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201 | 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. | 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. | Considering the couple's situation, which instrument would you use to assess their relationship? | DISC Personality Test | Female Sexual Function Index (FSFI) | Fear Questionnaire (FQ) | Dyadic Adjustment Scale (DAS) | (A): DISC Personality Test
(B): Female Sexual Function Index (FSFI)
(C): Fear Questionnaire (FQ)
(D): Dyadic Adjustment Scale (DAS) | Dyadic Adjustment Scale (DAS) | D | The Dyadic Adjustment Scale measures a partner's perceptions of his or her intimate relationship. Therefore, the correct answer is (C) | intake, assessment, and diagnosis |
202 | Initial Intake: Age: 19 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: African American Relationship Status: Single Counseling Setting: Group home run by the Office of Children and Family Services Type of Counseling: Individual | Elaina has little insight into her behaviors and is currently involved in an abusive relationship. Staff members are concerned for her safety, as well at the safety of her child. She is not functioning well socially or academically. | Elaina is a 19-year-old female who is living in a residence for pregnant teens in foster care. She has been displaying risk taking behaviors such as running away and fighting.
History:
Elaina has an extensive history of abuse and neglect. She entered foster care at the age of 5 when her mother was incarcerated for prostitution and drugs. Since then, she has been in and out of foster care homes and had several failed trial discharges back to her mother’s care. Elaina ran away from her foster homes multiple times. Another trial discharge date is set for the near future, after the baby is born.
Elaina never finished high school. She had difficulty focusing on her classes and was often teased because the other children knew that she was in foster care. Elaina would frequently get into fights, resulting in suspensions. She has a tumultuous relationship with the father of her child, and she recently told her case planner that he sometimes hits her.
Elaina walked into the counselor’s office, sighed, and stated, “Great- someone new- I have to tell my story again?”
The counselor responded “It sounds like you have told your story many times. I can imagine how that feels for you.”
Elaina stated, “It is very frustrating and annoying.” To which the counselor responded, “I like to hear from clients, their history in their own words as opposed to reading it on paper. When we make your goals, I would like you to be involved as well.”
Elaina visibly relaxed and began to tell the counselor about her history and current challenges. Elaina agreed to think about what she wanted her goals to be and agreed to discuss it next session. | null | Elaina has suffered from multiple traumatic events. The capacity for positive adaptation after a significant negative event or threat is called? | Resilience | Dynamics | Plasticity | Risk | (A): Resilience
(B): Dynamics
(C): Plasticity
(D): Risk | Resilience | A | Resilience is the capacity for adaption after a significant event. The amount of resilience one has can determine positive or negative outcomes in situations. Risk factors are things that increase the likelihood of negative outcomes. Plasticity is the ability for brain cells to change from various experiences. Dynamics are the behavioral and relationship patterns between people. Therefore, the correct answer is (B) | counseling skills and interventions |
203 | 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). | You and the client review his safety plan. The client believes the antidepressant has helped decrease his feelings of hopelessness and suicidality. Despite the hot and humid conditions, the client arrives at his counseling session in a hoodie. He explains that he has been getting out of the house “some” but continues to avoid social situations because of overwhelming thoughts of others staring at him and mocking his appearance. The client was a no-show for his appointment last week and has requested distance counseling to avoid anxiety experienced when leaving the house. You and the client work together to set appropriate treatment plan goals; however, this is difficult due to poor insight into his presenting problem. You provide psychoeducation about BDD and ask about his goals for the future. The client does not believe psychotherapy is the best solution to his problems | The client does not believe psychotherapy is the best solution to his problems. How should you respond to his lack of insight and motivation to change? | “When I look at you, I don’t see the imperfections you point out.” | “I’m wondering if you can keep a journal to record your thoughts and feelings when looking in the mirror” | “How does preoccupation with your appearance stop you from participating in life?” | “Can we examine how your distress is rooted in the core beliefs you developed as a child?” | (A): “When I look at you, I don’t see the imperfections you point out.”
(B): “I’m wondering if you can keep a journal to record your thoughts and feelings when looking in the mirror”
(C): “How does preoccupation with your appearance stop you from participating in life?”
(D): “Can we examine how your distress is rooted in the core beliefs you developed as a child?” | “How does preoccupation with your appearance stop you from participating in life?” | C | The best response is: “How does preoccupation with your appearance stop you from participating in life?” Individuals with BDD often exhibit poor insight due to delusional beliefs about their appearance and delusions of reference. Experts suggest psychoeducation, coupled with empathy and a non-judgmental stance, can help improve insight and increase motivation to change. Experts advise against arguing or disagreeing with inaccurate perceptions, which makes answer A incorrect. Core beliefs and individual schemas can contribute to inaccurate perceptions, particularly when the perceptions are tied to poor self-worth; however, answer C is incorrect because an individual must first develop insight and motivation prior to tying cognitive distortions to core beliefs from childhood. Recording thoughts and feelings is helpful for examining cognitive distortions; however, this response is less likely to help improve insight and increase motivation to change. Therefore, the correct answer is (B) | counseling skills and interventions |
204 | Name: Alberto Clinical Issues: Sexual functioning concerns Diagnostic Category: Sexual Dysfunctions Provisional Diagnosis: F51.22 Erectile Disorder, Situational Age: 43 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: White Marital Status: Married Modality: Individual Therapy Location of Therapy : Agency | The client is dressed in casual clothing and appears to be clean and well-groomed. He is of average height and build, with short black hair. He is noticeably tense and avoids eye contact when describing his symptoms. His speech is audible and clear. He is able to express himself clearly and articulately. The client reports feeling frustrated, embarrassed, and confused concerning issues with his wife. He denies any suicidal or homicidal ideation. His mood is anxious and affect is flat. He is able to recall pertinent events and information. He has no difficulty understanding the session process or comprehending instructions. He appears to be alert and oriented to person, place, and time. The client displays average insight into his current situation and expresses willingness to explore relevant issues in more depth with the therapist. He displays average judgment when answering questions. | First session The client, a 43-year-old male, presents for his first Telehealth session through the agency where you are an intern, finishing your final hours for licensure under clinical supervision. You begin the session by striving to create a safe, comfortable, and non-judgmental environment. You provide the client with an introduction to yourself, your qualifications, and your approach to therapy. You also explain how Telehealth works and provide the client with an opportunity to ask questions about the process. Next, you review his informed consent and other paperwork that was filled out prior to the session. You explain the policies and procedures for confidentiality within your agency. He nods his head and verbally acknowledges understanding. You then begin to explore the client's presenting issues and goals for therapy. You ask what prompted him to schedule an appointment for counseling, and he responds saying, "I don't know what is wrong with me, but lately, I've been having trouble with my wife....on an intimate level. It's been very frustrating and embarrassing, and it's causing a lot of tension between us. My wife is getting frustrated and accusing me of cheating on her. We have two children. I never thought this would happen to me." The client has seen a urologist and has no sign of prostate cancer but is in poor health. The client appears anxious when describing his symptoms. He is fidgeting and has trouble maintaining eye contact as you explore the issue more deeply. This is your first client who presents with this particular issue, and you are not entirely sure of how to proceed. You take a few moments to pause and reflect on what he has said while also noting his body language. As you consider the best way forward, you remember the importance of validation in establishing rapport. You nod your head and say, "I can see how this has been difficult for you and your wife. It's understandable why it might be causing tension between the two of you." | The client is an only child. As he grew up, he reports that his father was often vocal about his dissatisfaction with his sex life. The client also reports that his mother often expressed resentment toward him from the day he was born. This has left him with a deep-seated dislike of his mother, as well as resentment of women in general. Currently, his parents are facing health issues, with his father drinking heavily and his mother having lung cancer. The client feels overwhelmed and stressed due to his job and family responsibilities. He is worried about his parents' health and is not happy about the potential of having to take care of his mother if his father passes away. After a decade of working as an illustrator designing greeting cards, the client has recently been promoted to creative director of his department. Because of his introverted nature, he is now feeling overwhelmed with the new responsibilities and having to communicate with other departments within the company. The client drinks weekly and occasionally smokes marijuana. The client drinks at least one beer every other night after work with dinner. He will finish two six-packs on some weekends if they have company over to watch football. He says he rarely drinks hard liquor. The client has reported that his alcohol use or smoking marijuana is not causing any impairments in his ability to carry out his daily responsibilities, but he is overweight because of his inactivity and indicates he would like to return to his normal weight. He also says that he has never experienced any adverse physical or psychological effects due to his substance use. | What assessment tool would help you assess the client's presenting problems? | Functional Assessment | Beck Anxiety Inventory (BAI) | Behavior Assessment Rating Scale (BRS) | Continuous Performance Test (CPT) | (A): Functional Assessment
(B): Beck Anxiety Inventory (BAI)
(C): Behavior Assessment Rating Scale (BRS)
(D): Continuous Performance Test (CPT) | Beck Anxiety Inventory (BAI) | B | This is the correct answer because one of the client's presenting problems is anxiety. The Beck Anxiety Inventory determines the severity of anxiety and distinguishes between anxiety and depression. Therefore, the correct answer is (C) | intake, assessment, and diagnosis |
205 | Client Age: 24 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: African American Relationship Status: Single Counseling Setting: Private practice counseling clinic Type of Counseling: Individual counseling Presenting Problem: The client comes to counseling for help in managing anxiety, workplace dissatisfaction, and a pornography addiction. Diagnosis: Generalized anxiety disorder (F41.1), other problem related to employment (Z56.9), religious or spiritual problems (Z65.8) | Mental Status Exam: The client is oriented to person, place, time, and situation. The client appeared hesitant when talking about pornography | You are a professional counselor, and the client comes to counseling to work on anxiety, work dissatisfaction, and a pornography addiction. You and the client discuss his anxiety, and he identifies that he experiences anxiety at work, regarding daily tasks, and in social settings. The anxiety is characterized by restlessness, difficulty concentrating, muscle tension, and insomnia. The client states that at work he is often treated poorly by his supervisors, who often point out what he does wrong and do not acknowledge what he does right. He does not feel that he does as much wrong as they claim, and he often finds that their accusations do not accurately reflect his actions, which is frustrating. The client states that he has had many meetings with his supervisors and that they do not appear to try to understand his point of view. The client appears uncomfortable and begins to speak but stops for about a minute before saying that he also has a pornography addiction. The client says that he is a Christian and that he does not feel he should view any pornography, but also that he uses pornography a lot and does not feel like he has control over himself or the frequency at which he uses it. The client asks if you are a Christian, and you decide to disclose with him that you are, knowing this is an important part of the client’s life and perspective. The client states that his work problems and pornography use are his most pressing issues. | The client comes into the session smiling and says that he is excited to share his log this week. The client shares that he masturbated an average of one to two times daily and that he even went a day without masturbating. You express your excitement for the client achieving his goals. Through processing, the client identifies that he refrained from masturbating most often by leaving his bedroom and finding something to structure his time late at night. The client says that he had difficulty refraining from masturbating mostly when he came home from a difficult day at work, or when he struggled to sleep. You and the client discuss calming techniques to use when he is stressed after work. You also recommend approaches to address difficulty sleeping. On days when the client masturbates, he explains that he often decides that since he already messed up, he can do it again. The client says that he is happy at his new place of employment and that it is just a hard job. You support the client in challenging his past cognitive distortion that his future employment experiences will be the same as his past experiences. You are reviewing this case with a counseling resident, and she does not think that the client is doing anything wrong by masturbating because it is a typical part of human functioning | You are reviewing this case with a counseling resident, and she does not think that the client is doing anything wrong by masturbating because it is a typical part of human functioning. You encourage your resident to remember all of the following in regard to this client, EXCEPT: | The importance of supporting the diversity of clients | That although you can encourage different viewpoints, you cannot impose them | That the client is not causing himself any harm by refraining from masturbation | Refraining from imposing your own values and beliefs on clients | (A): The importance of supporting the diversity of clients
(B): That although you can encourage different viewpoints, you cannot impose them
(C): That the client is not causing himself any harm by refraining from masturbation
(D): Refraining from imposing your own values and beliefs on clients | The importance of supporting the diversity of clients | A | The counselor should always support the diversity of their clients’ beliefs despite their own value system. It can be helpful to remember that although the resident may not agree with the client’s interpretation of his actions, there is no harm to the client in his goal to refrain from masturbation. Client-centered therapy aligns counseling goals with the client’s goals, which in this case involve removing the urges for and eventually the act of masturbation in his life. With this client, it likely would not be helpful to encourage or impose other viewpoints because they would oppose his religious beliefs, and this may also make the client feel unsupported. Therefore, the correct answer is (A) | counseling skills and interventions |
206 | 7 Initial Intake: Age: 18 Gender: Female Sexual Orientation: Bisexual Ethnicity: African American Relationship Status: Single Counseling Setting: Agency Type of Counseling: Individual | Millie was well groomed and presented as anxious with constricted affect as evidenced by shaking her leg and tapping her pen frequently. Millie made good eye contact and speech was coherent and rational, however tangential with increasingly rapid rate at times. Speech content is somewhat guarded, demonstrating preoccupation with social influences and deflection from discussion about losing her mother. Millie was surprisingly graphic with detail about self-starvation and purging food and did not show concern; presented with incongruent affect and smiling while she talked about it. Millie denied SI.
Family History and Living Situation:
Millie lived alone with her mother in a different state until last year when her mother died, and she moved to a new state to live with her father and his girlfriend. Their relationship had already been strained therefore Millie opted to live with her paternal grandparents who also lived locally, which is where she lives now. Millie comes and goes as she pleases and does not regard house rules. She reports most often staying in her room with the door locked while on the computer or phone | Diagnosis: Major Depressive Disorder, single episode, recurrent (F33), Anxiety disorder (F41.9) provisional
You are a mental health counselor with a community agency and have been referred a new client named Millie, an 18-year-old African American girl, for problems adjusting to life without her mother who has passed away nearly one year ago from illness. Millie’s father brought her to your agency after convincing her to see a counselor. The referral form filled out by her father says she has never spoken about her mother’s death and does not talk about it with anyone he knows. Millie has had medical problems that have been best explained by disruptions in her eating and sleeping habits, which started after her mother died. You learn several reports were made during her senior year in high school of her fighting with other girls, which Millie tells you were erroneous and “not her fault”. Millie also demonstrates a highly active social life, but primarily online with strangers as she exhibits strong social phobic behavior in public and around others in person. You recommend in-person counseling rather than Telehealth virtual sessions to support her improvement. | llie was well groomed and presented as anxious with constricted affect as evidenced by shaking her leg and tapping her pen frequently. Millie made good eye contact and speech was coherent and rational, however tangential with increasingly rapid rate at times. Speech content is somewhat guarded, demonstrating preoccupation with social influences and deflection from discussion about losing her mother. Millie was surprisingly graphic with detail about self-starvation and purging food and did not show concern; presented with incongruent affect and smiling while she talked about it. Millie denied SI.
Family History and Living Situation:
Millie lived alone with her mother in a different state until last year when her mother died, and she moved to a new state to live with her father and his girlfriend. Their relationship had already been strained therefore Millie opted to live with her paternal grandparents who also lived locally, which is where she lives now. Millie comes and goes as she pleases and does not regard house rules. She reports most often staying in her room with the door locked while on the computer or phone. | Which treatment plan intervention addressing ED is most focused on client safety? | Assign client to self-monitor and record food intake while journaling feelings. | Assess severity of level of impairment to functioning to determine appropriate level of care. | Teach client model of eating disorder development and contributing factors. | Establish rapport and therapeutic alliance for client to feel safe in sharing. | (A): Assign client to self-monitor and record food intake while journaling feelings.
(B): Assess severity of level of impairment to functioning to determine appropriate level of care.
(C): Teach client model of eating disorder development and contributing factors.
(D): Establish rapport and therapeutic alliance for client to feel safe in sharing. | Assess severity of level of impairment to functioning to determine appropriate level of care. | B | Assessing for the presence of recurrent inappropriate eating disorder behavior and its level of impairment to Millie's daily functioning and health is vital to ensuring she is receiving adequate treatment at the appropriate level of care. Following this assessment, it is possible a client will be referred to a higher level of care facility, therefore it should be the first step in addressing safety. A quality therapeutic alliance as in answer a is always important to enhancing a client's experience of clinical safety but does not directly correlate to addressing physical safety. Monitoring her thoughts, feelings, and food intake in answer b is appropriate once Millie has identified and recognized her condition and it is being adequately monitored by her physician as well as properly indicated in her treatment plan. Psychoeducation on eating disorder as presented in answer c will be helpful once her condition has been defined. Therefore, the correct answer is (D) | treatment planning |
207 | 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. | k and Family History: The client obtained her bachelor’s degree in teaching and is currently a certified teacher. She comes from a family of educators, with her mother working as a teacher and her father as a high school guidance counselor. Before college graduation, she worked odd jobs, including waiting tables and working in a public library with preschool groups. She remembers enjoying her student teaching position but states that the class was “nothing like” what she has now. She explains that her student-teaching classroom contained 16 students and that she now struggles to stay on top of her current class of 24. She plays on a tennis team and serves as a “big sister” to a child through a local nonprofit organization. The client is married, and she and her husband do not have children. She reports that her husband has a high-stress job working as an attorney. The client says that he has “little patience with me when I complain about my job stress.” Which mindfulness-based theory would help the client become more actively involved in values-related activities (e\. g | Which mindfulness-based theory would help the client become more actively involved in values-related activities (e.g., playing tennis or volunteering as a “big sister”)? | Adlerian therapy | Reality therapy | Acceptance and commitment therapy | Narrative therapy | (A): Adlerian therapy
(B): Reality therapy
(C): Acceptance and commitment therapy
(D): Narrative therapy | Acceptance and commitment therapy | C | Acceptance and commitment therapy would help the client become more actively involved in values-related activities (eg, playing tennis or volunteering as a big sister). The goal of acceptance and commitment therapy is to investigate the client’s values and encourage the client to participate in life. It is a recommended therapy for chronic pain, which the client identified as a concern. Reality therapy focuses on creating a success identity that emphasizes the importance of one’s need for love and the need to feel worthwhile. Narrative therapy assumes that the subjective account of one’s life is socially, culturally, and politically constructed. Narrative therapists work with clients to reauthor or restory their lives to externalize the problem. Therefore, the correct answer is (D) | counseling skills and interventions |
208 | Name: Jeff Clinical Issues: Referral following hospitalization for suicidal ideation Diagnostic Category: Bipolar and Related Disorders Provisional Diagnosis: F31.32 Bipolar I Disorder, Moderate, Most Recent Episode Depressed Age: 33 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: White Marital Status: Never married Modality: Individual Therapy Location of Therapy : Private Practice | The client's overall presentation during the examination is disheveled. He is thin, taller than average, and hunches over in his chair. He appears tired and exhibits low energy. Several times during the examination, he massages his neck and shoulders. He has inconsistent eye contact and often looks down at the floor. Speech is quiet and slow. You have to wait several seconds for him to answer questions. Thought content reveals negative themes. At various times he appears numb and indifferent but then shifts to tearfulness. Memory is slightly impaired, and he has difficulty staying focused. He denies homicidal ideations but states having past suicidal ideations. | First session You are a clinical mental health therapist working in a private practice setting. The client is a 33-year-old male referred to you by an ER physician as a follow-up after being hospitalized due to suicidal ideation. This is not the first time the client has been hospitalized. During the initial counseling session, the client discloses, "I don't know why I'm here. No one can help me. My sister made this appointment for me because I got this referral when I left the hospital. She drove me here and is sitting out in the waiting room." He continues with a tearful eye, "I'm a total failure. No one cares about. My sister looks after me, but I think it's because she feels sorry for me." You continue with your assessment to gain a more thorough understanding of his current situation. He tells you that there are times when he feels "really low" and his mind tells him that he would be better off dead. Other times, he feels "pretty good" with a lot of energy, a positive self-image, and motivation to complete various projects. You ask about his relationships with friends and family, and the client reveals that he has lost contact with most of his close friends due to a "series of negative events" in his life. He further discloses that he has difficulty maintaining relationships. He expresses feelings of loneliness and disconnection from the world. He is worried that his sister will eventually "give up" on him. When asked about his parents, he softly laughs and says, "They took the easy way out and died. Mom in a car crash and Dad from cancer. They are the ones who deserve to suffer and instead, they've got it easy." You discuss your role as a therapist and what the client can expect from the counseling process. You also review the parameters of confidentiality involved in therapy. He tells you that he would like to "give counseling a try" and see you for another session. You schedule an appointment to see him the following week. Fourth session The client appears energetic during this session. He presents as much more carefully groomed and in an elevated mood. He states, "It sure has been a journey these past few days." He reports that he met a woman at a local bar, and after spending the night together at a local hotel, they ended up taking a spontaneous road trip to Florida. He talks about the weekend as "mind-blowing", and states that this adventure has helped him design his new goal, which will be "life-changing." He goes on to say that his boss "didn't appreciate my free spirit because I had a bunch of voicemails from her waiting for me when I got home." He laughs when he relates that he had turned his phone off, so he didn't have to be "brought down." He recognizes that he had made commitments to work over the weekend, but he states, "If you met this girl, you'd know why I did it." Then laughs. You listen to the client's story intently and encourage him to talk more about his experience. Then you explore his feelings around the situation and his decision to leave work without making prior arrangements to cover his absence. You also discuss with the client the potential consequences of his actions and help him consider how to move forward in a way that is not harmful or dangerous. You ask him to think about his goals and create an action plan to help him reach those goals. Together, you and the client come up with strategies for the client to move forward in a healthy way. 10th session As you have been working with the client over the past two and a half months, he has made significant progress with treatment goals, including mood stabilization and behavioral control. In the last session, as you reviewed the progress that the client had made over the course of treatment, you both agreed that the client was ready for termination as he felt he had gotten what he needed from therapy. The client was especially pleased when considering his progress in mood regulation and mindfulness, as well as addressing his thrill-seeking behaviors during his manic phases. For this final session, the client arrived ten minutes late. He appears out of breath as he runs into the room. The client states that he got a call from the hospital where his sister was just admitted. As he describes the phone call, he pauses and looks out the window with tears in his eyes. You ask him how he feels. The client responds quietly, "I don't know, my sister has been in a serious accident, and I don't know how I'll continue without her support," prompting you to recognize that unresolved issues may require additional therapy. You state, "It sounds like your sister's accident has brought up a lot of emotions for you. You are feeling overwhelmed and unsure about how to cope without her support. It must be difficult to process all of this at once." The client nods his head. You continue by telling him that it is natural to feel overwhelmed and uncertain in a situation like this. You engage him in a discussion about coping strategies or support systems that have helped him in the past when facing difficult challenges. You also ask him if it would be helpful to have additional therapy sessions during this time to which he replies, "Yes, I don't want to undo all the progress I've made." | The client's parents divorced when he was ten years old. He has an older sister who he currently lives with. He recalls his childhood memories as traumatic and reports experiencing verbal and physical abuse by both parents. The client states that he lived with his dad after his mom died when he was 14 years old. He explains that living with his dad was difficult, saying, "Being around my dad was like being around a ticking time bomb. There were times when he was calm and seemed interested in what I was doing, but there were other times when he would become very angry and I was never sure what might set him off." The client works in a local pizza shop. He says he is written up weekly for being late to work. He reports verbal altercations with his coworkers because they will not listen to him. In his teen years, the client used alcohol to cope with his family situation. Since that time, he only drinks socially. | What is your main intention when asking the client about previous coping strategies? | To evaluate the effectiveness of the client's previous coping strategies | To judge the client's ability to cope with difficult situations | To determine if the client has made any progress in managing his emotions | To empower the client by leveraging his own abilities and assets | (A): To evaluate the effectiveness of the client's previous coping strategies
(B): To judge the client's ability to cope with difficult situations
(C): To determine if the client has made any progress in managing his emotions
(D): To empower the client by leveraging his own abilities and assets | To empower the client by leveraging his own abilities and assets | D | By asking the client about their past coping strategies and support systems, the therapist is encouraging them to tap into their own strengths and resources. This can not only help the client feel more empowered, but it also provides the therapist with valuable insight into how they can continue to support the client in coping with their sister's accident. Therefore, the correct answer is (A) | counseling skills and interventions |
209 | 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 | What information provided by the client and his mother is required for the diagnosis of autism spectrum disorder? | Sleep-wake disturbances | Sensory hyper-reactivity | Extreme mood lability | Impulsive outbursts | (A): Sleep-wake disturbances
(B): Sensory hyper-reactivity
(C): Extreme mood lability
(D): Impulsive outbursts | Sensory hyper-reactivity | B | Researchers indicate over three-quarters of those diagnosed with ASD show hypo or hyper-reactivity to sensory stimuli. The 5th edition of the Diagnostic and Statistical Manual of Mental Disorders, Text Revision (DSM-5-TR) sensory processing difficulties as one of four types of restricted, repetitive patterns representative of the diagnosis of ASD. The client’s difficulty tolerating cafeteria noise is an example of sensory hyper-reactivity. It is common for individuals with ASD to have difficulties with sleep-wake disturbances, including insomnia, narcolepsy, and restless leg syndrome. However, the DSM-5-TR does not list sleep disturbance as a criterion for ASD. Mood lability is a comorbid symptom of ASD rather than a diagnostic criterion. For individuals with ASD, mood lability is often the result of sensory over-stimulation, difficulty tolerating a change in routine, or difficulty reading social cues. Impulsive outbursts are also commonly associated with ASD; however, the DSM-5-TR does not require this to diagnose ASD. Therefore, the correct answer is (C) | intake, assessment, and diagnosis |
210 | Client Age: 32 Sex: Female Gender: Female Sexual Orientation: Heterosexual Ethnicity: Latina; Mexican American Relationship Status: Married Counseling Setting: Community Mental Health Type of Counseling: Individual and Psychoeducation Presenting Problem: Depression Diagnosis: Major Depressive Disorder (MDD) with Psychotic Features 296.24 (F32.3) | Mental Status Exam: The client is well groomed and appropriately dressed. Her voice is soft and low, and she avoids eye contact, mainly when talking about her family. She states, “I’ve put them through so much. And I feel so ashamed when I’m unable to care for them.” She endorses feelings of hopelessness but denies suicidal and homicidal ideations. The client says that she hears voices and believes that they are the voices of her deceased ancestors trying to communicate with her. She explains that the “spirits” whisper her name in the middle of the night and come to her when she is alone. The client denies command hallucinations. Her appetite is poor, and she has difficulty sleeping “most nights.” She has experienced depressive symptoms most of her life, but, outside of the recent hospitalization, she has not sought treatment due to believing that mental illness is a sign of weakness. History of Conditio | You work in a community mental health setting. Your client is a 32-year-old Latina presenting with symptoms of depression and psychosis. She reports that she was hospitalized more than 6 months ago and did not attend follow-up appointments due to losing her health insurance coverage. The client currently reports anhedonia, sadness, feelings of worthlessness, and poor concentration. She explains that there are many days when she cannot get out of bed and is unable to fulfill her role as a wife and mother. The client also reports audio hallucinations and says this began when her grandmother died more than a year ago. She explains that her grandmother lived in her home and that her loss was “devastating” to the client. The client is fluent in Spanish and English. | n and Family History: You obtain a signed release of information before the client’s session today, which has enabled you to receive the client’s hospital records. The client was admitted due to hallucinations and suicidal ideation. The hospital psychiatrist provided a diagnosis of brief psychotic disorder and bipolar II disorder. The client was prescribed antipsychotic medication and an antidepressant. She reports that she discontinued the antipsychotic medication shortly after discharge because it caused excessive sleepiness. Regarding the antidepressant, the client states, “I just take it on the days when I’m really having a hard time.” The client has two teenage sons and lives near her extended family | The DSM-5-TR Cultural Formulation Interview (CFI) is a clinical assessment tool used to obtain culturally relevant information across all of the following domains EXCEPT: | Experiences of racism and discrimination | Cultural factors affecting current and past help seeking behaviors | The cultural definition of the problem | Perception of the problem’s cause, context, and support | (A): Experiences of racism and discrimination
(B): Cultural factors affecting current and past help seeking behaviors
(C): The cultural definition of the problem
(D): Perception of the problem’s cause, context, and support | Experiences of racism and discrimination | A | The CFI does not include direct lines of inquiry for experiences of racism and discrimination. Found in Section III of DSM-5-TR, the CFI uses clinically specific lines of inquiry useful for diagnostic and treatment planning purposes to include Cultural Definition of the Problem (questions 1-3); Cultural Perceptions of Cause, Context, and Support (questions 4-10); Cultural Factors Affecting Self-Coping and Past Help Seeking (questions 11-13); and Cultural Factors Affecting Current Help Seeking (questions 14-16). When inquiring about cultural factors affecting current help seeking, practitioners are encouraged to “elicit possible concerns about the clinic or the clinician-patient relationship, including perceived racism, language barriers, or cultural differences that may undermine goodwill, communication, or care delivery” (APA, 2022). However, the CFI does not ask directly about experiences of racism and discrimination. Therefore, the correct answer is (C) | intake, assessment, and diagnosis |
211 | Client Age: 24 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: African American Relationship Status: Single Counseling Setting: Private practice counseling clinic Type of Counseling: Individual counseling Presenting Problem: The client comes to counseling for help in managing anxiety, workplace dissatisfaction, and a pornography addiction. Diagnosis: Generalized anxiety disorder (F41.1), other problem related to employment (Z56.9), religious or spiritual problems (Z65.8) | Mental Status Exam: The client is oriented to person, place, time, and situation. The client appeared hesitant when talking about pornography | You are a professional counselor, and the client comes to counseling to work on anxiety, work dissatisfaction, and a pornography addiction. You and the client discuss his anxiety, and he identifies that he experiences anxiety at work, regarding daily tasks, and in social settings. The anxiety is characterized by restlessness, difficulty concentrating, muscle tension, and insomnia. The client states that at work he is often treated poorly by his supervisors, who often point out what he does wrong and do not acknowledge what he does right. He does not feel that he does as much wrong as they claim, and he often finds that their accusations do not accurately reflect his actions, which is frustrating. The client states that he has had many meetings with his supervisors and that they do not appear to try to understand his point of view. The client appears uncomfortable and begins to speak but stops for about a minute before saying that he also has a pornography addiction. The client says that he is a Christian and that he does not feel he should view any pornography, but also that he uses pornography a lot and does not feel like he has control over himself or the frequency at which he uses it. The client asks if you are a Christian, and you decide to disclose with him that you are, knowing this is an important part of the client’s life and perspective. The client states that his work problems and pornography use are his most pressing issues. | use. Family History: The client has a close relationship with his parents and his older sister. The client has close friends | All of the following are hormones released during masturbation or sex, EXCEPT: | Oxytocin | Cortisol | Dopamine | Testosterone | (A): Oxytocin
(B): Cortisol
(C): Dopamine
(D): Testosterone | Cortisol | B | Cortisol is a stress-induced hormone that is released when the fight-or-flight response is triggered. It regulates mood as it relates to stress; it also regulates the immune system, the inflammatory response, and blood sugar levels. Cortisol is not released by the act of masturbation. Oxytocin relates more to breastfeeding and childbirth; however, it is also linked with increased feelings of bonding during sexual intercourse and even while hugging. Testosterone increases stamina during sexual intercourse and the level of arousal. Dopamine is considered a “happiness” hormone and is part of the brain’s reward system that leads to increased desires for sexual intercourse in order to receive this hormonal reward. As a counselor, it is helpful to know how these hormones affect functioning because they can be a large factor in behavior and cognitions being reinforced and increasing in frequency or intensity. Therefore, the correct answer is (D) | intake, assessment, and diagnosis |
212 | 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. | 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. | How do you instruct the client to handle his father’s remarks and dismissive attitude? | Encourage the client to differentiate his self-acceptance from his father's acceptance. Practice using “I-statements” and conflict resolution phrases | Due to the father's intransigence, you should file a report with Child Protective Services of emotional abuse | Have the client write and deliver a letter to this father explaining what his father does that is hurtful and ways that his father could better communicate with his son. | In order to give the client a range of options that would be difficult to convey orally, practice using coping cards in the session | (A): Encourage the client to differentiate his self-acceptance from his father's acceptance. Practice using “I-statements” and conflict resolution phrases
(B): Due to the father's intransigence, you should file a report with Child Protective Services of emotional abuse
(C): Have the client write and deliver a letter to this father explaining what his father does that is hurtful and ways that his father could better communicate with his son.
(D): In order to give the client a range of options that would be difficult to convey orally, practice using coping cards in the session | Encourage the client to differentiate his self-acceptance from his father's acceptance. Practice using “I-statements” and conflict resolution phrases | A | By providing a safe and nurturing therapeutic relationship, you can help the client grow his self-confidence and self-acceptance. Therefore, the correct answer is (A) | counseling skills and interventions |
213 | 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. | When would be the most appropriate time to conduct your follow-up suicide assessment? | Right in this moment with her crying, as you will get the most accurate results. | Consider a reasonable moment in the next five or ten minutes as you discuss her feelings. | Do not bring up her suicidal thoughts unless she does, it might only trigger her more. | At the end of the session before she leaves, so you don't interrupt her thought process. | (A): Right in this moment with her crying, as you will get the most accurate results.
(B): Consider a reasonable moment in the next five or ten minutes as you discuss her feelings.
(C): Do not bring up her suicidal thoughts unless she does, it might only trigger her more.
