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301 | Client Age: 26 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Community Mental Health Agency Type of Counseling: Individual Presenting Problem: Hallucinations and Delusions Diagnosis: Schizophrenia 295.90 (F20.9) | Mental Status Exam: The client displays an angry affect, and his mood is irritable. His speech is disorganized and pressured. He is oriented to person, place, time, and situation. He reports audiovisual hallucinations, which include seeing “the shadow man” and hearing voices others cannot hear. The client exhibits tangential and disconnected thinking. He is firm in his conviction that he is being poisoned and says he is exhausted from constantly trying to maintain vigilance. The client’s insight and judgment are poor. He denies suicidal ideation, homicidal ideation, and command hallucinations. The client first experienced symptoms of schizophrenia in his late teens but was misdiagnosed with bipolar disorder until rece | You are a counselor working in an outpatient community mental health center serving clients with severe psychiatric disorders. A 26-year-old male, accompanied by his caseworker, presents for counseling due to symptoms of schizophrenia. The caseworker reports that the client was doing well until he stopped taking his prescription medication. He resides in assisted living, where he was placed after being discharged from the hospital last month. The client claims someone he calls “the shadow man” is following him and putting poison in his food. The caseworker reports that the client has been more agitated recently and has engaged in verbal altercations with other residents. The client is refusing to take his medication because of the side effects. He had an initial therapeutic response to Haldol, an antipsychotic, but stopped taking it because it made him restless and nervous. He explains, “I felt like I constantly had to keep moving.” The client is adamant about his desire to stay off medication and becomes angry when his caseworker mentions the possibility of going back into the hospital. | The client is attending group therapy and reports it helps him feel less isolated and alone. He has learned from the group leader and group participants that other medications (i\. e., second-generation atypical antipsychotics) have fewer side effects, and he has requested a psychiatric medication evaluation. The client states he is constantly worrying about “the shadow man,” which has taken its toll physically. He recounts a recent visit with his parents where his father blamed him for his mother’s anxiety. During the same visit, his father criticized the client’s poor choices in life and, according to the client, “He guilt-tripped me for not being more like my brother.” The client believes his parents are to blame for his current situation because they ignored his needs once he reached adolescence and refused to help when he was struggling. Which of the following best explains the parents’ emotional expression (e\. g | Which of the following best explains the parents’ emotional expression (e.g., criticism, anger) when interacting with the client? | Fundamental attribution error | The Dunning-Kruger effect | External locus of control | Self-serving bias | (A): Fundamental attribution error
(B): The Dunning-Kruger effect
(C): External locus of control
(D): Self-serving bias | Fundamental attribution error | A | Families high in emotional expression ascribe symptoms of mental disorders to internal attributes (eg, personality, intentionality). The fundamental attribution error occurs when people overemphasize personality traits and disregard situational or external explanations for behavior. Psychoeducation for families high in emotional expression uses a revised attribution model to help families shift from attributing behavior to personality towards attributing behavior to illness. Self-serving bias occurs when individuals assume personal success related to internal attributes and personal failures are related to external attributes. Individuals with an external locus of control believe that luck, environment, or other external features serve as explanations for events or outcomes. The Dunning-Kruger effect occurs when there is an overestimation of personal knowledge and skills due to an inaccurate self-appraisal. Therefore, the correct answer is (D) | counseling skills and interventions |
302 | Initial Intake: Age: 37 Gender: Female Sexual Orientation: Heterosexual Race/Ethnicity: Caucasian/non-Hispanic Relationship Status: Married Counseling Setting: Mental health counseling agency Type of Counseling: Individual telemedicine | Leah is casually dressed, presenting with anxious mood and affect. Speech is of fast rate but with normal tone. Breathing is shallow from speaking fast, you note she stops to take deep breaths before continuing. Leah denies SI/HI, reports many protective factors, and admits that nothing in her life is “really that wrong.” Leah demonstrates good insight and judgment into the nature of her concerns. | Diagnosis: Generalized Anxiety Disorder (F41.1), Adjustment disorder with mixed anxiety and depressed mood (F43.23)
Leah is referred to your counseling agency by the U.S. Department of Veterans Affairs (VA) mental health program due to their inability to accommodate her because of their high caseloads. Leah is a 37-year-old married woman with a 2-year-old child and is a disabled combat veteran who served 8 years in active-duty Air Force service. Both you and Leah work full-time as mental health counseling interns in your respective practices. Leah struggles to manage her own anxiety which causes both interpersonal and professional problems for her. Leah reports experiencing trauma related to deployments, past divorce, death of a pet and birth trauma with her daughter. Leah tells you she needs someone to process everything with regularly as she does not want to exhaust members of her family with her stress. Leah’s biggest problem, she shares, is that she knows how to resolve her negative thoughts that lead her to act impulsively but cannot apply her skills when she feels overwhelmed. |
Education and Work History:
Prior to military life Leah worked several different jobs since the age of 13. Leah joined the Air Force at age 21, worked overseas as well as in the states, and had several deployments including one year in Kabul, Afghanistan as a Staff Sergeant during her fifth year of service. Leah obtained her bachelor’s degree right after separation, and then returned to Afghanistan as a contractor. Following this experience, she completed her master’s degree in counseling. She admits she is “skeptical” working with someone who has the same amount of experience as herself.
Family History:
Leah grew up with two younger siblings, and her parents divorced when she was 11. Due to joint custody, her and her siblings moved back and forth weekly every Friday until she originally left home for college at 18. Both of Leah’s parents remarried; her father having three more children with her stepmother, and Leah inheriting a stepsister when her mother married her stepfather. Leah was also previously married to an Army Sergeant while active duty, but her husband had an affair and left her prior to her military separation. | Leah tells you she feels ready to process her past, but whenever you ask her to share about her trauma experiences, she ends up resisting due to her disbelief that you are qualified to help her. How should you proceed? | Re-label her reason for resistance as "fear" | Review your credentials and experience | Present the dilemma as only her decision to resolve | Suggest that you refer her out | (A): Re-label her reason for resistance as "fear"
(B): Review your credentials and experience
(C): Present the dilemma as only her decision to resolve
(D): Suggest that you refer her out | Present the dilemma as only her decision to resolve | C | Placing this conflict in Leah's hands empowers her to decide whether she wants to address her trauma with you, discuss other areas only, or see a new professional. Offering a referral to a higher-level professional may not be what Leah needs, and may be seen as "giving up" on her or "rejection"; quite possibly even seen as conceding to her claims that your credentials are not sufficient to treat her effectively. Recall that she has previous abandonment issues from her divorce; perhaps what will help Leah in multiple areas of her personality development is for you to remain in place unless she makes the request for another counselor. Answer b) can be seen as invalidating to her reported concerns or cause her to feel defensive if she is still not respecting your clinical perspective, although can be a good intervention to use once Leah is invested in sharing with you further. Answer c) is unnecessary unless she asks, and even then, removes the clinical focus from your client. Therefore, the correct answer is (D) | counseling skills and interventions |
303 | Name: Carter Clinical Issues: Developmental processes/tasks/issues Diagnostic Category: Neurodevelopmental Disorders Provisional Diagnosis: F90.0 Attention-Deficit/Hyperactivity Disorder, Predominately Inattentive Presentation; F81.2 Specific Learning Disorder with Impairment in Mathematics Age: 11 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Not Assessed Ethnicity: White Marital Status: Not Applicable Modality: Individual Therapy Location of Therapy : School | The client is of average build. He is dressed in a neat and appropriate manner for school. He is reluctant to engage in the conversation but does not display any hostility or aggression. The client displays a flat affect with occasional brief moments of animation which appear to be fueled by fleeting interests. His mood appears to be somewhat dysphoric as he often responds with a shrug or a one-word answer. The client’s thought process is non-linear and circumstantial. He is able to answer questions in a straightforward manner once he understands the topic being discussed. The client’s speech is of normal rate and volume for his age but it does contain some articulation errors due to his speech disorder. His memory appears intact as he can recall details from previous conversations with ease. | First session You are a mental health therapist in a public school. The client, an 11-year-old male, and his parents arrive at your office for the intake appointment per a referral from the committee on special education. The parents express concerns with their son's ongoing lack of concentration, being easily distracted, requiring multiple prompts and redirection throughout his day, and not following multi-step processes. The mother states that he tends to "drift off and is fidgety." He has trouble sitting still and cannot focus on anything for more than a few minutes. According to the parents, this behavior is present at both school and at home. As you progress with the intake session, you ask the parents to describe their current goals and any treatment barriers they have experienced up to this point. They state that they would like their son to be more focused throughout the day and be better able to follow instructions. They also mention that so far their efforts in trying to help him have been unsuccessful and he is still struggling. After gathering more insight into the client's home life, school performance, and developmental history from the parents, you turn your attention to the client. He has been looking around the room and has not been actively engaged