not give expressed permission for you to discuss the content of your sessions with a parent. Minors under age 18 have HIPAA rights and should be afforded the same confidentiality provisions as adults. Answer b is a great intervention to conduct with Malik but is not the most direct form of therapy as timeline therapy can involve numerous areas and goals outside of the target discussion. Therefore, the correct answer is (C) | counseling skills and interventions |
196 | Initial Intake: Age: 58 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Married Counseling Setting: Private Practice Type of Counseling: Individual | The client reports that in the past six months she has lost 40 pounds, which leaves her looking thinner than seems appropriate for her 5’8” frame. Her hair is combed and neat, but looks thin and lacks a healthy shine. Her clothes, while clean, appear rumpled as if they have been slept in. She is cooperative and engaged, but moves slowly and pauses in her speech, causing you to wonder if she is lost in thought or if speaking is too painful. She reports she has difficulty falling asleep at night and never feels like she has any energy, though she does go to work each day. She denies any suicidal thoughts but states she feels sad all the time and “can’t wait to see him again.” She admits she blames herself for not keeping him home that evening, which would have prevented his death. | You are a counselor in a private practice setting. You receive a telephone call from an attorney that would like to refer their client, who is engaged in a civil suit, to you for counseling treatment. The attorney provides you with a detailed description of a traumatic event, death of her son, and expresses concerns about the client’s well-being. The attorney requests that you work with their client and be prepared to testify in court when the case goes to trial. | Family History:
During the intake session, the client reports that her youngest son was killed in a car accident eighteen months ago, which was caused by an impaired driver. Her son was the youngest of her five children and while she said she loves them all equally, she reported that her children have always said their youngest brother was her favorite. | In evaluating the client's current condition, which of the following would you NOT expect to do? | Explore family of origin patterns related to loss | Assess for Schizoaffective, Schizophrenia, or Delusional Disorder in family history | Perform a Mental-Status Exam (MSE) | Assist client in exploring what would happen if she acknowledged his death | (A): Explore family of origin patterns related to loss
(B): Assess for Schizoaffective, Schizophrenia, or Delusional Disorder in family history
(C): Perform a Mental-Status Exam (MSE)
(D): Assist client in exploring what would happen if she acknowledged his death | Assess for Schizoaffective, Schizophrenia, or Delusional Disorder in family history | B | The client's actions are purposeful and consciously focused on relieving her feelings over her son's death. These may be cultural or familial patterns that she has learned to minimize the pain of grief. The MSE assesses for at-risk or bizarre thinking to ensure the client's safety; however, there is no indication of familial psychosis or schizophrenia-type illnesses at this time. Therefore, the correct answer is (A) | intake, assessment, and diagnosis |
197 | Client Age: 8 Sex: Female Gender: Female Grade: 3rd Ethnicity: African American Counseling Setting: School-based Type of Counseling: Individual and Family Presenting Problem: Defiance Diagnosis: Oppositional Defiant Disorder 313.81 (F91.3) | Mental Status Exam: The client displays an angry affect and sits with her arms crossed. She is well dressed and well groomed. The client’s PGM repeatedly prompts her to say, “yes ma’am” and “no ma’am” when answering questions. The client sits slumped in her chair. She agrees to color in a feelings thermometer that reflects increased anger, sadness, and fear. Her insight is poor. The client often refuses to eat school lunch, and the PGM reports that the client is a picky ea | You are a school-based mental health counselor conducting an initial intake with an 8-year-old African American female in the 3rd grade. The client presents today with her paternal grandmother (PGM), the client’s legal guardian. The PGM states that the client is argumentative, refuses to take responsibility for her actions, and has a tantrum when she receives a consequence for her behavior. She reports that the client is restricted from “every single privilege indefinitely.” The client has been told she can regain privileges once she “learns to act her age.” The client states she is treated unfairly and “blamed for everything” at home and school. The client’s teacher reports that she has difficulty following directions, is easily annoyed by her classmates, and frequently loses her temper. The client’s grades are poor, and she is below grade level in reading. However, she enjoys art and proudly reports that one of her pictures came in 1st place and is hanging in the library. | ter. F amily History: The client’s paternal grandmother received legal guardianship when the client was in 1st grade due to parental neglect. The client’s mother and father have had ongoing issues with substance abuse. The client’s father is currently incarcerated for drug-related offenses. The PGM reports that the client’s mother continues to “run the streets” and shows up periodically asking for money. The PGM states that the client’s mother abused drugs while pregnant and that the client was born prematurely. In addition, the client’s father had similar school difficulties and dropped out of high school in the 10th