(D): At the end of the session before she leaves, so you don't interrupt her thought process. | Consider a reasonable moment in the next five or ten minutes as you discuss her feelings. | B | Because suicidal thoughts were present, it is your ethical responsibility and clinical best practice to readdress her mental status by conducting a follow-up suicidal assessment. This information is significant for assessing her safety, developing a pattern of data to further justify interventions and future care, and ensuring her evaluations are improving and not degrading. Confronting Malik with questions of her suicidal thoughts right as she begins crying and is sharing her trauma for the first time may not be the optimal time as you are still working to develop rapport, help her feel safe, and receive accurate information when she is thinking more clearly and not responding out of heightened emotion. It is important to understand if she has suicidal thoughts while emotional, but this can still be discussed moments later when you can help her feel more comfortable and elaborate on her feelings. Saving the suicidal assessment for the end of her session is unwise at it may bring about further discussion that you no longer have time for and neglecting to discuss it altogether is in poor judgment and not the safest option. Therefore, the correct answer is (D) | intake, assessment, and diagnosis |
214 | 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. | Psychotherapy often uses a technique known as psychoeducation to help clients better understand their issues and how to cope with them. Which of the following is not one of the benefits of using psychoeducation with this client? | Changes external factors contributing to her distress like her ex or mother's comments | Increases her understanding of underlying motivations for behavior | Increases her insight by providing context related to her presenting problem | Increases her motivation or willingness to make positive changes in behavior | (A): Changes external factors contributing to her distress like her ex or mother's comments
(B): Increases her understanding of underlying motivations for behavior
(C): Increases her insight by providing context related to her presenting problem
(D): Increases her motivation or willingness to make positive changes in behavior | Changes external factors contributing to her distress like her ex or mother's comments | A | Psychoeducation would not enable changes in negative external influences themselves - like transforming what her ex or mother actually say or do - but instead would focus on building internal resilience and coping mechanisms for the client. Therefore, the correct answer is (A) | counseling skills and interventions |
215 | Name: Gordon Clinical Issues: Mood instability and substance use leading to occupational impairment Diagnostic Category: Bipolar and Related Disorders;Substance Use Disorders Provisional Diagnosis: F31.0 Bipolar I Disorder with Rapid Cycling; F10.20 Alcohol Use Disorder, Severe Age: 33 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: White Marital Status: Never married Modality: Individual Therapy Location of Therapy : Agency | The client appears to the intake session disheveled and displaying a strong presence of body odor. He is inconsistently cooperative within the session. His mood and affect are anxious and labile. His attention and concentration are impaired, and he is easily distracted in the session. He admits to his recent suicidal ideations and hospitalization but minimizes the impact stating, "Everyone overreacts these days." He mentions that when he was in his 20s, he was prescribed Lithium. He denies any homicidal ideations and displays no acts of delusion or hallucination. The client's ability to abstract and generalize is slightly lower than average. The client grapples with his impulse control regarding alcohol. He has insight into the level of the illness with which he is struggling but lacks judgment when making healthy choices. | First session You are a mental health therapist in an agency. The client, a 33-year-old former cab driver, comes to see you per his hospitalization discharge. The client's speech is characterized by an increased rate of speech, tangentially, and circumstantiality. He reports feeling overwhelmed and out of control, often losing his temper and having difficulty regulating his emotions. He reports a history of alcohol abuse, as well as self-medicating to cope with his emotional distress. He states that he has lost his job due to his difficulty controlling his emotions, and he is hopeful that therapy can help him regain his job. He also reports a history of legal trouble and has been incarcerated multiple times in the past. His legal record shows a history of violent offenses and domestic abuse. After the initial interview, you review the paperwork from the client. You recognize his last name and realize he is a distant cousin by marriage, although this is your first time meeting him. You consider the ethical implications of continuing to see him for therapy along with the possibility of transferring him to one of your colleagues. Third session After determining that you would be able to remain objective with the client, you met with him for a session and continued your assessment. You recommended seeing him once a week for therapy sessions and asked him to check in with you between sessions. You also provided him with a referral for a psychiatric evaluation to determine if medication was warranted for mood stabilization. Today is your third counseling session, and the client arrives 10 minutes late. The client's behavior during the session was increasingly concerning. He appeared disheveled, and his speech was slurred and jumbled, indicating that his level of intoxication was likely high. The client exhibited bizarre behaviors and laughed inappropriately, indicating a potential manic or hypomanic episode. His attention span during the session was limited, and he could not focus on the topics at hand. When asked, the client admits to drinking before the session and is unable to provide an accurate account of how much he has consumed. He reports going to the local bar down the street from his house to have "one drink." He is also unable to provide any information on the location of his emergency contact. This lack of insight and awareness of his current intoxication, combined with the inappropriate behaviors he is exhibiting, prompts you to assess for the next level of intervention that is needed. Seventh session The client's attendance in weekly therapy sessions has been inconsistent. Today, he presents to his scheduled session, and he hands you a discharge summary from another recent hospitalization. The client states that he was on one of his "highs," went to a bar, and ended up fighting with one of the other customers. He says he has no recollection of how the fight started, but the person he was fighting with told him that "his life was useless and that he would be better off dead." The client states that having a few drinks and driving around in his car while listening to music helps him calm down. You validate the client's attempts to identify coping skills. The client's depression is further evidenced by his lack of motivation and interest in activities he once found enjoyable. He reports feeling overwhelming hopelessness and expresses a pervasive feeling of worthlessness. His low self-esteem is apparent in his statements and is further evidenced by his inability to recall accurately the events leading up to the altercation. The client's risk for self-harm is elevated, given his recent suicidal ideation. He reports feeling his life has no value and that he would be better off dead. His current safety plan is inadequate to address his risk for self-harm and is further exacerbated by his use of alcohol as a coping mechanism. The client has little insight into his current mental state and cannot accurately identify the signs of his deteriorating mental health. He lacks insight into his coping skills and their potential consequences and is unable to recognize the need for more comprehensive safety planning | The client had a history of alcohol abuse and had been warned multiple times by his employer to stop drinking while on the job. The client's boss tried to counsel him, but he refused to accept help or advice. Instead, he continued driving while under the influence, and his reckless behavior eventually led to an accident. As a result, the client was dismissed from his job and has struggled ever since. The client has been unsuccessful in finding other employment due to his record of drinking on the job. He has been trying to seek help with his drinking but without any success. He believes that therapy may be his last hope for getting his job back, and he is desperate to change his life. The client tells you, "I started drinking years ago. I've tried to quit, but I can't do it." He further states, "It used to be a couple of beers, but that doesn't do it for me anymore. So now, I drink almost half a bottle of whiskey a day. I usually start in the morning because if I don't, I feel terrible; my hands shake, I feel clammy, and I get an upset stomach. For years, I used just to let the mood pass, but in the last year or so, the alcohol has helped." | In which of these statements are you demonstrating a Person-centered therapy technique? | "I'm concerned that you're making a mistake and need to find other coping strategies. Think about the other people that you're putting in danger. | "I'm concerned for your safety if you drink and drive and wonder if we can explore other ways you can listen to music in a safe environment." | "I'm concerned that you are endangering other people and being irresponsible, but I'm impressed that you found a coping skill that works for you." | "I'm concerned that you may hurt yourself or someone else. It's important that you consider the legal consequences of drinking and driving." | (A): "I'm concerned that you're making a mistake and need to find other coping strategies. Think about the other people that you're putting in danger.
(B): "I'm concerned for your safety if you drink and drive and wonder if we can explore other ways you can listen to music in a safe environment."
(C): "I'm concerned that you are endangering other people and being irresponsible, but I'm impressed that you found a coping skill that works for you."
(D): "I'm concerned that you may hurt yourself or someone else. It's important that you consider the legal consequences of drinking and driving." | "I'm concerned for your safety if you drink and drive and wonder if we can explore other ways you can listen to music in a safe environment." | B | This statement affirms a positive coping skill and attempts to protect the client rather than judge the client's behavior. Therefore, the correct answer is (D) | counseling skills and interventions |
216 | 39 Initial Intake: Age: 18 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Chinese Relationship Status: Single Counseling Setting: College Counseling Center Type of Counseling: Individual | The counselor noticed that Darrel’s clothes look disheveled, he had bags under his eyes and made very little eye contact. When asked, Darrel stated that he was working late the day before and he just needed to rest.
| Darrel is an 18-year-old freshman who comes into the college counseling center for some career counseling.
History
Darrel is a transfer student from China, living with a boarding family close to the college campus. He is an Advertising major at college. Darrel stated that he is unhappy at school. He didn’t know if he was unhappy with his major selection even though he couldn’t see himself doing anything else. Darrel described how recently he just doesn’t like anything he used to, including anything that has to do with Advertising. Darrel stated that his parent would be greatly disappointed if they knew that he was switching his major. He questioned why he had to do what they want anyway. The counselor suspected that the issues may be deeper than Darrel’s initial intake suggested. | null | According to Erikson's stages of psychosocial development, Darrel is in the stage of? | Autonomy vs. shame and doubt | Trust vs. mistrust | Industry vs. inferiority | Individual identity vs identity confusion | (A): Autonomy vs. shame and doubt
(B): Trust vs. mistrust
(C): Industry vs. inferiority
(D): Individual identity vs identity confusion | Individual identity vs identity confusion | D | Darrel appears to be in the stage of Individual identity vs identity confusion evidenced by the conflicting feelings of wanting autonomy from his parents and not wanting to disappoint them and questioning his career path. Industry vs inferiority occurs in middle childhood when an individual is focused on friendships, learning life skills and team play. Autonomy vs shame and doubt as well as trust vs mistrust occurs between the ages of birth to 3 years old. Therefore, the correct answer is (D) | intake, assessment, and diagnosis |
217 | Name: Michael Clinical Issues: Separation from primary care givers Diagnostic Category: Anxiety Disorders Provisional Diagnosis: F93.0 Separation Anxiety Disorder Age: 10 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Not Assessed Ethnicity: Guatemalan American Marital Status: Not Applicable Modality: Family Therapy Location of Therapy : Agency | Michael appears clean and dressed in appropriate clothing. He often fidgets with his hands and insists on sitting next to his father during the session. Speech volume is low, and pace is fast. He has a slightly flattened affect. He exhibits minimal insight consistent with his age. | First session You are a licensed mental health counselor at a pediatric behavioral health center. Michael, a 10-year-old male, presents along with his father. You conduct a thorough psychological exam, including a mental status examination. During the initial interview, you take note of Michael's behavior. He sits very close to his father and looks fearfully around the room. The father tells you Michael has been having trouble at school and home for the past few months and it has been getting worse. When you ask how Michael is doing in school, the father tells you there have been several incidents, including difficulty waking up for school, crying in the morning, and refusal to get dressed and ready. The father also tells you that Michael has been showing signs of frustration with his teachers and classmates. On the home front, the father mentions that his son has become "a nuisance for his babysitter, especially during bedtime." Both parents are paramedics on a 24-on/48-off shift rotation. Michael often calls his parents while at work, complaining that he feels sick and cannot fall asleep. He worries that someone might break into the house or that "something bad will happen" to his parents. The father reports that he and his wife have tried to reassure Michael, but their efforts have been unsuccessful. They are perplexed as to what is causing Michael's distress. The father tells you that Michael has always been a bright and energetic child, but now he seems overwhelmed and anxious. You conduct a more detailed interview with Michael alone, focusing on his current environment and daily routines. You ask him how he feels about school, and Michael denies having any issues. He tells you that he does not want to go because his new school is "boring." However, when you probe further, he admits to feeling scared and alone. He does not want to be away from his parents, and he imagines "all the ways they could be hurt" while they are not with him. You say, "I can understand why you might be feeling scared and anxious, Michael. It sounds like a lot has been going on recently. I'm here to help you and your parents understand what's causing your worries so you can start to feel better." You reconvene with Michael's father and provide a brief summary of your findings. You explain that you suspect Michael's anxiety is likely due to the family's recent relocation and having to adjust to a new school. His fears are also likely rooted in his parents' profession, which may lead him to worry about their safety while they are away from home. You have personal experience in dealing with pediatric anxiety and consider briefly sharing your story with Michael and his parents as you believe it may help them to feel supported and less alone in their struggles, while also providing a practical example of how to work through difficult times. You suggest developing an intervention plan to address Michael's distress and recommend meeting with Michael and his parents for weekly sessions. Fourth session When you arrive at your office today, you realize that you inadvertently left therapy notes on your desk after work on Friday, which included information about Michael's case, and the notes are not where you left them. The weekend cleaning crew lets you know that the notes were discarded in the trash. You take the appropriate action in managing this breach of confidentiality, following your practice's guidelines and policies. You also take time to reflect on how this incident could have been prevented and use it as a learning opportunity for yourself. When you met with Michael and his parents during the previous two sessions, you gathered additional information about his symptoms, thoughts, and feelings. You provided psychoeducation about separation anxiety and recommended that Michael's parents make an appointment for him to see his pediatrician. You also began to formulate a treatment plan with the overall goal of tolerating separation from his parents without severe distress. Michael and his parents present for today's session on time. The parents begin by reporting that their son's symptoms continue to be a problem. School refusal is still an issue. His mother has had to come home from work three times this past week. His outbursts were so loud that the neighbors came by to check on him. The mother says, "My boss has been patient with me so far, but pretty soon, I'm going to be at risk of losing my job if we can't get a handle on our son's behavior. What are we doing wrong?" Your focus during this session is on helping the parents understand their role in the therapy process. You start by reviewing some of the psychoeducation you provided in prior sessions, focusing on the importance of consistency in parenting approaches and providing structure for Michael at home. You discuss different strategies they can use at home to help build their son's coping skills. You also provide some relaxation exercises that Michael can do when he feels anxious. At the end of the session, you thank Michael and his parents for coming in today and assure them that they are on the right track. You take time to summarize the key points of the session and emphasize the importance of follow-through with what was discussed in order for progress to be made. You provide them with resources to further support their efforts and suggest a follow-up appointment in one week. | Michael's parents have been married for nine years and both are dedicated to the well-being of their children. The father reports that he and his wife communicate openly with each other and make joint decisions about parenting issues. They also model healthy family dynamics, such as expressing affection and respect towards one another, being honest with one another, and sharing responsibilities. Michael has a five-year-old sister. His father characterizes the family as very close; they do everything together. The father says that he and his wife go to their children's sporting events and school meetings. Every weekend, the four of them are together doing family activities. Except when required to be away due to their work schedules as paramedics, the parents are home with the children at night. Prior to the family's move to a new state 6 months ago, Michael had been a successful student at school, typically performing at or above grade level. He was an active participant in the classroom, often volunteering to answer questions or participate in class discussions. Since the move, however, getting ready for school has been a struggle each day. He is struggling academically; while his grades haven't dropped drastically, he appears to be having trouble focusing and understanding the material. His parents have attended parent-teacher conferences and Michael's teachers have also reported that he seems distracted and uninterested in class. His parents also report that they are having difficulty getting him to stay on task when doing his homework at home. | Using a behavioral therapy approach, what would you recommend to the parents to reduce the frequency and severity of Michael's temper tantrums when his parents leave the house? | Using time-outs and taking away privileges when he has outbursts | Providing a token economy as positive reinforcement to shape the client's behavior and extinguish the negative interactions. | Providing opportunities for him to practice regulating his emotions and express himself in acceptable ways | Providing positive reinforcements for when Michael is able to remain calm when his parents leave the house | (A): Using time-outs and taking away privileges when he has outbursts
(B): Providing a token economy as positive reinforcement to shape the client's behavior and extinguish the negative interactions.
(C): Providing opportunities for him to practice regulating his emotions and express himself in acceptable ways
(D): Providing positive reinforcements for when Michael is able to remain calm when his parents leave the house | Providing positive reinforcements for when Michael is able to remain calm when his parents leave the house | D | Providing positive reinforcements for when Michael is able to remain calm and composed when his parents leave the house. Positive reinforcement is a key element of behavioral therapy, as it helps to reward desired behaviors and encourage them in the future. Therefore, the correct answer is (B) | counseling skills and interventions |
218 | Initial Intake: Age: 68 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: African-American Relationship Status: Married Counseling Setting: Private Practice 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.” | Using the information provided, which referral will be most helpful for this client at this time? | A respite care agency | A new counselor who specializes only in addictions | A support group for caregivers | A psychiatrist who can prescribe medications that reduce alcohol use | (A): A respite care agency
(B): A new counselor who specializes only in addictions
(C): A support group for caregivers
(D): A psychiatrist who can prescribe medications that reduce alcohol use | A respite care agency | A | At this time, a respite care agency will provide the most benefits for this client. Respite care agencies provide caregivers or take the patient into their facility for a short time so that the family member can have time away and exercise self-care. Referring the client to a support group for caregivers would be suitable, except the client has already stated that he generally cancels his plans because he cannot leave his wife alone. This would make it difficult for him to attend a support group. Referral to a new counselor who only specializes in addictions is needed only if the current counselor is not competent to work in this area and does not have access to adequate supervision or consultation, as needed. Referring to psychiatry for medications to reduce alcohol use (ie, Antabuse) is not a helpful referral as the client has already stated they do not want to take medications and are not yet ready to stop drinking. Therefore, the correct answer is (A) | treatment planning |
219 | 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. | In planning treatment for this client that is consistent with this diagnosis, which of the following would be the most effective referral? | Religious or Spiritual advisor for holistic care | Family physician for medical check up | Group counseling for support | Psychiatry for medication evaluation | (A): Religious or Spiritual advisor for holistic care
(B): Family physician for medical check up
(C): Group counseling for support
(D): Psychiatry for medication evaluation | Psychiatry for medication evaluation | D | Standard treatment for body dysmorphic disorder includes cognitive behavioral therapy and medication, typically SSRIs. Referral to a psychiatrist or psychiatric nurse practitioner would be the appropriate referral for treatment of this disorder. Group counseling can be supportive and help her connect with others that experience some of the same symptoms. Referral to a family physician is helpful to ensure that the client is in good physical health, but family physicians may not have the training or experience to work with body dysmorphic disorder, making a psychiatry referral the most effective. Referral to a religious or spiritual advisor, if desired, can be helpful as values play an important role in people's lives and can be an important source of strength during counseling, however the referral for medication evaluation is required for treatment of this disorder. Therefore, the correct answer is (B) | treatment planning |
220 | Name: Marta Clinical Issues: Caregiving concerns Diagnostic Category: Trauma and Stressor Related Disorders Provisional Diagnosis: F43.23 Adjustment Disorder, with Mixed Anxiety and Depressed Mood Age: 55 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: Colombian American Marital Status: Married Modality: Individual Therapy Location of Therapy : Agency | The client appears older than her stated age. She is disheveled, poorly groomed, and has a strong body odor. She is cooperative but demonstrates a high level of distress manifested as restlessness, being easily distracted, and consistently rubbing her hands. Her speech is initially slow and halted but later becomes elevated and loud. She is oriented X3. Her affect is characterized by anxiety and depression, as she is having difficulty answering your questions. The client indicates that she has thoughts about putting a pillow over her mother's face or taking an overdose of sleeping pills so that she does not have to deal with her family or her mother's demands anymore. | First session You are a counseling intern for a mental health agency. A 55-year-old Colombian American female presents to therapy with tears in her eyes. She appears distraught, anxious, and despondent. She describes feeling guilty about wanting to put her mother in an assisted living facility. Although the client knows that putting her mother in an assisted living facility is probably the best decision, she feels guilty because it goes against the values of her culture. She explains that in traditional Colombian culture, elders are revered, and it is the responsibility of the oldest child to take care of them. The client's siblings have been "critical of me even talking about moving her into an assisted living facility" and are pressuring her to keep their mother at home. The client starts to cry and covers her face. Finally, she looks up and says, "I feel torn. There are these cultural expectations that I look after my mother, but she never even liked me and made my life miserable when I was growing up." The client does not have any nearby family who can help support her or assist in the care of her elderly mother. Her brothers live in different states, and her husband is an only child whose parents both passed away a few years ago. The client has expressed feeling overwhelmed by the responsibility of taking care of her mother and running her own household. She says, "I feel like I just can't keep up with everything. My kids need me, my husband needs me, and now I have to take care of my mother, too. And as for having any time to myself, that's a dream that's never going to happen." She further explains that her current circumstances remind her of what it felt like growing up in a chaotic household and feeling the pressure of having to take care of her younger siblings. She states, "It's like history is just repeating itself." She reports feeling "like a failure at being a wife, mother, sister, and daughter." As you listen to the client's story, you sense her feelings of guilt, frustration, and overwhelm about not being able to meet all the demands placed on her. You empathize with the client and validate her feelings. You compliment her on the strength it took for her to take on an additional responsibility despite the hardships that come with it. When asked what she hopes to gain from therapy, the client tells you that she wants to figure out how to balance her responsibilities. She expresses wanting to find a way to care for her family members without "losing myself and my sanity in the process." You suggest meeting with the client for weekly sessions as a place to begin, and you walk the client through what she can expect from therapy. | The client is the oldest child in her family. She has 3 younger brothers, all of whom are separated in age by one year. She was born and raised in Colombia. When she was in middle school, her family immigrated to the United States in search of better opportunities. Her father worked long hours as a taxi driver while her mother worked as a nanny taking care of other people's children. The client stated that she often felt like she had no parents because they were always working. The client stated that when they moved, her mother asked her to help out more at home with the cooking, cleaning, and taking care of her siblings. She often felt overwhelmed and guilty because she wanted to spend time with friends or focus on her studies rather than watching her brothers. The client revealed that she often feel a deep sense of resentment knowing that while other girls were able to go outside and play, she had responsibilities to take care of. Personal/Social Relationships: The client's father passed away four months ago and her 76-year-old mother has been living with the client since then. The mother does not speak English and requires assistance with medical appointments, financial dealings, and daily care. She constantly "nags" the client about how she is raising her children and often complains about her cooking. The client's husband, who is second-generation Irish American and grew up in Boston, is becoming increasingly irritated with his mother-in-law. He complains to his wife about her mother, which puts a "massive strain" on the couple's relationship. | Based on the narrative, what appears to be the most significant factor contributing to the client's depression and anxiety? | Relationship with children | Family dynamics | Economic class background | Unique physical characteristics | (A): Relationship with children
(B): Family dynamics
(C): Economic class background
(D): Unique physical characteristics | Family dynamics | B | The client comes from a Colombian background and has shared that she has long struggled to keep up with the demands of her family's Colombian culture. She struggles to meet her family's expectations in caring for her mother. Additionally, the client's husband's lack of understanding of the family dynamics adds stress. Therefore, the correct answer is (A) | counseling skills and interventions |
221 | 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. | book. Family History: The client reports that his parents are supportive of his issues that are a result of autism. The client says that his 8-year-old brother gets frustrated sometimes because his parents often support the client and focus on him more due to his autism. The client reports that he does not have any friends | Which one of the following would be an appropriate referral to make for this client? | Occupational therapy | Medication management | Applied behavior analysis | Speech therapy | (A): Occupational therapy
(B): Medication management
(C): Applied behavior analysis
(D): Speech therapy | Medication management | B | Medication may be helpful in managing the client’s anxiety regarding situations in which he experiences rigidity. Because prescribing medications is outside of the scope of the counselor, a referral to a psychiatrist for medication management would be necessary. Occupational and speech therapy are more helpful with individuals with autism spectrum disorders that have intellectual deficits. Applied behavioral analysis is helpful for individuals with autism who experience behavioral issues but who also have trouble engaging in cognitive counseling; therefore, this client would not be a candidate for applied behavioral analysis. Therefore, the correct answer is (D) | treatment planning |
222 | Client s Age: Client 1: age 12 Client 2: age 14 Client 3: age 14 Client 4: age 16 Client 5: age 13 Client 6: age 16 Sex: Males Gender: Males Sexuality: Varying Ethnicity: Multiracial Relationship Status: Single Counseling Setting: Juvenile Justice Facility Type of Counseling: Group Counseling Presenting Problem: Involvement with the Justice System That Includes Various Mental Health Disorders and Crimes Diagnosis: Imprisonment (Z65.1) | Mental Status Exam: All of the clients appear to maintainappropriate hygiene, and they are all oriented to person, place, time, and situation. They are all somewhat reserved with regard to going into deeper topics, but theyparticipate f | You are a licensed counselor working in a juvenile justice facility for teenage males. The group comprises six males that are required to attend as part of their incarceration with the expectation that it will shorten their sentences. The purpose of the group is to work on emotional regulation and to work together to share common experiences and identify goals that can be helpful in preventing reincarceration. During the intake session, you explained the purpose of the group and started with an ice-breakeractivity. The clients participated in the ice-breaker activity that required you to redirect them back to the activity several times because they would joke and get off task. You attempt to go a little deeper by encouraging your clients to start talking about what happened to get them incarcerated, and they appear to be taking pride in the reasons they were in juvenile detention and making fun of those with lesser sentences. You redirect the clients to another topic. | You meet with the group, and they appear to be starting to become more comfortable with one another. You noticed that throughout the past week, when you saw your clients on their unit, they were spending more time together and that they are all talking when they come in for the session. During the session, you and the clients discuss past experiences that led to them engaging in the crimes that led to their incarceration. During this conversation, client 1 is talking about his father and how he killed a pedestrian while driving. Client 4 then asserts that client 1’s father is going to hell for killing someone. You cut off client 4 and redirect the attention back to client 1. Toward the end of this group session, you and the group talk about how being with peers who engage in antisocial behavior often leads to all members engaging in antisocial behavior | Toward the end of this group session, you and the group talk about how being with peers who engage in antisocial behavior often leads to all members engaging in antisocial behavior. All of the following are mechanisms of peer group influence EXCEPT: | Transmission of skills and values | Extinction | Reinforcement | Social comparison | (A): Transmission of skills and values
(B): Extinction
(C): Reinforcement
(D): Social comparison | Extinction | B | Extinction is a behavioral modification technique that focuses on removing reinforcement of a previously reinforced behavior with the hopes that it decreases and stops the behavior. This is not part of peer group influence. Reinforcement is present peer group influence, referring to the use of coercion, teasing, encouragement, criticism, and validation to dictate desired behavior. Social comparison is when an individual compares oneself to others in the group, which could lead to the individual changing their behavior to match the group’s behavior. Transmission of skills and values happens when older or more experienced group members share values and skills with younger or less experienced group members. Therefore, the correct answer is (D) | counseling skills and interventions |
223 | 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 | Li's reaction on the subway meets the criteria for? | Panic Disorder | Hyperventilation | Panic Attack | Paroxysmal episode | (A): Panic Disorder
(B): Hyperventilation
(C): Panic Attack
(D): Paroxysmal episode | Panic Attack | C | What Li described meets the criteria for a panic attack. It does not yet meet the criteria for Panic Disorder which consists of repeated attacks. Hyperventilation is rapid or deep breathing often caused by panic. A Paroxysmal episode can mimic a seizure and may include loss of consciousness. Therefore, the correct answer is (B) | counseling skills and interventions |
224 | 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. | How often should you assess for suicidal ideation for this client? | Daily, through the school psychologist | When the client mentions suicidal ideation | Every session | Monthly | (A): Daily, through the school psychologist
(B): When the client mentions suicidal ideation
(C): Every session
(D): Monthly | Every session | C | Knowing this client has a history of suicidal ideation suggests that this should be assessed during each session. Therefore, the correct answer is (B) | intake, assessment, and diagnosis |
225 | 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. | The client arrives with his wife for his scheduled individual session today. You have yet to meet his wife in person. Before you can obtain an accurate appraisal of the situation, you find yourself mediating a conflict that has quickly intensified. The wife has given the client an ultimatum—to either stop the “endless manipulation, control, and sharp criticism” or she will take their daughter and go live with her mother, who resides in another state. The wife states that she has shown up today in a last-ditch effort to save their marriage. The client expresses a desire to remain with his wife and daughter | If the client and his wife were to pursue couples counseling, which approach would best address attachment needs and bonding? | Systematic desensitization | Rational-emotive behavioral therapy | Emotionally focused therapy | Solution-focused therapy | (A): Systematic desensitization
(B): Rational-emotive behavioral therapy
(C): Emotionally focused therapy
(D): Solution-focused therapy | Emotionally focused therapy | C | Emotionally focused therapy (EFT) is based on John Bowlby’s attachment theory. EFT acknowledges the role attachment plays in forming intimate bonds and lasting relationships. The goal is to tap into the couple’s capacity and desire to attain a deeper connection with one another. Systemic desensitization is a behavioral intervention used with individuals experiencing anxiety, particularly with individuals experiencing phobias. Solution-focused therapy (SFT), or solution-focused brief therapy (SFBT), is future-oriented and limited in duration. SFT focuses on the couple’s individual strengths rather than addressing more profound childhood experiences. Rational-emotive behavioral therapy (REBT) is a cognitive approach used to identify and dispute irrational thoughts. Therefore, the correct answer is (C) | counseling skills and interventions |
226 | 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. | ship. Family History: The client is close with her parents and her younger brother (28 years old). The client says that she was engaged twice before but that neither engagement progressed to marriage because her two fiancés both felt that she was too clingy and unable to care for herself. The client is hesitant about sharing her experiences of physical abuse | The client is hesitant about sharing her experiences of physical abuse. How does this inform your course of treatment? | Check in every session to see if the client is ready to talk about the physical abuse, and then strongly encourage it when you think you have a strong therapeutic rapport with her. | Encourage the client to talk about the abuse during the intake session, and remind her that the more you learn about her, the more effective treatment will be. | Allow the client a few sessions to become more comfortable, and then strongly encourage the client to talk about the physical abuse. | Allow the client the space needed to become ready on her own, and bring it up every few sessions to check in and see if she is ready. | (A): Check in every session to see if the client is ready to talk about the physical abuse, and then strongly encourage it when you think you have a strong therapeutic rapport with her.
(B): Encourage the client to talk about the abuse during the intake session, and remind her that the more you learn about her, the more effective treatment will be.
(C): Allow the client a few sessions to become more comfortable, and then strongly encourage the client to talk about the physical abuse.
(D): Allow the client the space needed to become ready on her own, and bring it up every few sessions to check in and see if she is ready. | Allow the client the space needed to become ready on her own, and bring it up every few sessions to check in and see if she is ready. | D | When processing any sort of trauma, the counselor should follow the client’s lead regarding their readiness to discuss the trauma (in this case, abuse). There is no obligation for clients to talk about something that they do not want to, or are not ready to, talk about. It would be helpful to check in every few sessions to show this client that you remember that this was an issue she presented and to open up the opportunity to discuss it, should her willingness/readiness to do so change. Asking about the trauma every session or pressuring the client to talk about the trauma could cause more harm than good and could induce more resistance to openly discuss it. Although it is important to talk about the client’s history of physical abuse at some point (because it likely contributes to her presenting issues), the timing must be dictated by the client. Therefore, the correct answer is (C) | treatment planning |
227 | 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 | Bullying is defined as behaviors that include all of the following components EXCEPT: | Behaviors within a larger school or community setting | Actions that are intentionally aggressive or mean | Situations involving an imbalance of power | Behaviors that are repeated over time | (A): Behaviors within a larger school or community setting
(B): Actions that are intentionally aggressive or mean
(C): Situations involving an imbalance of power
(D): Behaviors that are repeated over time | Behaviors within a larger school or community setting | A | Bullying is being intentionally aggressive or mean, it is repeated over time, and it involves situations in which there is an imbalance of power. Bullying can occur in a variety of settings, including school, the community, or online. There are various subtypes of bullying, including physical bullying, verbal bullying, relational bullying, and electronic bullying. This differs from teasing and other acts of aggression in that there is an imbalance of power. Power can be physical, social, intellectual, or mental. Therefore, the correct answer is (D) | professional practice and ethics |
228 | Name: Ella Clinical Issues: Seeking help after experiencing a trauma Diagnostic Category: Trauma and Stressor Related Disorders Provisional Diagnosis: F43.0 Acute Stress Disorder Age: 35 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: White Marital Status: Married Modality: Individual Therapy Location of Therapy : Private Practice | The client is a 35-year-old white female with a slender build. She is wearing jeans and a t-shirt and appears to be clean and well groomed. Her posture is slumped, her facial expression is flat, her eyes are downcast, and she has been displaying signs of crying. She speaks softly in a monotone voice. The client appears depressed and anxious, with tearfulness and trembling. She seems overwhelmed by her current situation and is unable to control her emotions. She reports difficulty concentrating on day-to-day activities. Her thoughts are logical and organized with tangential moments. She reports feeling as if she is living in a dream-like state since the trauma occurred. She experiences frequent nightmares about people she loves being killed. She is able to recall her personal history accurately. She is able to understand and follow your instructions and questions. She recognizes that she needs help. She denies suicidal ideation or intent. | First session You are a mental health counselor working in a private practice setting while under supervision. The client is a 35-year-old white female who presents for therapy following a trauma. When you ask the client why she made an appointment to see you, she begins to cry and shake uncontrollably. She tells you that her friend was shot two weeks ago and the client saw it happen. Her friend is in the intensive care unit at the hospital. She cannot consciously recall the actual shooting. Since the assault, she cannot concentrate and feels anxious all the time. She does not want to talk to her friends, and she has been withdrawing from her family. The client tearfully tells you that "life has no meaning." She is seeking your help to find some relief. You validate the client's emotions and begin processing her subjective experience. You help her to understand that witnessing such a traumatic event can lead to the physical and emotional symptoms that she is experiencing. She appears receptive to what you are saying and nods her head. You emphasize that she has taken a courageous step by seeking professional help. As you continue with the initial session, you focus on providing an empathetic space where she can explore her feelings without fear of being judged. You provide her with information about resources she can access for further help. You also discuss the principles of cognitive-behavioral therapy as a method to begin to process her traumatic experience. Before the session ends, you present relaxation exercises that she can practice at home in order to reduce distress and tell her that learning healthy coping skills will be an important part of her recovery. Following the session with your client, your supervisor tells you that she has worked extensively with the client’s parents in the past and offers to give you their files so that you can understand more of the client's family history. | The client's family has a long history of living in the Bronx, New York, as her great-great-grandparents immigrated from Italy. She currently lives with her parents in a house that has been in her family for generations. Her entire life she has always felt safe and secure living in her Italian neighborhood. The client has one older brother who is married and works as a paramedic. She is close to her parents and describes them as supportive, hardworking, and loving. Her father was diagnosed with cancer several years ago and she has tried to be there for him in every way possible. Stressors & Trauma: The client witnessed her friend being shot during a robbery. Since then, she cannot stop thinking about the event. As a result, she has insomnia and frequent nightmares about people she loves being killed. She is unable to stop shaking and crying when discussing the nightmares. In addition, the event has left the client feeling angry, confused, ashamed, depressed, and highly anxious in her day-to-day activities. | How might you address your supervisor's offer to share records with you? | You obtain your supervisor’s notes on your client's parents to better inform your treatment. | You tell your supervisor you can discuss the issue in person, but you cannot view the case files. | You tell your supervisor that you cannot review the parent's case files. | You tell your supervisor she cannot discuss these case files until you get a written release of information from the parents. | (A): You obtain your supervisor’s notes on your client's parents to better inform your treatment.