in the conversation. When asked directly about his feelings about school, he shrugs and says, "It's okay." You ask him if there is anything that makes it hard for him to stay focused in class, and after a few seconds of reflection he admits that it is sometimes difficult because "there are too many things happening at the same time." He states that he cannot keep up with all of the activity going on around him and it is distracting. You inquire further as to what else may be contributing to his difficulty maintaining attention in school and he admits that sometimes he gets frustrated when tasks are too challenging for him. While he is answering your questions, he is looking at the small tabletop clock sitting on the corner of your desk. Once you feel that you have an accurate understanding of the current presenting issues, you discuss next steps with the parents. You discuss meeting with the client for individual weekly sessions to help him develop effective coping skills, build self-esteem, and manage emotions associated with frustration, failure, and low self-worth. You also suggest collateral sessions with the parents to check in with them about their son's progress and discuss strategies they can use at home to help him. They agree to this arrangement and ask if there are any tools or techniques they can try between now and the next time they meet with you. You suggest they start by creating a daily routine that will provide a sense of predictability and help to reduce chaos, and having a set time for homework, meals, and bedtime. You also mention that stimulant medication is often prescribed for children with ADHD, which can help to improve focus and concentration. Lastly, you let the parents know there is some evidence that certain foods can trigger or worsen ADHD symptoms, such as sugary, processed, or artificial foods. Fourth session Last week you met with the client's parents to discuss behavioral parent management training, educating them on how this approach can be used to decrease disruptive behavior and encourage positive behaviors. You taught them how to identify and reinforce desired behaviors and asked them to start keeping a log to record the client's behaviors during the day, what actions they took in response to his behaviors, and how he responded. Additionally, you suggested introducing rewards for meeting goals and discussed the importance of consistency. They followed up with you prior to today's appointment, stating that they believe the parent management training has been beneficial so far, as they have seen a slight decrease in disruptive behaviors and an increase in compliance. The client arrives for his fourth individual session with you. When you ask him how he has been feeling this week, he states that he does not want to go to math class because they "move too fast," and he cannot keep up. The client says he does not feel it is fair that "the teacher yells at me every day even when I'm trying my best." He says, "She's mean, and I won't go back to her class ever again!" He is displaying signs of anger and frustration. His arms and legs are tense, he is tapping his feet, and his facial expression is scrunched up in a frown. His breathing is shallow and rapid. You attempt to calm him down by guiding him in a breathing exercise that you first introduced during a previous session that involves taking slow, deep breaths. You repeat this exercise a few times with the client until he is feeling calmer. In order to further explore the client's feelings about math class, you ask that he draw a picture of the classroom and how it makes him feel. He draws an angry teacher standing in front of a chalkboard with a lot of numbers written on it in random order. The client says that this is how his math class feels to him: overwhelming and confusing. You explain to the client that you understand how overwhelmed and confused he feels, and that it can be really hard to focus on a task when it feels too hard. You also assess the client's perceptions of the teacher, noting his feelings of mistrust and apprehension. Additionally, you assess the client's ability to self-regulate in the classroom and his overall attitude towards class participation. You talk to him about some strategies to help him feel more comfortable in class, and you also reassure him that you are going to talk to his math teacher. | The client is currently a fifth grader participating in the general education curriculum. He has a disability classification with his school district as learning disabled. He receives consultant teacher services via classroom support aide for English Language Arts (ELA) and Math. In addition, he attends the resource room daily for added support. The client arrives to class prepared with necessary materials and homework assignments but requires prompts throughout his day to stay on track. He is conscientious about his grades and doing well academically but is easily distracted by environmental factors surrounding him. Three years ago, the client's triennial evaluation report indicated a classification of Speech Language Disorder. To date, staff suggests that the client's speech deficits manifesting as notably impaired speech do not seem to cause concern in social situations. Additional Characteristics: The client is a very pleasant, quiet, shy, reserved boy. He tends to lack confidence in his academic abilities, which seems to cause him stress. Small glimpses of the client's good sense of humor can often be seen in small group settings. | Which assessment tool would you use to screen for Attention-Deficit/Hyperactivity Disorder? | Ages and Stages Questionnaire | Auditory Continuous Performance Test | Autism Rating Scale | Attachment Diagnosis Assessment | (A): Ages and Stages Questionnaire
(B): Auditory Continuous Performance Test
(C): Autism Rating Scale
(D): Attachment Diagnosis Assessment | Auditory Continuous Performance Test | B | The Auditory Continuous Performance Test determines ADD/ADHD by assessing auditory attention deficit. Therefore, the correct answer is (C) | intake, assessment, and diagnosis |
304 | 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. | The client informs you that she is upset because of a recent incident involving her two sons. She states that her teenage sons were walking in a neighborhood park when they came across a group of white men who used xenophobic slurs and threatened them. The boys said the men spit on them and told them to “go back to where they came from.” The client’s bouts of depression persist, and this is now coupled with the feeling that she has somehow failed to protect her sons. The client is also concerned that her husband is becoming increasingly intolerant of her inability to cook, clean, and care for their boys. The client states this makes her feel “worthless” and a “nobody.” She has also become more isolated and misses “having the energy” to connect with those in her community. When the client recounts the incident with her two sons in the park, you remain open to the client’s underlying experiences in the present moment and respond authentically | When the client recounts the incident with her two sons in the park, you remain open to the client’s underlying experiences in the present moment and respond authentically. This is an example of which one of the following? | Providing congruence | Shaping competence | Increasing differentiation | Supplying positive reinforcement | (A): Providing congruence
(B): Shaping competence
(C): Increasing differentiation
(D): Supplying positive reinforcement | Providing congruence | A | You are providing congruence by remaining open to the client’s underlying experiences in the present moment and responding authentically. Congruence (or genuineness) is expressed when counselors accurately attend to the interpersonal and intrapersonal aspects of the therapeutic relationship. Counselors need to be mindfully aware of their own intrapersonal experiences to skillfully respond to the client’s experiences (ie, the interpersonal facet). Increasing differentiation is a Bowenian family therapy technique. Bowen believed that optimal family functioning occurs with healthy boundaries or differentiation. Shaping competence is a technique used by structural family therapists when emphasizing the positive behaviors of family members. Positive reinforcement is a behavior modification technique used to increase desired behaviors. Therefore, the correct answer is (D) | counseling skills and interventions |
305 | 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 contacted you to reschedule a session sooner than the one you had originally scheduled. The client reported that he continues to have difficulty getting to work on time and was told that he needs to meet with his supervisor on Friday. The client expresses anxiety surrounding this because he worries about getting fired. The client began to cry during the session when talking about worry regarding being unemployed. The client came to the session in clothes that had stains on them, and his hair was messy and appeared greasy. During the session, the client states, “Why should I even try to get to work on time? I’m just going to get fired anyway | During the session, the client states, “Why should I even try to get to work on time? I’m just going to get fired anyway.” Which one of the following would be the most accurate cognitive distortion to describe this statement? | Labeling | Overgeneralization | Emotional reasoning | Jumping to conclusions | (A): Labeling
(B): Overgeneralization
(C): Emotional reasoning
(D): Jumping to conclusions | Jumping to conclusions | D | This client is jumping to conclusions with this statement because he has deduced what is going to happen with little evidence. This cognitive distortion could negatively affect his work performance. Emotional reasoning involves using a feeling to determine reality, which would not characterize the thinking reflected in his statement. Labeling occurs when an individual makes an evaluation of value based on a situation. Overgeneralization is taking a single experience and applying it to other experiences. Therefore, the correct answer is (D) | counseling skills and interventions |
306 | 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 | Possible stand-alone treatment modalities for Tony to work in with this individual therapist include all of the following except? | Aversion therapy | Sex therapy | CBT | Medication | (A): Aversion therapy
(B): Sex therapy
(C): CBT
(D): Medication | Medication | D | Medication alone will not be effective in treating Tony's symptoms. Medication in conjunction with the other modalities mentioned has been proven effective in treating transvestic disorder. A sex therapist has expertise in this area and may use cognitive behavioral therapy to examine Tony's thoughts which lead him to cross dress. Aversion therapy uses classical conditioning to deter unwanted behaviors. Therefore, the correct answer is (D) | treatment planning |
307 | 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. | What is the first step in collaborating with the school psychologist? | Explain to the parents why expanding the child's continuum of care would be crucial for her treatment. | Email the school psychologist to complete a release of information (ROI) | Request consent from the parents to contact the school psychologist. | Provide the parents with a release of information | (A): Explain to the parents why expanding the child's continuum of care would be crucial for her treatment.