grade. History of Condition: The client’s disruptive behavior began in early childhood. When the client was four years old, her tantrums were so severe that she disrupted two daycare placements and was not allowed to return. In kindergarten, the client was given a stimulant by her primary care provider to assist with symptoms of ADHD. The PGM says she is no longer on the medication and believes the client chooses to misbehave, explaining, “she is strong-willed, just like her father.” The client’s school records show she has an individualized education plan (IEP) and receives limited services for developmental delays in reading and written expression | In the DSM-5-TR, ODD is classified under which of the following? | Disruptive and impulse control disorders | Bipolar and related disorders | Neurodevelopmental disorders | Trauma and stressor related disorders | (A): Disruptive and impulse control disorders
(B): Bipolar and related disorders
(C): Neurodevelopmental disorders
(D): Trauma and stressor related disorders | Disruptive and impulse control disorders | A | Oppositional defiant disorder is classified with disruptive and impulse control disorders. Other diagnoses listed in this classification include intermittent explosive disorder, conduct disorder, pyromania, kleptomania, and other specified and unspecified disruptive and impulse-control disorders. While the diagnosis of ADHD is highly comorbid with ODD, ADHD belongs to the neurodevelopmental disorders category. Bipolar and related disorders include bipolar 1, bipolar 2, and cyclothymic disorder. Trauma and stressor related disorders include reactive attachment disorder, social engagement disorder, posttraumatic stress disorder, acute stress disorder, other specified trauma-and-stressor-related disorder, and unspecified trauma-and stressor-related disorder. Therefore, the correct answer is (B) | intake, assessment, and diagnosis |
198 | Clients Age: Husband: 45 Wife: 43 Sex: Husband: Male Wife: Female Gender: Husband: Male Wife: Female Sexuality: Heterosexual Ethnicity: Both Individuals Are Caucasian Relationship Status: Married Counseling Setting: Private Practice Counseling Clinic Type of Counseling: Couples Counseling Presenting Problem: Marital Distress Diagnoses: Couple Diagnosis: Adjustment Disorder with Anxiety (F43.22) and Relationship Distress with Spouse or Intimate Partner (Z62.898) Individual Diagnosis (Wife): Generalized Anxiety Disorder (F41.1) | Mental Status Exam: The husband and wife were both oriented to person, place, time, and situation. Both individuals were dressed appropriately for the season and appeared clean. The husband presented as angry, and the wife presented as remors | You are a licensed therapist working at a private practice. The couple comes to counseling in order to work on their relationship following an infidelity. The wife has difficulty expressing what happened, and the husband interrupts her and expresses that his wife had an affair with a coworker 3 weeks ago. The couple states that they are currently talking very little aside from conversations that involve their children. The wife states that she is regretful of what she did and that she does want her marriage “to be saved.” The husband explains that he is very hurt by her infidelity and that he is unsure if he can forgive her and continue being married to her. The couple has been married for 25 years and report that they both are in counseling to see if they can continue to be married following the affair. The husband expresses strong anxiety following the revelation of the affair and questions how he can be in a relationship with his wife following the infidelity. The wife is experiencing anxiety regarding her husband leaving her because she reports regretting the sexual interaction with her coworker and does not want to get divorced. | eful. Family History: The couple has been married for 25 years. They have two children,a 14-year-old son and a 17-year-old daughter, and they report good relationships with their families of origin | Which of the following would be important to discuss when reviewing informed consent that would be uniquely different for couples counseling? | The clinician promoting the well-being of the individuals involved in counseling | The nature of counseling | The risks of counseling that includes dealing with difficult topics during sessions | Confidentiality | (A): The clinician promoting the well-being of the individuals involved in counseling
(B): The nature of counseling
(C): The risks of counseling that includes dealing with difficult topics during sessions
(D): Confidentiality | Confidentiality | D | A unique limit to confidentiality is the clinician’s inability to ensure that both individuals in couples counseling will not share information about the other. It is important to encourage both individuals to maintain confidentiality for each other in order to ensure a safe environment in the couples counseling session. The nature of counseling, the risks involved, and promotion of well-being are all common factors in the counseling setting. Therefore, the correct answer is (A) | professional practice and ethics |