(B): You tell your supervisor you can discuss the issue in person, but you cannot view the case files.
(C): You tell your supervisor that you cannot review the parent's case files.
(D): You tell your supervisor she cannot discuss these case files until you get a written release of information from the parents. | You tell your supervisor that you cannot review the parent's case files. | C | This is the best choice. The client is seeking help following a trauma in which her friend was shot. The client's presenting problem has nothing to do with the client's parents. Accessing their old therapy case records (even with their written consent for you to view the records) would not in any way be relevant to your client's current situation. Therefore, the correct answer is (A) | professional practice and ethics |
229 | Name: Alberto Clinical Issues: Sexual functioning concerns Diagnostic Category: Sexual Dysfunctions Provisional Diagnosis: F51.22 Erectile Disorder, Situational Age: 43 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: White Marital Status: Married Modality: Individual Therapy Location of Therapy : Agency | The client is dressed in casual clothing and appears to be clean and well-groomed. He is of average height and build, with short black hair. He is noticeably tense and avoids eye contact when describing his symptoms. His speech is audible and clear. He is able to express himself clearly and articulately. The client reports feeling frustrated, embarrassed, and confused concerning issues with his wife. He denies any suicidal or homicidal ideation. His mood is anxious and affect is flat. He is able to recall pertinent events and information. He has no difficulty understanding the session process or comprehending instructions. He appears to be alert and oriented to person, place, and time. The client displays average insight into his current situation and expresses willingness to explore relevant issues in more depth with the therapist. He displays average judgment when answering questions. | First session The client, a 43-year-old male, presents for his first Telehealth session through the agency where you are an intern, finishing your final hours for licensure under clinical supervision. You begin the session by striving to create a safe, comfortable, and non-judgmental environment. You provide the client with an introduction to yourself, your qualifications, and your approach to therapy. You also explain how Telehealth works and provide the client with an opportunity to ask questions about the process. Next, you review his informed consent and other paperwork that was filled out prior to the session. You explain the policies and procedures for confidentiality within your agency. He nods his head and verbally acknowledges understanding. You then begin to explore the client's presenting issues and goals for therapy. You ask what prompted him to schedule an appointment for counseling, and he responds saying, "I don't know what is wrong with me, but lately, I've been having trouble with my wife....on an intimate level. It's been very frustrating and embarrassing, and it's causing a lot of tension between us. My wife is getting frustrated and accusing me of cheating on her. We have two children. I never thought this would happen to me." The client has seen a urologist and has no sign of prostate cancer but is in poor health. The client appears anxious when describing his symptoms. He is fidgeting and has trouble maintaining eye contact as you explore the issue more deeply. This is your first client who presents with this particular issue, and you are not entirely sure of how to proceed. You take a few moments to pause and reflect on what he has said while also noting his body language. As you consider the best way forward, you remember the importance of validation in establishing rapport. You nod your head and say, "I can see how this has been difficult for you and your wife. It's understandable why it might be causing tension between the two of you." Fourth session It has been a month since you began therapy with the client. You have been meeting with him weekly. Today, the client states he and his wife attempted to have sex last week, and he could not maintain an erection. He says she called him "a lousy cheat with a beer belly who can't satisfy her." He lets you know that this remark triggers him as it reminds him of his relationship with his mother. He reports that sex feels like a "chore," and it is not fun anymore. "Sometimes, I fantasize about being with an ex-girlfriend of mine just to get an erection." The client seems sad and looks down at his feet. You and the client discuss his wife's comments, and he expresses feeling overwhelmed and helpless. You ask him to reflect on how he feels about his wife's reaction, and he reports feeling "hurt and rejected." You then discuss the possibility of exploring underlying issues that may be impacting his ability to find pleasure in sex. You then ask if he is able to recall any past experiences or traumas contributing to his difficulty with erectile dysfunction. He has never felt anxious about past experiences with erectile dysfunction, but now he sees to be struggling with feelings of guilt and shame. You then discuss strategies for improving communication with his wife and ways to build trust within their relationship. You encourage the client to explore his feelings and identify potential triggers impacting his ability to enjoy sex. Lastly, you role-play a scenario in which the client communicates his feelings to his wife in a non-confrontational manner. At the end of the session, he tells you that he is beginning to understand how he can relate better to his wife. He states, "I guess it's important to tell each other what we need and want." | The client is an only child. As he grew up, he reports that his father was often vocal about his dissatisfaction with his sex life. The client also reports that his mother often expressed resentment toward him from the day he was born. This has left him with a deep-seated dislike of his mother, as well as resentment of women in general. Currently, his parents are facing health issues, with his father drinking heavily and his mother having lung cancer. The client feels overwhelmed and stressed due to his job and family responsibilities. He is worried about his parents' health and is not happy about the potential of having to take care of his mother if his father passes away. After a decade of working as an illustrator designing greeting cards, the client has recently been promoted to creative director of his department. Because of his introverted nature, he is now feeling overwhelmed with the new responsibilities and having to communicate with other departments within the company. The client drinks weekly and occasionally smokes marijuana. The client drinks at least one beer every other night after work with dinner. He will finish two six-packs on some weekends if they have company over to watch football. He says he rarely drinks hard liquor. The client has reported that his alcohol use or smoking marijuana is not causing any impairments in his ability to carry out his daily responsibilities, but he is overweight because of his inactivity and indicates he would like to return to his normal weight. He also says that he has never experienced any adverse physical or psychological effects due to his substance use. | Based on the information you have gathered so far on the client, which issue is least significant to address? | The client's potential triggers impacting his ability to enjoy sex | The client's weight possibly impacting his erectile dysfunction | The client's feelings regarding his wife's poor communication skills | The client's fantasies about his ex-girlfriend | (A): The client's potential triggers impacting his ability to enjoy sex
(B): The client's weight possibly impacting his erectile dysfunction
(C): The client's feelings regarding his wife's poor communication skills
(D): The client's fantasies about his ex-girlfriend | The client's fantasies about his ex-girlfriend | D | Although this issue might be emotionally significant for the client, it is not as important to address in therapy as his feelings of hurt and rejection from his wife's comments, exploring any underlying issues that may be impacting his ability to find pleasure in sex, and improving communication with his wife. These topics are more likely to lead to meaningful progress in the therapy sessions. Therefore, the correct answer is (B) | intake, assessment, and diagnosis |
230 | 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. Second session The client presents to her second counseling session in a defensive state. She is upset that you reported her suicidal ideation to her parents because she thought that everything she told you would remain confidential. She says, "Why should I tell you anything else? You'll just tell my parents." You tell the client that you understand her frustrations and empathize with her. You explain to her why confidentiality is not always absolute and that as a clinician, it is your responsibility to keep clients safe, even when they don't want you to. You further explain that in this case, you felt it was important for her parents to know about the suicidal ideation she has been experiencing. You emphasize that her parents care deeply about her, and they need to know what is going on with her in order for them to help. She responds by saying, "Okay, I get what you're saying, but telling them about it has only made things worse." She reports that her parents now treat her "differently" and do not allow her access to any "dangerous items like kitchen knives" without supervision. She feels restricted and watched. You nod your head in understanding and reflect that it can be difficult to feel like your parents don't trust you and have put restrictions on things they normally wouldn't. You also encourage her to try and see the situation from their perspective and agree that although the restrictions can be inconvenient, her safety is their top priority. She takes a deep breath and says, "I guess I can understand why they did it, but it still doesn't feel fair." You acknowledge her feelings of unfairness and validate that feeling. After your discussion, the client appears to have a better understanding of her parents' motivation for the restrictions and feels less resentful towards them. You ask her to tell you more about how she has been feeling lately and invite her to share any other issues she is having trouble managing. She tells you that her ballet teacher has invited her to help teach the younger ballet classes, but she is ambivalent about pursuing this opportunity. Though she still loves ballet, she thinks it will be painful to watch other children fulfill the dreams that she can no longer pursue. She says, "I'm afraid that if I agree to teach, I'll never get over my injury. It will just keep reminding me of what I could have been." You explain to her that it is natural for her to have these feelings and that it is okay to take time to make a decision. You ask her if she can see any benefits to teaching. She pauses and says, "I don't know...I've never really thought of myself as a teacher. I've always been the student." You acknowledge the difficulty of this transition and understand that it can feel risky to try something new. You suggest that teaching could be an opportunity for her to gain a sense of purpose, as well as an activity to help her stay connected to something she loves. You encourage her to try and explore her capacity for teaching and imagine what impact she could have on her students. | 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. | If you had chosen to prioritize maintaining therapeutic rapport over your mandated reporting obligations, would your actions be considered ethical or unethical? | They would be ethical because you are uphold the principle of autonomy. | They would be unethical as you are required to report the client's threat of self-harm to her parents. | They would be ethical because no therapeutic progress can occur without therapeutic rapport. | They would be unethical because the client is a minor and all information must be disclosed to the parents. | (A): They would be ethical because you are uphold the principle of autonomy.
(B): They would be unethical as you are required to report the client's threat of self-harm to her parents.
(C): They would be ethical because no therapeutic progress can occur without therapeutic rapport.
(D): They would be unethical because the client is a minor and all information must be disclosed to the parents. | They would be unethical as you are required to report the client's threat of self-harm to her parents. | B | Therapists are ethically obligated to disclose limits to confidentiality to the client. Any threats of self-harm, suicidal ideation, or violence must be reported to ensure their safety. Therefore, the correct answer is (C) | professional practice and ethics |
231 | 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. Fourth session Today, the couple arrives for their afternoon appointment ten minutes late. The wife appears to have been crying. Her husband smells like mouthwash, and his movements are slightly slower than normal. You ask if he has been drinking today. He states that he has not had any alcohol today, but his wife says, "That's not true!" and proceeds to tell you that she "caught" him holding a bottle of liquor in their garage this morning. The husband replies, "I didn't do anything wrong. This is just another example of you looking for problems where there are none. Why can't you believe me when I tell you that I'm not drinking?" She replies, "I really want to believe you, but you make it really hard to do that." He shakes his head and throws his hands up in the air in frustration. You ask the husband to step out of the room for a few minutes. He agrees and says, "Fine. You know where to find me." The wife shares that she feels like her husband is not taking the process seriously, and she questions whether or not counseling will work for them. You thank her for expressing her thoughts and explain that it is very common for couples to have doubts about therapy, especially when there has been a history of substance abuse. You discuss the potential treatment barriers and emphasize that it is important to have insight into these problems in order to create positive outcomes. The wife appears to understand and is reassured by your words. You invite the husband back into the room and ask him to share his thoughts about the counseling process. He takes a deep breath and says that he still wants to make their marriage work, but he is afraid of failing. He admits that he does not know how to "make things right" and this makes him feel helpless. You explain to him that counseling can help them gain insight into their communication patterns, learn new ways to interact with each other, and develop healthier coping strategies. You also discuss a plan for handling escalations in future sessions. You explain to the couple that it is important to have a plan in place whenever they are feeling overwhelmed or angry. Next, you discuss conflict resolution skills, emphasizing the importance of communicating their feelings and needs in an honest, respectful, and non-judgmental way. You also stress the importance of each partner taking responsibility for their own actions. You encourage them to practice these strategies outside of the session in order to improve their communication and relationship. After the session, you discover that the community-based mental health facility where you work will be closing in six months due to a lack of funding. You view this as a potential barrier that will inhibit mental health treatment access for many clients as this is the only mental health treatment facility in the city. | 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. | Of the following, which is an ethically appropriate action to take to address the issue associated with your treatment facility's closing in six months? | You embrace that since you are in a helping profession, you are already contributing to the community's welfare. | You express your advocacy for affordable treatment by writing an editorial for the newspaper. | You resolve to devote your time to enhancing your effectiveness as a therapist in order to counteract any negative fallout. | You recognize that your clients will be affected by this change and encourage them to contact local authorities. | (A): You embrace that since you are in a helping profession, you are already contributing to the community's welfare.
(B): You express your advocacy for affordable treatment by writing an editorial for the newspaper.
(C): You resolve to devote your time to enhancing your effectiveness as a therapist in order to counteract any negative fallout.
(D): You recognize that your clients will be affected by this change and encourage them to contact local authorities. | You express your advocacy for affordable treatment by writing an editorial for the newspaper. | B | The therapist has an ethical responsibility to advocate for professional and client issues. Therefore, the correct answer is (B) | professional practice and ethics |
232 | Initial Intake: Age: 26 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Married Counseling Setting: Private Practice Type of Counseling: Individual | Molly was initially guarded, but pleasant, during the intake session. After some time, she became tearful. Molly stated to the counselor that although she always had a level of anxiety, she never came to counseling before because she thought that only unsuccessful people with serious issues get counseling.
| Molly came into individual counseling due to increased feelings of anxiety.
History:
Molly began showing symptoms of anxiety when she was in high school. Molly was star of the track team and on the honor roll. During her senior year she was writing for the yearbook and preparing to attend college at an Ivy League university. She successfully finished college and law school. Despite the symptoms she experienced throughout her educational career, she was able to ride it out and has been extremely successful in her law career. | null | Which of the following is not part of an assessment interview? | Past evaluations and assessments | Structured interview | Unstructured interview | Observation of behavior | (A): Past evaluations and assessments
(B): Structured interview
(C): Unstructured interview
(D): Observation of behavior | Past evaluations and assessments | A | Past evaluations and assessments can be helpful in the overall clinical picture and can confirm information provided by the client but can be gathered later. The assessment interview should include a structured interview which follows a standard format or form, an unstructured interview which is more conversational and observation of behavior/non-verbal cues. Therefore, the correct answer is (B) | treatment planning |
233 | Name: Alberto Clinical Issues: Sexual functioning concerns Diagnostic Category: Sexual Dysfunctions Provisional Diagnosis: F51.22 Erectile Disorder, Situational Age: 43 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: White Marital Status: Married Modality: Individual Therapy Location of Therapy : Agency | The client is dressed in casual clothing and appears to be clean and well-groomed. He is of average height and build, with short black hair. He is noticeably tense and avoids eye contact when describing his symptoms. His speech is audible and clear. He is able to express himself clearly and articulately. The client reports feeling frustrated, embarrassed, and confused concerning issues with his wife. He denies any suicidal or homicidal ideation. His mood is anxious and affect is flat. He is able to recall pertinent events and information. He has no difficulty understanding the session process or comprehending instructions. He appears to be alert and oriented to person, place, and time. The client displays average insight into his current situation and expresses willingness to explore relevant issues in more depth with the therapist. He displays average judgment when answering questions. | First session The client, a 43-year-old male, presents for his first Telehealth session through the agency where you are an intern, finishing your final hours for licensure under clinical supervision. You begin the session by striving to create a safe, comfortable, and non-judgmental environment. You provide the client with an introduction to yourself, your qualifications, and your approach to therapy. You also explain how Telehealth works and provide the client with an opportunity to ask questions about the process. Next, you review his informed consent and other paperwork that was filled out prior to the session. You explain the policies and procedures for confidentiality within your agency. He nods his head and verbally acknowledges understanding. You then begin to explore the client's presenting issues and goals for therapy. You ask what prompted him to schedule an appointment for counseling, and he responds saying, "I don't know what is wrong with me, but lately, I've been having trouble with my wife....on an intimate level. It's been very frustrating and embarrassing, and it's causing a lot of tension between us. My wife is getting frustrated and accusing me of cheating on her. We have two children. I never thought this would happen to me." The client has seen a urologist and has no sign of prostate cancer but is in poor health. The client appears anxious when describing his symptoms. He is fidgeting and has trouble maintaining eye contact as you explore the issue more deeply. This is your first client who presents with this particular issue, and you are not entirely sure of how to proceed. You take a few moments to pause and reflect on what he has said while also noting his body language. As you consider the best way forward, you remember the importance of validation in establishing rapport. You nod your head and say, "I can see how this has been difficult for you and your wife. It's understandable why it might be causing tension between the two of you." Fourth session It has been a month since you began therapy with the client. You have been meeting with him weekly. Today, the client states he and his wife attempted to have sex last week, and he could not maintain an erection. He says she called him "a lousy cheat with a beer belly who can't satisfy her." He lets you know that this remark triggers him as it reminds him of his relationship with his mother. He reports that sex feels like a "chore," and it is not fun anymore. "Sometimes, I fantasize about being with an ex-girlfriend of mine just to get an erection." The client seems sad and looks down at his feet. You and the client discuss his wife's comments, and he expresses feeling overwhelmed and helpless. You ask him to reflect on how he feels about his wife's reaction, and he reports feeling "hurt and rejected." You then discuss the possibility of exploring underlying issues that may be impacting his ability to find pleasure in sex. You then ask if he is able to recall any past experiences or traumas contributing to his difficulty with erectile dysfunction. He has never felt anxious about past experiences with erectile dysfunction, but now he sees to be struggling with feelings of guilt and shame. You then discuss strategies for improving communication with his wife and ways to build trust within their relationship. You encourage the client to explore his feelings and identify potential triggers impacting his ability to enjoy sex. Lastly, you role-play a scenario in which the client communicates his feelings to his wife in a non-confrontational manner. At the end of the session, he tells you that he is beginning to understand how he can relate better to his wife. He states, "I guess it's important to tell each other what we need and want." Eighth session The client has been coming to therapy consistently for seven weeks. During today's session, he states that he has been able to have sex once to full term and has been practicing his relaxation skills before initiating sexual activity with his wife. The client tells you, "My wife just doesn't do it for me anymore. With the other two women I am currently seeing, I can go two, even three times. I don't feel guilty, and it feels great to feel like a man now." This is the first time your client has admitted his infidelity to you. The client expresses feelings of relief to speak honestly about his infidelities and the dual benefit of "feeling like a man again" and being able to perform sexually. He reports that he feels more confident and his anxiety levels have decreased since engaging in extra sexual activity with the other two women and his wife. | The client is an only child. As he grew up, he reports that his father was often vocal about his dissatisfaction with his sex life. The client also reports that his mother often expressed resentment toward him from the day he was born. This has left him with a deep-seated dislike of his mother, as well as resentment of women in general. Currently, his parents are facing health issues, with his father drinking heavily and his mother having lung cancer. The client feels overwhelmed and stressed due to his job and family responsibilities. He is worried about his parents' health and is not happy about the potential of having to take care of his mother if his father passes away. After a decade of working as an illustrator designing greeting cards, the client has recently been promoted to creative director of his department. Because of his introverted nature, he is now feeling overwhelmed with the new responsibilities and having to communicate with other departments within the company. The client drinks weekly and occasionally smokes marijuana. The client drinks at least one beer every other night after work with dinner. He will finish two six-packs on some weekends if they have company over to watch football. He says he rarely drinks hard liquor. The client has reported that his alcohol use or smoking marijuana is not causing any impairments in his ability to carry out his daily responsibilities, but he is overweight because of his inactivity and indicates he would like to return to his normal weight. He also says that he has never experienced any adverse physical or psychological effects due to his substance use. | You state to the client, "Last week you were telling me that you weren't attracted to your wife. Today, you're saying that you have been having affairs, and it makes you feel more like a man. Am I understanding you correctly?" What microskill are you using here? | Confronting | Reflecting on meaning | Reflecting the client's feelings | Clarifying | (A): Confronting
(B): Reflecting on meaning
(C): Reflecting the client's feelings
(D): Clarifying | Clarifying | D | You are clarifying the client's situation and gaining an understanding of how multiple partners increase his libido. Therefore, the correct answer is (B) | counseling skills and interventions |
234 | 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. | You are meeting with the client for the termination session. You review the treatment goals and the client’s progress. The client is no longer experiencing panic attacks, and she reports that she has felt panic attacks coming on but that she intervenes early and often to prevent them from occurring. You and the client have prepared for this date during the last few sessions in order to prepare the client for transitioning to independence from therapy. You and the client discuss her use of coping skills and natural supports to continue to manage panic symptoms. You also inform the client of how to reconnect if she needs to receive therapeutic support again and then terminate services. Some clients may need to be referred to another counselor | Some clients may need to be referred to another counselor. All of the following are appropriate reasons to make a referral, EXCEPT: | The client would benefit more from a psychiatrist or a medical specialist. | The client and you have very different political affiliations, and their presenting problems relate to political events. | You fail to connect with the client due to personality differences. | You do not specialize in the disorder experienced by the client. | (A): The client would benefit more from a psychiatrist or a medical specialist.
(B): The client and you have very different political affiliations, and their presenting problems relate to political events.
(C): You fail to connect with the client due to personality differences.
(D): You do not specialize in the disorder experienced by the client. | The client and you have very different political affiliations, and their presenting problems relate to political events. | B | Political affiliations should not affect the counseling process. You must support the client’s values and beliefs even when trying to reframe what you perceive as illogical thoughts. A failed connection due to personality differences is a valid reason for referral if a connection cannot be made. Personality differences are important to consider because the therapeutic relationship relies on a real interpersonal connection between two people. If the client’s needs are outside of your competency, or if the issue at hand is a medical issue or would benefit more from psychiatric intervention, then a referral is also appropriate. Therefore, the correct answer is (D) | professional practice and ethics |
235 | Initial Intake: Age: 53 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Married Counseling Setting: Community Agency Type of Counseling: Individual | The client appears his stated age and is dressed appropriately for the circumstances. He rates his mood as “anxious.” His affect is congruent though he appears to relax as the session continues. He demonstrates some limited insight and frequently responds with “I don’t know” but when encouraged, is able to access thoughts and emotions that are disturbing to him. He demonstrates appropriate judgment, memory, and orientation. He reports never having considered suicide or harming himself or anyone else. He states that he is very engaged individually and with his family in their religious practices and views these as a source of strength. He currently takes 50 mg of Pristiq and Concerta 18 mg. | You are a counselor in a community agency setting. Your client is a 53 year-old male who presents with complaints of feeling insignificant, unworthy, and a failure. He admits to having these feelings for the past 30 years and while he has never had suicidal ideations or plans, he has often wondered if his life had purpose and what that purpose was. Your client additionally tells you that he doesn’t feel happy on most days though he does have happy feelings at times; they just don’t last. He is good at his job and finds it challenging, yet tells you “it’s a job” and that there is nothing special or “exciting” about it to him. He tells you that he has been married for twenty years and has five children; three of whom he adopted when he married his wife. He states he adores his wife and children, though he knows that he often does not meet their needs emotionally, “tunes out,” and frequently puts his own “wants and desires” before their requests, needs, or previously made plans. He admits he gets “jealous, I guess” when someone else in the family gets something that he didn’t. He also says that he often says “the wrong thing” when his wife or children are upset about something and he struggles to understand how they are feeling. He tells you that these actions cause conflict in his marriage and with his children and he is ashamed that he does this, but feels hopeless that things will change because he cannot figure out how to change or why he does these things. He reports that he does not believe himself to be better than others but that others often perceive that he sees himself that way because of how he interacts with them. He also tells you that his family often wishes he would “think before I speak or make decisions.” He reports that in spite of these “failures,” he and his wife have a very strong marriage and express their love for each other daily. They enjoy activities together although he needs very active recreation such as roller coasters, bike riding, and swimming while his wife leans towards less physical activities. Finally, your client tells you that over the years he has had some trouble focusing at work and at home. He views himself as “forgetful” and says “I don’t have a good memory.” He says this causes troubles at home and work when he frequently forgets to do something that he said he would do or when he is not as careful or gets distracted in his work and is slow to finish projects or makes small mistakes that have greater impacts on reports. | Family History:
The client reports his parents were married to each other until his father’s death at age 60. Your client states he was very close to his father although his father’s activities were often curtailed due to illness. He states that his father accompanied him to boy scouts and was involved with the client and his older siblings. The client states that he has always been close to his mother although he acknowledges often feeling angry at her but being unable to tell her that, so instead he “tuned her out.” He describes her as extremely “critical and consistent.” He tells you that the first time he decorated a Christmas tree was with his wife as his mother always decorated their family trees “so they were done right.” He also says his father and siblings could always count on her to be the one who made the family late for everything and left them waiting during outings. In one example, he shares that when going out together, his mother would often set a meeting place and time for him. He reports that he would either wait at the meeting spot for hours because she was late or that he would sometimes go looking for her and then get in trouble for leaving the meeting spot. He reports that his oldest sibling died in his 40s from excessive drug and alcohol use, and that his other sibling has a very conflictual relationship with their mother and sees their mother “when needed” but is often angry with their mother. He describes his relationship with his mother over the past twenty-five years as one in which his mother makes promises without keeping them and was often dismissive of the client’s wife and children during the time that he was dating and for several years after their marriage. He relates one account where his mother was helping his wife organize something in their home, but refused to organize it in the manner that his wife needed it, and instead became very angry, defensive, and accusatory when his wife reorganized what his mother had done. | Using the information you have learned, which of the following should be addressed first in this session? | Suggest that client and his wife not engage in the conversations outside of sessions | Review the client's progress and help identify how these were accomplished. | Have client explain what frustrates when he doesn't "catch on" right away | Tell client he's doing well and to "just keep doing what you're doing" | (A): Suggest that client and his wife not engage in the conversations outside of sessions
(B): Review the client's progress and help identify how these were accomplished.
(C): Have client explain what frustrates when he doesn't "catch on" right away
(D): Tell client he's doing well and to "just keep doing what you're doing" | Review the client's progress and help identify how these were accomplished. | B | Reviewing the client's progress and having him identify what he has done to make changes is the correct response. The client is making small changes in lifelong personality characteristics and it will be important for the counselor and client to help him identify exactly what he has been doing that is different now. Telling him to keep doing what he is doing does not recognize the progress and does not identify the different steps he is actually making to act differently. Without this information, the client may not know how he has made his recent accomplishments. It will be important to discuss the client's frustration after reviewing his progress and identifying the changes he has made. Since the client and his wife are able to work together through the client's traits and he is able to move from angry and frustrated to feeling "good" or satisfied that he has understood where he struggled before, there is no reason to restrict those conversations to therapy sessions. Should the client say that these conversations are making him more upset, causing self-esteem injuries, or are nonproductive, then the counselor might ask if the client would want to restrict them to couple's sessions. Therefore, the correct answer is (B) | counseling skills and interventions |
236 | Name: Tina Clinical Issues: Maladaptive eating behaviors Diagnostic Category: Feeding and Eating Disorders Provisional Diagnosis: F50.01 Anorexia Nervosa, Restricting Type Age: 21 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: Italian American Marital Status: Not Married Modality: Individual Therapy Location of Therapy : University counseling center | The client presented with a slender physique and was observed wearing conservative, dark-colored attire. Her overall demeanor was reserved, displaying noticeable nervousness and a tendency to withdraw from interactions. Upon conversing with her, it became evident that her train of thought often deviated from the topic at hand, hinting at a tangential pattern. This difficulty in maintaining concentration appears to be a consequence of her heightened anxiety levels. Delving deeper into her thought content, a recurring theme of obsessions surrounding food and body weight emerged. Additionally, a palpable fear of judgment from her peers and the broader society was evident. In terms of her cognitive functioning, she was found to be alert and fully oriented to her personal details, as well as her current location and time. However, a significant concern is her limited insight into her present circumstances and the implications of her behaviors. Throughout the assessment, there were no indications of any memory impairments. | First session You are a mental health therapist working in a university counseling center. The client, a 21-year-old female, presents issues related to anxiety, poor body image, and eating. You begin the session by introducing yourself and explaining your role as a therapist. You also explain how confidentiality is handled and make sure that she understands her rights as a client. After the initial introductions, you ask her to tell you about her current situation and what led her to seek out therapy. She reports that she has been feeling anxious for a while, but it has gotten worse since a basketball game when someone in the audience yelled to the referee "thunder thighs over there needs to get her act together!" Even though the comment was not directed at her, she internalized it. She explains that she was already feeling uneasy due to her stepfather's comments about her weight from a few years ago, and the recent insult at the game made it "all come crashing down" for her. Now, she cannot stop ruminating about her appearance. She saw a poster in her dorm room promoting counseling services and decided to make an appointment. You continue your interview by asking about her current eating behaviors. She explains that she avoids carbohydrates, sugar, and most dairy "since that stuff makes you fat." When you ask her to describe what she eats during a typical day, she says, "I usually have a fruit smoothie with almond milk for breakfast, an apple and 12 nuts for lunch, and then some steamed vegetables or a salad for dinner." When asked about exercise or other physical activity besides basketball, she reports that she runs at least seven miles on a nearby trail every morning and spends two hours swimming laps at the indoor gymnasium pool every evening before bed. She says, "The pool is pretty quiet at night. I don't like to be around a lot of people when I'm exercising." As you continue your dialogue, you ask the client open-ended questions to explore her relationship with her parents, especially her stepfather. She reports that her stepfather has always had negative remarks about her size and shape. She states that she feels like he views her as "less-than" because of her weight, which has led to feelings of shame and worthlessness. You explore the dynamic further by inquiring about how these comments have impacted her self-esteem. She reports feeling anxious, embarrassed, and inadequate when her stepfather is critical. You validate her feelings and explain that comments like these can be very damaging to a person's self-image. You ask the client what she hopes to accomplish in therapy. After some thought, the client says that she wants to learn how to manage her anxiety. She looks at your shyly and says, "I also want to be able to eat a piece of chocolate. I know that sounds crazy, but I just want to be able to enjoy it, without feeling guilty or like I'm going to get fat." You affirm her desires and explain that a key part of the therapeutic process will be to help her build self-confidence and develop healthier relationships with food. | The client's parents divorced when she was six years old. Her mother remarried 12 years ago. The client has a younger half-brother who lives with her mother and stepfather. She is close to her mother, but "my stepfather is a different story." She reports that he is critical of her and often remarks on how she looks or what she is eating. She states that he has commented on her weight and body shape since middle school. Her mother tries to intervene, but her stepfather continues to be critical. She tells you she couldn't wait to graduate high school and move out of the house. She tells you, "I remember that when I went home for a visit during winter break during my freshman year, my stepdad had this shocked look on his face when he saw me. He told me I had gained so much weight that I didn't even look like myself anymore. I've never forgotten that. And it's not like he's the picture of health." Previous Counseling: The client has a history of anxiety. She saw a therapist for a few sessions in high school after being referred by her school counselor, but she did not feel comfortable with the therapist and refused to continue attending sessions. She did not receive a clinical diagnosis related to her anxiety. The client reports that she has been feeling more anxious lately and is struggling to cope with her anxiety. She says that she feels "on edge," and that makes it difficult for her to concentrate. She is interested in exploring therapy to manage her anxiety. Additional Characteristics: The client is currently on the school's basketball team. She was voted most valuable player two years in a row. | Given the current disposition and behaviors in which this client has presented herself, what would be strategies or approaches that would be most effective in forging a strong working alliance with her? | Utilize a Gestalt position to help her embrace here-and-now concerns | Take an Adlerian approach, and assess social dynamics at this time | Use a person-centered approach to encourage self-assurance and trust | Use a solution-focused approach to identify strengths | (A): Utilize a Gestalt position to help her embrace here-and-now concerns
(B): Take an Adlerian approach, and assess social dynamics at this time
(C): Use a person-centered approach to encourage self-assurance and trust
(D): Use a solution-focused approach to identify strengths | Use a person-centered approach to encourage self-assurance and trust | C | The success of person-centered therapy relies on unconditional positive regard. This means the therapists must be empathetic and non-judgmental to convey their feelings of understanding, trust, and confidence. This will encourage clients to make their own decisions and choices. Therefore, the correct answer is (C) | counseling skills and interventions |
237 | 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. | 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 | Which one of the following statements would be the most beneficial cognitive reframe for the client’s beliefs about her roommate that would address an approach from a reality perspective? | “My thoughts aren’t reality; therefore, I should distract myself using coping skills.” | “My roommate may actually do something bad, so I need to set some boundaries with her regarding my room.” | “I should talk with my roommate about boundaries.” | “Currently, my roommate hasn’t done anything other than enter my space without permission and borrow things, so this isn’t the same as my past experiences.” | (A): “My thoughts aren’t reality; therefore, I should distract myself using coping skills.”
(B): “My roommate may actually do something bad, so I need to set some boundaries with her regarding my room.”
(C): “I should talk with my roommate about boundaries.”