(B): Email the school psychologist to complete a release of information (ROI)
(C): Request consent from the parents to contact the school psychologist.
(D): Provide the parents with a release of information | Request consent from the parents to contact the school psychologist. | C | This allows the client and her parents to decide whether or not to coordinate treatment as well as whether or not confidential information is to be shared. Therefore, the correct answer is (C) | professional practice and ethics |
308 | Client Age: 12 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Private Practice Type of Counseling: Individual Counseling Presenting Problem: Withdrawn and Avoidant Behavior Diagnosis: Undetermined | Mental Status Exam: The client appears oriented to person, place, time, and situation. The client is dressed appropriately for the weather and appears to be maintaining appropriate hygiene. The client was withdrawn for most of the session but was able to open up slightly about what was going on with | You are a licensed therapist working in private practice. A 12-year-old female client comes into your office for the intake session and is accompanied by her parents. The client’s parents report that their daughter has been withdrawn and has refused to return to school for the past 6 school days. The client is avoiding eye contact with anyone and is slouching with her arms crossed. You try to engage the client in open questions to initiate the intake session with her, and she does not answer you or look at you. You ask her if privacy would make her more comfortable, and she nods, so you ask her parents if they would mind waiting in the lobby, and they agree. The client continues to refuse to talk about school, but she does engage in conversation with you about other topics. | You and the client meet 4 days after the initial intake session due to truancy because she has missed several days of school. For about half of the session, the client seems to be withdrawn. She asks you what you are required to report, and you remind her of the limits of confidentiality. The client says that she understands, and then says she is going to talk about what happened anyway. She says that her volleyball coach asked to meet with her after practice about 7 months ago and when she entered his office, he asked to look at her right thigh following a fall during practice. She continues to state that when she showed him, he started to touch her genital area from the outside of her pants. She states that she ran out of the room and went home. She explains that after this event she quit the team and told her parents that she did not want to play anymore, but recently she has started to experience distressing memories of the sexual abuse; she refuses to go to school because she would see the man daily; she has difficulty feeling happiness; and she is experiencing feelings of shame, insomnia, and difficulty concentrating. You praise the client for disclosing this information and empathize with her about how hard it must have been to share this experience. You are having difficulty disconnecting from the session today | You are having difficulty disconnecting from the session today. What is the LEAST helpful self-care technique for you to actively manage your emotions? | Go home and go to sleep. | Seek clinical supervision. | Spend time with friends after work. | Go to the gym and exercise for an hour. | (A): Go home and go to sleep.
(B): Seek clinical supervision.
(C): Spend time with friends after work.
(D): Go to the gym and exercise for an hour. | Go home and go to sleep. | A | Going home and going to sleep may meet physical needs for sleep if work is overwhelming; however, it may not meet your self-care needs because you are having trouble refraining from thinking about your session today. Going to sleep does not deal with the emotions that are present and therefore would not be managing your reaction to the session. Exercise, clinical supervision, and socialization could all be beneficial acts of self-care to help you focus on the present and manage your thoughts regarding your client’s situation. Therefore, the correct answer is (D) | professional practice and ethics |
309 | Client Age: 13 Sex Assigned at Birth: Male Gender: Transgender; Gender Nonconforming (TGNC) Ethnicity: Caucasian Counseling Setting: Child and Family Agency, School-Based Services Type of Counseling: Individual and Family Presenting Problem: Truancy; Gender Dysphoria Diagnosis: Gender Dysphoria, Provisional (F64.1); Social Exclusion or Rejection V62.4 (Z60.4) | Mental Status Exam: The client is dressed in age-appropriate clothing. They wear eye makeup and chipped black fingernail polish, and they have bitten most fingernails down to the quick. The client’s mood is irritable, and they are quick to show anger toward their mother when misgendered. Their thoughts are coherent, and they deny audio/visual hallucinations. The client acknowledges feeling sad and hopeless but denies suicidal ideation. They attribute increased levels of anxiety at school to bullying, particularly with select peers. They explain that a select group of students threaten the client and call them offensive and derogatory names. Family History and History of th | You are a school-based mental health counselor in a public middle school. Your client is a 13-year-old Caucasian 7th grader who presents for the initial intake with their mother. The mother says that the client has had several unexcused absences from school because “he is confused about his gender.” The client adamantly denies being confused and explains that they self-identify as transgender. The client’s preferred pronouns are “they/them.” The client further states that they have had a strong desire to be a different gender since early childhood, and this desire and their distress have recently intensified. The mother reports that the client is chronically irritable, spends a lot of time alone, and has “basically shut everyone out.”The client reports experiencingbullying—both verbal and physical—in school “nearly every day.” In addition to the bullying, the client says that certain teachers refuse to allow them to use the bathroom aligned with their identified gender. To prevent this conflict, the client does not eat breakfast or lunch at school. | The client arrives for the session without her husband. Her affect is flat, and she presents as more subdued. The client explains that she has been in bed for the last 4 days, which has caused escalated conflict and tension with her husband. She says that her husband believes that they are at an impasse and threatened to leave during their fight last night. When processing the details of their altercation, the client states that her fear of being alone has become unbearable. She denies any suicidal plans but says she feels hopeless and void of purpose and is in significant levels of physical pain due to intractable migraines. You conduct a suicide risk assessment to determine the client’s level of safety | You ask the client “What are your reasons for living?” What are you are trying to determine with this question? | The level of marital distress | Protective factors | The appropriate level of care | Religious or spiritual support | (A): The level of marital distress
(B): Protective factors
(C): The appropriate level of care
(D): Religious or spiritual support | Protective factors | B | You are trying to determine the client’s protective factors. Protective factors mitigate suicide risk and include coping skills, social support, religious beliefs, and restricted access to lethal means. The client’s level of marital distress is a risk factor that has already been determined. Religious or spiritual support is one example of a protective factor; however, the question is posed to help determine all protective factors. This question is one of a series of questions posed as part of a suicide risk assessment, which helps guide recommendations for an appropriate level of care (eg, outpatient, inpatient, residential). Therefore, the correct answer is (B) | intake, assessment, and diagnosis |