199 | Client Age: 13 Sex Assigned at Birth: Male Gender: Transgender; Gender Nonconforming (TGNC) Ethnicity: Caucasian Counseling Setting: Child and Family Agency, School-Based Services Type of Counseling: Individual and Family Presenting Problem: Truancy; Gender Dysphoria Diagnosis: Gender Dysphoria, Provisional (F64.1); Social Exclusion or Rejection V62.4 (Z60.4) | Mental Status Exam: The client is dressed in age-appropriate clothing. They wear eye makeup and chipped black fingernail polish, and they have bitten most fingernails down to the quick. The client’s mood is irritable, and they are quick to show anger toward their mother when misgendered. Their thoughts are coherent, and they deny audio/visual hallucinations. The client acknowledges feeling sad and hopeless but denies suicidal ideation. They attribute increased levels of anxiety at school to bullying, particularly with select peers. They explain that a select group of students threaten the client and call them offensive and derogatory names. Family History and History of th | You are a school-based mental health counselor in a public middle school. Your client is a 13-year-old Caucasian 7th grader who presents for the initial intake with their mother. The mother says that the client has had several unexcused absences from school because “he is confused about his gender.” The client adamantly denies being confused and explains that they self-identify as transgender. The client’s preferred pronouns are “they/them.” The client further states that they have had a strong desire to be a different gender since early childhood, and this desire and their distress have recently intensified. The mother reports that the client is chronically irritable, spends a lot of time alone, and has “basically shut everyone out.”The client reports experiencingbullying—both verbal and physical—in school “nearly every day.” In addition to the bullying, the client says that certain teachers refuse to allow them to use the bathroom aligned with their identified gender. To prevent this conflict, the client does not eat breakfast or lunch at school. | You work with the client and their parents to help the parents understand how the client conceptualizes their gender identity. You use the client’s self-identified, gender-affirming pronouns and praise the client for taking a brave first step. The client’s mother is fearful and anxious, particularly when thinking about the client’s safety. The client’s father expresses an overall lack of understanding and thinks it could be a phase. You recognize the father’s efforts to understand and help the client explain the distressing emotions associated with coming to terms with their gender identity, including an increase in severity since the onset of adolescence. The father states that he is unsure if he can accept the client’s transgender identity but says that he is committed to the counseling process | What is the main purpose of supporting the client’s use of self-identified, gender-affirming pronouns? | To lay the groundwork for reparative therapy as an evidence-based practice (EBP) | To illustrate potential difficulties associated with social transitions | To normalize and validate gender diversity as a natural human variation | To help the parents become acclimated to the lifelong use of the client’s selected pronouns | (A): To lay the groundwork for reparative therapy as an evidence-based practice (EBP)
(B): To illustrate potential difficulties associated with social transitions
(C): To normalize and validate gender diversity as a natural human variation
(D): To help the parents become acclimated to the lifelong use of the client’s selected pronouns | To normalize and validate gender diversity as a natural human variation | C | The purpose of supporting the client’s use of self-identified, gender-affirming pronouns is to normalize and validate gender diversity as a natural human variation. Some research has shown that gender-affirmative care is associated with improved outcomes for gender dysphoria. Counselors using gender-affirmative care provide a safe and supportive environment for gender-diverse individuals through advocacy, psychoeducation, and person-centered counseling. Social transitions for TGNC include identifying preferred pronouns; however, the counselor’s primary purpose for using preferred pronouns in family therapy is to affirm, normalize, and validate gender diversity. Gender diversity is fluid; therefore, the client may or may not use the same pronouns in the future. Therefore, the correct answer is (D) | professional practice and ethics |
200 | Name: Christopher Clinical Issues: Gender identity development Diagnostic Category: Gender Dysphoria Provisional Diagnosis: F64.1 Gender Dysphoria Age: 13 Sex Assigned at Birth: Male Gender and Sexual Orientation: Female, Heterosexual Ethnicity: White Marital Status: Not Applicable Modality: Individual Therapy Location of Therapy : Agency | The client presents partially as her preferred gender, wearing makeup and a semi-long hairstyle while still dressed as a cis-gendered 12-year-old male. She reports feelings of depression, anger, and suicidal ideation without a plan or intent. She appears to be her stated age, cooperates during the interview, and maintains good eye contact. Speech is normal in rate, rhythm, and volume. The client's thought processes are organized and goal-directed. She is alert and oriented X2. Insight and judgment are fair. | First session A 13-year-old, assigned male at birth and identifying as female, arrives at your office in a community mental health agency where you work as a mental health therapist. Both parents are also in attendance. The client introduces herself to you as "Christine," although the father says "Christopher" each time he addresses the client. The client appears dejected every time her father misgenders her. The client reports experiencing bullying from male peers at school and is upset that her father refuses to use her chosen pronouns or name. The client reports that she has been feeling increasingly isolated and hopeless since the start of her transition, leading to intrusive thoughts associated with suicide. She is trying to express her identity through clothing, hair, and physical appearance but is not allowed to do so by her father. The