(D): “Currently, my roommate hasn’t done anything other than enter my space without permission and borrow things, so this isn’t the same as my past experiences.” | “Currently, my roommate hasn’t done anything other than enter my space without permission and borrow things, so this isn’t the same as my past experiences.” | D | Focusing on the current situation, in which the roommate has not done anything other than disrespect boundaries, and seeing how it is different from past events is the most helpful cognitive reframe. This focuses on the reality and helps the client refrain from blowing it out of proportion. Although focusing on enforcing boundaries is helpful, it is not a cognitive reframe. Identifying that it is a possibility that the roommate may sexually assault her is not helpful because this reinforces fear and irrational thinking. Identifying that the client’s thoughts are not reality is important, but this does not focus on the root of the thoughts, which stem from a fear of a past situation becoming the present reality. Therefore, the correct answer is (B) | counseling skills and interventions |
238 | Client Age: 25 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Counseling Clinic Type of Counseling: Individual Presenting Problem: Depression and Suicidal Ideation Diagnosis: Major Depressive Disorder, Recurrent, Mild (F33.0) | Mental Status Exam: The client appears to not have bathed recently because his hair is greasy and unkempt. The client has food stains on his clothing; however, he is dressed appropriately for the season. His motor movements are within normal limits. He is engaged in therapy, but he appears anxious as evidenced by hesitating before speaking and by his hand wringing. The client reports suicidal ideation with no plan or intent. The client reports a depressed mood more often than not and difficulty enjoying most activities. The client is oriented to person, place, time, and situation. The client reports that his appetite has increased lately and that he is experiencing hyperso | You are a resident in counseling practicing in a private practice agency. During the initial counseling session, the 25-year-old single male client reports feeling depressed and hopeless. He has difficulty enjoying activities that he has enjoyed in the past and feels unsatisfied with most areas of his life. The client identifies that he is not happy at work and wants to make a career change. The client verbalizes feeling sad more often than not, and that this has been going on for about 2 years. The client decided to start counseling when he began experiencing suicidal thoughts. The client reports no plan or intent to attempt suicide but is concerned about his own well-being. | The client reports that he has been sleeping more than usual and that this is affecting his ability to get to work on time. He reports that his boss started noticing his tardiness and has given him a verbal warning. Combined with the fear of losing his job, he expressed worry regarding increased conflict with his girlfriend and feeling more “on edge | All of the following interventions are clinically appropriate therapeutic approaches to treating major depressive disorder, recurrent, mild EXCEPT: | Support groups | Referral for electroconvulsive therapy | Cognitive behavioral therapy (CBT) | Referral for psychiatric medication management | (A): Support groups
(B): Referral for electroconvulsive therapy
(C): Cognitive behavioral therapy (CBT)
(D): Referral for psychiatric medication management | Support groups | A | CBT and electroconvulsive therapy are clinically proven, effective treatments for depressive disorders. Medications may be beneficial in the treatment of depression, and a referral to a psychiatrist or psychiatric nurse practitioner is required for that assessment and prescription because prescribing medications is outside of the scope of the counselor. Although support groups may be beneficial to a client, they are not clinical in nature. Therefore, support groups would not provide treatment; rather, they would provide a support system for a client. Therefore, the correct answer is (A) | treatment planning |
239 | 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 | By saying, "Tell me about your experience coming into a new culture and going through what you did" the counselor is demonstrating the attribute of? | Empathy | Curiosity | Inclusion | Cultural awareness | (A): Empathy
(B): Curiosity
(C): Inclusion
(D): Cultural awareness | Cultural awareness | D | Cultural awareness is understanding that someone's cultural experiences and views are unique and may differ from your own. Curiosity is being inquisitive about a different culture. Empathy is trying to put yourself in the shoes of another and inclusion is providing equal access or opportunities to others who may be marginalized. Therefore, the correct answer is (A) | counseling skills and interventions |
240 | 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. | The client’s formal assessment, along with informal observations, warrants a psychiatric evaluation to assess for ADHD, and the PGM has agreed to this. The client has done well in therapy and has met her short-term counseling goals. She has processed grief and loss concerning separation from her parents and shows improvement with emotional regulation. The use of brief strategic family therapy (BSFT) has helped address patterns of interaction between the client and her PGM, and the client is having fewer tantrums. The PGM reports that the client continues to talk back, and she is not completing her chores. You plan to conduct a series of home visits to assist the PGM with parent management skills but receive word from your agency’s office indicating the client has lost insurance coverage | Which of the following aspects of parent management training (PMT) illustrates the concept of extinction? | The teacher progressively removes prompts that are no longer required for the client to stay in her seat. | The PGM ignores temper tantrums that were previously reinforced with attention, causing the tantrums to discontinue. | The PGM’s end goal of shaping the client’s behavior (e.g., cleaning her room) is achieved by reinforcing successive approximations to the goal. (I.e., “I need you to pick your clothes up off the floor” or “I need you to pull the covers up to your pillow.”). | The client refuses to do a chore and loses a portion of her allowance. | (A): The teacher progressively removes prompts that are no longer required for the client to stay in her seat.
(B): The PGM ignores temper tantrums that were previously reinforced with attention, causing the tantrums to discontinue.
(C): The PGM’s end goal of shaping the client’s behavior (e.g., cleaning her room) is achieved by reinforcing successive approximations to the goal. (I.e., “I need you to pick your clothes up off the floor” or “I need you to pull the covers up to your pillow.”).
(D): The client refuses to do a chore and loses a portion of her allowance. | The PGM ignores temper tantrums that were previously reinforced with attention, causing the tantrums to discontinue. | B | Extinction is demonstrated when the client’s temper tantrums, which were previously reinforced with attention, are ignored and, as a result, discontinue. Ignoring the behavior does not automatically stop the behavior. For extinction to occur, the behavior must have previously been reinforced, and the behavior must stop after ignoring the same behavior. Punishment is illustrated when the client loses a portion of her allowance due to refusing to do a chore. One way to differentiate punishment from other aspects of PMT is that punishment refers to methods that decrease a specific behavior. Fading involves the progressive removal of prompts that were previously (and successfully) used when telling the client to stay in her seat. Fading is used after the response is consistently performed without prompts. Finally, the end goal of shaping is known as the terminal response. Therefore, the correct answer is (B) | counseling skills and interventions |
241 | Name: Michael Clinical Issues: Separation from primary care givers Diagnostic Category: Anxiety Disorders Provisional Diagnosis: F93.0 Separation Anxiety Disorder Age: 10 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Not Assessed Ethnicity: Guatemalan American Marital Status: Not Applicable Modality: Family Therapy Location of Therapy : Agency | Michael appears clean and dressed in appropriate clothing. He often fidgets with his hands and insists on sitting next to his father during the session. Speech volume is low, and pace is fast. He has a slightly flattened affect. He exhibits minimal insight consistent with his age. | First session You are a licensed mental health counselor at a pediatric behavioral health center. Michael, a 10-year-old male, presents along with his father. You conduct a thorough psychological exam, including a mental status examination. During the initial interview, you take note of Michael's behavior. He sits very close to his father and looks fearfully around the room. The father tells you Michael has been having trouble at school and home for the past few months and it has been getting worse. When you ask how Michael is doing in school, the father tells you there have been several incidents, including difficulty waking up for school, crying in the morning, and refusal to get dressed and ready. The father also tells you that Michael has been showing signs of frustration with his teachers and classmates. On the home front, the father mentions that his son has become "a nuisance for his babysitter, especially during bedtime." Both parents are paramedics on a 24-on/48-off shift rotation. Michael often calls his parents while at work, complaining that he feels sick and cannot fall asleep. He worries that someone might break into the house or that "something bad will happen" to his parents. The father reports that he and his wife have tried to reassure Michael, but their efforts have been unsuccessful. They are perplexed as to what is causing Michael's distress. The father tells you that Michael has always been a bright and energetic child, but now he seems overwhelmed and anxious. You conduct a more detailed interview with Michael alone, focusing on his current environment and daily routines. You ask him how he feels about school, and Michael denies having any issues. He tells you that he does not want to go because his new school is "boring." However, when you probe further, he admits to feeling scared and alone. He does not want to be away from his parents, and he imagines "all the ways they could be hurt" while they are not with him. You say, "I can understand why you might be feeling scared and anxious, Michael. It sounds like a lot has been going on recently. I'm here to help you and your parents understand what's causing your worries so you can start to feel better." You reconvene with Michael's father and provide a brief summary of your findings. You explain that you suspect Michael's anxiety is likely due to the family's recent relocation and having to adjust to a new school. His fears are also likely rooted in his parents' profession, which may lead him to worry about their safety while they are away from home. You have personal experience in dealing with pediatric anxiety and consider briefly sharing your story with Michael and his parents as you believe it may help them to feel supported and less alone in their struggles, while also providing a practical example of how to work through difficult times. You suggest developing an intervention plan to address Michael's distress and recommend meeting with Michael and his parents for weekly sessions. Fourth session When you arrive at your office today, you realize that you inadvertently left therapy notes on your desk after work on Friday, which included information about Michael's case, and the notes are not where you left them. The weekend cleaning crew lets you know that the notes were discarded in the trash. You take the appropriate action in managing this breach of confidentiality, following your practice's guidelines and policies. You also take time to reflect on how this incident could have been prevented and use it as a learning opportunity for yourself. When you met with Michael and his parents during the previous two sessions, you gathered additional information about his symptoms, thoughts, and feelings. You provided psychoeducation about separation anxiety and recommended that Michael's parents make an appointment for him to see his pediatrician. You also began to formulate a treatment plan with the overall goal of tolerating separation from his parents without severe distress. Michael and his parents present for today's session on time. The parents begin by reporting that their son's symptoms continue to be a problem. School refusal is still an issue. His mother has had to come home from work three times this past week. His outbursts were so loud that the neighbors came by to check on him. The mother says, "My boss has been patient with me so far, but pretty soon, I'm going to be at risk of losing my job if we can't get a handle on our son's behavior. What are we doing wrong?" Your focus during this session is on helping the parents understand their role in the therapy process. You start by reviewing some of the psychoeducation you provided in prior sessions, focusing on the importance of consistency in parenting approaches and providing structure for Michael at home. You discuss different strategies they can use at home to help build their son's coping skills. You also provide some relaxation exercises that Michael can do when he feels anxious. At the end of the session, you thank Michael and his parents for coming in today and assure them that they are on the right track. You take time to summarize the key points of the session and emphasize the importance of follow-through with what was discussed in order for progress to be made. You provide them with resources to further support their efforts and suggest a follow-up appointment in one week. Tenth session You have been working with Michael to develop and practice effective coping skills appropriate to his age. You have been using behavioral modification techniques to decrease his anxiety about being away from his parents. During previous sessions, you suggested that his parents leave your office space for progressively more extended periods. Michael has complied with these requests, although he was initially anxious and agitated. After five weeks, he is now able to tolerate being away from his parents for up to an hour. In today's session, the parents reflect on their son's progress since he started therapy. They believe that he has made a significant improvement. To date, there have only been "little incidents." The parents report that two days ago, Michael was reluctant to go to bed without them and had a minor fit. Instead of escalating the situation, they calmly reminded him of the strategies he had learned in therapy such as taking deep breaths when feeling anxious. To their surprise, Michael began using his coping skills and went to bed peacefully. Michael's mother tells you, "It finally feels like we've turned a corner. I'm so proud of him!" The parents have also received positive updates from Michael's teachers who say that he is doing much better in school. They report that he has made a new friend and was invited to a sleepover. Michael seems excited about the idea. His parents are not sure how he will handle being away from home overnight, but they are willing to try. After providing you with an update, the parents leave the room to wait in the waiting room while you talk to Michael. He appears receptive and comfortable with this arrangement. He tells you, "I kind of feel dumb for being scared. I'm sorry for causing so much trouble." You respond affirmatively and validate his feelings. Next, you say, "I remember when you first came to my office with your mom and dad. You were having a lot of trouble being away from them. Do you think that's still a problem for you?" He shakes his head "No" and reports that he is now able to be away from his parents for longer periods of time without feeling scared or upset. You ask him what has been most helpful to him when he starts to feel anxious. He says, "The counting and breathing stuff you showed me how to do. Also, I think about something fun that I did with my mom and dad, like that time we went to the beach and built a giant sandcastle!" You tell him how proud you are of his progress and encourage him to keep using the coping strategies he has learned in therapy. Near the end of the session, you invite Michael's parents back into your office to check in with them about next steps. The parents agree that Michael has made significant progress in tolerating separation and they feel that the treatment has been successful. You offer additional resources for follow-up care and suggest a plan for transitioning out of therapy. Lastly, you thank Michael and his parents for their dedication throughout the course of therapy and let them know that you are available if they have any further questions or concerns. | Michael's parents have been married for nine years and both are dedicated to the well-being of their children. The father reports that he and his wife communicate openly with each other and make joint decisions about parenting issues. They also model healthy family dynamics, such as expressing affection and respect towards one another, being honest with one another, and sharing responsibilities. Michael has a five-year-old sister. His father characterizes the family as very close; they do everything together. The father says that he and his wife go to their children's sporting events and school meetings. Every weekend, the four of them are together doing family activities. Except when required to be away due to their work schedules as paramedics, the parents are home with the children at night. Prior to the family's move to a new state 6 months ago, Michael had been a successful student at school, typically performing at or above grade level. He was an active participant in the classroom, often volunteering to answer questions or participate in class discussions. Since the move, however, getting ready for school has been a struggle each day. He is struggling academically; while his grades haven't dropped drastically, he appears to be having trouble focusing and understanding the material. His parents have attended parent-teacher conferences and Michael's teachers have also reported that he seems distracted and uninterested in class. His parents also report that they are having difficulty getting him to stay on task when doing his homework at home. | When the client says, "I kind of feel dumb for being scared. I'm sorry for causing so much trouble." as a response to recognizing the efficacy of therapy, what response would be most appropriate? | Reframe the client's statement into a positive affirmation of his recognition of growth. | "You've been working really hard in therapy, and you should be proud of how far you've come." | "It's understandable to feel scared in new or unfamiliar situations. It takes a lot of courage to face your fears and overcome them." | "Don't be too hard on yourself. Everyone feels scared sometimes and you don't need to feel ashamed about that." | (A): Reframe the client's statement into a positive affirmation of his recognition of growth.
(B): "You've been working really hard in therapy, and you should be proud of how far you've come."
(C): "It's understandable to feel scared in new or unfamiliar situations. It takes a lot of courage to face your fears and overcome them."
(D): "Don't be too hard on yourself. Everyone feels scared sometimes and you don't need to feel ashamed about that." | "It's understandable to feel scared in new or unfamiliar situations. It takes a lot of courage to face your fears and overcome them." | C | This response validates the client's feelings and recognizes his effort in overcoming his anxiety. It acknowledges that feeling scared is normal, and applauds the client for his bravery in tackling the challenge. This type of statement also helps to foster a positive therapeutic relationship by providing a nonjudgmental, affirming message. Therefore, the correct answer is (C) | core counseling attributes |
242 | Client Age: 42 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Divorced Counseling Setting: Agency Type of Counseling: Individual and Group Presenting Problem: Social Anxiety Diagnosis: Social Anxiety Disorder (Social Phobia), Provisional 300.23 (F 40.10) | Mental Status: The client is meticulously dressed and well groomed. She is cooperative and periodically exhibits a nervous smile. The client is fidgety and frequently repositions herself when seated. Her mood is anxious, and she becomes tearful when discussing feeling “stupid” during job interviews. She exhibits cohesive thinking, and her insight and judgment are intact. The client is oriented to person, place, situation, and time. Her affect is reserved. She denies suicidal and homicidal ideation as well as audio/visual hallucinations. | You are a certified mental health counselor working in a community mental health center. Your client is a 42-year-old white female who presents today with symptoms of social anxiety disorder. The client reports debilitating anxiety when interacting with others, particularly when meeting unfamiliar people or going somewhere for the first time. She states that she cannot sleep and has a poor appetite on the days leading up to social events. When encountering anxiety-provoking situations, she says that her hands shake, she sweats excessively, and her voice trembles. The client is recently divorced and, after more than 15 years of being out of the workforce, she is seeking employment. She explains that job interviews have been “humiliating” because of what she perceives as an “inherent lack of knowledge and a substantially impaired skill set.” | The client attends a process-oriented CBT group that is nearing the middle stage of group development. The client presents today with a bright affect and arrives early to converse with two other women in the group. During group activities, she is reticent to share and is sensitive to a conflict between two members that has started to emerge. One member becomes openly critical of the group tasks and their usefulness. Other members start to weigh in and take sides. The conflict quickly escalates between two members, with one shouting at another, “You have monopolized every session with your opinions. You are the most judgmental person I know! This group would be so much better without you.” Other members nod in agreement. How would a gestalt therapist describe the boundary disturbance that characterizes the group member’s statements of “You have monopolized every session with your opinions | How would a gestalt therapist describe the boundary disturbance that characterizes the group member’s statements of “You have monopolized every session with your opinions. You are the most judgmental person I know! This group would be so much better without you”? | Projection | Confluence | Deflection | Introjection | (A): Projection
(B): Confluence
(C): Deflection
(D): Introjection | Projection | A | Gestalt therapists use the term boundary disturbance to describe various forms of resistance. Boundary disturbances include projection, introjection, retroflection, confluence, and deflection. Gestalt therapists address boundary disturbances in the here and now, making it applicable to this client’s process-oriented group. Projection is the tendency for a person to blame the environment (ie, other people) for personality traits, thoughts, feelings, and behaviors that originate in themselves. Individuals use projection to disown or deny aspects of their personality by blaming others for their circumstances. Disowning aspects of one’s personality makes the person a victim of circumstance by assigning hidden meanings to others. During group conflict, the member’s statement, which consists of personality aspects consistent with social anxiety (ie, feelings of not being wanted, included, or judged), likely originate in elements of the member’s self and other members being in agreement. Introjection, which is the opposite of projection, is the process of assimilating information from the environment without critical discernment. This tends to develop in childhood when information from parents or authority figures is passively incorporated so that there is no identification of what one wants and needs. Deflection occurs when a distraction is created to avoid aspects of the environment that may be threatening. Examples of distractions include the use of humor, speaking for others, and asking questions. Confluence occurs when aspects of one’s internal and external environments are blurred or diffuse, which prevents one from differentiating the two. Confluence often occurs when individuals avoid conflict and possess an increased need to be accepted. Therefore, the correct answer is (D) | counseling skills and interventions |
243 | Client Age: 7 Grade:2nd Sex: Male Gender: Male Ethnicity: African American Counseling Setting: Community Mental Health, School-Based Services Type of Counseling: Individual and Collateral Presenting Problem: Impulsivity; Inattention; Hyperactivity Diagnosis: Attention-Deficit Hyperactivity Disorder (ADHD) 314.01 (F90.2) | Mental Status: The client is dressed appropriately, and he is well groomed. His affect is bright when engaged in an activity of his choice, but he becomes irritable when asked to comply with a direct request (e.g., pick up the toys, walk in the hallway). He is energetic, eager to please, and interrupts your conversation with the mother, as evidenced by the client stating multiple times, “Watch this! Hey! Watch! Look what I can do!” The client has difficulty transitioning from your office and back to his classroom. He runs ahead of you in the hallway and does not respond to redirection. The client has not voiced suicidal or homicidal ideation. Developmenta | You are a clinical mental health counselor providing on-site school-based services in a public elementary school. Your client is a 7-year-old African American male enrolled in the 2ndgrade. The client is accompanied by his mother, who states that she is here because the school “requested an ADHD assessment.” The school reports that the client is disruptive, refuses to follow directions, disturbs others, and has difficulty staying on task. The mother describes the client as “energetic” and “strong-willed”—behaviors that she believes are “just typical for a boy.” She is upset that the school wants to conduct a formal evaluation to determine if the client qualifies for a more restrictive classroom setting. The school’s population is predominantly white, and the mother believes that her son is being treated unfairly because of his race. | You meet with the client’s mother today to update the client’s treatment plan. Since the beginning of the school year, the client has been suspended for a combined total of 8 days. He has responded poorly to many of the behavioral classroom interventions. The mother has reluctantly granted the school permission to begin testing to determine if the client qualifies for an Individualized Education Program. You inform the mother of her parental rights pertaining to this process, particularly as they apply to protections against disability-related discrimination and the maximum number of disability-related suspensions. She is encouraged by the possibility of the client receiving additional supports that consider the client’s strengths and challenges. You teach the mother to use time-out with the client at home | You teach the mother to use time-out with the client at home. The effectiveness of time-out is a function of which one of the following? | Counterconditioning | Punishment | Classical conditioning | Operant conditioning | (A): Counterconditioning
(B): Punishment
(C): Classical conditioning
(D): Operant conditioning | Operant conditioning | D | Principles of operant conditioning include extinction, punishment, reinforcement, and stimulus control. With operant conditioning, learning occurs in the presence of behavioral consequences or reinforcement. Extinction happens when the reinforcer for that response is stopped, which lessens the possibility of the behavior’s recurrence. Time-out is also known as time-out from reinforcement. When a child is sent to time-out, they are being removed from a situation that is reinforcing undesirable behavior. Classical conditioning entails paring a previously neutral stimulus with an unconditioned stimulus. Operant conditioning varies from classical conditioning in that operant conditioning involves using reinforcement or punishment to increase or decrease behavior. Punishment can be negative (eg, taking away privileges) or positive (eg, dispensing a noxious stimulus). Counterconditioning is a form of classical conditioning used to replace a negative emotional response (eg, fear) with a stimulus that elicits a positive or pleasant response (eg, happiness). Therefore, the correct answer is (A) | counseling skills and interventions |
244 | 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. | In addition to a potential substance use disorder, which of the following mental health disorders should be viewed as potential diagnoses based on the information provided? | Borderline Personality Disorder (BPD) | General Anxiety Disorder (GAD) | Narcissistic Personality Disorder (NPD) | Post Traumatic Stress Disorder (PTSD) | (A): Borderline Personality Disorder (BPD)
(B): General Anxiety Disorder (GAD)
(C): Narcissistic Personality Disorder (NPD)
(D): Post Traumatic Stress Disorder (PTSD) | Borderline Personality Disorder (BPD) | A | null | intake, assessment, and diagnosis |
245 | 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 | What is the least important for the counselor to review currently? | Assess competency to provide informed consent | Clarify that it is not the counselor's role to "fix" the child but to help identify patterns and reasons for behaviors | Review Carlos' successes and strengths | Discuss limits of confidentiality | (A): Assess competency to provide informed consent
(B): Clarify that it is not the counselor's role to "fix" the child but to help identify patterns and reasons for behaviors
(C): Review Carlos' successes and strengths
(D): Discuss limits of confidentiality | Assess competency to provide informed consent | A | There is no indication that Carlos and his mother are not capable of providing informed consent. It is important to address Claudia's commend about "fixing" Carlos. This can be incorporated in the informed consent process. Also, discussing confidentiality and the limits of confidentiality when you are treating a minor is imperative. Given Carlos' response, reviewing his successes and strengths will not only help his mother focus on the positive but it can also be a way to engage Carlos. Therefore, the correct answer is (D) | professional practice and ethics |
246 | Initial Intake: Age: 19 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: African American Relationship Status: Single Counseling Setting: Group home run by the Office of Children and Family Services Type of Counseling: Individual | Elaina has little insight into her behaviors and is currently involved in an abusive relationship. Staff members are concerned for her safety, as well at the safety of her child. She is not functioning well socially or academically. | Elaina is a 19-year-old female who is living in a residence for pregnant teens in foster care. She has been displaying risk taking behaviors such as running away and fighting.
History:
Elaina has an extensive history of abuse and neglect. She entered foster care at the age of 5 when her mother was incarcerated for prostitution and drugs. Since then, she has been in and out of foster care homes and had several failed trial discharges back to her mother’s care. Elaina ran away from her foster homes multiple times. Another trial discharge date is set for the near future, after the baby is born.
Elaina never finished high school. She had difficulty focusing on her classes and was often teased because the other children knew that she was in foster care. Elaina would frequently get into fights, resulting in suspensions. She has a tumultuous relationship with the father of her child, and she recently told her case planner that he sometimes hits her.
Elaina walked into the counselor’s office, sighed, and stated, “Great- someone new- I have to tell my story again?”
The counselor responded “It sounds like you have told your story many times. I can imagine how that feels for you.”
Elaina stated, “It is very frustrating and annoying.” To which the counselor responded, “I like to hear from clients, their history in their own words as opposed to reading it on paper. When we make your goals, I would like you to be involved as well.”
Elaina visibly relaxed and began to tell the counselor about her history and current challenges. Elaina agreed to think about what she wanted her goals to be and agreed to discuss it next session. | null | Of the following, which is the least important area to explore in this session? | Her relationship with her mother | What areas Elaina wants to explore | Her suspensions in school | The safety of her current relationship with her boyfriend | (A): Her relationship with her mother
(B): What areas Elaina wants to explore
(C): Her suspensions in school
(D): The safety of her current relationship with her boyfriend | Her suspensions in school | C | It is important for the counselor to conduct a comprehensive assessment. Although understanding the situation and reasons around her fighting in school, focusing on the school sanctions is not as important as the other information that should be obtained. It is important to assess her safety in her current relationship as she and her baby could possibly be in danger. It is also important to find out more about her current relationship with her mother, especially since Elaina is going to be a mother herself. Therefore, the correct answer is (C) | counseling skills and interventions |
247 | Client Age: 26 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: African American Relationship Status: Single Counseling Setting: Community Mental Health Center Type of Counseling: Individual Presenting Problem: Depressive Symptoms Diagnosis: Persistent Depressive Disorder (PDD) (Dysthymia) Diagnostic Criteria 300.4 (F34.1) | Mental Status Exam: The client is dressed in age-appropriate clothing and is well groomed. His affect is blunted and anxious at times. The client denies anxiety but discloses that he is nervous about the counseling process and doesn’t know what to expect. He is cooperative but hesitant to offer more information than is asked. The client is tearful when discussing his breakup and states that there are days when it is a struggle to get out of bed and go to work. He denies suicidal ideation, and he says that he has had no previous attempts. The client is oriented to person, place, time, and situation, and his thought content is organized. Fam | You are a counselor working in a community mental health center. Your initial intake appointment is with a 26-year-old African American male who presents with symptoms of depression. The client states that he has felt depressed since his teens, with symptoms increasing within the last couple of months. He reports feelings of worthlessness, fatigue, and occasional bouts of insomnia. In addition, the client indicates that his symptoms worsened after his girlfriend of 2 years broke things off with him. He explained that she grew tired of his low energy and pessimistic outlook on life. As a result, he has been hesitant to seek help, believing that he just needed to “man up” and handle his problems privately. The client is unsure of his insurance benefits but thinks his policy allows for a limited number of counseling sessions. | ily and Work History: The client grew up in a home with his mother, father, and maternal grandmother. He has a 22-year-old sister who he believes also experiences depression, but he is unsure if she has received treatment. The client says that he attends church “most Sundays” with his family, primarily because he knows it is important to his grandmother. The client holds an associate degree in information technology and is a computer network support specialist. He has worked for the same company for the past 4 years | Considering the client’s hesitancy to participate in counseling, which of the following instruments would you select to better understand his help-seeking behaviors? | Ethnic-Sensitive Inventory (ESI) | Munroe Multicultural Attitude Scale Questionnaire (MASQUE) | Iowa Cultural Understanding Assessment—Client Form | Cultural Formulation Interview (CFI) | (A): Ethnic-Sensitive Inventory (ESI)
(B): Munroe Multicultural Attitude Scale Questionnaire (MASQUE)
(C): Iowa Cultural Understanding Assessment—Client Form
(D): Cultural Formulation Interview (CFI) | Cultural Formulation Interview (CFI) | D | Developed for the DSM-5-TR, the CFI is a tool used to collect culturally relevant information related to the client’s current and past help-seeking behaviors, coping skills, treatment expectations, and other relevant socially and culturally contextualized factors (Lewis-Fernandez et al, 2020). The Ethnic-Sensitive Inventory (ESI) is a self-assessment questionnaire for counselors and related practitioners that measures counselor-client interactions in four phases of counseling (ie, from precontact to termination). The Munroe Multicultural Attitude Scale Questionnaire (MASQUE) is a tool that measures multicultural knowledge, care, and active experiences among students attending secondary educational institutions (Monroe & Pearson, 2006). Finally, the Iowa Cultural Understanding Assessment—Client Form is a questionnaire intended to provide feedback on culturally responsive care for clinical and program services. Therefore, the correct answer is (B) | intake, assessment, and diagnosis |
248 | Name: Chad Clinical Issues: Maladaptive eating behaviors Diagnostic Category: Feeding and Eating Disorders Provisional Diagnosis: F50.2 Bulimia Nervosa, Moderate Age: 16 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: White Marital Status: Not Assessed Modality: Individual Therapy Location of Therapy : Agency | The client is appropriately dressed but disheveled. He is dressed in clothes associated with anime characters. Concentration is drifting. His speech is somewhat low, and he keeps his head low to avoid making eye contact with you. His mood is anxious. There is no suicidal ideation. Thought content shows no current homicidal ideation or plans. Thoughts are appropriate. The estimated level of intelligence is in the low average range with abstract thinking. | First session You are a mental health therapist who works for an agency specializing in helping teens with eating disorders. The client is 16 years old. He presents for therapy along with his mother. You start by welcoming both of them into your office. Then you introduce yourself, explain your role as a therapist, and briefly describe the experience you have in treating eating disorders. Next, you ask the client to explain and his mother to share with you why they came to see you today and what their expectations are for therapy. The mother begins by telling you, "My son is doing dangerous things to his body. He needs help, but he won't listen to me." The client rolls his eyes and replies, "She doesn't get it. Look at her. She's fat and is always overeating!" His mother's face turns red and she starts to yell at him. You remain neutral and ask them both take a few deep breaths and give each other some space. You explain that your goal is to create a trusting relationship with the client and his mother so that you can start working together towards understanding the issues that bring them to counseling and how to best help. You ask the mother to take a seat in the waiting room while you speak with her son for the first part of the session. She reluctantly agrees and leaves the room. Once the mother leaves, you start by letting the client know that you understand that this situation is difficult, and that you are here to help. You focus on building rapport with the client, emphasizing that you are here to help him. You ask him open-ended questions to get to know more about him, and to help him feel seen and understood. You acknowledge the client's feelings of being misunderstood and provide empathy by validating that it must feel difficult not having his mother understand what he is going through. You also recognize his mother’s concerns by saying, "It sounds like your mom is really worried about you." He tells you that his mother is constantly trying to control him and that he does not understand why she is always so angry all the time. You continue your assessment with structured questioning to understand the client’s current experiences with food, including what he likes to eat and how often he eats. At the end of your discussion with the client, you thank him for being open and honest with you. You acknowledge how brave it is to come in and start talking about his experiences. You invite him to bring his mother back in to the office so you can start working together and discuss the next steps. | The client does well in high school. He is concerned that he could quickly gain weight and no longer be in optimum shape for cheerleading and gymnastics. The client's self-esteem is closely related to his weight and body image, and he appears to lack insight into the dangers of his current eating behaviors. Stressors & Trauma: The client tells you throughout elementary school he was overweight. As a result, he was bullied by other boys and girls alike. They would leave notes on his desk saying "fatty" or "crispy crème." One student pushed him down in the schoolyard, and all the others stood in a circle around him and laughed as the client cried. Pre-existing Conditions: No significant medical issues were reported based on his last medical exam. He does, however, admit to eating four hamburgers and a large bag of French fries at a fast-food restaurant "as a treat" about four or five times a week. He shares that after these fast food "splurges," he goes home and purges to not gain weight. Feeling guilty after each episode, he does not eat anything the next day and doubles his workout routine. | Which assessment tool would be most appropriate to use with this client? | Adjective checklist (ACL) | Behavioral Summarized Evaluation (BSE) | ACORN Eating Disorder Inventory | Five Facet Mindfulness Questionnaire | (A): Adjective checklist (ACL)
(B): Behavioral Summarized Evaluation (BSE)
(C): ACORN Eating Disorder Inventory
(D): Five Facet Mindfulness Questionnaire | ACORN Eating Disorder Inventory | C | The ACORN Eating Disorder Scale is used to discover a range of eating disorder symptoms. Based on his medical history, this tool would be most beneficial. Therefore, the correct answer is (B) | intake, assessment, and diagnosis |
249 | 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.” Based on the information discussed in this session, you decide to begin supporting the parents in improving their son’s attachment with them | Based on the information discussed in this session, you decide to begin supporting the parents in improving their son’s attachment with them. All of the following would be beneficial homework assignments, EXCEPT: | Assigning reading homework for the parents regarding positive attachment | Having intentional weekly family time | Creating a reward system for behavior to create consistency and structure | Assigning intentional one-on-one activities with each parent and the client | (A): Assigning reading homework for the parents regarding positive attachment
(B): Having intentional weekly family time
(C): Creating a reward system for behavior to create consistency and structure
(D): Assigning intentional one-on-one activities with each parent and the client | Creating a reward system for behavior to create consistency and structure | C | Consistency and structure are important for anyone, but they are especially for someone with conduct disorder. Although a reward system may be beneficial in treating behavior related to conduct disorder, it is not an intervention that is focused on enhancing the parents’ understanding of attachment and is therefore the least appropriate option in meeting that goal. In fact, reward systems can potentially strain attachment. Reading related to positive attachment would be beneficial for the parents and likely would include information on attachment-enhancing activities such as intentional one-on-one activities and consistent family time. Therefore, the correct answer is (C) | counseling skills and interventions |
250 | Initial Intake: Age: 20 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Community Mental Health Agency Type of Counseling: Individual | The client presents looking appropriate to stated age and with positive signs of self-care related to hygiene and dress. Mood and affect are congruent, and motor activity is within normal limits. His interpersonal communication is cooperative, open, and forthcoming. His speech is within normal limits with respect to volume, tone, or rate. His thought processes appear within normal limits with insight into his thoughts and behaviors, including concerns others express about his situation. He demonstrates the ability to connect ideas with circumstances and choices. He reports no thoughts of suicide or self-harm. | You are a counselor in a community mental health agency setting. Your client presents as a 20 year old man with feelings of sadness, discouragement, being overwhelmed, and anxious. These feelings have been present for the past 4 to 5 years. He reports that while in high school, he had planned to commit suicide but did not follow through with it as he did not want to hurt his family and friends. The client tells you that he has moved frequently with his family; living overseas during his last two years of high school then beginning college in the United States. He states that he moved here 8 months ago because he wanted to be independent of his family and start “a new life without so many ups and downs.” He lives in a house that his paternal aunt left to his family when she died. His mother and father recently separated and his father provides him with financial support. Until recently, he reports having been employed as a server in a restaurant but was fired after being accused of disrespect to a coworker. Your client states that the coworker had never liked him and he had not been disrespectful of her; however, their manager chose to let him go. He is currently attending classes at the community college and is in a mechanical engineering program. He chose this program because he thought he would really like it but he has been struggling with his courses due to his work schedule and now his major concern is making a living so that he can stay in school. He says he’s beginning to doubt whether this is the right path for him. He reports having no friends or anyone to spend time with on his days off. | Family History:
The client is an only child. His parents have moved frequently with his father’s job and have lived in different areas of the world. His mother currently lives across the country and his father lives in the Middle East due to his work. They formally separated three months ago. Prior to moving here, the client lived with his mother but was concerned that she was “spending all our money.” His mother is retired and is supported by his father. He states he doesn’t want to be like her and live off of his father’s wealth. | Based on this new information, which intervention should be used during this session? | Develop suicide contract to keep client safe | Explore questions related to sexual attraction based on current employment | Explore client's experience of internal and external locus of control | Assess for alcohol use disorder and referral to Alcoholics Anonymous | (A): Develop suicide contract to keep client safe
(B): Explore questions related to sexual attraction based on current employment
(C): Explore client's experience of internal and external locus of control
(D): Assess for alcohol use disorder and referral to Alcoholics Anonymous | Explore client's experience of internal and external locus of control | C | The client's statements about frequent moves because of parents, losing his job because of others, and having no choice about his new employment, demonstrates an external locus of control which is the belief that his success is dependent on external forces rather than himself. His circumstances are not optimal; thus, he believes he cannot be successful, which impacts his emotional health and well-being. A suicide contract may be helpful but would have been completed in the intake if used, as the client states he has no suicidal ideation at this time. His increase in alcohol is an important clue to his lack of coping skills and should be addressed in session, but not for the purpose of diagnosis and referral at this time since it is a recent development. Exploring possible same-sex attraction may be beneficial later when the client is stable but may cause greater stress right now. Therefore, the correct answer is (D) | counseling skills and interventions |
251 | 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. | Since the fourth session, child protective services investigated the client’s abuse allegations and determined that they were unfounded. You discuss this with the client and he says he was lying because he was mad at his parents that day. You praise the client for being forthright today regarding the allegations and discuss how false allegations can be incredibly harmful to others and can strain his relationship with his parents further. You and the client process several situations similar to this in which he avoided responsibility. You empathize with the client and support his reflection on his behavior | From a behavior therapy perspective, which of the following would best define what the client does when he blames others for his actions? | Attention | Sensory needs/stimulation | Escape | Item/activity | (A): Attention
(B): Sensory needs/stimulation
(C): Escape
(D): Item/activity | Escape | C | The function of this client’s behavior when he blames others is to escape consequences and escape possible pain from being in trouble or having to accept his own behavior. The client is not seeking attention because he is redirecting attention. The client might blame others in an attempt to maintain access to activities or items, but in the case of a client with conduct disorder, he is likely trying to avoid punishment. There is no indication that this client is looking for sensory input or cognitive stimulation. Therefore, the correct answer is (A) | counseling skills and interventions |
252 | 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. | You meet with the client 2 weeks after the initial intake because she refused to come for the session scheduled the past week. Because of the cancellation, you decide to change the focus of your session to meet the client’s needs for comfort and security over the foster parents’ need for guidance and skills. The client engages a little more in interacting with you, and you praise her for her involvement. At one point in the session, the client hits you and goes and sits down to continue playing. At the end of the session, you provide the foster parents with ways that they can increase attachment and positive interactions with your client. You empathize with the foster parents regarding their desire to help the client feel loved and cared for | From a behavioral therapy perspective, which of the following interventions would demonstrate conflict tolerance in a manner that would meet the client’s needs when she hits you? | You minimize your reaction and prompt the client to communicate her wants or needs. | You redirect the client to another activity in order to support her with managing her strong emotions. | You disengage from the client and provide no response so as to not reinforce the behavior. | You engage the client in cognitive reframing to manage her strong emotions. | (A): You minimize your reaction and prompt the client to communicate her wants or needs.