310 | Client Age: 15 Sex: Female Gender: Female Sexual Orientation: Heterosexual Ethnicity: African American Counseling Setting: Agency Type of Counseling: Individual and Group Presenting Problem: Anxiety Diagnosis: Generalized Anxiety Disorder (GAD) 300.02 (F41.1) | Mental Status Exam: The client is dressed in age-appropriate clothing and is neat in appearance. She is cooperative and, at times, overly compliant with the interview questions, which is exemplified by apologizing unnecessarily for “not answering questions in the right way.” Her eye contact is poor, but she is engaged in the interview process. The client is restless and fidgety, and her tone of voice is soft. She states that she gets between 5 and 6 hours of sleep each night, which makes her irritable at times. Her affect is anxious, and she reports poor concentration. Her excessive worry has resulted in exhaustion and feeling like she is “always playing catch-up” with sleep and schoolwork. She denies any suicidal or homicidal ideations. The client also denies drug or alcohol use. Family History and History of th | You are a counselor working in a child and family outpatient mental health center. Your client is a 15-year-old African American female enrolled in the 10th grade at a predominately white private high school. She presents today with her father, who says she “has not been herself lately.” The client reports that she is under an enormous amount of pressure to excel academically and athletically. She is the number-one ranked player on the varsity tennis team and is in the school’s honors program. The client states that she perseverates the night before a tennis match and worries that her performance will be subpar. She reports excessively practicing her serves and backhands in her spare time because she is constantly dissatisfied with her less-than-perfect performance. The client says that she feels like she doesn’t fit in with her peers, which she attributes to being the only person of color on her tennis team, and one of few in the student body. | The client attends group therapy and is making therapeutic gains. Her overall anxiety has decreased, and she is engaging in more constructive thinking. Today is week 6 out of the 12 scheduled weekly group sessions. The client continues to work on increasing her assertiveness and has become less tentative with self-disclosures. She is pleasant and cooperative but remains eager to please others. Three group participants have formed a subgroup (i\. e., clique) and have excluded others. The client has begun to take social risks, and today she shares about a time when she felt most anxious. You notice the subgroup whispering and laughing after her disclosure. She nervously turns to you to gauge your response | How should you respond to the negative interactions between the client and the members of the subgroup? | Use linking to help the client recognize similar feelings that she experienced in her past. | Evoke universality by asking the client to share how the experience has made her feel. | Impart information by offering your interpretation of the interaction. | Block the negative behavior and reestablish protective norms. | (A): Use linking to help the client recognize similar feelings that she experienced in her past.
(B): Evoke universality by asking the client to share how the experience has made her feel.
(C): Impart information by offering your interpretation of the interaction.
(D): Block the negative behavior and reestablish protective norms. | Block the negative behavior and reestablish protective norms. | D | The best response to the negative interaction is to block the negative behavior and reestablish protective norms. It is important to note that the group is in the storming stage of development. Without group cohesion, the group leader must keep members safe by taking charge and addressing conflict. Reestablishing group norms and rules involves reminders about the group rules, tasks, and purpose. Universality, one of Irvin Yalom’s group therapeutic factors, helps clients feel less alone as they relate to one another’s experiences. This is not achieved by placing pressure on the client to share, particularly as it may relate to experiences of shame. Linking connects group members to foster universality. Groups need to have a here-and-now focus, which would not apply to feelings that the client experienced in the past. Imparting information, also one of Yalom’s therapeutic factors, is not necessarily accomplished by offering your interpretation of the interaction. In doing so, you may risk isolating the client, the subgroup, and other group members. Therefore, the correct answer is (A) | counseling skills and interventions |
311 | 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 explains that she is having difficulty paying for her session and requests to trade the produce she grows in exchange for the cost of her sessions | The client explains that she is having difficulty paying for her session and requests to trade the produce she grows in exchange for the cost of her sessions. All of the following are ethical considerations for bartering, EXCEPT: | Which individual in the counseling relationship initiates the idea of bartering | The possibility of exploitation or harm | Whether this is a common practice in the community | Whether, upon researching and identifying the monetary value of the trade, the costs match the value of therapy | (A): Which individual in the counseling relationship initiates the idea of bartering
(B): The possibility of exploitation or harm
(C): Whether this is a common practice in the community
(D): Whether, upon researching and identifying the monetary value of the trade, the costs match the value of therapy | Whether, upon researching and identifying the monetary value of the trade, the costs match the value of therapy | D | Identifying the match in value between the bartered items or services is not an ethical consideration related to bartering. The ACA Code of Ethics identifies that the important factors to ensure as they relate to bartering include that exploitation or harm does not occur as part of bartering, that the client initiates bartering and not the therapist, and the consideration of whether it is common practice in the community to trade goods or services. Therefore, the correct answer is (C) | professional practice and ethics |
312 | Initial Intake: Age: 29 Gender: Female Sexual Orientation: Heterosexual Ethnicity: Caucasian Relationship Status: In a relationship Counseling Setting: Private practice Type of Counseling: Individual | Taylor presents as well groomed, has good eye contact, and movements are within normal limits. Taylor appears anxious with tense affect and is occasionally tearful. Taylor has no history of suicidal thoughts or behaviors, no reported trauma history and has never been in counseling. | Diagnosis: Adjustment disorder with anxiety (F43.22)
You are a counseling intern working in a private practice with your supervisor and several other interns. Taylor is a 29-year-old college student who was referred to you by her university’s resource center for mental health counseling. Taylor went to them requesting someone to talk to about her family stress. Taylor’s 18-year-old brother has autism and is preparing to go to college in another state, and Taylor is feeling anxious about the transition since he will be leaving home for the first time and their family will not be around to help him. Taylor has been manifesting her anxiety in ways that are causing her difficulty in school and in her relationship, such as trouble concentrating, completing assignments, and lashing out with aggressive reactions towards her parents or her boyfriend whenever they bring up the topic of her brother’s college. She has even yelled at her brother once out of frustration. Taylor is hoping to find ways to cope with her stress and manage her emotions over her family’s decisions. | Family History:
Taylor lives at home with her parents and her brother, and commutes to University for her Bachelor studies. She stayed at home since graduating high school to help her parents with her brother with autism. Her parents had separated on and off for several years because of an affair her mother had, so the house has had tension and instability making Taylor feel responsible to keep her brother on a stable routine. Taylor comments that her brother’s challenges have always “taken up all her time” and that she used to complain about them, but now that he is going to be on his own, she is very upset she will not be able to be there for him. She complains her parents are “flaking out” on her and feels left out of their decision making but does not know what to do about it. | Which of the following scales are not likely to be used in this scenario? | State-Trait Anxiety Inventory (STAI) | Depression Anxiety Stress Scale (DASS) | Beck Anxiety Inventory (BAI) | Hamilton Anxiety Rating Scale (HARS) | (A): State-Trait Anxiety Inventory (STAI)
(B): Depression Anxiety Stress Scale (DASS)
(C): Beck Anxiety Inventory (BAI)
(D): Hamilton Anxiety Rating Scale (HARS) | Depression Anxiety Stress Scale (DASS) | B | The DASS measures the structure of negative emotional states and addresses both depression and anxiety. While a counselor may benefit from information provided in any instruments used, there was no noted depression in Taylor's case making this option the least helpful choice. On the NCMHCE, it is best to focus only on symptoms provided leading you to address the listed diagnosed condition. The BAI is a brief, self-report assessment for measuring anxiety and its severity level. The HARS helps detect the extensiveness of anxiety using clinical ratings to help better understand individuals with already diagnosed conditions. The STAI is used to measure trait and state anxiety differentiate for depression symptoms and has been used in research as an indicator of caregiver distress. Any of these would be useful at some point in Taylor's counseling process. Therefore, the correct answer is (D) | intake, assessment, and diagnosis |