client's mother is somewhat more supportive of her transition and has been trying to advocate for her, but her father remains resistant to the idea and is often dismissive of her identity. The client expressed feeling frustrated and helpless in her home life, as she cannot express her gender identity freely. Once the client's parents leave the room, the client reports wanting to kill herself and tells you about the depression that sets in after being bullied at school or after arguments with her father. She also holds a lot of anger toward her father. Toward the end of the initial counseling session, the client says she feels safe with you and "would like to work together." Fourth session The client has been "looking forward to working with you" and appears more comfortable today than in previous sessions. You recommended meeting with her once a week for therapy. You have built a positive rapport, and she no longer considers suicide a coping mechanism for dealing with her problems and stressors. However, when assessing her family relationships, the client states that her dad is "hard on her." She asks if you would mediate between her and her father in your next session, and you agree. She is relieved at the idea of having a mediator present during the conversation with her father and shares her father's expectations of her and how she is being treated differently at home than her siblings. You role-play the future encounter to help the client to be able to verbalize her needs and feelings in a way that will be heard and understood by her father. Ninth session The client has reported increased dysphoria due to persistent bullying and lack of support at school. As a result, she has noted an increase in negative self-talk and feelings of worthlessness. She has also reported increased feelings of isolation, as she does not have any friends she can confide in or turn to for support. The client has also expressed that her home environment is still difficult, as her father has not entirely accepted her gender identity, leaving her feeling unsupported. The client has further said that she does not feel safe or secure at school and feels uncomfortable seeking help from her peers. The client has further reported that her emotional regulation has been difficult. She finds herself becoming overwhelmed and frustrated more quickly than before. She has also noted difficulty concentrating on tasks and completing schoolwork. Her mood has become increasingly labile, and she has experienced more frequent thoughts of self-harm and has expressed that she doesn't know how to cope with her emotions. The client's mental health has also been deteriorating. She has reported increased symptoms of depression and anxiety. She has difficulty sleeping, often unable to fall asleep or only sleeping for short intervals. She has been experiencing intrusive thoughts, racing thoughts, and difficulty focusing on tasks. She has also been avoiding social situations and expressed that she feels uncomfortable around people due to her negative self-image. She does like the school psychologist but needs help setting up a meeting. You intend to reach out to the school psychologist to expand the continuum of care. | The client loves her mother but has difficulties with her father. Her parents differ in child-rearing styles, with her father not understanding her gender presentation. The client has a deep-seated fear of rejection and abandonment from her father due to the ongoing disagreement about her gender presentation. She feels that her father does not accept her for who she is and does not understand her identity. The client has a strong need for her father's acceptance and approval, but her attempts to bridge the gap between them have been unsuccessful. This has caused her to feel disconnected from her father and has created a sense of sadness and insecurity in the client. Neither parent supports her gender choice, but her father actively confronts her daily. Her mother is confused and worried for the client but does not know what to do. The client is high achieving academically and is well-liked by her teachers. In addition, she is involved in a community dance team where she excels. However, she is socially isolated and has few friends. Her classmates mock her for "acting like a girl" and bully her on the playground. She is especially bullied by her male peers in school. The client is displaying symptoms of social anxiety as she has difficulty developing and maintaining relationships with her peers. Her fear of being ridiculed and judged by her peers has resulted in her feeling socially isolated, impacting her self-esteem. The client is anxious in social situations, particularly when interacting with her male peers, and displays a pattern of avoiding social interactions due to the fear of being judged. | Due to your own childhood experiences, you are spending a lot of time thinking about the client's well-being. What is an appropriate method of managing your emotions around this case? | Seek supervision from a colleague | Share with the school psychologist with whom you are collaborating treatment | Talk the case over with your own therapist | Put aside your emotional reactions to this case as the client is the priority | (A): Seek supervision from a colleague
(B): Share with the school psychologist with whom you are collaborating treatment
(C): Talk the case over with your own therapist
(D): Put aside your emotional reactions to this case as the client is the priority | Seek supervision from a colleague | A | Self-care is an important part of a therapist's work and can help maintain healthy boundaries. Therefore, the correct answer is (C) | professional practice and ethics |
Subsets and Splits