(B): You redirect the client to another activity in order to support her with managing her strong emotions.
(C): You disengage from the client and provide no response so as to not reinforce the behavior.
(D): You engage the client in cognitive reframing to manage her strong emotions. | You minimize your reaction and prompt the client to communicate her wants or needs. | A | From a behavioral perspective, the function of the behavior would be to escape. In order to address this, you want to avoid reinforcing the behavior by providing a response, and you also want to prevent escape by encouraging her to communicate what she needs or wants. Encouragement to engage in cognitive reframing would not be developmentally appropriate because the client may not be able to use this skill and it is not a behavioral intervention. Choosing to disengage from the client and to not respond would not address the function of the behavior because when the function is “escape,” you would be allowing the client to escape by disengaging and would reinforce the behavior. It may be helpful to redirect the client to calm down; however, this would not address the function of the behavior. Therefore, the correct answer is (B) | counseling skills and interventions |
253 | 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. | You conduct the Columbia Suicide Severity Rating Scale (C-SSRS) with Malik. Which component is most critical to assessing her current safety? | History of family depression or suicidal ideation | The length of time it has been since her suicidal thoughts | The severity of her suicidal thoughts on a scale of 1-5 | If suicidal ideations have proceeded to methods and plans | (A): History of family depression or suicidal ideation
(B): The length of time it has been since her suicidal thoughts
(C): The severity of her suicidal thoughts on a scale of 1-5
(D): If suicidal ideations have proceeded to methods and plans | If suicidal ideations have proceeded to methods and plans | D | While the other choices are crucial in understanding the overall safety of your client, the indicators that are most alarming and qualify for immediately raising a client's risk level are if their suicidal thoughts have developed into consideration of methods of suicide and the creation of specific plans for when and how to commit suicide. This demonstrates level of intent versus remaining in the realm of "ideation" and may increase or intensify the type and level of interventions applied. Therefore, the correct answer is (C) | intake, assessment, and diagnosis |
254 | Name: Tina Clinical Issues: Maladaptive eating behaviors Diagnostic Category: Feeding and Eating Disorders Provisional Diagnosis: F50.01 Anorexia Nervosa, Restricting Type Age: 21 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: Italian American Marital Status: Not Married Modality: Individual Therapy Location of Therapy : University counseling center | The client presented with a slender physique and was observed wearing conservative, dark-colored attire. Her overall demeanor was reserved, displaying noticeable nervousness and a tendency to withdraw from interactions. Upon conversing with her, it became evident that her train of thought often deviated from the topic at hand, hinting at a tangential pattern. This difficulty in maintaining concentration appears to be a consequence of her heightened anxiety levels. Delving deeper into her thought content, a recurring theme of obsessions surrounding food and body weight emerged. Additionally, a palpable fear of judgment from her peers and the broader society was evident. In terms of her cognitive functioning, she was found to be alert and fully oriented to her personal details, as well as her current location and time. However, a significant concern is her limited insight into her present circumstances and the implications of her behaviors. Throughout the assessment, there were no indications of any memory impairments. | First session You are a mental health therapist working in a university counseling center. The client, a 21-year-old female, presents issues related to anxiety, poor body image, and eating. You begin the session by introducing yourself and explaining your role as a therapist. You also explain how confidentiality is handled and make sure that she understands her rights as a client. After the initial introductions, you ask her to tell you about her current situation and what led her to seek out therapy. She reports that she has been feeling anxious for a while, but it has gotten worse since a basketball game when someone in the audience yelled to the referee "thunder thighs over there needs to get her act together!" Even though the comment was not directed at her, she internalized it. She explains that she was already feeling uneasy due to her stepfather's comments about her weight from a few years ago, and the recent insult at the game made it "all come crashing down" for her. Now, she cannot stop ruminating about her appearance. She saw a poster in her dorm room promoting counseling services and decided to make an appointment. You continue your interview by asking about her current eating behaviors. She explains that she avoids carbohydrates, sugar, and most dairy "since that stuff makes you fat." When you ask her to describe what she eats during a typical day, she says, "I usually have a fruit smoothie with almond milk for breakfast, an apple and 12 nuts for lunch, and then some steamed vegetables or a salad for dinner." When asked about exercise or other physical activity besides basketball, she reports that she runs at least seven miles on a nearby trail every morning and spends two hours swimming laps at the indoor gymnasium pool every evening before bed. She says, "The pool is pretty quiet at night. I don't like to be around a lot of people when I'm exercising." As you continue your dialogue, you ask the client open-ended questions to explore her relationship with her parents, especially her stepfather. She reports that her stepfather has always had negative remarks about her size and shape. She states that she feels like he views her as "less-than" because of her weight, which has led to feelings of shame and worthlessness. You explore the dynamic further by inquiring about how these comments have impacted her self-esteem. She reports feeling anxious, embarrassed, and inadequate when her stepfather is critical. You validate her feelings and explain that comments like these can be very damaging to a person's self-image. You ask the client what she hopes to accomplish in therapy. After some thought, the client says that she wants to learn how to manage her anxiety. She looks at your shyly and says, "I also want to be able to eat a piece of chocolate. I know that sounds crazy, but I just want to be able to enjoy it, without feeling guilty or like I'm going to get fat." You affirm her desires and explain that a key part of the therapeutic process will be to help her build self-confidence and develop healthier relationships with food. Sixth session You have been working with the client in intensive outpatient therapy and have been meeting with her two times per week. She is under medical care at the university's health center and has started taking an anti-anxiety medication that was prescribed by her physician. You have also referred her to a nutritionist for specialized guidance on developing a healthier relationship with food. You have established a strong, trusting relationship, and she has told you that she feels comfortable talking to you. Today, the client brings up an issue that has been bothering her for a while: anxiety about eating around other people. She tells you that she usually gets her food "to go" from the cafeteria and eats at a bench outside or alone in her dorm room. She avoids eating in front of others when possible. However, at least once or twice a week, her teammates all go out to lunch after practice. This usually requires her to order food in front of them and she feels very anxious about it. She has been ordering the same salad with dressing "on the side" for several months because that is what makes her feel the most comfortable. One of her teammates commented on her "same old salad" and asked why she never got anything else to eat. Everyone at the table got quiet and turned to look at her. The client reports that the comment made her feel embarrassed and ashamed, like everyone was laughing at her. You ask her how she responded in the moment and she shares that she just laughed it off, but internally, she felt very embarrassed and anxious. You explore this further by asking her what emotions arise when she is around food, particularly in social settings. She reports feeling ashamed for wanting to eat "fattening food" because of her father's comments about her size. She skipped the last team lunch because she was so anxious about someone drawing attention to her food choices again. She closes her eyes and takes a breath. When she opens her eyes, you can see that she is struggling to hold back tears. She says, "Everyone eats their food like it's no big deal. But it's a huge deal for me. It's all I can think about. I just want to be able to eat a meal without feeling guilty or like I'm going to get fat. I'm so tired of worrying about food all the time!" You consider using exposure and response prevention techniques to address her fear and anxiety related to eating. You continue the session by identifying a list of foods and situations that trigger her anxiety and negative feelings about her body. You ask the client if she would like to meet with you for her next session right after practice and bring a lunch to eat in your office. She appears relieved and grateful to have a break from eating in front of her teammates. | The client's parents divorced when she was six years old. Her mother remarried 12 years ago. The client has a younger half-brother who lives with her mother and stepfather. She is close to her mother, but "my stepfather is a different story." She reports that he is critical of her and often remarks on how she looks or what she is eating. She states that he has commented on her weight and body shape since middle school. Her mother tries to intervene, but her stepfather continues to be critical. She tells you she couldn't wait to graduate high school and move out of the house. She tells you, "I remember that when I went home for a visit during winter break during my freshman year, my stepdad had this shocked look on his face when he saw me. He told me I had gained so much weight that I didn't even look like myself anymore. I've never forgotten that. And it's not like he's the picture of health." Previous Counseling: The client has a history of anxiety. She saw a therapist for a few sessions in high school after being referred by her school counselor, but she did not feel comfortable with the therapist and refused to continue attending sessions. She did not receive a clinical diagnosis related to her anxiety. The client reports that she has been feeling more anxious lately and is struggling to cope with her anxiety. She says that she feels "on edge," and that makes it difficult for her to concentrate. She is interested in exploring therapy to manage her anxiety. Additional Characteristics: The client is currently on the school's basketball team. She was voted most valuable player two years in a row. | Which statement best reflects the client's feelings about her relationship with food and eating? | "You're feeling very anxious about eating and trying to be mindful of what you eat, which is making it more difficult for you to enjoy meals with others." | "I can hear the distress in your voice when you talk about food and eating. It sounds like your relationship with food has been one of guilt and anxiety, which has been intensified by comments from people around you." | "I'm sorry that you've had to deal with negative feelings about food and eating. It sounds mentally and emotionally exhausting, and I can understand why you are feeling frustrated." | "It seems like all of your teammates have no problem with eating together, but you feel embarrassed and ashamed when they comment on your food choices." | (A): "You're feeling very anxious about eating and trying to be mindful of what you eat, which is making it more difficult for you to enjoy meals with others."
(B): "I can hear the distress in your voice when you talk about food and eating. It sounds like your relationship with food has been one of guilt and anxiety, which has been intensified by comments from people around you."
(C): "I'm sorry that you've had to deal with negative feelings about food and eating. It sounds mentally and emotionally exhausting, and I can understand why you are feeling frustrated."
(D): "It seems like all of your teammates have no problem with eating together, but you feel embarrassed and ashamed when they comment on your food choices." | "I can hear the distress in your voice when you talk about food and eating. It sounds like your relationship with food has been one of guilt and anxiety, which has been intensified by comments from people around you." | B | This response accurately reflects the client's feelings about her relationship with food and eating. It acknowledges her distress and validates that she is feeling a lot of guilt and anxiety when it comes to food, which is made worse by comments from people around her. Therefore, the correct answer is (C) | counseling skills and interventions |
255 | 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 | This factor can exacerbate tics? | Putting together a puzzle | Epsom bath | Stressful/exciting events | Going for a hike | (A): Putting together a puzzle
(B): Epsom bath
(C): Stressful/exciting events
(D): Going for a hike | Stressful/exciting events | C | Stressful/exciting events can cause or worsen tics. An activity that is structured and requires focus such as putting a puzzle together can help suppress tics as well as enjoyable activities such as going for a hike. An Epsom bath, or any type of bath can help towards relaxation and may also help to suppress tics. It can be helpful to journal or monitor what is effective and what is not. Therefore, the correct answer is (A) | intake, assessment, and diagnosis |
256 | Client Age: 25 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Counseling Clinic Type of Counseling: Individual Presenting Problem: Depression and Suicidal Ideation Diagnosis: Major Depressive Disorder, Recurrent, Mild (F33.0) | Mental Status Exam: The client appears to not have bathed recently because his hair is greasy and unkempt. The client has food stains on his clothing; however, he is dressed appropriately for the season. His motor movements are within normal limits. He is engaged in therapy, but he appears anxious as evidenced by hesitating before speaking and by his hand wringing. The client reports suicidal ideation with no plan or intent. The client reports a depressed mood more often than not and difficulty enjoying most activities. The client is oriented to person, place, time, and situation. The client reports that his appetite has increased lately and that he is experiencing hyperso | You are a resident in counseling practicing in a private practice agency. During the initial counseling session, the 25-year-old single male client reports feeling depressed and hopeless. He has difficulty enjoying activities that he has enjoyed in the past and feels unsatisfied with most areas of his life. The client identifies that he is not happy at work and wants to make a career change. The client verbalizes feeling sad more often than not, and that this has been going on for about 2 years. The client decided to start counseling when he began experiencing suicidal thoughts. The client reports no plan or intent to attempt suicide but is concerned about his own well-being. | The client reports that he has been sleeping more than usual and that this is affecting his ability to get to work on time. He reports that his boss started noticing his tardiness and has given him a verbal warning. Combined with the fear of losing his job, he expressed worry regarding increased conflict with his girlfriend and feeling more “on edge.” The client asks the clinician to call his girlfriend for some more insight into how depression is affecting his functioning | The client asks the clinician to call his girlfriend for some more insight into how depression is affecting his functioning. What is important to obtain in order to facilitate this collaboration? | A signed informed consent form | A signed release of protected health information (PHI) | A written and signed letter of consent from the client | Verbal consent from the client to collaborate with his girlfriend | (A): A signed informed consent form
(B): A signed release of protected health information (PHI)
(C): A written and signed letter of consent from the client
(D): Verbal consent from the client to collaborate with his girlfriend | A signed release of protected health information (PHI) | B | The Healthcare Information Portability and Accountability Act of 1986 (HIPAA) Privacy Rule requires a signed release of PHI before a client’s health information is shared with individuals internal and external to a facility (except for people directly involved in the client’s care). The signed release of PHI identifies to whom the information can be provided, what information can be provided, what method of communication is permitted, and how long the communication can continue. Informed consent, although required in many circumstances, does not provide permission to release information and is more relevant to obtain from clients prior to performing procedures or interventions after the details, risks, and benefits have been thoroughly discussed. A written or verbal consent from the client would not be sufficient for this kind of contact. Therefore, the correct answer is (C) | professional practice and ethics |
257 | Client Age: 25 Sex: Male Gender: Male Sexuality: Bisexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Telehealth Type of Counseling: Individual counseling Presenting Problem: The client is experiencing difficulty focusing on work due to a childhood diagnosis of attention-deficit/hyperactivity disorder (ADHD) and thinks that if he cannot keep up with work, he is going to get fired. Diagnosis: Attention-deficit/hyperactivity disorder (ADHD), predominantly inattentive presentation (F90.0) | Mental Status Exam: The client is oriented to person, place, time and situation. The client is engaged and participates fully in the intake session. The client does not appear anxious. The client has a flat af | You are a licensed counselor working in your own private practice and providing telehealth sessions to clients. The client states that he is having trouble keeping up with tasks at work. The client reports that he wakes up and does not want to go to work because he knows he will not get much done. The client is often late to work, and although he is typically the only one in the office, his employer comes to work every now and then, and he worries that he will get caught arriving late. He says that he procrastinates on tasks but, often near the end of the day, finds motivation to complete the tasks and stays late to do so. In addition to his trouble at work, the client says he thinks that he does not do much that makes him happy. He expresses the desire to write stories and play guitar more because these activities used to make him happy, but he has trouble finding motivation to engage in them at the present. | fect. Family History: The client reports a strained relationship with his parents, but he says that he does not want to talk about them because they are not the reason that he is in therapy. The client says that he has a younger sister (age 23) and that they are not close. The client reports that he currently has a girlfriend | Which of the following differential diagnoses should be considered for this client? | Specific learning disorder | Major depressive disorder | Substance use disorder | Generalized anxiety disorder | (A): Specific learning disorder
(B): Major depressive disorder
(C): Substance use disorder
(D): Generalized anxiety disorder | Major depressive disorder | B | Considering the client’s presenting problems, which include the identification of often feeling unhappy, assessing for major depressive disorders is appropriate because they can co-occur with ADHD. Anxiety may be present surrounding completing tasks; however, this anxiety is likely related to ADHD and is not indicated as a possible diagnosis. There are no reports of substance use, so this would not be considered for this client at this time. Therefore, the correct answer is (D) | intake, assessment, and diagnosis |
258 | 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. Second session The client presents to her second counseling session in a defensive state. She is upset that you reported her suicidal ideation to her parents because she thought that everything she told you would remain confidential. She says, "Why should I tell you anything else? You'll just tell my parents." You tell the client that you understand her frustrations and empathize with her. You explain to her why confidentiality is not always absolute and that as a clinician, it is your responsibility to keep clients safe, even when they don't want you to. You further explain that in this case, you felt it was important for her parents to know about the suicidal ideation she has been experiencing. You emphasize that her parents care deeply about her, and they need to know what is going on with her in order for them to help. She responds by saying, "Okay, I get what you're saying, but telling them about it has only made things worse." She reports that her parents now treat her "differently" and do not allow her access to any "dangerous items like kitchen knives" without supervision. She feels restricted and watched. You nod your head in understanding and reflect that it can be difficult to feel like your parents don't trust you and have put restrictions on things they normally wouldn't. You also encourage her to try and see the situation from their perspective and agree that although the restrictions can be inconvenient, her safety is their top priority. She takes a deep breath and says, "I guess I can understand why they did it, but it still doesn't feel fair." You acknowledge her feelings of unfairness and validate that feeling. After your discussion, the client appears to have a better understanding of her parents' motivation for the restrictions and feels less resentful towards them. You ask her to tell you more about how she has been feeling lately and invite her to share any other issues she is having trouble managing. She tells you that her ballet teacher has invited her to help teach the younger ballet classes, but she is ambivalent about pursuing this opportunity. Though she still loves ballet, she thinks it will be painful to watch other children fulfill the dreams that she can no longer pursue. She says, "I'm afraid that if I agree to teach, I'll never get over my injury. It will just keep reminding me of what I could have been." You explain to her that it is natural for her to have these feelings and that it is okay to take time to make a decision. You ask her if she can see any benefits to teaching. She pauses and says, "I don't know...I've never really thought of myself as a teacher. I've always been the student." You acknowledge the difficulty of this transition and understand that it can feel risky to try something new. You suggest that teaching could be an opportunity for her to gain a sense of purpose, as well as an activity to help her stay connected to something she loves. You encourage her to try and explore her capacity for teaching and imagine what impact she could have on her students. Seventh session Almost two months have passed since you first met with the client. She has been meeting you for weekly therapy sessions. During previous sessions, you continued to work on developing a sense of trust with the client which has allowed her to open up to you about the myriad of feelings that she has regarding her injury. You explored and processed feelings of grief and sadness, as well as feelings of anger and resentment. Several sessions have been dedicated to identifying automatic thoughts that have been contributing to the client's negative attitude and replacing negative self-talk like "I'm broken" with more positive and realistic statements. You have also been using solution-focused techniques to help her to focus on what is within her power to change and take active steps toward making those changes. During today's session, the client agrees with you when you state that you believe she has achieved many of her goals in therapy. The client has worked through her ambivalence towards teaching the younger ballet classes and is now actively pursuing this opportunity. She reports that she finds a sense of purpose in helping the students learn and appreciate dance, as well as feel accomplished for their achievements. She says, "It's still strange not being the student anymore, but I'm glad that I decided to try it. The kids had a performance last week, and one of the girls gave me this really sweet clay ballet shoe that she made in her art class. She told me that I'm the reason she felt 'brave enough' to keep dancing even though she was scared. That meant a lot to me." You then ask her about her relationship with her parents. She reports that it has improved since they had the discussion about trust. They are now more willing to listen to her opinions and have loosened some of the restrictions, though there are still some limits in place. Although they still have expectations of her and restrict certain activities, they now talk to her more openly and engage with her in a positive manner. She tells you that she would like to get all A's this semester to make her parents proud. She is getting better grades in history but states that her other classes are "boring." She also mentions wanting to put some limits on the amount of time she spends with her friends and "get away from smoking as much." She says that she is trying to be a better role model for her ballet students. You acknowledge how hard she has worked to reach this point and congratulate her on taking initiative in improving her academic performance and setting new boundaries with her friends. | 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. | How would you respond to the client's comment "I'm broken" using mindfulness-based cognitive therapy? | Engage the client in an exercise to role-play different parts of herself in order to understand why she feels broken | Reflect back to the client the feelings she experiences when she believes she is broken and validate those emotions | Encourage the client to practice self-compassion and non-judgmental awareness when she finds herself engaging in negative self-talk | Help the client to replace her negative self-talk with positive affirmations and rewards for making progress | (A): Engage the client in an exercise to role-play different parts of herself in order to understand why she feels broken
(B): Reflect back to the client the feelings she experiences when she believes she is broken and validate those emotions
(C): Encourage the client to practice self-compassion and non-judgmental awareness when she finds herself engaging in negative self-talk
(D): Help the client to replace her negative self-talk with positive affirmations and rewards for making progress | Encourage the client to practice self-compassion and non-judgmental awareness when she finds herself engaging in negative self-talk | C | Mindfulness-based cognitive therapy encourages the client to become aware of their thoughts, feelings, and emotions in a non-judgmental, compassionate way. By encouraging self-compassion and awareness when engaging in negative self-talk, the client can begin to recognize patterns and better understand how their thoughts are impacting their wellbeing. This understanding can help the client to make positive and realistic statements which can replace the negative self-talk. Therefore, the correct answer is (D) | counseling skills and interventions |
259 | 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 a client with stereotypic movements display? | Rapid, jerky, nonrepetitive movements | Repetitive, seemingly driven, and nonfunctional motor behaviors | Excessive motor activity is associated with a feeling of inner tension, usually non-productive and repetitious | Agitated, purposeless motor activity, uninfluenced by external stimuli | (A): Rapid, jerky, nonrepetitive movements
(B): Repetitive, seemingly driven, and nonfunctional motor behaviors
(C): Excessive motor activity is associated with a feeling of inner tension, usually non-productive and repetitious
(D): Agitated, purposeless motor activity, uninfluenced by external stimuli | Repetitive, seemingly driven, and nonfunctional motor behaviors | B | These would be considered stereotypic movements. Therefore, the correct answer is (A) | intake, assessment, and diagnosis |
260 | 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. | The husband and wife come into the session and sit as far as they can from each other on the couch, and their individual body positions are oriented away from each other. You ask for any updates in the couple’s relationship, and the husband states that they have not been talking about the affair and continue to only communicate regarding the kids. You attempt to process with the couple what the affair means for their relationship and what events led up to the affair. During the session, the husband stops talking and looks away from his wife when she talks about how she became frustrated that her husband did not spend quality time with her prior to the affair. She thinks that this led to her seeking attention from a man outside of the couple’s relationship | Which one of the following best defines mindful listening? | Being able to summarize what is being said | Focusing on listening when someone is speaking and focusing on what you are saying when you are talking | Trying to relate to the emotions expressed by others while listening | Repeating the message that you interpreted from what was said | (A): Being able to summarize what is being said
(B): Focusing on listening when someone is speaking and focusing on what you are saying when you are talking
(C): Trying to relate to the emotions expressed by others while listening
(D): Repeating the message that you interpreted from what was said | Focusing on listening when someone is speaking and focusing on what you are saying when you are talking | B | Mindful listening is the act of being present when someone is speaking and when you are speaking. Relating to emotions would be better defined by empathy. Repeating the message heard is considered paraphrasing. Summarizing is only one element of mindful listening, and it does not necessarily reflect the act of being truly present as the sender and the receiver of the communication. Therefore, the correct answer is (A) | counseling skills and interventions |
261 | Client Age: 24 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: African American Relationship Status: Single Counseling Setting: Private practice counseling clinic Type of Counseling: Individual counseling Presenting Problem: The client comes to counseling for help in managing anxiety, workplace dissatisfaction, and a pornography addiction. Diagnosis: Generalized anxiety disorder (F41.1), other problem related to employment (Z56.9), religious or spiritual problems (Z65.8) | Mental Status Exam: The client is oriented to person, place, time, and situation. The client appeared hesitant when talking about pornography | You are a professional counselor, and the client comes to counseling to work on anxiety, work dissatisfaction, and a pornography addiction. You and the client discuss his anxiety, and he identifies that he experiences anxiety at work, regarding daily tasks, and in social settings. The anxiety is characterized by restlessness, difficulty concentrating, muscle tension, and insomnia. The client states that at work he is often treated poorly by his supervisors, who often point out what he does wrong and do not acknowledge what he does right. He does not feel that he does as much wrong as they claim, and he often finds that their accusations do not accurately reflect his actions, which is frustrating. The client states that he has had many meetings with his supervisors and that they do not appear to try to understand his point of view. The client appears uncomfortable and begins to speak but stops for about a minute before saying that he also has a pornography addiction. The client says that he is a Christian and that he does not feel he should view any pornography, but also that he uses pornography a lot and does not feel like he has control over himself or the frequency at which he uses it. The client asks if you are a Christian, and you decide to disclose with him that you are, knowing this is an important part of the client’s life and perspective. The client states that his work problems and pornography use are his most pressing issues. | The client comes into the session smiling and says that he is excited to share his log this week. The client shares that he masturbated an average of one to two times daily and that he even went a day without masturbating. You express your excitement for the client achieving his goals. Through processing, the client identifies that he refrained from masturbating most often by leaving his bedroom and finding something to structure his time late at night. The client says that he had difficulty refraining from masturbating mostly when he came home from a difficult day at work, or when he struggled to sleep. You and the client discuss calming techniques to use when he is stressed after work. You also recommend approaches to address difficulty sleeping. On days when the client masturbates, he explains that he often decides that since he already messed up, he can do it again. The client says that he is happy at his new place of employment and that it is just a hard job. You support the client in challenging his past cognitive distortion that his future employment experiences will be the same as his past experiences. The client is engaging in all-or-nothing thinking with regard to his rationalization of masturbating again if he has already done so | The client is engaging in all-or-nothing thinking with regard to his rationalization of masturbating again if he has already done so. Which of the following would be the most helpful reframe of this thought? | “I didn’t meet my goal, but this doesn’t have to affect the rest of my day.” | “I’ll take some time to do yoga to disconnect from this event and move forward with my day.” | “I did mess up, but I’m only human, so I won’t beat myself up over it.” | “What happened can’t be changed, so I’ll just continue to move forward.” | (A): “I didn’t meet my goal, but this doesn’t have to affect the rest of my day.”
(B): “I’ll take some time to do yoga to disconnect from this event and move forward with my day.”
(C): “I did mess up, but I’m only human, so I won’t beat myself up over it.”
(D): “What happened can’t be changed, so I’ll just continue to move forward.” | “I didn’t meet my goal, but this doesn’t have to affect the rest of my day.” | A | The best reframe in this case of all-or-nothing thinking is the client acknowledging that he did not meet his goal but that he has power over the rest of his day to make changes. This reframe helps the client see that one event in his day does not have to define the whole day. Acknowledging his humanity is helpful, but it does not address the client’s all-or-nothing thinking. The client saying that he “messed up” has a negative connotation, when the reality is that he is working toward a goal, which often involves setbacks. The client acknowledging that he cannot change what he did is a helpful technique, but it does not change his mindset for the rest of the day. Yoga or other calming activities also do not address all-or-nothing thinking when done in isolation (without a mental reframe); instead, these activities can be used as a diversion to avoid confronting the cognitive distortion completely. Therefore, the correct answer is (B) | counseling skills and interventions |
262 | 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. | The client comes to this session, sits down, and starts talking about how she met a man and talked to him for about an hour and was frustrated at the end of the conversation because she feels that he is “like everyone I’ve been with before.” The client continues to explain that she knows these men are not good for her and that she wants something different, but she is still talking to him. The client becomes frustrated talking about this and begins crying and breathing heavily, stating that, “I am broken and can’t have a healthy relationship.” You support the client through her strong emotions and provide empathetic listening. The client inquires about circumstances in which you, as the counselor, are able to disclose information from your sessions with her | The client inquires about circumstances in which you, as the counselor, are able to disclose information from your sessions with her. All of the following are true regarding disclosure of information, EXCEPT: | You may disclose information to the client’s insurance company because they are a payor. | You may disclose information when the client expresses suicidal ideation with a plan and intent. | Even if the client is deceased, you cannot disclose information. | You may disclose information when the client does not show up for a session because you are required to call the emergency contact. | (A): You may disclose information to the client’s insurance company because they are a payor.
(B): You may disclose information when the client expresses suicidal ideation with a plan and intent.
(C): Even if the client is deceased, you cannot disclose information.