313 | Initial Intake: Age: 28 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Married Counseling Setting: Private Practice Type of Counseling: Couple | The couple appear to be their stated ages with positive signs of self-care related to hygiene and dress. Both individuals appear overweight for height, and John appears to visually be categorizable as obese. Both individuals presented with congruent affect to their stated moods. Neither demonstrated retardation, spasticity, or hyperactivity of motor activity. The couple present as cooperative, open, and forthcoming, though each frequently looks at the other and confirms that the information they are presenting individually is accurate. Jane is noted to be caregiving of and highly empathetic to John. John is noted to respond appropriately to Jane’s statements. Neither presents with reports of suicidal ideations, thoughts of harm to self or others, or difficulties with memory, judgement, or concentration. | You are a counselor in a private practice setting. Your client, Jane, is 28 years old and presents with her spouse, John, a 24 year-old Hispanic male for “problems communicating.” The couple report that they have been married for one year after cohabitating for one year prior to marriage. Immediately after their marriage they began trying to become pregnant. They state they sought help from a specialist after several months and on learning that some degree of infertility existed, Jane began hormone therapy. Jane notes that it was soon after this time that the communication problems between them began. She tells you that it was at this point that she and John realized that they may not be able to have a biological child together. John acknowledges that Jane has tried many times over the last year to bring up this topic for discussion, but he chooses not to engage her. He tells you that he tends to believe that “if I don’t think about it, it will probably go away.” Jane agrees with John and reports that over time, the couple have talked less and spend much less time together. John agrees and says that sometimes “I may not say more than five words to Jane in a day.” Jane reports that they have not been intimate in over two months. When completing the intake paperwork, John endorsed no problems on any symptom criteria. Jane reported “serious” problems with “feeling sad, loss of interest in things she previously enjoyed, crying spells, and stress. She reported “moderate” problems with “feelings of worthlessness, anxiety, loss of appetite, and sleep disturbance. The couple states they were to sign divorce papers last week but made the decision to try counseling first. Neither has participated in counseling previously. | Family History:
The couple currently live with Jane’s 10 year-old son from her previous marriage and Jane’s 75 year-old grandfather, for whom the couple provide care. Jane owns and operates a small shop, is completing her bachelor’s degree, cares for her grandfather, and parents her son, who is heavily involved in baseball. She describes a history of hypothyroid disease though is no longer taking medication as her disease is now controlled with diet and exercise. She reports taking an antidepressant for two years, approximately seven years ago. She currently is taking Provera and Clomid for infertility and states these have had a noticeable effect on her mood. John reports this is his first marriage and he has no children from prior relationships. He was laid off two years ago and has been working in his uncle’s business, but the family has no insurance. He is actively involved in caring for Jane’s son and grandfather. He reports a history of high blood pressure. Prior to their wedding, John states he experienced irritability, agitation, difficulty sleeping due to “thinking about things” and worry. He was prescribed an SSRI and took this for six months. He tells you it seemed to help but he discontinued it 8 to 9 months ago. He reports that his doctor said his anxiety might have been because of his high blood pressure. | Considering the information provided, which question should the counselor ask John? | What are his family's views on having a child? | How much does John enjoy working for his uncle? | What does John do for stress relief? | How strong is John's relationship with Jane's family? | (A): What are his family's views on having a child?
(B): How much does John enjoy working for his uncle?
(C): What does John do for stress relief?
(D): How strong is John's relationship with Jane's family? | What are his family's views on having a child? | A | Hispanic cultures tend to be family oriented and this may influence how John views a diagnosis of infertility and the potential inability to have a biological child. This is an important question for the counselor and John to discuss. Questions about how John reduces stress can help the counselor work with John on healthy living practices, but is not specific to the issue of problematic communication due to infertility. The strength of John's relationship with his wife's family and his work satisfaction are all important questions when getting to know the client, but are not directly related to the presenting issue of decreased communication and intimacy related to infertility. Therefore, the correct answer is (B) | intake, assessment, and diagnosis |
314 | Client Age: 13 Sex Assigned at Birth: Male Gender: Transgender; Gender Nonconforming (TGNC) Ethnicity: Caucasian Counseling Setting: Child and Family Agency, School-Based Services Type of Counseling: Individual and Family Presenting Problem: Truancy; Gender Dysphoria Diagnosis: Gender Dysphoria, Provisional (F64.1); Social Exclusion or Rejection V62.4 (Z60.4) | Mental Status Exam: The client is dressed in age-appropriate clothing. They wear eye makeup and chipped black fingernail polish, and they have bitten most fingernails down to the quick. The client’s mood is irritable, and they are quick to show anger toward their mother when misgendered. Their thoughts are coherent, and they deny audio/visual hallucinations. The client acknowledges feeling sad and hopeless but denies suicidal ideation. They attribute increased levels of anxiety at school to bullying, particularly with select peers. They explain that a select group of students threaten the client and call them offensive and derogatory names. Family History and History of th | You are a school-based mental health counselor in a public middle school. Your client is a 13-year-old Caucasian 7th grader who presents for the initial intake with their mother. The mother says that the client has had several unexcused absences from school because “he is confused about his gender.” The client adamantly denies being confused and explains that they self-identify as transgender. The client’s preferred pronouns are “they/them.” The client further states that they have had a strong desire to be a different gender since early childhood, and this desire and their distress have recently intensified. The mother reports that the client is chronically irritable, spends a lot of time alone, and has “basically shut everyone out.”The client reports experiencingbullying—both verbal and physical—in school “nearly every day.” In addition to the bullying, the client says that certain teachers refuse to allow them to use the bathroom aligned with their identified gender. To prevent this conflict, the client does not eat breakfast or lunch at school. | The couple acknowledge some improvement with communication, but they continue to feel significant levels of relationship distress. The client has been asking for what she needs, mainly when she is in pain and functionally limited, but she reports that the husband continues to do little to support her. The husband reiterates that he has a demanding job that depletes his energy and that he has little to give when he gets home at night. The husband’s child has been verbally abusive to the client, and her husband minimizes her concern. The client feels “stuck in the middle” when determining her stepson’s schedule and activities. The client states that her husband’s bitter ex-wife makes her new role as stepparent “nearly impossible.” To help with the postdivorce adjustment and lessen conflict, you provide information on local support groups, parent education programs through family court, and additional educational resources | The client states, “His ex-wife makes coparenting nearly impossible, and he continues to do absolutely nothing about it!” You state, “Can you turn to him and tell him what that is like for you?” What are you trying to accomplish with your request? | Increase change talk by reducing ambivalence. | Assess for transference and countertransference. | Help him “mirror” back the emotional content. | Create new experiences of emotional attachment. | (A): Increase change talk by reducing ambivalence.
(B): Assess for transference and countertransference.
(C): Help him “mirror” back the emotional content.