(D): You may disclose information when the client does not show up for a session because you are required to call the emergency contact. | You may disclose information when the client does not show up for a session because you are required to call the emergency contact. | D | Reaching out to an emergency contact after one missed session is not by itself a sufficient justification for disclosure because you are unsure if the client is at imminent risk of harm. You may disclose information to the insurance company because they are a payor. You can also break confidentiality if the client is at risk of harming themselves or others. Even when the client is deceased, you must maintain confidentiality to the level requested by the client. Therefore, the correct answer is (C) | professional practice and ethics |
263 | 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 | All of the following are appropriate conflict resolution strategies for the client and his ex-wife EXCEPT: | Focusing on supporting your client in expressing himself effectively as the priority because he was the party that was hurt | Identifying and establishing the co-parenting goals that benefit the children and parents most | Identifying and establishing ground rules for conflict resolution | Supporting the client in empathizing with his ex-wife for deeper understanding of how the situation occurred | (A): Focusing on supporting your client in expressing himself effectively as the priority because he was the party that was hurt
(B): Identifying and establishing the co-parenting goals that benefit the children and parents most
(C): Identifying and establishing ground rules for conflict resolution
(D): Supporting the client in empathizing with his ex-wife for deeper understanding of how the situation occurred | Focusing on supporting your client in expressing himself effectively as the priority because he was the party that was hurt | A | With the focus of this session being conflict resolution, focusing only on one party would not be the most beneficial approach. The client does need to express himself effectively, but the individuals should take turns expressing themselves regarding the situation. Empathy toward his ex-wife would help the client understand what led her to talk with their children about the divorce in the manner that she did. The parents share custody of the children; therefore, they will need to work out what coparenting looks like and what their goals are as parents. Ground rules can add a framework for tough conversations and help the conversations stay on track toward resolution. Therefore, the correct answer is (C) | counseling skills and interventions |
264 | Name: Chad Clinical Issues: Maladaptive eating behaviors Diagnostic Category: Feeding and Eating Disorders Provisional Diagnosis: F50.2 Bulimia Nervosa, Moderate Age: 16 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: White Marital Status: Not Assessed Modality: Individual Therapy Location of Therapy : Agency | The client is appropriately dressed but disheveled. He is dressed in clothes associated with anime characters. Concentration is drifting. His speech is somewhat low, and he keeps his head low to avoid making eye contact with you. His mood is anxious. There is no suicidal ideation. Thought content shows no current homicidal ideation or plans. Thoughts are appropriate. The estimated level of intelligence is in the low average range with abstract thinking. | First session You are a mental health therapist who works for an agency specializing in helping teens with eating disorders. The client is 16 years old. He presents for therapy along with his mother. You start by welcoming both of them into your office. Then you introduce yourself, explain your role as a therapist, and briefly describe the experience you have in treating eating disorders. Next, you ask the client to explain and his mother to share with you why they came to see you today and what their expectations are for therapy. The mother begins by telling you, "My son is doing dangerous things to his body. He needs help, but he won't listen to me." The client rolls his eyes and replies, "She doesn't get it. Look at her. She's fat and is always overeating!" His mother's face turns red and she starts to yell at him. You remain neutral and ask them both take a few deep breaths and give each other some space. You explain that your goal is to create a trusting relationship with the client and his mother so that you can start working together towards understanding the issues that bring them to counseling and how to best help. You ask the mother to take a seat in the waiting room while you speak with her son for the first part of the session. She reluctantly agrees and leaves the room. Once the mother leaves, you start by letting the client know that you understand that this situation is difficult, and that you are here to help. You focus on building rapport with the client, emphasizing that you are here to help him. You ask him open-ended questions to get to know more about him, and to help him feel seen and understood. You acknowledge the client's feelings of being misunderstood and provide empathy by validating that it must feel difficult not having his mother understand what he is going through. You also recognize his mother’s concerns by saying, "It sounds like your mom is really worried about you." He tells you that his mother is constantly trying to control him and that he does not understand why she is always so angry all the time. You continue your assessment with structured questioning to understand the client’s current experiences with food, including what he likes to eat and how often he eats. At the end of your discussion with the client, you thank him for being open and honest with you. You acknowledge how brave it is to come in and start talking about his experiences. You invite him to bring his mother back in to the office so you can start working together and discuss the next steps. | The client does well in high school. He is concerned that he could quickly gain weight and no longer be in optimum shape for cheerleading and gymnastics. The client's self-esteem is closely related to his weight and body image, and he appears to lack insight into the dangers of his current eating behaviors. Stressors & Trauma: The client tells you throughout elementary school he was overweight. As a result, he was bullied by other boys and girls alike. They would leave notes on his desk saying "fatty" or "crispy crème." One student pushed him down in the schoolyard, and all the others stood in a circle around him and laughed as the client cried. Pre-existing Conditions: No significant medical issues were reported based on his last medical exam. He does, however, admit to eating four hamburgers and a large bag of French fries at a fast-food restaurant "as a treat" about four or five times a week. He shares that after these fast food "splurges," he goes home and purges to not gain weight. Feeling guilty after each episode, he does not eat anything the next day and doubles his workout routine. | When conducting a Mental Status Exam, the global impression (above average, average, below average) is assessing what dimension? | Intellect | Mood | Insight | Sensorium | (A): Intellect
(B): Mood
(C): Insight
(D): Sensorium | Intellect | A | Intellect is expressed in terms of global impression of the client's level of educational achievement. It is categorized as above average, average, or below average. Therefore, the correct answer is (A) | intake, assessment, and diagnosis |
265 | 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 | Using the DSM-5-TR criteria, how would you differentiate oppositional defiant disorder (ODD) from conduct disorder (CD)? | ODD includes destruction of property, while CD does not. | ODD includes cruelty to animals, while CD does not. | ODD includes conflict with authority, while CD does not. | ODD includes emotional dysregulation, while CD does not. | (A): ODD includes destruction of property, while CD does not.
(B): ODD includes cruelty to animals, while CD does not.
(C): ODD includes conflict with authority, while CD does not.
(D): ODD includes emotional dysregulation, while CD does not. | ODD includes emotional dysregulation, while CD does not. | D | Criteria for ODD include emotional dysregulation, while CD does not. Both ODD and CD include the criterion of conflict with authority. Only CD includes the destruction of property and cruelty to animals. It is important to distinguish between ODD and CD, and the DSM-5-TR makes that distinction in the differential diagnosis section. The differential diagnosis section can be found after the diagnostic criteria, along with additional text descriptions such as diagnostic features. According to the DSM-5-TR, both conduct disorder and ODD are related to issues of behavior as it relates to conflict with figures of authority, but ODD behaviors are generally less severe than those of conduct disorder and do not target animals or property. Additionally the DSM-5-TR describes ODD to include issues with regulating emotions. Therefore, the correct answer is (A) | intake, assessment, and diagnosis |
266 | 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. | ship. Family History: The client is close with her parents and her younger brother (28 years old). The client says that she was engaged twice before but that neither engagement progressed to marriage because her two fiancés both felt that she was too clingy and unable to care for herself | Which of the following assessment tools would be used to best support the diagnosis of dependent personality disorder? | Rorschach inkblot test | Likert scale | Symptom Checklist 90-Revised (SCL-90-R) | Minnesota Multiphasic Personality Inventory-3 (MMPI-3) | (A): Rorschach inkblot test
(B): Likert scale
(C): Symptom Checklist 90-Revised (SCL-90-R)
(D): Minnesota Multiphasic Personality Inventory-3 (MMPI-3) | Minnesota Multiphasic Personality Inventory-3 (MMPI-3) | D | The MMPI-3 assesses for characteristics of many personality disorders including dependent personality disorder and can provide a large amount of information regarding an individual’s personality. Rorschach inkblots can be used in diagnosing dependent personality disorder; however, these tests have low reliability and validity. The SCL-90-R assesses 90 items that include (but are not limited to) depression, anxiety, poor appetite, and hostility. A Likert scale is not an assessment itself; rather, it is a way to scale a response to a question using answer options such as very likely, likely, unlikely, and very unlikely. Therefore, the correct answer is (A) | intake, assessment, and diagnosis |
267 | Initial Intake: Age: 23 Gender: Male Sexual Orientation: Heterosexual Ethnicity: Indian American Relationship Status: Single Counseling Setting: Private Practice Type of Counseling: Individual | Shawn is slightly unkempt, completes ADLs and has good hygiene. His motor movements are fidgety and tense, and he consistently averts eye contact and darts his eyes around the room and towards the door every time he hears a noise. He appears to be sensitive to the lighting in the office as evidenced by fluttering his eyes when he looks up and commenting about its brightness. Shawn speaks within normal rate and tone, however low volume and often mutters under his breath. He denies any past suicidal or homicidal ideation and denies hallucinations or delusions. Shawn also denies history of trauma. | Diagnosis: Social Phobia, unspecified (F40.10) provisional; Alcohol Use Disorder, moderate, in early remission (F10.10)
Rishaan is a 23-year-old heterosexual male of Indian origin and is being referred to you by his parents for counseling in your private practice who are telling you Rishaan is at risk for going back to his drinking because he “never does anything constructive.” Further complaints by Rishaan’s parents include that “all he does is play video games and watch TV,” that he “never has money to pay for anything himself” and is constantly asking them for money. His parents offer to self-pay for Rishaan’s sessions. You welcome Rishaan to your office for an initial assessment. He respectfully requests that you refer to him as “Shawn,” which he explains is his preferred American name, and remarks that his parents really want him to talk to you. Shawn has agreed to counseling because he shares with you that he “has stuff to talk about anyway” and does not think he can go to his parents. | Substance Use History:
Shawn entered treatment and rehabilitation five months ago after his ex-girlfriend’s family had an intervention with him about his abusive drinking and he has now been through all phases of treatment for Alcohol use disorder. Shawn tells you he is ashamed that his parents found out about his problem through his ex-girlfriend’s parents, because he had been lying to his own parents about his well-being for several years since he left home for college at 18 years old. Shawn is currently five months sober but is not engaged in any post-treatment recovery program nor has he continued counseling.
Family History:
Shawn has two older siblings, both of whom he shares are “successful and have families.” Shawn says, “my parents always want me to be like them and are constantly comparing me to them, it’s so annoying.” Shawn’s father is a dermatologist, and his mother is his father’s secretary in their medical practice. Both parents observe traditional Indian cultural practices in their social lives and with respect to Hinduism.
Work History:
Shawn has attempted part-time work following his graduation from his alcohol rehabilitation treatment program but was unable to make his shifts on time and was let go from his job. He tried another job selling products by cold calls but could not keep up with the volume required to make a viable salary. When asked what Shawn would like to do for a living, he says “I’d like to be a gaming coder or tester, something like that.” | Which approach should be used to assess Shawn's level of commitment to his sobriety? | "So, are we going to be drinking again or are we all done with that now?" | "Please share with me about your experience with recovery from alcohol dependence and what has motivated you to get to this point without drinking." | Assume he is committed based on Biopsychosocial information and his presence in counseling | "Do you feel like you want a drink right now or have you thought about drinking again?" | (A): "So, are we going to be drinking again or are we all done with that now?"
(B): "Please share with me about your experience with recovery from alcohol dependence and what has motivated you to get to this point without drinking."
(C): Assume he is committed based on Biopsychosocial information and his presence in counseling
(D): "Do you feel like you want a drink right now or have you thought about drinking again?" | "Please share with me about your experience with recovery from alcohol dependence and what has motivated you to get to this point without drinking." | B | Directly approaching the subject of Shawn's risk factors of alcohol use using a strengths-based approach from a non-judgmental stance is the best approach for learning more about Shawn's commitment to recovery. It is a significant factor in counseling Shawn considering he is currently in early remission, has low protective factors supporting him and that he is not in ongoing recovery support for his condition (which is highly recommended when completing addiction rehab). Furthermore, his parents referred him for counseling under this basis, so it is not presumptuous to present this to your client if it is in his best interest. Answer a is not empathic and does not demonstrate unconditional positive regard, answer b is not helpful as it is quite common for alcoholics in recovery to think often about drinking and reinforcing that factor at this time could either be triggering or shaming. Regarding answer d it is unwise to assume a level of commitment based on initial assessment information gathering. Therefore, the correct answer is (C) | intake, assessment, and diagnosis |
268 | 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. | At the start of the session, the foster parents ask the client if she would mind meeting alone with you; she agrees and asks to have access to the toy bin in your office. You and the client begin to play together, and you ask her if she talked to her birth parents. The client says “yeah, Mommy talked about coming home in a few years.” You ask how she feels about living with her mother again, and she says she does not want to be with her because her mother does not want to be with her. You try to process this with the client, and she says that she likes her house and her school and does not want to leave. You meet with the foster parents and the client at the end of the session, and they report that spending quality time with the client on a daily basis has been helpful in improving their relationship. They state that they think they had been too afraid to overwhelm her and that at times they were trying to give her space, but they realize that the intentional time together has been helpful. You empathize with the foster parents and encourage them to continue to spend quality family time with her | Which of the following terms describes the client’s belief that “no one wants me”? | Thought stopping | Automatic thought | Schema | Transference | (A): Thought stopping
(B): Automatic thought
(C): Schema
(D): Transference | Schema | C | A schema is a core belief that one has about themselves based on what has happened to them. Schemas may be irrational or unhelpful at times, but a healthy schema leads to a strong sense of self-worth and self-esteem. Although cognitive therapy approaches might not be directly helpful for the client, the parents can assist in adjusting schemas. Automatic thoughts occur when a situation triggers a thought that is unconscious and can be negative or positive. Thought stopping is a technique that focuses on stopping a negative or irrational thought. Transference is when an individual redirects feelings and emotions about one individual to an entirely different individual. Transference is likely happening from the birth parents to the foster parents. Therefore, the correct answer is (A) | intake, assessment, and diagnosis |
269 | 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 treatment modalities would not be recommended for Sandy? | Controlled drinking | Insight-oriented therapy | Rational-behavior therapy | Cognitive behavioral therapy | (A): Controlled drinking
(B): Insight-oriented therapy
(C): Rational-behavior therapy
(D): Cognitive behavioral therapy | Controlled drinking | A | Controlled drinking is an approach for those with mild alcohol problems and has been met with some controversy. In this approach an individual does not abstain from alcohol completely. Since Sandy displays more severe alcohol problems, this would not be an effective modality. Cognitive behavioral therapy focuses on modifying negative thoughts, behaviors and emotional responses associated with psychological distress which may decrease the desire to drink. Insight-oriented therapy is an approach in which one tries to understand their inner motivation for their actions. Rational behavior therapy looks at an individual's irrational or self-defeating thoughts and replaces them with positive messages. Therefore, the correct answer is (A) | treatment planning |
270 | 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 | One way to help Michael with his concern about school is to? | Speak to the parents about who is bullying him | Tell him to ignore the kids | Talk to the teacher about possibly leaving class if the tics worsen | Encourage the use of relaxation exercises in class | (A): Speak to the parents about who is bullying him
(B): Tell him to ignore the kids
(C): Talk to the teacher about possibly leaving class if the tics worsen
(D): Encourage the use of relaxation exercises in class | Talk to the teacher about possibly leaving class if the tics worsen | C | An appropriate intervention would be to collaborate with Michael's teacher to possibly let him leave class if the tics worsen. To tell him to ignore the kids would be difficult for Michael and doesn't really give him a tangible intervention. Speaking to the parents about who is bullying him may lead to further issues. Using relaxation exercises in class may not be a practical solution as it is a public not private setting. Therefore, the correct answer is (C) | professional practice and ethics |
271 | Initial Intake: Age: 29 Gender: Female Sexual Orientation: Heterosexual Ethnicity: Caucasian Relationship Status: Engaged Counseling Setting: Agency - Telehealth Type of Counseling: Individual | Client presents as unkempt, hygiene unknown as it is unable to be assessed via telehealth. She is appropriately dressed. Motor movements are within normal limits. Her eye contact is intermittent as she appears to have difficulty focusing both eyes in the same direction (amblyopia or “lazy eye”). She is cooperative and engaged. She admits to having passive suicidal ideation when triggered with distressing emotions and has considered taking pills as a method that would be the most comfortable but declines having intent or plan to collect pills for this purpose. She states her anxiety increases when she takes her children to the grocery store and when she is around crowds, experiencing panic-like symptoms necessitating her to call a friend to calm her down. She reports experiencing flashbacks of sexual trauma and prefers to stay at home as often as possible. She is alert despite being distracted often by her children in the background and is oriented to person, place, time, and situation. She is fidgeting with her hands and speaking circumstantially, often changing topics and going on rants in different directions before returning to her main points. She reports low energy, sleeping too much and weight gain. She adds that she cries every night over losing her paternal grandfather over 10 years ago. | Diagnosis: Anxiety disorder, unspecified (F41.9), Reaction to severe stress, unspecified (F43.9)
You are a new counseling intern in a community agency conducting virtual individual counseling sessions using Telemedicine technology. You were referred a 29-year-old female client by your agency’s Psychiatrist who felt she needed to return to weekly psychotherapy as she had previously been doing two years ago. During your initial assessment session, you learn she has three young children under age 8, lives with her fiancé who is the father of the two youngest children, and that due to medical reasons she is on disability through Medicaid and is unable to work. She tells you she has been depressed and contemplating suicide because she cannot find relief from her anxious thoughts. She wants to be a better mom to her children than her mother was to her and wants help overcoming grief and loss, traumatic memories, panic attacks and irritability. | Family History:
Client has a strained relationship with her mother whom she reports is “always dating an alcoholic” and has been abusive to her growing up. She adds that her mother has “Bipolar depression and ADHD.” She complains often about both her mother and her fiance’s mother mistreating her, making her feel resentful and angry. Client has two sisters, one of which lives with her mother and is mentally challenged. Her other sister has little to no contact with her family. Her father, who has been divorced from her mother for over 20 years, was once accused of child sexual abuse which has alienated him from the rest of their family. The client is the only one who remains in contact with him. | Given the client's report of having skipped taking her medication for several days, which of the following actions should be taken? | Process with her the reasons she didn't take the medication and validate her reasons | Trust she already knows the implications and don't say anything that might affect rapport | Confront her irresponsibility of her own mental health and family's welfare | Educate her on the dangerous effects of missing medication dosages | (A): Process with her the reasons she didn't take the medication and validate her reasons
(B): Trust she already knows the implications and don't say anything that might affect rapport
(C): Confront her irresponsibility of her own mental health and family's welfare
(D): Educate her on the dangerous effects of missing medication dosages | Educate her on the dangerous effects of missing medication dosages | D | It is in your and your client's best interest to ensure your client is aware of the chemical changes that can occur in the brain when medications are inconsistently taken, and to understand how medication is no longer as effective when dosages are missed. The risk of negative consequences increases when a client lacks sufficient coping skills to accommodate a medication transition or has any history or symptoms of depression. Non-compliance with psychiatric medications is a common behavior of individuals with bipolar disorder and can further exacerbate a person's symptoms. Therefore, the correct answer is (A) | intake, assessment, and diagnosis |
272 | Initial Intake: Age: 15 Sex: Non-binary Gender: chose not to answer Sexuality: chose not to answer Ethnicity: East Indian Relationship Status: Single Counseling Setting: Community Outpatient Clinic Type of Counseling: Individual | Shar is 15-years old and looks younger than stated age due to their weight. Shar had a flat affect throughout the interview and looked down frequently. Despite there being an empty seat on the couch next to their mother, Shar sat in a chair across the room. | Shar was brought it by their mother, Nadia, for concerns about being isolated and argumentative.
Mental Status:
Shar is 15-years old and looks younger than stated age due to their weight. Shar had a flat affect throughout the interview and looked down frequently. Despite there being an empty seat on the couch next to their mother, Shar sat in a chair across the room.
History:
Shar and Nadia reported that they used to have a close relationship. There have been no issues or discord until now. Recently, Nadia noticed Shar staying to themself more in their room, which is unlike them. Shar recently lost a significant amount of weight and teachers reported their grades have declined. Nadia shared problems started when the topic of the sophomore dance came up and Nadia asked Shar what boy they were going with.
When this topic came up during the intake, Shar rolled their eyes at this and stated, “Mom, you are so narrow minded. Why do I have to go with a boy, why can’t you just ask me WHO I am going with?” Nadia looked at the counselor and stated, “Do you see why I brought her here? She is so disrespectful, and she is lucky that her father did not hear her say these things. We used to be so close.” | null | Shar's symptoms meet the criteria for | Transvestic Disorder | Body dysmorphic disorder | Gender Dysphoria | Unspecified Gender Dysphoria | (A): Transvestic Disorder
(B): Body dysmorphic disorder
(C): Gender Dysphoria
(D): Unspecified Gender Dysphoria | Gender Dysphoria | C | Gender dysphoria is characterized by "marked incongruence between one's experienced/expressed gender and assigned gender" which is evident in Shar's current symptomology. In addition, they have expressed the desire to be rid of their current sex characteristics and has a strong desire to be of the other gender. The dissatisfaction of a body part in Body Dysmorphic Disorder is caused by the perception that it is abnormally formed. There is no evidence of this symptom in the facts. Transvestic disorder is characterized by sexual arousal from cross dressing. Therefore, the correct answer is (B) | intake, assessment, and diagnosis |
273 | Client Age: 7 Grade:2nd Sex: Male Gender: Male Ethnicity: African American Counseling Setting: Community Mental Health, School-Based Services Type of Counseling: Individual and Collateral Presenting Problem: Impulsivity; Inattention; Hyperactivity Diagnosis: Attention-Deficit Hyperactivity Disorder (ADHD) 314.01 (F90.2) | Mental Status: The client is dressed appropriately, and he is well groomed. His affect is bright when engaged in an activity of his choice, but he becomes irritable when asked to comply with a direct request (e.g., pick up the toys, walk in the hallway). He is energetic, eager to please, and interrupts your conversation with the mother, as evidenced by the client stating multiple times, “Watch this! Hey! Watch! Look what I can do!” The client has difficulty transitioning from your office and back to his classroom. He runs ahead of you in the hallway and does not respond to redirection. The client has not voiced suicidal or homicidal ideation. Developmenta | You are a clinical mental health counselor providing on-site school-based services in a public elementary school. Your client is a 7-year-old African American male enrolled in the 2ndgrade. The client is accompanied by his mother, who states that she is here because the school “requested an ADHD assessment.” The school reports that the client is disruptive, refuses to follow directions, disturbs others, and has difficulty staying on task. The mother describes the client as “energetic” and “strong-willed”—behaviors that she believes are “just typical for a boy.” She is upset that the school wants to conduct a formal evaluation to determine if the client qualifies for a more restrictive classroom setting. The school’s population is predominantly white, and the mother believes that her son is being treated unfairly because of his race. | You meet with the client’s mother today to update the client’s treatment plan. Since the beginning of the school year, the client has been suspended for a combined total of 8 days. He has responded poorly to many of the behavioral classroom interventions. The mother has reluctantly granted the school permission to begin testing to determine if the client qualifies for an Individualized Education Program. You inform the mother of her parental rights pertaining to this process, particularly as they apply to protections against disability-related discrimination and the maximum number of disability-related suspensions. She is encouraged by the possibility of the client receiving additional supports that consider the client’s strengths and challenges. The mother reports that she has tried to use planned ignoring when the client interrupts but reports that this behavior has actually worsened | The mother reports that she has tried to use planned ignoring when the client interrupts but reports that this behavior has actually worsened. This is likely attributed to which of the following? | Negative reinforcement | Response cost | Extinction burst | Behavioral activation | (A): Negative reinforcement
(B): Response cost
(C): Extinction burst
(D): Behavioral activation | Extinction burst | C | Planned ignoring involves deliberately ignoring a predetermined target behavior. In this case, the target behavior is interrupting. An extinction burst occurs when the client increases his maladaptive behavior (ie, interrupting) to gain the mother’s attention. If the mother does not consistently hold a firm boundary, the behavior is reinforced and becomes more difficult to extinguish. Behavioral activation is a cognitive-behavioral technique used to help clients initiate values-based activities to improved depressive symptoms. Negative reinforcement occurs when there is a behavioral change that happens with the removal of unpleasant stimuli. For example, a parent yells at their child to clean up, the client complies, and the negative stimulus (ie, yelling) discontinues. Response cost is a consequence-based strategy for ADHD that involves taking away token reinforcers in the presence of negative behaviors. Token reinforcers can be exchanged for preferred activities (ie, extra computer time). An example of response cost would be to remove a token each time the client interrupts. Therefore, the correct answer is (A) | counseling skills and interventions |
274 | 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 reports being told, “There’s no way I’d go out with someone who is bisexual. They’d eventually leave me for someone from the opposite sex | The client reports being told, “There’s no way I’d go out with someone who is bisexual. They’d eventually leave me for someone from the opposite sex.” Which form of microaggression is represented by this statement? | Microinsult | Microassault | Microinvalidation | Microinjury | (A): Microinsult
(B): Microassault
(C): Microinvalidation
(D): Microinjury | Microinsult | A | There are three types of microaggressions: microinsults, microinvalidations, and microassaults. Microinsults are behaviors or comments that are not meant to be discriminatory and generally stem from a lack of awareness and/or reliance on stereotypes. Researchers show that microaggressions are usually cumulative and detrimental to the health and well-being of those who experience them. It is not uncommon for individuals who identify as bisexual to experience biphobia within LGBTQ communities. Microinvalidations occur when comments or experiences are dismissed or seen as irrelevant. Microinvalidations often stem from heterosexism. An example of a microinvalidation would be to assume a married female has a husband. Microassaults are intentionally discriminatory and include purposeful acts of insensitivity, rudeness, and intolerance. Microinjury is not identified as a microaggression. Therefore, the correct answer is (A) | core counseling attributes |
275 | Client Age: 20 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: African American Relationship Status: Single Counseling Setting: College Campus Counseling Clinic Type of Counseling: Individual Counseling Presenting Problem: Depression and “Odd Behavior” Diagnosis: Bipolar 1 Disorder, Current Episode Manic Without Psychotic Features, Moderate (F31.12) | Mental Status Exam: The client states that she slept for 4 hours the night before, which was the most she has slept in one night in the past week and that she now feels tired for the first time. The client had dark circles around her eyes and was wearing sweatpants and a t-shirt with stains on it. The client is oriented to person, place, time, and situation. The client’s affect and speech are | You are a licensed therapist working on a college campus in the counseling center. A 20-year-old female client comes to counseling following 8 days of experiencing the following symptoms: little to no sleep most nights with the longest stretch of sleep being 2 hours, several middle-of-the-night shopping sprees, and distractibility. She reports that some of her college professors have called on her to stop talking during class and that she has not been doing very well in school this semester. The client identifies that she has felt this way before over the past 2 years and that this last time scared her because she was more aware of the negative impact it is having on her schooling. The client continues to relate that she also experiences depression at times and that she does not understand where it comes from but that it happens for a few weeks at a time every few months. When in a depressive episode, the client experiences a depressed mood more often than not, decreased enjoyment of activities, hypersomnia, fatigue, and a significant decrease in appetite. | flat. Family History: The client says that she and her family moved to the United States from Kenya when she was 5 years old. The client is the first member of her family to go to college, and she reports significant pressure from her parents to succeed. She feels that she has a good relationship with both of her parents. Her sister is 2 years younger than her, and they talk on the phone on a daily basis. The client identifies no other close family members because most are still living in Kenya | All of the following are strengths that your client has that can be helpful in making progress toward her goals EXCEPT: | Desire to learn | Perseverance | Insight | Energy | (A): Desire to learn
(B): Perseverance
(C): Insight
(D): Energy | Energy | D | Energy could be a strength for some clients, but due to the client’s diagnosis, it is also the part of bipolar disorder that causes impulsivity and lack of sleep and in turn impairs functioning. Due to bipolar disorder, the client is also experiencing hypersomnia during major depressive episodes; therefore, energy is not a reliable or constant state for the client. The desire to learn is helpful to the client as a student who is willing to take in and apply new information. Perseverance is also a strength because the client is going through a difficult adjustment and perseverance is the ability to push through the situation despite these difficulties. Insight is a strength because it means that the client can look inwardly and gain a deeper understanding of her thoughts, feelings, and actions. Therefore, the correct answer is (A) | treatment planning |
276 | Initial Intake: Age: 22 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: African American Relationship Status: In a long-term relationship Counseling Setting: Adult inpatient psychiatric Type of Counseling: Individual | Mark was unable to complete a mental status exam as he was not speaking coherently and was displaying violent behavior towards hospital staff. The ER nurse interviewed Mark’s girlfriend, Erin. | Mark came into ER after his girlfriend Erin called 911 when Mark attacked someone on the bus.
History:
Erin told the ER nurse that Mark has been displaying increasingly irrational behaviors. Erin shared that Mark recently took a trip to Africa. Since then, Mark told Erin that he was hearing the voice of God, telling him that it was his responsibility to rid the world of evil. At first Erin noticed Mark staying up late at night, writing all his thoughts in a journal. When Erin read the journal, the content was incoherent. Erin also shared that Mark was recently put on probation at work for going into the women’s restroom. Mark told his boss that God told him to keep an eye on one of his coworkers. | null | Mark is displaying symptoms of? | Substance/Medication induced psychotic disorder | Schizoaffective | Brief psychotic disorder | Schizophrenia | (A): Substance/Medication induced psychotic disorder
(B): Schizoaffective
(C): Brief psychotic disorder
(D): Schizophrenia | Schizophrenia | D | Mark meets the criteria for Schizophrenia looking at his symptomology (hallucinations, sleep disturbances, incoherent speaking and writing, catatonia) and duration of onset. Brief psychotic disorder is ruled out as it is beyond the one month required timeframe. Schizoaffective disorder is also ruled out as there are no depressive or manic episodes. Substance/medication induced psychotic disorder is ruled out as there were no indications of substance use prior to the onset of the psychosis. Therefore, the correct answer is (B) | intake, assessment, and diagnosis |
277 | 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. Eighth session The client has been attending sessions weekly for two months. Today, you begin by reviewing the progress the client has made in therapy. She has joined a support group and has made some new friends but still feels anxious about her future. She has also joined a bridge group but is finding that she is having difficulty remembering what cards are being played. At your suggestion, she also made an appointment with a psychiatrist and was prescribed a low dosage of Paxil. She feels more positive and states that she may volunteer at a local animal shelter. The client also mentions that yesterday she received official divorce documents in the mail. As she tells you about this, you notice her mood shifts. She quietly shares, "On some level, I think I've known that my marriage has been over for a while, but when I got the legal papers, it made it feel real for the first time. My thoughts are all over the place. I'm still very hurt by all of this, but I know that I need to move forward with my life." The client tells you one of the friends she met in her support group suggested that she consider joining a dating app, and she asks if you could help her. She says, "Technology has changed so much since I first started dating my soon-to-be ex-husband. I don't know how any of this works!" You validate her feelings and offer her reassurance that these kinds of emotions are completely normal in this situation. You suggest she take some time to process and grieve the end of her marriage. You also remind her that it is important to focus on some of the positive aspects of starting a new chapter in her life. You talk about how she can use the skills she has learned in therapy to manage her negative emotions and focus on positive self-talk. Additionally, you suggest some healthy coping strategies for managing the stress of this transition including exercise, meditation, journaling, and spending time with her new friends. You then refocus on the topic of dating, and you provide some helpful tips such as creating a profile that accurately reflects her interests, making sure to be honest about who she is, and being mindful of safety when meeting people in person. Finally, you remind her that it is important to take things slow and enjoy the process of getting to know someone. You also encourage her to remember that relationships can take different forms and that it is okay if she is not ready for a romantic relationship right now. At the end of the session, you check in with her and ask how she is feeling. She tells you that while she still feels overwhelmed, she is feeling more prepared to move forward with her life. You end the session with words of encouragement and remind her that you are here to support her. | null | You revise the client's treatment plan to include the new objectives she has mentioned. Which of the following would be an appropriate short-term goal to work on with the client? | Focus on her declining intellectual functioning | Discuss her childhood memories | Explore her relationship with her father and how it led her to the husband she chose | Explore her feelings about the divorce | (A): Focus on her declining intellectual functioning
(B): Discuss her childhood memories
(C): Explore her relationship with her father and how it led her to the husband she chose
(D): Explore her feelings about the divorce | Explore her feelings about the divorce | D | Although the client mentioned that she is considering joining an online dating app, she is still distraught about her impending divorce. Exploring her feelings more would be an appropriate short-term goal. Therefore, the correct answer is (B) | treatment planning |
278 | 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. | rded. Family History: Most of the clients report distressed relationships with their parents or guardians and that they have not had stable relationships throughout their lives. Client 3 is resistant to the group process | Client 3 is resistant to the group process. Which of the following would be a helpful tactic in engaging the client? | Process with the client about his feelings by taking him aside during the session, reminding him that other group members may feel similarly. | Provide psychoeducation on the effectiveness of groups with borderline personality disorder. | Encourage client 3 and the other clients to process their hesitancy about therapy. | Use dyads to encourage the client to share his feelings with a peer. | (A): Process with the client about his feelings by taking him aside during the session, reminding him that other group members may feel similarly.
(B): Provide psychoeducation on the effectiveness of groups with borderline personality disorder.
(C): Encourage client 3 and the other clients to process their hesitancy about therapy.
(D): Use dyads to encourage the client to share his feelings with a peer. | Use dyads to encourage the client to share his feelings with a peer. | D | Using dyads (breaking away into groups of two to discuss prompted topics) can be helpful in this scenario because they provide the client an opportunity to speak with a peer, a context that may be more comfortable to hesitant group members than speaking to the therapist, whom they are yet to trust. Processing with the client alone may take up valuable group time, and processing with all clients about resistance might align them against the group process. Psychoeducation about groups might be helpful; however, this happened already during the start of the intake session and was not beneficial in preventing resistance for client 3. Therefore, the correct answer is (B) | counseling skills and interventions |
279 | Initial Intake: Age: 20 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Married Counseling Setting: Community Mental Health Agency Type of Counseling: Individual | The client presents appropriately dressed with evidence of positive self-care related to hygiene and appearance. Her mood is stated as anxious about being labeled as “crazy” though you note her affect appears to be angry. Her movements and speech demonstrate no retardation; she is cooperative, engaged, and forthcoming. She reports past suicidal attempts using alcohol or pills when she was extremely angry at her boyfriend or her parents, but emphasizes she has no current suicidal ideations. She also states she has had past thoughts of hurting others but emphasizes she does not desire to or think about hurting others now. Her short- and long-term memory appear to be intact, but demonstrates poor insight and judgement in choices. | You are a counselor in a community mental health agency. The client presents for “an evaluation,” which she states is required by her parents before she is allowed to move back into their home. During the intake session, you learn that your client was married for 18 months and has been divorced for two years. The client states that her husband had an affair during their marriage, which led to the divorce. She states she has a daughter who is five years old and shares custody with her ex-husband, who is now remarried. She reports that she was living with her parents until recently and is now sleeping on a friend’s couch. The client acknowledges that she has had several traffic incidents related to driving while intoxicated in the past few months. She reports she “totaled” her new car last week but was not arrested, likely because her companion had a felony warrant and the police arrested him at the scene and not her. It was at this time that she says her parents insisted she move out of the house and cannot return until she has sought counseling. She states she wants to “move on from my past,” she misses how things used to be, and wishes that her parents understood her better. The client reports that she drinks at least 20 alcoholic drinks per week and uses marijuana intermittently. She states she takes Adderall to help her clean the house quickly, uses cocaine, and has used Klonopin in the past, but stopped due to a “back experience.” She states she does not have a problem with substance use but acknowledges it is a stressor in her relationship with her parents. She reports that using substances are the “only way to get to know people” and has found herself angry when attending parties where others were having fun but she was not drinking or high. | Family History:
Client reports that she is the youngest of two children and that her family relationships were terrific until she turned 14 years old and then her parents “went crazy” when her grades in school declined and she was often grounded. She tells you that her parents didn’t like her after that and were always angry at her. On further discussion, the client says that she began dating a 19-year-old male when she was 14 but her parents decided he was too old for her and would not allow her to see him. She admits being furious at him for not taking her out after that and she called him daily to try to change his mind for over two months. She says she can’t stand him now and that he is currently in prison for aggravated assault on a police officer. She also tells you that at 15 years old, she began a long-term relationship with another man, who is now in prison for attempting to shoot someone. She states that he got involved with another girl and your client ended up getting arrested after she started a fight with the girl. Her third relationship was with her husband and with whom she became pregnant. At that time, her parents “kicked me out of the house and I couldn’t even come back inside to get my things.” They divorced two years ago after he called the police after “he said I attacked him when I found out he was cheating on me.” | Based on the client's ratings of herself as a parent, which of the following diagnostic criteria is she most likely exhibiting? | Affective instability due to a marked reactivity of mood | Chronic feelings of emptiness | Unstable interpersonal relationships characterized by alternating between extremes of idealization and devaluation | Persistently unstable sense of self | (A): Affective instability due to a marked reactivity of mood
(B): Chronic feelings of emptiness
(C): Unstable interpersonal relationships characterized by alternating between extremes of idealization and devaluation
(D): Persistently unstable sense of self | Persistently unstable sense of self | D | The client's ratings demonstrate a persistently unstable sense of self based on an inability to evaluate herself with respect to various characteristics that define motherhood. Her ratings do not appear to include her ongoing mood reactivity or continuing interpersonal relationships, as she rates herself as a 6-7 while engaging in risky and illegal behavior, recurrent "blowing her top" when her child appears bored, and continuing to have negative interpersonal relationships with her ex-husband and parents. Therefore, the correct answer is (D) | treatment planning |
280 | 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. | The client arrives twenty minutes late for his appointment today. He explains that Mondays are the days he does laundry, and he cannot come again on a Monday. You review the required components of informed consent with the client. He expresses an understanding of the counseling process and provides written consent. The client states he has re-considered counseling because he believes you can help him find another girlfriend who will have sex with him. You tell him about a small group you run with other neurodiverse men, most of whom are on the autism spectrum. He expresses an interest in joining after hearing that sexual intimacy would be part of the curriculum. He provides a more solid commitment when you tell him the group is not held on Mondays. Applied behavior analysis (ABA), an evidence-based practice for individuals with ASD, relies on the principles of social learning theory | Applied behavior analysis (ABA), an evidence-based practice for individuals with ASD, relies on the principles of social learning theory. Which of the following best illustrates the four steps of social learning? | The group discusses appropriate sexual behavior, the client correctly recalls behavioral skills, the client applies the skills to a consensual relationship, and the client has sex. | The group discusses appropriate sexual behavior, the client correctly recalls behavioral skills, the client applies the skills to a consensual relationship, and the client does not have sex. | The group watches a video on appropriate sexual behavior, the client correctly recalls appropriate behavioral skills, the client applies the skills to a consensual relationship, and the client has sex. | The group watches a video on appropriate sexual behavior, the client correctly recalls the behavioral skills, the client applies the skills to a consensual relationship, and the client does not have sex. | (A): The group discusses appropriate sexual behavior, the client correctly recalls behavioral skills, the client applies the skills to a consensual relationship, and the client has sex.
(B): The group discusses appropriate sexual behavior, the client correctly recalls behavioral skills, the client applies the skills to a consensual relationship, and the client does not have sex.
(C): The group watches a video on appropriate sexual behavior, the client correctly recalls appropriate behavioral skills, the client applies the skills to a consensual relationship, and the client has sex.
(D): The group watches a video on appropriate sexual behavior, the client correctly recalls the behavioral skills, the client applies the skills to a consensual relationship, and the client does not have sex. | The group watches a video on appropriate sexual behavior, the client correctly recalls appropriate behavioral skills, the client applies the skills to a consensual relationship, and the client has sex. | C | Developed by Albert Bandura, social learning theory is based on the premise that individuals repeat behaviors when certain conditions are met. The theory asserts that individuals grow and learn when four conditions (in order) are met: attention, retention, reproduction, and motivation. In answer C, the client attends to a video (attention), he recalls the skill (retention), he applies the skills to a consensual relationship (reproduction), and has sex (a motivating reinforcer). A group discussion does not include an observed model, making answers A and B incorrect. In answer D, the client accurately recalled and retained the information and applied the skill. The client did not have sex, which did not create motivation to continue to apply learned skills. Therefore, the correct answer is (C) | counseling skills and interventions |
281 | 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 | All of the following are appropriate short-term treatment goals for the couple EXCEPT: | The couple will improve their quality time together in order to improve relationship satisfaction. | The couple will learn and implement effective communication skills. | The couple will identify and process areas of resentment that led to the affair. | The couple will process events leading up to the affair in order to identify problem areas in the relationship. | (A): The couple will improve their quality time together in order to improve relationship satisfaction.
(B): The couple will learn and implement effective communication skills.
(C): The couple will identify and process areas of resentment that led to the affair.
(D): The couple will process events leading up to the affair in order to identify problem areas in the relationship. | The couple will improve their quality time together in order to improve relationship satisfaction. | A | The couple is having difficulty with quality interaction at this point due to breakdowns in communication, so quality time would not be the focus for short-term goals. The couple does need to work on effective communication skills so they can work through what events led up to the affair and also so they can interact in a meaningful manner. The couple would also benefit from processing resentment because this is a common problem that leads to infidelity and is also a current barrier to the counseling process. Therefore, the correct answer is (C) | treatment planning |
282 | Client s Age: Client 1: age 12 Client 2: age 14 Client 3: age 14 Client 4: age 16 Client 5: age 13 Client 6: age 16 Sex: Males Gender: Males Sexuality: Varying Ethnicity: Multiracial Relationship Status: Single Counseling Setting: Juvenile Justice Facility Type of Counseling: Group Counseling Presenting Problem: Involvement with the Justice System That Includes Various Mental Health Disorders and Crimes Diagnosis: Imprisonment (Z65.1) | Mental Status Exam: All of the clients appear to maintainappropriate hygiene, and they are all oriented to person, place, time, and situation. They are all somewhat reserved with regard to going into deeper topics, but theyparticipate f | You are a licensed counselor working in a juvenile justice facility for teenage males. The group comprises six males that are required to attend as part of their incarceration with the expectation that it will shorten their sentences. The purpose of the group is to work on emotional regulation and to work together to share common experiences and identify goals that can be helpful in preventing reincarceration. During the intake session, you explained the purpose of the group and started with an ice-breakeractivity. The clients participated in the ice-breaker activity that required you to redirect them back to the activity several times because they would joke and get off task. You attempt to go a little deeper by encouraging your clients to start talking about what happened to get them incarcerated, and they appear to be taking pride in the reasons they were in juvenile detention and making fun of those with lesser sentences. You redirect the clients to another topic. | You meet with the group for the sixth session, and they are focused and appear to be more respectful toward you because it appears that you can get their attention more easily to start the session. You separate the group into dyads at the start of the session and prompt the group members to talk about feelings related to the pros and cons of engaging in school. You overhear client 4 telling client 3 that it does not matter if client 3 does well in school because he is in juvenile detention for sexual assault and therefore he cannot redeem himself. You intervene and remind client 4 of the group rules about respecting others. Client 4 continues to accuse other members of the group of engaging in sinful activities and continues to be disruptive to the group process | Client 4 continues to accuse other members of the group of engaging in sinful activities and continues to be disruptive to the group process. All of the following are important considerations EXCEPT: | Considering to ask client 4 to sit silently or in the same room but not participate. | Having a conversation with client 4 about finding a more appropriate group during the session because it can be a good moment to teach other group members what is tolerable in the group, especially considering the detention setting. | Whether significant attempts have been made to redirect client 4 and to reinforce group rules. | If client 4 is actively causing harm to others, you can ask him to leave the group immediately without a discussion. | (A): Considering to ask client 4 to sit silently or in the same room but not participate.
(B): Having a conversation with client 4 about finding a more appropriate group during the session because it can be a good moment to teach other group members what is tolerable in the group, especially considering the detention setting.
(C): Whether significant attempts have been made to redirect client 4 and to reinforce group rules.
(D): If client 4 is actively causing harm to others, you can ask him to leave the group immediately without a discussion. | Having a conversation with client 4 about finding a more appropriate group during the session because it can be a good moment to teach other group members what is tolerable in the group, especially considering the detention setting. | B | The client has been causing significant disruptions that have affected other group members, and you need to address this after the group with the client. If you plan to address the client’s disruptions and his need to be in another group provided by the facility, you do not want to do this in front of the other clients because this would present a power struggle in front of the others. It is important to consider your attempts at redirection and enforcing rules in order to assess and adjust your interventions. If the client is actively causing harm, you need to protect your other clients, which may involve ejecting the member from the group immediately or asking them to sit silently for the rest of the session. Although ejecting the client may affect his sentence, this was a decision that the client made, and attempts to refer to another group or problem-solve can be done after the group. Therefore, the correct answer is (B) | counseling skills and interventions |
283 | 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. Fourth session The client came to her weekly session with you feeling discouraged and embarrassed about what happened in school earlier that day. She had been called on to read a paragraph from the science textbook in front of the whole class, and she could not get through it. Her classmates, who she usually gets along with, began to laugh at her, and she quickly excused herself to the clinic, saying she had a stomachache. It was the worst experience she had ever encountered, making her feel even more vulnerable. You offered comfort as you discussed strategies for the client's reading struggles. You also encourage the client not to give up and assure her that no matter what happens tomorrow, next week, or next month, she can reframe the fear and embarrassment she felt with being surrounded by support and people that will help her through these challenging times. After the client leaves, you talk with her parents over the phone. You suggest they meet at school with everyone involved with their daughter to discuss how best to implement an Individualized Education Plan (IEP). Your objective with this meeting is to review the areas where improvements and support could be given and determine if any changes need to occur for your client. Ninth session The client's parents were elated to see their daughter make significant progress in her reading at school. After careful consideration and collaboration between you, the client, her teachers, and the paraprofessional, the team has all devised a treatment plan tailored specifically to her needs. Incorporating a small group setting provided the client with the individualized attention she needed to become successful in her reading skills. As the session came to an end today, it was clear that both the client and her parents were satisfied with the results of their hard work. To ensure that they felt comfortable moving forward and everybody was on the same page, you asked them, "What I hear you saying is that you feel as though your daughter has met her educational goals and has the support to continue to succeed? Is that correct?" Both of them smiled knowingly and nodded affirmatively. With a sense of closure now achieved by this family team, the parents left feeling confident about continuing on this path towards helping their daughter reach success with reading deficits. Together they had created a practical plan which could be adapted as necessary along the way, one which would pave a brighter future for the client. | 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 are you attempting to do by summarizing what the client's parents told you during the session? | Decrease their anxiety | Determine the extent of their daughter's learning disability | Identify discrepancies and conflict | Allow them an opportunity to clarify any misconceptions | (A): Decrease their anxiety
(B): Determine the extent of their daughter's learning disability
(C): Identify discrepancies and conflict
(D): Allow them an opportunity to clarify any misconceptions | Allow them an opportunity to clarify any misconceptions | D | Summarizing serves several purposes. It presents the client with an opportunity to clarify any misconceptions that you have about them; it acts as a spring board to explore additional topics; and it helps to sum up the main points of what a person has been talking about. Therefore, the correct answer is (B) | counseling skills and interventions |
284 | Name: Tina Clinical Issues: Maladaptive eating behaviors Diagnostic Category: Feeding and Eating Disorders Provisional Diagnosis: F50.01 Anorexia Nervosa, Restricting Type Age: 21 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: Italian American Marital Status: Not Married Modality: Individual Therapy Location of Therapy : University counseling center | The client presented with a slender physique and was observed wearing conservative, dark-colored attire. Her overall demeanor was reserved, displaying noticeable nervousness and a tendency to withdraw from interactions. Upon conversing with her, it became evident that her train of thought often deviated from the topic at hand, hinting at a tangential pattern. This difficulty in maintaining concentration appears to be a consequence of her heightened anxiety levels. Delving deeper into her thought content, a recurring theme of obsessions surrounding food and body weight emerged. Additionally, a palpable fear of judgment from her peers and the broader society was evident. In terms of her cognitive functioning, she was found to be alert and fully oriented to her personal details, as well as her current location and time. However, a significant concern is her limited insight into her present circumstances and the implications of her behaviors. Throughout the assessment, there were no indications of any memory impairments. | First session You are a mental health therapist working in a university counseling center. The client, a 21-year-old female, presents issues related to anxiety, poor body image, and eating. You begin the session by introducing yourself and explaining your role as a therapist. You also explain how confidentiality is handled and make sure that she understands her rights as a client. After the initial introductions, you ask her to tell you about her current situation and what led her to seek out therapy. She reports that she has been feeling anxious for a while, but it has gotten worse since a basketball game when someone in the audience yelled to the referee "thunder thighs over there needs to get her act together!" Even though the comment was not directed at her, she internalized it. She explains that she was already feeling uneasy due to her stepfather's comments about her weight from a few years ago, and the recent insult at the game made it "all come crashing down" for her. Now, she cannot stop ruminating about her appearance. She saw a poster in her dorm room promoting counseling services and decided to make an appointment. You continue your interview by asking about her current eating behaviors. She explains that she avoids carbohydrates, sugar, and most dairy "since that stuff makes you fat." When you ask her to describe what she eats during a typical day, she says, "I usually have a fruit smoothie with almond milk for breakfast, an apple and 12 nuts for lunch, and then some steamed vegetables or a salad for dinner." When asked about exercise or other physical activity besides basketball, she reports that she runs at least seven miles on a nearby trail every morning and spends two hours swimming laps at the indoor gymnasium pool every evening before bed. She says, "The pool is pretty quiet at night. I don't like to be around a lot of people when I'm exercising." As you continue your dialogue, you ask the client open-ended questions to explore her relationship with her parents, especially her stepfather. She reports that her stepfather has always had negative remarks about her size and shape. She states that she feels like he views her as "less-than" because of her weight, which has led to feelings of shame and worthlessness. You explore the dynamic further by inquiring about how these comments have impacted her self-esteem. She reports feeling anxious, embarrassed, and inadequate when her stepfather is critical. You validate her feelings and explain that comments like these can be very damaging to a person's self-image. You ask the client what she hopes to accomplish in therapy. After some thought, the client says that she wants to learn how to manage her anxiety. She looks at your shyly and says, "I also want to be able to eat a piece of chocolate. I know that sounds crazy, but I just want to be able to enjoy it, without feeling guilty or like I'm going to get fat." You affirm her desires and explain that a key part of the therapeutic process will be to help her build self-confidence and develop healthier relationships with food. Sixth session You have been working with the client in intensive outpatient therapy and have been meeting with her two times per week. She is under medical care at the university's health center and has started taking an anti-anxiety medication that was prescribed by her physician. You have also referred her to a nutritionist for specialized guidance on developing a healthier relationship with food. You have established a strong, trusting relationship, and she has told you that she feels comfortable talking to you. Today, the client brings up an issue that has been bothering her for a while: anxiety about eating around other people. She tells you that she usually gets her food "to go" from the cafeteria and eats at a bench outside or alone in her dorm room. She avoids eating in front of others when possible. However, at least once or twice a week, her teammates all go out to lunch after practice. This usually requires her to order food in front of them and she feels very anxious about it. She has been ordering the same salad with dressing "on the side" for several months because that is what makes her feel the most comfortable. One of her teammates commented on her "same old salad" and asked why she never got anything else to eat. Everyone at the table got quiet and turned to look at her. The client reports that the comment made her feel embarrassed and ashamed, like everyone was laughing at her. You ask her how she responded in the moment and she shares that she just laughed it off, but internally, she felt very embarrassed and anxious. You explore this further by asking her what emotions arise when she is around food, particularly in social settings. She reports feeling ashamed for wanting to eat "fattening food" because of her father's comments about her size. She skipped the last team lunch because she was so anxious about someone drawing attention to her food choices again. She closes her eyes and takes a breath. When she opens her eyes, you can see that she is struggling to hold back tears. She says, "Everyone eats their food like it's no big deal. But it's a huge deal for me. It's all I can think about. I just want to be able to eat a meal without feeling guilty or like I'm going to get fat. I'm so tired of worrying about food all the time!" You consider using exposure and response prevention techniques to address her fear and anxiety related to eating. You continue the session by identifying a list of foods and situations that trigger her anxiety and negative feelings about her body. You ask the client if she would like to meet with you for her next session right after practice and bring a lunch to eat in your office. She appears relieved and grateful to have a break from eating in front of her teammates. 10th session During your last session with the client, she discussed the anxiety that she was feeling about going home for winter break in a few weeks. She told you that her mom and stepdad always prepare a large meal for the holidays, and the extended family members get together to eat. She expressed a desire to participate in the family festivities but concern about her mom and stepdad's lack of understanding about her illness. She told you, "I don't want to make anyone feel bad, but I just can't eat like everyone else. It's not only the food - it's the conversations and comments about my body that really bother me." You listened as she expressed her fear of disappointing her family and reassured her that is was okay to set boundaries and have conversations about food. Together, you brainstormed coping strategies to manage her anxiety. You also suggested that she bring a dish of food that she would be comfortable eating to the winter break gathering. At the end of the session, she asked if she could bring her parents to the next session in an effort to gain their support and to help them understand what she is going through. You agreed to her request and scheduled an appointment to meet with the client and her parents. At the start of today's session, you introduce yourself to her parents and explain your role in helping their daughter. The client's mother tearfully shares that she had no idea her daughter was struggling so much and that she wishes she had picked up on the signs sooner. The stepfather appears quiet and reserved. You help guide a conversation between the client and her parents about her eating disorder and symptoms that she is experiencing. The client shares her fears, triggers, and struggles around food. Her stepfather speaks up and says, "I've heard enough. This is just ridiculous. You should just be able to eat, like everyone else. Your generation has gone 'soft' and started making up problems. There are people out there who don't have any food. When I was growing up, we had nothing. Your behavior is disrespectful." As he is talking, the client's mother is quiet and visibly uncomfortable. The client interjects, "Are you kidding? I'm the one who's being disrespectful?" She looks toward you and says, "When I'm home, he cooks these extravagant meals and refuses to let me leave the table until I've eaten what he's served me because it's 'wasteful to throw away food.' It's abuse! I feel like a captive when I'm at home." She looks back at her stepfather and says, "All I'm asking is that you understand what I'm going through and try to be a little more supportive." The stepfather's face turns red with anger, and he gets up to leave the room. You intervene and ask him to stay, offering a suggestion that you all take a few moments to reflect on what each person has shared before continuing the conversation. While the stepfather takes a break, you encourage the mother to open up and express her feelings. She reveals that she is scared of not being able to help her daughter and feels helpless in understanding how to come together as a family. You discuss ways that she can be supportive and provide an empathetic environment for her daughter. | The client's parents divorced when she was six years old. Her mother remarried 12 years ago. The client has a younger half-brother who lives with her mother and stepfather. She is close to her mother, but "my stepfather is a different story." She reports that he is critical of her and often remarks on how she looks or what she is eating. She states that he has commented on her weight and body shape since middle school. Her mother tries to intervene, but her stepfather continues to be critical. She tells you she couldn't wait to graduate high school and move out of the house. She tells you, "I remember that when I went home for a visit during winter break during my freshman year, my stepdad had this shocked look on his face when he saw me. He told me I had gained so much weight that I didn't even look like myself anymore. I've never forgotten that. And it's not like he's the picture of health." Previous Counseling: The client has a history of anxiety. She saw a therapist for a few sessions in high school after being referred by her school counselor, but she did not feel comfortable with the therapist and refused to continue attending sessions. She did not receive a clinical diagnosis related to her anxiety. The client reports that she has been feeling more anxious lately and is struggling to cope with her anxiety. She says that she feels "on edge," and that makes it difficult for her to concentrate. She is interested in exploring therapy to manage her anxiety. Additional Characteristics: The client is currently on the school's basketball team. She was voted most valuable player two years in a row. | As the therapist, which of the following ethical principles is most relevant to consider in your decision about whether to report the stepfather's abusive behavior? | Nonmaleficence - avoiding causing harm by acting (or failing to act) that damages the client. | Beneficence - acting in the best interest of the client's health and empowerment. | Autonomy - respecting the client's capacity for self-determination. | Justice - treating people equitably and distributing benefits/burdens fairly. | (A): Nonmaleficence - avoiding causing harm by acting (or failing to act) that damages the client.
(B): Beneficence - acting in the best interest of the client's health and empowerment.
(C): Autonomy - respecting the client's capacity for self-determination.
(D): Justice - treating people equitably and distributing benefits/burdens fairly. | Nonmaleficence - avoiding causing harm by acting (or failing to act) that damages the client. | A | Nonmaleficence speaks directly to the therapist's duty to report abuse/maltreatment to authorities to protect the client from harm. This duty supersedes other principles. Therefore, the correct answer is (C) | professional practice and ethics |
285 | 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 intervention should be used to immediately address Nadia's risk-taking behavior and aggression toward others? | Psychoanalysis | Psychoeducation | Crisis planning | Life skills development | (A): Psychoanalysis
(B): Psychoeducation
(C): Crisis planning
(D): Life skills development | Crisis planning | C | Crisis planning is important regarding her risk-taking behavior and aggression towards others and is helpful to use when Nadia starts to decompensate. Psychoanalysis would not be the best treatment in this case as psychoanalysis is a longer-term treatment and Nadia is requiring more immediate symptom relief. Psychoeducation may be beneficial for Nadia to understand her symptoms of disassociation as well as how her past trauma can affect the types of relationships she seeks. However, this is not as immediate as a crisis plan. Finally, life skills development is important to improve her adaptive functioning but is a longer-term intervention. Therefore, the correct answer is (B) | intake, assessment, and diagnosis |
286 | Client Age: 25 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Counseling Clinic Type of Counseling: Individual Presenting Problem: Depression and Suicidal Ideation Diagnosis: Major Depressive Disorder, Recurrent, Mild (F33.0) | Mental Status Exam: The client appears to not have bathed recently because his hair is greasy and unkempt. The client has food stains on his clothing; however, he is dressed appropriately for the season. His motor movements are within normal limits. He is engaged in therapy, but he appears anxious as evidenced by hesitating before speaking and by his hand wringing. The client reports suicidal ideation with no plan or intent. The client reports a depressed mood more often than not and difficulty enjoying most activities. The client is oriented to person, place, time, and situation. The client reports that his appetite has increased lately and that he is experiencing hyperso | You are a resident in counseling practicing in a private practice agency. During the initial counseling session, the 25-year-old single male client reports feeling depressed and hopeless. He has difficulty enjoying activities that he has enjoyed in the past and feels unsatisfied with most areas of his life. The client identifies that he is not happy at work and wants to make a career change. The client verbalizes feeling sad more often than not, and that this has been going on for about 2 years. The client decided to start counseling when he began experiencing suicidal thoughts. The client reports no plan or intent to attempt suicide but is concerned about his own well-being. | mnia. Family History: The client reports that he has two younger brothers who are 19 and 22 years old. His parents divorced when he was 10 years old, and he grew up living with his mother but maintained a strong consistent relationship with his father. The client reports no history of trauma, neglect, physical abuse, sexual abuse, or emotional abuse. The client denies drug or alcohol use, although he reports that his father previously was an active alcoholic | Which one of the following would be the most appropriate frequency for sessions based on the client’s present suicidal ideation? | Weekly | Fortnightly (every other week) | Twice weekly | Daily | (A): Weekly
(B): Fortnightly (every other week)
(C): Twice weekly
(D): Daily | Twice weekly | C | It is important to provide frequent sessions to this client at this point in treatment due to his reported suicidal ideation. Because the client’s risk appears moderate due to the presence of suicidal ideation with no current intent or plan, seeing him twice weekly would be most appropriate. Weekly and fortnightly (every other week) sessions might not provide the oversight and guidance needed to stabilize the client. Daily sessions would be more appropriate in the presence of intent, and it would likely not be possible due to insurance not covering that frequency of sessions. Requiring daily sessions would also indicate severe risk and, therefore, the need for a higher level of care such as hospitalization. Therefore, the correct answer is (B) | treatment planning |
287 | Initial Intake: Age: 31 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Widowed Counseling Setting: Private Practice Type of Counseling: Individual | The client appears her stated age, dressed appropriately for the circumstances. Her mood is identified as sad and frustrated and her affect is restricted and flat. Her primary emotion in the session is anger, though it is expressed in a tempered manner. She demonstrates limited insight, and appropriate judgment, memory, and orientation. She reports having considered suicide when she was in high school but made no attempt and would now never consider harming herself or anyone else. | You are a counselor in a private practice setting. Your client is a 31 year-old female who reports that she is very impatient and feels angry all the time, and is taking it out on her children and others with angry outbursts. She says that her children are good but they don’t pick up when she tells them to and often, they put their toys away in the wrong places. The client states that her husband died while the family was on a vacation. She tells you that they had stopped for a break and her husband was hit by a car. She says that it happened in front of her and the children, who are now 6 and 7 years old. She endorses feeling angry, restless, and having trouble making decisions. She tells you that she is having trouble falling asleep, is anxious and overwhelmed. The client tells you that her husband was a good man and “very much my opposite.” She has high expectations for neatness and being on time, he was often messy and ran late. She tells you that sometimes she felt like the whole activity they were doing was “ruined” because he made them late or the kids didn’t follow the rules. She states that she was the “controller” in their relationship, which worked well for both of them, except when she got angry with him for not doing what she wanted, when she wanted, or how she wanted it. She acknowledges that she was often angry and frustrated with his casual way of going through life but now regrets it because he’s gone. She states that her goals for counseling are to be more patient and decrease her anger. | Family History:
The client reports a significant family history with her mother diagnosed with schizophrenia, with catatonia and was not medicated. She describes her mother as a “zombie” who loved her children but never told them because she was “absent.” The client describes her father as verbally abusive and involved with drugs and alcohol, often yelling, screaming, and throwing things. She states he often told the client that any mistakes she made were the reason that their life was so bad. She has no siblings but her husband has two sisters, with whom the client does not engage. She states one of his sisters is living with her boyfriend and the other asked to borrow money from her and her husband, which made the client angry. She identifies her support system as her church and a group of couples whom she and her husband were friends with prior to his death, most of whom attended the client and her husband’s high school and college. The client says she tends to be drawn to overly controlling people and her church, though fundamentalist and legalistic, became like family to her in high school. She tells you that the couple’s closest friends are her husband’s best friend, whom the client dated in high school, and his wife. She says that while dating, her then boyfriend was very attentive, “almost smothering,” but also very demanding by leaving her notes with things or work he wanted her to do for him. She states they dated for several years and then she met and married his best friend, who was her husband. She tells you that their best friend’s wife is her best friend, although “she irritates me all the time, and I don’t really like her that much.” She says her friend has a strong personality, is controlling, and wants to make all the decisions and plans in their relationship. | Which of the following will be most appropriate to process during this session? | The client's presentation and link to a personality disorder diagnosis | New treatment goals as the client demonstrates more patience with her child | The symptoms of schizophrenia as compared to the client's presentation | The client should consider forming a new support group as her friend is not supportive | (A): The client's presentation and link to a personality disorder diagnosis
(B): New treatment goals as the client demonstrates more patience with her child
(C): The symptoms of schizophrenia as compared to the client's presentation
(D): The client should consider forming a new support group as her friend is not supportive | The symptoms of schizophrenia as compared to the client's presentation | C | The client's concerns about depression are linked to her worries about ending up with schizophrenia, like her mother. It will be most helpful for the counselor and the client to review the signs and criteria for schizophrenia in comparison with the client's symptoms to ease her anxiety. It would not be appropriate to suggest the client form a new support group at this time because the client is already overwhelmed. The counselor has not observed her friend and does not know if the client misperceives her friend's help or that the friend's way of helping is not effective for this client. The client is demonstrating appropriate care and patience for her child during the session. This does not mean that she has been able to modify her emotions and behavior to maintain this change and therefore the goal is not met until that occurs. This would not be the appropriate time to talk about the counselor's suspicions that the client may exhibit traits consistent with a personality disorder because the client is concerned about a possible schizophrenia diagnosis (being "seen as crazy"). Therefore, the correct answer is (D) | intake, assessment, and diagnosis |
288 | Name: Tabitha Clinical Issues: Family conflict and pregnancy Diagnostic Category: V-codes Provisional Diagnosis: Z71.9 Other Counseling or Consultation Age: 16 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: Latina Marital Status: Not Married Modality: Individual Therapy Location of Therapy : School | The client appears healthy but tired and distracted. She is dressed in loose-fitting clothing and sits with her hands between her knees. Eye contact is minimal. Speech volume is low. She is reluctant to talk at first and denies having a problem. Thought processes are logical, and her thoughts are appropriate to the discussion. The client's estimated level of intelligence is within average range. She appears to have difficulty maintaining concentration and occasionally asks you to repeat your questions. The client denies suicidal ideation but states that she has been considering abortion. She has not acted on anything but is feeling very overwhelmed and desperate. | First session You are a school counselor in an urban school setting. The client is a 16-year-old student who is reluctant to see you. The session begins with a discussion of the teacher's concerns and your role as a school therapist. After some gentle probing and reassurance, the client is able to open up more and discuss her difficult relationship with her father. She identifies feeling overwhelmed and frustrated by his expectations, which leads to frequent arguments between them. She appears tired and has trouble sleeping at home because her parents constantly argue. She suggests that her parents "are the ones who need therapy, not me." She briefly describes the arguments that she claims her parents get into regularly. "They are always going at it, unless thay are at church. Then they act like everything is perfect." When you ask about her friends and activities, she tells you she is involved in her church youth group and has an on-again/off-again boyfriend. You ask the client, "Can you tell me more about your relationship with your boyfriend? How long have you been together?" She says that they have been seeing each other for about a year, and she thought he was 'the one', but they had a "big fight" last week and have not talked since. You ask what she means by 'the one'. She looks down at the floor and starts to bite her fingernails. You see a tear fall down her cheek. She says, "I don't know what to do." You continue the session by providing a safe space for her to express and explore her feelings about her relationship with her boyfriend. She takes a deep breath and tells you that there is something she has not told anyone and she is scared that if she says it out loud that "it will make it too real." You tell her to take her time and that you are here to listen without judgment. She tells you that she missed her last menstrual period, and several "in-home" tests confirm that she is pregnant. She has not told her boyfriend and is scared to tell her parents because she is afraid they will disown her, so she has decided to keep the pregnancy a secret. While you are tempted to try to talk the client into telling her parents and boyfriend about her pregnancy, you recognize that it is important to respect her autonomy and allow her to make the best decision for herself. You provide her with accurate information about the options available to her and encourage her to explore the pros and cons of each option. You share that having a support system and someone to talk to during this time can be helpful. She nods her head and tells you that she knows that her parents will find out about the baby eventually, whether she tells them or not, but she is anxious about how they will react to the news. You listen and provide empathetic reflections to help her gain insight into her feelings. You then focus on helping the client develop effective coping strategies for managing her stress and anxiety about the situation. You let the client know that she can come back to see you at any time if she feels overwhelmed or needs additional support. The session concludes with an understanding of what to expect in future sessions, including exploring possible solutions for dealing with her parents and boyfriend, as well as developing healthy coping skills for managing her emotions. Second session A fews day after the intake session with your client, she stopped by your office and asked if she could talk to you for a few minutes. She told you that since your last session, she decided that she wanted to tell her parents and asked if you could be there when she told them. You set up an appointment to meet with the family. This is your second session with the client and she appears very nervous. When she sits down in the chair in your office, she tells you that she changed her mind about telling her parents. She keeps repeating, "I can't do this. You tell them." Your office phone rings, and the secretary tells you the client's parents have arrived. The client immediately bursts into tears and begs you not to let them in. You calmly explain that you are here to provide a safe space for her and will support her. You walk her through a grounding exercise and encourage her to take slow, deep breaths. After a few minutes, she relaxes and indicates she is ready to talk to her parents. You welcome the parents into your office and introduce yourself as a mental health professional who has been working their daughter. You explain that the client has something she would like to tell them and you will be here to help facilitate their conversation. Her father says, "We know that something is going on." He starts talking about his daughter's academic issues and recent argumentative behavior at home. The mother adds, "We pray daily that she will grow out of this hormonal phase. We miss our innocent little girl." You listen and reflect on the parents' feelings as they talk about their daughter. The client is quiet and looks down, not making eye contact with anyone. After a few moments, you gently encourage the client to share her thoughts and feelings. She tells you that she has something important to tell them but does not know where to start. You suggest that she take her time and start with whatever feels most comfortable for her. The client takes a deep breath and slowly begins to tell her story. She tells them about her pregnancy and how scared and overwhelmed she has been. At that moment, everything changed. The client's parents are no longer focused on her academic or behavioral issues. Instead, they are now focused on their daughter and her pregnancy. They are full of questions and concerns for their daughter's well-being. The mother looks shocked, and the father demands to know who the boy is that "did this to our daughter." The initial conversation is difficult, but you provide support as the family talks through their feelings. | The client has an older brother who is in college. The client lives at home with her parents. They are members of a Christian church and are all actively involved in their church group, and the client has a good relationship with her pastor. The client has never felt close with her father and says he has always had "high standards and expectations" for everyone in their family. The client says her parents "treat her like a child." She has not told her parents about her 16-year-old boyfriend as she knows they will disapprove. For the last year, she has been asserting her independence from her parents, which has caused conflict, friction, and discord within the family. The teacher who referred the client to you mentioned that the client has seemed distracted and anxious lately. She has not been completing homework assignments and failed a test last week. The client acknowledges these concerns and tells you she struggles to keep her grades up and has difficulty adjusting to hybrid learning. "One day, we're in school, and the next day we're virtual. It's just exhausting. I feel like giving up." | The client and her parents have shown evidence of a longer-term relationship issue, suggesting that outside insight could be of value. Which referral would be most appropriate for this client and her parents? | The family's pastor | A community social worker | The family physician | A psychiatrist | (A): The family's pastor
(B): A community social worker
(C): The family physician
(D): A psychiatrist | The family's pastor | A | Given the family's often expressed connection with their church, their pastor could offer contextualization that the parents can relate to in accepting their daughter's condition. Therefore, the correct answer is (C) | professional practice and ethics |
289 | Initial Intake: Age: 31 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Widowed Counseling Setting: Private Practice Type of Counseling: Individual | The client appears her stated age, dressed appropriately for the circumstances. Her mood is identified as sad and frustrated and her affect is restricted and flat. Her primary emotion in the session is anger, though it is expressed in a tempered manner. She demonstrates limited insight, and appropriate judgment, memory, and orientation. She reports having considered suicide when she was in high school but made no attempt and would now never consider harming herself or anyone else. | You are a counselor in a private practice setting. Your client is a 31 year-old female who reports that she is very impatient and feels angry all the time, and is taking it out on her children and others with angry outbursts. She says that her children are good but they don’t pick up when she tells them to and often, they put their toys away in the wrong places. The client states that her husband died while the family was on a vacation. She tells you that they had stopped for a break and her husband was hit by a car. She says that it happened in front of her and the children, who are now 6 and 7 years old. She endorses feeling angry, restless, and having trouble making decisions. She tells you that she is having trouble falling asleep, is anxious and overwhelmed. The client tells you that her husband was a good man and “very much my opposite.” She has high expectations for neatness and being on time, he was often messy and ran late. She tells you that sometimes she felt like the whole activity they were doing was “ruined” because he made them late or the kids didn’t follow the rules. She states that she was the “controller” in their relationship, which worked well for both of them, except when she got angry with him for not doing what she wanted, when she wanted, or how she wanted it. She acknowledges that she was often angry and frustrated with his casual way of going through life but now regrets it because he’s gone. She states that her goals for counseling are to be more patient and decrease her anger. | Family History:
The client reports a significant family history with her mother diagnosed with schizophrenia, with catatonia and was not medicated. She describes her mother as a “zombie” who loved her children but never told them because she was “absent.” The client describes her father as verbally abusive and involved with drugs and alcohol, often yelling, screaming, and throwing things. She states he often told the client that any mistakes she made were the reason that their life was so bad. She has no siblings but her husband has two sisters, with whom the client does not engage. She states one of his sisters is living with her boyfriend and the other asked to borrow money from her and her husband, which made the client angry. She identifies her support system as her church and a group of couples whom she and her husband were friends with prior to his death, most of whom attended the client and her husband’s high school and college. The client says she tends to be drawn to overly controlling people and her church, though fundamentalist and legalistic, became like family to her in high school. She tells you that the couple’s closest friends are her husband’s best friend, whom the client dated in high school, and his wife. She says that while dating, her then boyfriend was very attentive, “almost smothering,” but also very demanding by leaving her notes with things or work he wanted her to do for him. She states they dated for several years and then she met and married his best friend, who was her husband. She tells you that their best friend’s wife is her best friend, although “she irritates me all the time, and I don’t really like her that much.” She says her friend has a strong personality, is controlling, and wants to make all the decisions and plans in their relationship. | Considering the information provided, which is the best question to ask when setting treatment goals for the client? | What are some things that make you feel impatient and angry? | How would you know if you were more patient and less angry? | What do you think would make you more patient and less angry? | Have you ever been more patient and less angry? | (A): What are some things that make you feel impatient and angry?