(D): Create new experiences of emotional attachment. | Create new experiences of emotional attachment. | D | You are hoping to create new experiences of emotional attachment. Emotionally focused couples therapy uses enactments to counterbalance negative interactions, uncover underlying vulnerabilities, and develop emotional attunement. Enactments increase awareness of emotional attachment by encouraging couples to engage with one another directly. Counselors using emotionally focused couples therapy enactments first work to identify the couple’s negative patterns of interaction. Counselors then help couples safely address vulnerabilities to create secure bonds with one another. Creating change talk by reducing ambivalence is a motivational interviewing technique. Although it is helpful to assess readiness for change with the couple, this is not accomplished by using enactments. Transference and countertransference are not present in this interaction. The technique of mirroring is used in imago couples therapy. Therapists use mirroring to encourage the message receiver to paraphrase or mirror back exactly what was conveyed by the message sender. Therefore, the correct answer is (A) | counseling skills and interventions |
315 | 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. | 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. | Which assessment tool would you use to conduct a comprehensive evaluation of the client's current cognitive and emotional functioning? | Beck Depression Inventory (BDI) | Luria-Nebraska Neurological Battery (LNNB) | Mental Status Examination (MSE) | California Psychological Inventory (CPI) | (A): Beck Depression Inventory (BDI)
(B): Luria-Nebraska Neurological Battery (LNNB)
(C): Mental Status Examination (MSE)
(D): California Psychological Inventory (CPI) | Mental Status Examination (MSE) | C | The MSE is used to evaluate an individual's current psychological functioning. It assesses the individual's overall appearance, behavior, intellectual abilities, cognitive functions, and thought processes. It can also provide insight into the individual's mood, affect, memory, and insight. Therefore, the correct answer is (D) | intake, assessment, and diagnosis |
316 | Name: Tony Clinical Issues: Feeling alone and disconnected from children Diagnostic Category: V-codes Provisional Diagnosis: Z60.0 Phase of Life Problem Age: 66 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: White Marital Status: Divorced Modality: Individual Therapy Location of Therapy : Private Practice | The client is well dressed and well-groomed. He appears healthy for his stated age. Speech flow is normal, and eye contact is appropriate. The client is cooperative with adequate rapport. His thought process is logical. He expresses feeling angry, "even though there is nothing to be angry about." You do not observe any physical evidence of anger. When asked to describe a time when he felt angry recently, he mentions a road rage incident. His affect is more sad than angry. | First session You are a licensed mental health professional working in a private practice setting. The client is a 66-year-old male who is returning to therapy with you. When he called to schedule the appointment, he asked if he could meet with you for dinner beforehand and offered to pay. He presents for his session today, reporting that he has been experiencing what he labels "anger," but he cannot figure out where these feelings are coming from. He says he often talks to himself and ruminates over problems to find solutions. He is seeking your help to improve his relationship with his children. He felt that working with you in the past was helpful, and now that his children are all adults and he is financially secure, he has the time and resources to spend with them. The client has a history of difficulty in forming and maintaining meaningful relationships, particularly with his children. He has a history of conflict with them and has difficulty with communication and boundaries. He has had difficulty constructively expressing his feelings and has frequently resorted to outbursts of anger and aggression. He has had difficulty positively expressing his needs and has often felt overwhelmed and frustrated by his inability to be heard or understood. The client also has difficulty with impulse control and self-regulation, contributing to his difficulty managing his anger. He has frequently engaged in self-destructive behaviors to manage these feelings and has had difficulty finding effective coping strategies to control his emotions. He has also reported a pattern of avoidance, in which he avoids or withdraws from difficult situations rather than confront them. At the end of today's session, the client asks if he can go ahead and schedule therapy appointments with you every Tuesday for the next month so that he is "guaranteed" a spot. You can accommodate his request and plan to see him again in one week. | null | What method might you use initially to address the client's desire to improve his relationship with his children? | Construct a Genogram | Engaging in a role-play exercise | Examining the family constellation | Beginning family therapy | (A): Construct a Genogram
(B): Engaging in a role-play exercise
(C): Examining the family constellation
(D): Beginning family therapy | Engaging in a role-play exercise | B | Role-playing allows clients to identify their feelings surrounding a given situation while simultaneously learning how others may feel. These exercises also help clients learn to apply words to their feelings and more successfully navigate any interactions they may have with others. Therefore, the correct answer is (B) | counseling skills and interventions |
317 | 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. | What do you identify as a significant barrier to the client achieving her stated goal of getting A's in all classes? | The client's level of engagement in classes | The client's relationship with her parents | The client's medical history | The client's substance use history | (A): The client's level of engagement in classes
(B): The client's relationship with her parents
(C): The client's medical history
(D): The client's substance use history | The client's level of engagement in classes | A | The client describes the classes as boring, indicating that her level of engagement in the assignments may be a barrier to achieving her stated goal. Therefore, the correct answer is (C) | counseling skills and interventions |
318 | Name: Rick Clinical Issues: Referred for emotional and behavior issues Diagnostic Category: No Diagnosis Provisional Diagnosis: No Diagnosis Age: 18 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: Korean Marital Status: Single Modality: Group Therapy Location of Therapy : Community Center | The client is slouched over in his seat and appears withdrawn with a flat affect. He keeps his head down. The client plays with his shirt sleeve, twisting the material and pulling at it. You cannot see any cuts on his arms as reported by the mother. He does not appear to be angry at this time, which was also a symptom reported by his mother. He responds to your questions with one-word answers. He seems uninterested. The client denies any suicidal and homicidal ideation. The client mumbles, "I don't want to talk about anything here." | First session You work as both an individual and group therapist at a community center that primarily sees adolescents with emotional and behavioral issues. Rick is a senior in high school and lives with his mother and two sisters. Rick does not want to participate in individual or group therapy, but his mother insists that he get help. During the intake, you work to establish rapport with Rick. You also gather information to determine if he is an appropriate candidate for one of the groups you are preparing to start, along with a co-facilitator. You suspect he may have trouble trusting females as he expresses anger when talking about his mother, sister, and ex-girlfriend. Since his father left, Rick says that his mother has been "in his business" all the time, and he does not feel like he has any real privacy. You remain patient with Rick, listening to his story and validating his feelings. You empathize with him, letting him know it is understandable to feel frustrated about not having much privacy. You explain that you are here to help him, not to control him and that you are interested in learning more about him. You explain to Rick that you are planning to start a group therapy session with a co-facilitator and that you would like to see if it would be a good fit for him. You explain that the group will provide an opportunity for him to talk about his experiences in a safe space with others who may have gone through similar situations In addition, you share that it could be an excellent way for him to practice expressing himself and developing trust in others. You also explain to Rick that individual therapy sessions could be beneficial in addition to group therapy. You discuss the possibility of one-on-one sessions that would give him a chance to talk more deeply about his experiences in a safe, private setting You emphasize that this could be an excellent way for him to explore his feelings and learn how to cope with them in a healthy way. | The client is a first-generation American whose parents immigrated from Korea. He has an old sister who, based on Korean culture, is his superior whom he must obey and be subservient to. His parents have high expectations for him and are very controlling, expecting him to study every night and attend tutoring sessions on the weekend. They have arranged for him to marry a daughter of a prestigious family in Korea after he completes medical school eight years from now, with the intention that he and his wife will live with them and provide financial support. However, this plan has drastically changed. Seven months ago, the client's father moved out after his mother had an affair. The client became sullen, angry, and withdrawn after this event. Four months ago, while doing laundry, the client's mother saw dried blood on his shirt sleeve. She also noticed that he was wearing long-sleeved shirts all the time. She waited until he was getting dressed, walked in on him, and found he had cuts up and down his arms. The client does not speak to his father much since his parents separated. The client expresses a lot of anger toward the women in his life, specifically his mother, sister and ex-girlfriend. The client is a senior in high school. His grades have been suffering lately, and he is currently failing his math and science classes. Personal/Social Relationships: The client had been concealing his romantic relationship with a girl from his Saturday tutoring class, but following his father's abrupt departure from the family, he chose to discontinue the relationship and cease attending the class. He has since refrained from any communication or contact with her. His mother's affair has caused him to feel overwhelmed with anger, leading him to develop a dislike of all women. | Given his presenting issues, which initial theoretical approach would work best with Rick? | Psychoanalytic therapy | Gestalt therapy | Behavioral therapy | Narrative therapy | (A): Psychoanalytic therapy