(B): How would you know if you were more patient and less angry?
(C): What do you think would make you more patient and less angry?
(D): Have you ever been more patient and less angry? | How would you know if you were more patient and less angry? | B | When setting goals, it is important for the client to determine what it would look like if their goal was met. Having the client identify how she would know if she was more patient and less angry allows the counselor and client to develop goals that are specific, realistic, and achievable. Asking the client what would make her more patient and less angry is not helpful because if she knew this answer or could achieve it on her own, she would not be seeking help. Asking her to identify some things that make her feel impatient and angry is a helpful question when setting up objectives and interventions so that the counselor and client can choose specific areas to focus on during counseling. Asking the client whether there has been a time where she has been more patient and less angry can help the client and counselor determine if the client needs to build new skills to reach this goal or whether the client has possessed these skills in the past and needs to remember how to use them. This is an important part of planning interventions, but not an important part of setting the treatment goal. Therefore, the correct answer is (C) | counseling skills and interventions |
290 | 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 | All of the following statements are in accordance with the standards of the Code of Ethics regarding couple counseling, except? | Counselors seek agreement and document in writing such agreement among all parties regarding the confidentiality of information | If one part of the couple is absent for a session, individual confidentiality standards apply. | In couples and family counseling counselors clearly define who is considered "the client" and discuss expectations and limits of confidentiality | In the absence of an agreement to the contrary, the couple or family is the client | (A): Counselors seek agreement and document in writing such agreement among all parties regarding the confidentiality of information
(B): If one part of the couple is absent for a session, individual confidentiality standards apply.
(C): In couples and family counseling counselors clearly define who is considered "the client" and discuss expectations and limits of confidentiality
(D): In the absence of an agreement to the contrary, the couple or family is the client | If one part of the couple is absent for a session, individual confidentiality standards apply. | B | It is up to the discretion of the counselor to determine if an individual should be seen when their partner is absent. All appropriate information which is shared during the individual session should be shared in the next session with all parties present. Choices A, B and C are all legitimate standards under the American Counseling Association Code of Ethics regarding couple counseling. It is imperative that at the onset of counseling a counselor defines who the client is as well as the limits to confidentiality. This information should be memorialized. If a single client is not identified, the couple is considered the client. Therefore, the correct answer is (D) | counseling skills and interventions |
291 | Name: Amy Clinical Issues: Hopelessness/depression Diagnostic Category: Depressive Disorders Provisional Diagnosis: F34.1 Persistent Depressive Disorder (Dysthymia), Severe Age: 15 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: White Marital Status: Not Applicable Modality: Individual Therapy Location of Therapy : Private Practice | The client appears in your office with loose clothing and a thin physical frame. She has inconsistent eye contact and portrays a drowsy level of consciousness. Her speech rate is slow, her volume is soft yet monotone, and her fluency and rhythm are unclear and hesitant at times. She talks about how much she hates her life. Her mood is depressed and discouraged, while her affect is flat and sad. The client has been previously hospitalized for suicidal ideation. Her thoughts are slowed, and she is easily distracted. Her concentration is impaired with frequent lapses in attention. She is unable to follow a long line of thought or argument. She also reports difficulty making decisions. Her insight and judgment are limited. The client's emotional state is characterized by a pervasive sadness, irritability, and feelings of hopelessness. She exhibits difficulty in concentrating, making decisions, and expressing herself coherently. Additionally, she is experiencing disrupted sleep patterns, including insomnia and excessive daytime sleepiness, and has reported a diminished appetite with subsequent weight loss | First session You are licensed as a mental health therapist working on a post-doctoral thesis related to depression and have been working with several clients diagnosed with Persistent Depressive Disorder. One of your new research participants is a 15-year-old client who arrives at your office with her mother after being released from the hospital. Before beginning the session, you ask to talk with the mother and daughter separately. When interviewing the mother, she tells you about her daughter's ongoing behavioral difficulties, experimenting with drugs and alcohol, and getting involved with a "bad group of kids." The client's academic performance has also been affected, with teachers reporting a notable decline in grades and participation in class. This behavior has been ongoing for approximately six months and appears to be intensifying. The strained familial relationships that the client is experiencing are a constant irritation to the entire family. The father's instability may have contributed to the client's current emotional distress, exacerbating her depressive symptoms. The client's mother, while providing primary care, struggles to maintain any bond with her daughter due to the increasing social withdrawal and lack of communication Next, you interview the daughter. You ask her questions about school, friends, and activities she enjoys. She states that she is picked on daily at school, has no "real" friends, and hates her life. The client sighs heavily, saying, "Some nights I go to bed hoping that I won't wake up in the morning. There's nothing to look forward to. School is horrible. She explains that she feels like she is "stuck in a dark hole" and that she cannot get out. She reports feeling hopeless, helpless, and alone. You summarize what she has told you, and she confirms your understanding of her feelings. After completing your interview with the daughter, you invite the mother to join you in your office. You continue to gather information about the client's personal and family history, symptoms of depression, and risk factors contributing to her current state. You explore potential triggers for her suicidal ideation and any protective factors in place. The mother reports that her daughter has been struggling with a lack of self-confidence and low self-esteem. You also discuss her current support system and any potential areas for improvement. Through the assessment, you can comprehensively understand the client's challenges and strengths. At the end of the intake, you check to ensure that both mother and daughter clearly understand what you have discussed today. You plan to meet with the client on a weekly basis, and you schedule a session for the following week. Third session As the client enters your office, you notice she has been crying. She states that she does not want to be here and feels like she has "no say" in what happens to her. She says that she wants to start attending a virtual school, but her mother "forced" her back to a physical school. The client says, "I can't stand it anymore. My mom yells at me every day about how I'm doing something wrong. Yesterday she blew up at me about leaving my shoes and backpack in the living room. It's my house, too. She's such a control freak." You respond to her with empathy and understanding. You ask her to tell you more about how she has felt since the argument. She explains that in addition to feeling like she has no control over her life, she feels guilty and confused because she loves her mother but does not understand why she is so controlling and demanding. You let her know that it is natural to have complicated feelings in this situation and that you are here to help her work through them. You create a plan with her, outlining different goals and activities she can do on her own or with the support of her mother. Through further exploration, you discover that she has an interest in drawing and is used to create characters for stories. She admits she feels calm when creating these drawings but that it does not take away from her depressive symptoms. You explain that having a creative outlet and developing it further can give her a healthy outlet for her emotions. The client appears to be receptive to this idea, expressing that she is willing to try it. She leaves your office feeling hopeful and slightly less overwhelmed. You make an appointment for the following week and suggest she come with a piece of art or design to share. She nods in agreement before leaving. Seventh session It has been almost two months since you began therapy with the client. You suggested a session in which both she and her mother were present to discuss the client's progress. She presents to today's session with her mother. The client followed up with your referral from a previous session for her to see a psychiatrist and has provided you with a release of information to communicate with her psychiatrist. The client has been prescribed an antidepressant and says she does not feel any notable change yet but the psychiatrist told her it would take a few weeks to know if the medication was working. The mother states that since her daughter started taking the antidepressant, she is sleeping more than usual and struggles to get out of bed. She has been late to school several times. She is also having trouble with motivation. You reflect the client's current state and suggest she establish a daily routine to gain a sense of control in her life. You discuss the importance of making small achievable goals and explain that taking on too much can be overwhelming, so it is more beneficial to focus on one task at a time. The mother begins listing off potential activities that her daughter should take part in. The client closes her eyes and begins to sigh. When you ask her about her reaction, she says, "See, yet another example of my mom trying to control everything." The mother responds by saying, "I'm not trying to control you. Believe it or not, I just want what's best for you!" Understanding the tension between them, you suggest a compromise. You explain that if the client completes one activity each day, her mother will not pressure her to do more. The client appears hesitant but agrees to try it out. You then turn to the mother, thanking her for being willing to compromise and understanding. You encourage them to be patient with one another and remind them that progress takes time. You suggest they continue to have regular check-ins so that each party is aware of how the other is doing in following through on the agreement. You end the session by summarizing what was discussed, reinforcing the importance of communication between the client and her mother. | The client's mother reports that the client's father has a history of depression. The client's mother is her primary caregiver, as her father is in and out of psychiatric facilities. When the client was a child, she had a positive relationship with her mother, but as a teenager, she has been withdrawing from her mother and spending most of her time alone in her room. The client has missed many days of school in the past few months. She feels that no one at school likes her; she has tried to fit in by experimenting with alcohol and marijuana, controlling her weight, and staying out late at night. The client is struggling academically and lacks concentration in the classroom. At home, the client is withdrawn and spends most of her time in her room pretending she is doing homework but is actually scrolling through social media posts for several hours. In addition, she is having trouble sleeping and stays up late. | You suggested that the client establish a daily routine to gain a sense of control in her life. Of the listed activities, which would be the best to recommend she start doing each day after school? | Share her feelings with her mother | Draw a picture that represents her feelings | Have a time of meditation | Journal her feelings and experiences | (A): Share her feelings with her mother
(B): Draw a picture that represents her feelings
(C): Have a time of meditation
(D): Journal her feelings and experiences | Draw a picture that represents her feelings | B | Since the client has had difficulties integrating her feelings, this exercise will help her maintain a sense not only of structure but of continuing integration. Therefore, the correct answer is (C) | counseling skills and interventions |
292 | Client Age: 8 Sex: Male Gender: Male Sexuality: Unknown Ethnicity: Hispanic Relationship Status: Single Counseling Setting: Home Health Outpatient Therapy Type of Counseling: Individual with Family Involvement Presenting Problem: Behavioral Issues Diagnosis: Oppositional Defiant Disorder, Severe (F91.3) | Mental Status Exam: The client was argumentative and did not engage in the entire intake session. The client was oriented to person, place, situation, and time. He was dressed appropriately for the weather and appeared well groomed. The client appeared clean and had appropriate hyg | You are a home health outpatient therapist working with an 8-year-old male in the home setting. The client’s parents will be actively involved in counseling due to the client’s age. The client was referred to receive counseling by his school social worker. He has been having behavioral issues in school that have led to difficulty staying in the classroom and is resultantly falling behind in academics. During the first session, the client refuses to engage and leaves the room. The client’s parents prompt him to return, and he calls them “jackasses” and leaves the room again. The parents finish the intake session with you and provide you with a report on their observations in the home and reports from the school social worker. The client reportedly often loses his temper and is generally easily annoyed or angered. The client has trouble taking direction from his teachers and parents. The client’s parents also state that he often blames his younger sister for things that he does and often tries to annoy her. The parents have trouble identifying any of the client’s friends and state that he does not get along with his peers. | iene. Family History: The client’s parents are married, and he has a younger sister who is 6 years old. The client often deliberately annoys or angers his younger sister and has difficulty following directions from his parents | All of the following are considered a differential diagnosis for oppositional defiant disorder EXCEPT: | Attention-deficit/hyperactivity disorder | Social anxiety disorder | Disruptive mood dysregulation disorder | Generalized anxiety disorder | (A): Attention-deficit/hyperactivity disorder
(B): Social anxiety disorder
(C): Disruptive mood dysregulation disorder
(D): Generalized anxiety disorder | Generalized anxiety disorder | D | Generalized anxiety disorder would not be considered a differential diagnosis because anxiety about everyday situations does not generally lead to defiance to authority. Attention-deficit/hyperactivity disorder would be considered a differential diagnosis if failure to conform to requests of others occurs in situations that require sustained attention. Disruptive mood dysregulation disorder also presents as negative mood and temper outbursts, but these are often much more intense than in oppositional defiant disorder. Social anxiety disorder can be considered if the defiance occurs because of the fear of judgment and negative evaluation of others. Therefore, the correct answer is (D) | intake, assessment, and diagnosis |
293 | Initial Intake: Age: 68 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: African-American Relationship Status: Married Counseling Setting: Private Practice 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 will help the client identify barriers to attaining his goals? | Processing the importance of antidepressants instead of a depressant like alcohol | Processing how difficult it is to stop using the amount of alcohol he drinks | Processing his ability to meet his wife's needs as her health continues to decline | Processing the unconscious benefits the client gets from his depression | (A): Processing the importance of antidepressants instead of a depressant like alcohol
(B): Processing how difficult it is to stop using the amount of alcohol he drinks
(C): Processing his ability to meet his wife's needs as her health continues to decline
(D): Processing the unconscious benefits the client gets from his depression | Processing the unconscious benefits the client gets from his depression | D | Secondary gains are the conscious or unconscious benefits that individuals get from their current way of responding to life. In this case, the client may continue to use ineffective coping skills because it is comfortable and familiar to him rather than experiencing the discomfort of change. Secondary gains include the interpersonal or social advantages that an individual may consciously or unconsciously experience because of their own illness or, in this case, the client's role as caregiver for his parents and now his wife. Identifying secondary gains is critical to determining if a client is willing to give these up to meet their stated goals. The difficulty the client will have in stopping his alcohol use may be a barrier for the client, not because of the amount he drinks, but because he uses it as a coping strategy. He has previously demonstrated the ability to stop drinking when he chooses and has noted the improvement in his thoughts and emotions. Processing the importance of antidepressants is not helpful for the client as he has previously stated his refusal to use antidepressants. Focusing on his ability to meet his wife's needs as her health declines is most likely to cause the client greater stress and increase his depressive symptoms, which will create a barrier to meeting his goals, rather than identifying the current barriers. Therefore, the correct answer is (C) | counseling skills and interventions |
294 | 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. | age.” Family History: As part of the Karen community in Southeast Asia, the client and his family lived in a refugee camp near the Thai-Burma border before coming to the United States. His family fled to an internal displacement camp (IDC) to escape ethnic violence and torture. The family arrived in the refugee camp when the client was two years old and stayed for nearly a decade before coming to the United States. He reports that his parents do not drink or use drugs; however, he states that drugs and alcohol were prevalent in the IDC. His family is Christian and is involved with a local church that sponsors individuals from the Karen community and helps with resettlement | Which of the substance abuse interventions offers a parent training component to reinforce drug-incompatible behaviors at home? | Motivational enhancement therapy (MET) | Cognitive-behavioral therapy (CBT) | Contingency management therapy (CM) | Multi-systemic therapy (MST) | (A): Motivational enhancement therapy (MET)
(B): Cognitive-behavioral therapy (CBT)
(C): Contingency management therapy (CM)
(D): Multi-systemic therapy (MST) | Contingency management therapy (CM) | C | Contingency management (CM) is an evidence-based practice with a parent training component. CM works by using behavioral modification strategies, including positive reinforcement, negative reinforcement, positive punishment, and negative punishment. The goal is to reinforce abstinence-related behaviors (eg, negative drug screen) by offering low-cost vouchers or incentives. Motivational enhancement therapy is an evidence-based practice for substance abuse used to increase change talk by reducing ambivalence. Cognitive-behavioral theory is also an evidence-based practice that challenges distorting thinking and encourages healthy coping strategies. Multi-systemic therapy is a comprehensive in-home intervention for teens involved in the criminal justice system. It is a community-based, intensive intervention to assist families with collaboration with multiple systems, including schools, courts, and other community locations. Therefore, the correct answer is (D) | treatment planning |
295 | 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. | What should be your first order of business in addressing Shania's needs? | Scheduling psychiatric appointment for youngest daughter | Developing treatment plan goal for SI | Applying for government assistance | Reporting suspected child abuse | (A): Scheduling psychiatric appointment for youngest daughter
(B): Developing treatment plan goal for SI
(C): Applying for government assistance
(D): Reporting suspected child abuse | Reporting suspected child abuse | D | As a counselor you cannot ignore a report of child abuse. Even if the child is in another state, if you can obtain enough information to file a report with that state's department of child and family services, they can begin an investigation to ensure the child's safety. After this has been prioritized, you can continue to address Shania's and her family's needs. Therefore, the correct answer is (A) | professional practice and ethics |
296 | Initial Intake: Age: 68 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: African-American Relationship Status: Married Counseling Setting: Private Practice 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 will be most beneficial to help the client access the self-care he needs? | Invite the client's wife to session so you can help her understand why respite care is needed | Go with your client to a residential respite care facility to help him determine which one to use | All of the above | Provide psychoeducation on the concepts of boundaries and how to implement them | (A): Invite the client's wife to session so you can help her understand why respite care is needed
(B): Go with your client to a residential respite care facility to help him determine which one to use
(C): All of the above
(D): Provide psychoeducation on the concepts of boundaries and how to implement them | Provide psychoeducation on the concepts of boundaries and how to implement them | D | Teaching the client about the concepts of boundaries will be helpful for him in setting his own boundaries for self-care and in determining what he is able to do for his wife and what he cannot. Learning to set and maintain boundaries will help the client feel less "stuck". Inviting the client's wife to the session, even with the client's permission, is not likely to be beneficial as there is no established trust or therapeutic relationship between the counselor and the client's wife. His wife may feel attacked or ganged up on if the counselor advocates for respite care. It would not be unusual for a client to need support in choosing a respite care, however it would be unprofessional for the counselor to accompany the client to help him determine which facility is best. Accompanying him may breach the ethical principles of autonomy (right to self-determination or choice) and nonmaleficence (refraining from taking action that might harm another). Therefore, the correct answer is (B) | counseling skills and interventions |
297 | Initial Intake: Age: 8 Gender: Male Sexual Orientation: N/A Ethnicity: Caucasian Relationship Status: N/A Counseling Setting: Through agency inside school and via telehealth Type of Counseling: Individual | Avery presents as fair, with some stains on his t-shirt. His mood is euthymic but with anxious affect as evidenced by hyperactivity, some pressured speech and fidgeting of the hands and feet as he cannot sit still. There is no evidence of suicidal or homicidal ideation and no reported hallucinations or delusions. The initial assessment revealed no significant trauma, other than not having his biological father around his entire life. Avery reports feeling tired often but overall happy. Mom reports his appetite is very good, but his diet could be better. He also has headaches at times in school or when he comes home. | Diagnosis: Attention-deficit hyperactivity disorder, combined type (F90.2)
Avery is an 8-year-old Caucasian male that has been referred to you by his school counselor because of emotional breakdowns, failing grades and falling asleep in class. You set up an initial assessment session with Avery and his parents in person at the school’s conference room and learn that he refers to his biological mother as “dad” and her wife as “mom”, and that he has a twin brother with Autism. Mom tells you Avery sees a psychiatrist for medications but frequently has them changed because she feels they are not working. Mom reports Avery has trouble sleeping at night, hits and kicks her and his brother when he’s angry and steals food from the kitchen and hides it in his room. She must ask him multiple times to complete a task and he often will not comply or forget each time he is told. Dad adds that Avery is very smart and does well in most subjects in school but struggles with reading comprehension and worded math problems. Avery is already on an IEP (Individualized Educational Plan) in school to better support his unique learning needs. They ask for your help in regulating his affect and behaviors. | Family History:
Avery is very close with his two mothers and does not seem to notice that he does not have his father present in his life. His mother mentions that he has made several remarks recently about wanting to be a girl. Avery’s brother is high functioning on the autism spectrum but has poor communication and coping skills, increasing Avery’s stress level at home due to their constant fighting. Both parents work full-time and take shifts in caring for the children, often sleeping at odd hours of the day and therefore have trouble keeping Avery on a regular schedule. Avery has some extended family on both sides and sees them occasionally. Dad reveals she was also diagnosed with ADHD and Dyslexia growing up and had trouble in school. | As you are concluding your conversation with Avery's parents, they ask if you can also treat his twin brother Marc, who has autism spectrum disorder and is non-verbal. You should reply? | "It is unethical to provide counseling for a family member of an existing client." | "I can't treat him or help you with that, but Google some local autism resources." | "I am happy to conduct an assessment, but I also might refer you to an ABA Specialist." | "Of course I can treat him! Let me check my calendar and we will get him right in!" | (A): "It is unethical to provide counseling for a family member of an existing client."
(B): "I can't treat him or help you with that, but Google some local autism resources."
(C): "I am happy to conduct an assessment, but I also might refer you to an ABA Specialist."
(D): "Of course I can treat him! Let me check my calendar and we will get him right in!" | "I am happy to conduct an assessment, but I also might refer you to an ABA Specialist." | C | It is best practice to offer or assess each client on your own prior to agreeing to or denying services. To better understand Marc's needs, conducting an assessment can help you to rule out which conditions you can or cannot support. You should also prepare your clients to know that external support from other specialists might be an option you provide depending on the client's needs that may be outside of your scope of practice. It is not unethical to treat more than one member of the same family depending on the circumstances and situation, specifically when it comes to child siblings; often the parents of children in counseling will prefer the same counselor to meet with their different children and resolve family dynamics issues and provide insight to the parent. The situation must be screened for boundary issues and unethical dual relationships or roles. Answer d) sounds supportive and encouraging but could be giving a family false hope if agreeing to provide services without properly screening through initial assessments. Therefore, the correct answer is (A) | treatment planning |
298 | Initial Intake: Age: 32 Gender: Female Sexual Orientation: Bisexual Ethnicity: Caucasian Relationship Status: In a relationship Counseling Setting: Community mental health agency Type of Counseling: Individual via Telehealth | Melanie is unkempt, looks tired and is casually dressed. Motor movements are within normal limits, eye contact is appropriate. Melanie reported passive suicidal ideation intermittently throughout her depressive episode as a means for escaping her feelings but has no plan or intent. Melanie reluctantly admits to several instances of past trauma which include losing her son’s father to a tragic car accident four years ago where her son witnessed him die, as well as having three other older children, all with separate fathers, with whom she has no contact. Her only support system is her boyfriend who takes great care of her and her son’s school, which provides help with his Individualized Education Plan. | Diagnosis: Dysthymic disorder (F34.1), provisional, Anxiety disorder, unspecified (F41.9), Post-traumatic stress disorder (PTSD) (F43.1)
Melanie has been in mental health counseling for several years through your agency and was referred to you by her last counselor who obtained a position with a local University and was leaving your company. Melanie is a 32-year-old Caucasian female who lives in a house with her boyfriend and her 9-year-old son, Gus, who suffers from ADHD, anxiety, and PTSD. Melanie is receiving psychiatric medication from your agency’s Psychiatrist, another Psychiatric practice by a Nurse Practitioner in a different city and is being treated medically by a Gastroenterologist who has also prescribed medications. Melanie is complaining of ongoing depression caused by her chronic nausea and a cyclic vomiting syndrome and does not want to leave her bed out of helplessness and hopelessness that nothing will ever change. She also reports experiencing anxiety and panic-like attacks when she is around others which causes her to socially isolate for sometimes days at a time. She is upset she cannot care for her son the way she desires and wants to continue counseling to help her feel better. | Family History:
Melanie has what she states is a “complicated” relationship with her family, including her mother, whom she believes wants no involvement with her or her son, and has no contact with anyone else. Melanie states her falling out with her mother began when she was just a child. She comments that her father and her were “very close”, but his new wife makes it “challenging to communicate with him.” Melanie has lived on her own for much of her life and has not engaged in or sustained any relationship with her first three children. She adds that in each instance they were either unfairly taken away by the father or the state and that she has tried to initiate contact, but it has not been successful. Melanie continues to deflect from discussing family dynamics, causing gaps in your initial interviewing process.
Work History:
Melanie reports never having an “official” job but always being able to make money “somehow.” She has been on Medicaid for most of her life and continues to survive off government support and the charity of others. She tells you she has dreams of writing a book or even owning her own bakery but does not demonstrate willingness to take the steps at achieving those goals.
Legal History:
Melanie has incurred a criminal record for failing to pay child support several times over the past nine years and continues to receive notices and warnings to ensure she is making her payments on time. | After the first session, what should be your next steps in counseling Melanie? | Conduct an intervention immediately and refer to an inpatient rehabilitation facility | Conduct evidence-based substance use assessment screenings | Engage Melanie in discussing her use further using MI and evidence-based screening tools | Align with her empathically and refer her to a 12-Step program in her area | (A): Conduct an intervention immediately and refer to an inpatient rehabilitation facility
(B): Conduct evidence-based substance use assessment screenings
(C): Engage Melanie in discussing her use further using MI and evidence-based screening tools
(D): Align with her empathically and refer her to a 12-Step program in her area | Engage Melanie in discussing her use further using MI and evidence-based screening tools | C | While it may seem pertinent to conduct an intervention and refer to a rehabilitation facility, only through a thorough and detailed inventory of the type, amount, frequency, and consequences of Melanie's substance use, followed by an understanding of her perception of her usage and level of readiness to change can you make an educated next step in response to her reported legal use of marijuana. Cannabis is considered by the FDA as a schedule I drug with no accepted medical purpose and a high potential for abuse. If you feel uncomfortable or untrained in performing official screening tools, using basic counseling interventions such as Motivational Interviewing (MI) to have Melanie provide more details would be sufficient prior to considering a referral to a detox or rehab facility or even to an interventionist. Based on Melanie's denial, it is unlikely she is in a stage of change willing to undergo treatment for marijuana use and it is presumptuous to consider it the primary cause of her problems without learning more. Therefore, the correct answer is (D) | counseling skills and interventions |
299 | Name: Dana Clinical Issues: Relationship distress with mother during divorce Diagnostic Category: Depressive Disorders;V-codes Provisional Diagnosis: F33.1 Major Depressive Disorder, Moderate, Recurrent Episodes; Z62.820 Parent-Child Relational Problem Age: 15 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: Multiracial Marital Status: Never married Modality: Individual Therapy Location of Therapy : Under Supervision | The client is dressed in black attire. She sits with her hands folded and slumped over in the chair. She makes little eye contact and seems to distrust you. Her mood seems flat. During the intake, the mother complains about how her daughter "does not listen," "acts out all the time," and "picks fights with her sister." The client is reticent and shrugs her shoulders. The client reported several other symptoms indicative of a depressive episode, including feelings of worthlessness, anhedonia, and lethargy. She also said having recurrent thoughts of self-harm that had become pervasive throughout her day-to-day life. On objective examination, the patient demonstrated psychomotor retardation, appearing to move and speak in a lethargic and sluggish manner. Cognitively, the patient's attention span was limited, and her concentration was impaired. She could not sustain her train of thought and had difficulty forming coherent sentences. Her mood was notably depressed, and her affect was constricted. This suggests a severe depressive episode, and these symptoms will likely require aggressive treatment. | First session You are a limited permit holder under direct supervision. The client is a 15-year-old multiracial female who presents to the first counseling session with her mother. The session begins with the client's mother monopolizing the conversation, and it is difficult for the client to get a word in edgewise. The client's mother continually brings up her husband as a source of her daughter's problems. The mother says, ""Our daughter is not doing well in school and has been talking back to her teacher. I think it comes from the relationship she's had with her father." The client interrupts and says, "It's not Dad's fault! You're the one who abuses me!" The mother is incredulous and begins to yell, saying that she would never hit her daughter and that the client is lying. The mother tells you that her daughter is a "liar, a thief, and creates problems." She reports that Child Protective Services (CPS) has been to their house several times, and she believes that these visits are her husband's fault. The client is visibly upset, and her mother continues to berate her. You intervene and explain that the client's disclosure is serious and should be taken seriously. You explain that you must speak to the client alone before deciding the best course of action. While speaking alone with the client, you notice that she is shaking and close to tears. You encourage her to take deep breaths and explain that she can take some time to regroup before continuing. After a few minutes, she appears calmer and begins to describe her home situation. It becomes clear that the client's home life is chaotic and that she is being subjected to verbal and emotional abuse from her mother. She tells you that she wants to live with her father. The client also states that she has been bullied in school, and this has been going on for some time. You explain to the client that she has a right to feel safe and that you will do everything in your power to ensure her safety. You continue asking question to assess her level of distress, and you note the client's self-reported symptoms consistent with depression, including insomnia, fatigue, and a significant decrease in her appetite. She is also alienating herself from her peers and family. After completing the initial session, you schedule an appointment to see the client and her mother next week to continue your assessment to determine the best course of action. | The client has experienced a great deal of distress due to the chaotic environment of her home life. Her adoptive parents are in the middle of a "messy divorce," and it has been difficult for her to process, as she has had to witness her parents' arguments and the shifting dynamics of her family. This strain has been further compounded by her mother and grandmother's favoritism towards her younger sister, leading to the client feeling neglected and overlooked. In addition, her attempts to connect with her mother and sister have often been met with hostility, leading to frequent arguments and further exacerbating her feelings of alienation and loneliness. The client has also expressed feelings of anxiety and depression due to her current living situation. She has expressed a strong desire to live with her father and escape the hostile environment of her mother's home, yet her mother has continuously denied this request. This has resulted in the client feeling trapped and powerless to alter her current situation, leading to a sense of hopelessness. The client's relationship with her mother is strained, and she has difficulty trusting her. As a result, she is often guarded around her mother and expresses her distrust and resentment, resulting in further conflict and tension between them. The client's school environment has affected her mental health. She is constantly subjected to verbal and physical bullying from her peers, leading to feelings of worthlessness and insecurity. Her academic performance is suffering, and she cannot concentrate in class, leading to further isolation from her classmates. Previous Counseling: The client has been in and out of therapy with many different professionals. She has been diagnosed with Major Depressive Disorder. Her mother is also in therapy and believes her daughter needs "help." The client states that her mother has abused her before, and Child Protective Service (CPS) has been to the house numerous times but has not found any evidence of abuse. | Which assessment instrument would be most appropriate to further evaluate the client's symptoms? | Children’s Depression Inventory (CDI) | Children's Apperception Test (CAT) | Adolescent Problem Severity Index | Quick Inventory of Depressive Symptomatology-Self-Report (QIDS-SR) | (A): Children’s Depression Inventory (CDI)
(B): Children's Apperception Test (CAT)
(C): Adolescent Problem Severity Index
(D): Quick Inventory of Depressive Symptomatology-Self-Report (QIDS-SR) | Children’s Depression Inventory (CDI) | A | The Children’s Depression Inventory (CDI) is a widely used tool to help assess the level of depressive symptoms in children and adolescents, age 7-17 years old. Therefore, the correct answer is (D) | intake, assessment, and diagnosis |
300 | 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 | If the counselor responds, "So, you are not eating because it is too painful to go into the kitchen and cook for yourself and not because of a loss of appetite?" This is an example of what counseling skill? | Reflection of feelings | Open ended questions | Clarification | Confrontation | (A): Reflection of feelings
(B): Open ended questions
(C): Clarification
(D): Confrontation | Clarification | C | The counselor is demonstrating the skill of clarification. The purpose of clarification is to make sure that the counselor understands the situation correctly. In this situation, the counselor is trying to determine the reason behind Theodore's significant weight loss which will also aid in the formulation of the diagnosis. A reflection of feelings would focus on the how being in the kitchen makes Theodore feel. Confrontation is not a confrontation between the client and counselor, it occurs within the client through self-examination. The question can be answered with a yes or a no, therefore it is not an open-ended question. Therefore, the correct answer is (B) | counseling skills and interventions |
Subsets and Splits