(B): Gestalt therapy
(C): Behavioral therapy
(D): Narrative therapy | Gestalt therapy | B | Gestalt therapy would be appropriate for this client as the main goal of this approach is to unlock blocked feelings. Gestalt therapy targets anger, grief, anxiety, and depression. The client has expressed anger toward the women in his life, has trust issues, is withdrawing, and is engaging in self-harming behaviors, all of which make Gestalt an ideal approach to use. Therefore, the correct answer is (C) | counseling skills and interventions |
319 | Initial Intake: Age: 42 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Hispanic Relationship Status: Married Counseling Setting: Private Practice Type of Counseling: Individual | The client appears her stated age and is dressed appropriately for the circumstances. She identifies her mood as “somewhat anxious” and her affect is labile and congruent. She is noted to rub her hands together at times and she appears uncomfortable at times as she talks about herself. She demonstrates good insight, appropriate judgment, memory, and orientation. She reports no history of trauma, suicidal thoughts, or harm towards others. | You are a non-Hispanic counselor in a private practice setting. Your client is a 42 year old female who reports that she has been working for the same accounting firm for 10 years and was recently laid off due to a downturn in the economy. She tells you that prior to this firm, she worked in a company doing managerial accounting that she joined right after college. She says that she has liked the people that she has worked with but over the past several years she has enjoyed her work less and less. She reports that she is upset to have lost her job but, in some ways, she sees it as an opportunity to find something else she is more passionate about, but she has no idea where to start. She does say that she wants a job and work environment that is a better fit for her personality. She also tells you that she is afraid that she is too old to begin again or that she doesn’t have “what it takes” to begin a new career. | Family History:
The client reports no significant family history related to mental health issues or relationship problems. The client tells you that she chose accounting in college because she grew up in a small town and her parents told her that she needed a skill that would help her support herself. Additionally, she states that she has been married for 19 years and has a good relationship with her spouse. She tells you that he is supportive of her exploring new careers but that her income is helpful for the family and it is important that she works. | Which of the following will be least helpful for the client in managing her stress or panic? | Closing eyes and breathing slowly through her nose | Find one object to focus on while breathing slowly | Avoid places and situations that trigger her stress or panic | Using a grounding technique to remind herself that she is safe | (A): Closing eyes and breathing slowly through her nose
(B): Find one object to focus on while breathing slowly
(C): Avoid places and situations that trigger her stress or panic
(D): Using a grounding technique to remind herself that she is safe | Avoid places and situations that trigger her stress or panic | C | Avoiding places and situations that trigger stress or panic do not help the client to manage her emotions and instead may create more fear of those triggers. Instead, it is helpful for clients to either close their eyes and breathe slowly through the nose to control hyperventilation, or to find one object to focus on while breathing slowly. Noticing everything possible about the object helps the client to distract her mind from her panic and allows her to regain control. Using a grounding technique such as 3 things I can see, 3 things I can feel, and 3 things I can hear allows the client to distract themselves from their anxiety or panic and allows them to separate themselves from their heightened emotions. Therefore, the correct answer is (C) | intake, assessment, and diagnosis |
320 | Client Age: 9 Sex: Male Gender: Male Sexuality: Unknown Ethnicity: Caucasian Relationship Status: Not Applicable Counseling Setting: School Type of Counseling: Individual Presenting Problem: Severe Temper Outbursts Diagnosis: Disruptive Mood Dysregulation Disorder (DMDD), Provisional (F34.81) | Mental Status Exam: The client’s affect is irritable and angry. He sits with his arms crossed and exhibits poor eye contact. His appearance is somewhat disheveled. Mother reprimands the client multiple times, requesting that he “sit up straight” and “answer the lady’s questions.” The client mumbles responses at his mother’s prompting and is otherwise minimally engaged. The client reports that he “gets mad” daily and feels unjustly “blamed for everything.” His motor activity is somewhat fidgety. Speech and language skills are developmentally appropriate. The client states he “sometimes” feels sad and denies feeling worried or scared. His appetite is good and his sleep is poor. The mother attributes his sleep difficulties to the client staying up late playing video games. | You are a school-based mental health clinical counselor conducting an initial intake evaluation. A 9-year-old 3rd-grade male is accompanied by his mother, who reports that the client has been in several school and neighborhood altercations. She states she is at her “wit’s end” with him and is about to lose her job due to constant calls from his school. The client’s teacher reports that the client has daily temper outbursts, and his mother says that his mood is irritable for most of the day, every day. The client was recently suspended from school for flipping over his desk when his teacher told him he lost recess privileges. The mother first noticed these behaviors when her son was in kindergarten. The client recently kicked a hole in his wall after losing a video game. His grades are poor, and the school is currently evaluating him for special education services. The client was reluctant to take part in the intake. He shrugged his shoulders when asked if he would agree to participate in counseling. | History of Condition: The client’s milestones were all developmentally appropriate; he was walking at ten months, toilet trained by 24 months, and speaking in complete sentences at almost 30 months. The mother describes the client as “moody” beginning in kindergarten. His temper outbursts began to escalate in intensity and duration within the last few years. During this time, there were no known associated stressors. The mother reports that the client has always had a hard time following directions and difficulty complying with authority figures. Family History: The client has two maternal half-brothers, ages 18 and 20, and has positive relationships with both of them. His parents divorced when the client was three years old, and the mother has physical custody of the child\. Before the divorce, the client witnessed verbal and physical altercations between his parents. The client’s father visits periodically, and he has been in and out of substance abuse treatment centers for most of the client’s life. When angry with his mother, the client tells her he wishes he could live with his father. The client’s maternal grandmother is diagnosed with bipolar disorder, and the client’s mother states she struggles “off and on” with depression. Aside from the father’s substance use disorder, a paternal history of mental illness is unknown | Which of the following would best help create a therapeutic alliance with this client? | Helping the client master coping skills he can successfully apply when feeling angry | Using core facilitative conditions, such as reflection and validation | Demonstrating universality to minimize transference and instill hope | Sharing the treatment plan with the client to establish clear expectations | (A): Helping the client master coping skills he can successfully apply when feeling angry
(B): Using core facilitative conditions, such as reflection and validation
(C): Demonstrating universality to minimize transference and instill hope
(D): Sharing the treatment plan with the client to establish clear expectations | Using core facilitative conditions, such as reflection and validation | B | The use of humanistic, person-centered responses, including reflection and validation, significantly influence the therapeutic alliance. Helping the client to master coping skills to apply when he is feeling angry is an appropriate counseling intervention but is less likely to contribute to creating a therapeutic alliance. Including the client in the treatment planning process, rather than solely sharing the completed treatment plan, helps build and strengthen the therapeutic alliance. Presenting the client with a menu of goals and objectives is one way to include a child in developing a treatment plan. Universality and the installation of hope, part of Irvin Yalom’s curative factors, are therapeutic experiences associated with group therapy; these factors are not associated with minimizing transference. Therefore, the correct answer is (C) | counseling skills and interventions |
321 | Initial Intake: Age: 35 Gender: Male Sexual Orientation: Heterosexual Ethnicity: African American Relationship Status: Divorced Counseling Setting: Community Mental Health Center Type of Counseling: Individual | Davone presents as well-groomed, of fair hygiene and motor movements are within normal limits. Davone makes decent eye contact throughout session. Speech tone and rate are normal. Thought process unremarkable. Denies SI/HI. Davone becomes tearful when he recalls past family information, sharing that his father was never around for him for the same reasons he is not around for his family. Davone frequently refers to his racial background and where he grew up, becomes angry as evidenced by tense expression, furrowed brow, and clenched fists, and then self-soothes without prompting by taking a deep breath and moving forward in conversation. When asked, Davone tells you he learned those skills in past anger management classes he was mandated to take years ago. | Diagnosis: Adjustment disorder with mixed disturbance of emotions and conduct (F43.25) Provisional, Problems related to other legal circumstances (Z65.3)
Davone is referred to you by his probation officer after being mandated by the court to undergo weekly emotional and behavioral health counseling sessions for a minimum of 9 months or until his next court hearing is scheduled, whichever is sooner. Davone’s Medicaid insurance cover his sessions. The probation officer tells you Davone is undergoing sentencing for violating his probation and restraining orders put in place by his ex-wife, which render him unable to set foot on their property or visit with his children (twin boys, age 9, and girl, age 4). In the initial assessment, Davone shares that he has had run-ins with the criminal justice system for most of his life “just like his father” and that he fears a lifetime of being in prison and not being able to be there to watch his kids grow up. Davone tells you he will do anything to get out of his situation and return to having a life where he can continue going to work and providing for his children. | Legal and Work History:
You learn from Davone’s referral paperwork that Davone’s legal record extends back to age 9 when he was first beginning to show signs of conduct at school. Davone was often sent to the “recovery room” in elementary school for aggressive outbursts and defiance towards teachers. He has a record with the Juvenile Justice System for breaking rules and truancy in middle and high school. After age 18, he was arrested several times for misdemeanors of vandalism, shoplifting and reckless driving. He then married and became employed full-time by age 25, where he did not get into trouble with the law again until age 31 when he got fired for stealing from his company. This caused marital discord and led to Davone’s divorce two years ago. Davone has had a continued string of misbehavior, arrests, and short-term jail stays ever since. Davone adds that his ex-wife accused him of consistently endangering her and the kids without caring, which is why she got the restraining order. He disagrees with her, saying “I would never harm my kids.” | What aspect of Rational Emotive Behavioral Therapy (REBT) would be useful for Davone? | Resolving cognitive distortions and underlying emotional disturbances | Learning unconditional self-acceptance | Reducing secondary disturbance behaviors | Framing anger as unhealthy and inappropriate | (A): Resolving cognitive distortions and underlying emotional disturbances
(B): Learning unconditional self-acceptance
(C): Reducing secondary disturbance behaviors
(D): Framing anger as unhealthy and inappropriate | Resolving cognitive distortions and underlying emotional disturbances | A | REBT posits that you uproot your absolutistic demands in order that cognitive distortions get corrected. Cognitive distortions are part of what prevents Davone from addressing his root issues. REBT highlights how secondary disturbances have a negative effect on behavior (feeling anxious about appearing anxious or worrying about having too much worry) however they do not seem to be present in Davone's situation. While Davone learning self-acceptance is a positive and healthy step for his well-being, he is currently undergoing severe consequences for his illegal and destructive behaviors so using a strategy that avoids inherent change can backfire. REBT also considers anger as a negative emotion (as opposed to CBT that considers some anger as healthy), but invalidating Davone's only complaint about being angry over not having his children can be harmful to your therapeutic relationship and is not realistic. Therefore, the correct answer is (B) | counseling skills and interventions |
322 | Name: Tony Clinical Issues: Feeling alone and disconnected from children Diagnostic Category: V-codes Provisional Diagnosis: Z60.0 Phase of Life Problem Age: 66 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: White Marital Status: Divorced Modality: Individual Therapy Location of Therapy : Private Practice | The client is well dressed and well-groomed. He appears healthy for his stated age. Speech flow is normal, and eye contact is appropriate. The client is cooperative with adequate rapport. His thought process is logical. He expresses feeling angry, "even though there is nothing to be angry about." You do not observe any physical evidence of anger. When asked to describe a time when he felt angry recently, he mentions a road rage incident. His affect is more sad than angry. | First session You are a licensed mental health professional working in a private practice setting. The client is a 66-year-old male who is returning to therapy with you. When he called to schedule the appointment, he asked if he could meet with you for dinner beforehand and offered to pay. He presents for his session today, reporting that he has been experiencing what he labels "anger," but he cannot figure out where these feelings are coming from. He says he often talks to himself and ruminates over problems to find solutions. He is seeking your help to improve his relationship with his children. He felt that working with you in the past was helpful, and now that his children are all adults and he is financially secure, he has the time and resources to spend with them. The client has a history of difficulty in forming and maintaining meaningful relationships, particularly with his children. He has a history of conflict with them and has difficulty with communication and boundaries. He has had difficulty constructively expressing his feelings and has frequently resorted to outbursts of anger and aggression. He has had difficulty positively expressing his needs and has often felt overwhelmed and frustrated by his inability to be heard or understood. The client also has difficulty with impulse control and self-regulation, contributing to his difficulty managing his anger. He has frequently engaged in self-destructive behaviors to manage these feelings and has had difficulty finding effective coping strategies to control his emotions. He has also reported a pattern of avoidance, in which he avoids or withdraws from difficult situations rather than confront them. At the end of today's session, the client asks if he can go ahead and schedule therapy appointments with you every Tuesday for the next month so that he is "guaranteed" a spot. You can accommodate his request and plan to see him again in one week. | null | What would you consider as a short-term goal for this client? | Identify his emotions | Develop positive relationships with his children | Identify his Eriksonian stage of development | Reduce alcohol use | (A): Identify his emotions
(B): Develop positive relationships with his children
(C): Identify his Eriksonian stage of development
(D): Reduce alcohol use | Identify his emotions | A | You noted in the Mental Status Exam that the client talked about feeling angry, but his affect appeared sad. Helping the client to identify his emotions is an appropriate short-term goal and a good place to start with this client. Therefore, the correct answer is (B) | treatment planning |
323 | Initial Intake: Age: 65 Gender: Male Sexual Orientation: Heterosexual Race/Ethnicity: Caucasian Relationship Status: Married Counseling Setting: Inpatient detox facility Type of Counseling: Individual | William presents as irritable and quite anxious with congruent strained affect. William is casually dressed and with good hygiene. William’s rate and tone of speech are normal with motor movements appearing tense and agitated as evidenced by shifting of position and frequent crossing of arms. William avoids eye contact the entire visit. William denies any depression however his chart indicates that he reported having a history of depression with suicidal thoughts. He says, “Only God can judge me, and I know where I’m goin’ so I don’t have any worries about whether I go now or later.” You then notice in his intake he identified as Christian with active faith-based beliefs. He repeats several times that he plans to leave as soon as he meets with the doctor later today and receives “medical clearance” saying “I can’t stay the whole three weeks it’s just not possible, not going to happen.” | Diagnosis: Alcohol dependence (F10.20), Major depressive disorder, single episode, unspecified (F32.9)
You are a mental health counseling intern providing brief crisis intervention and counseling support for patients admitted to a substance use rehabilitation facility at the detox-level of care. Your clinical director schedules William to meet with you on his first Monday morning after being admitted the Friday night before for alcohol dependency. William tells you he had a “medical issue” last week that “freaked his wife out” and she said she would “kick him out of the house” if he did not come to your program. He notes that he has been drinking their entire marriage and does not understand why it is suddenly such an issue for her, but that he would have “nowhere to go” otherwise so he conceded to coming in. You learn from the overnight staff nurse that William had several bouts of delirium and vomiting with tremors over the weekend, and one instance of a seizure which required emergency interventions to have him stabilized. You ask what “medical issue” he was referring to and she tells you that his chart indicates he had a heart attack. William interjects, saying “She thought I had a stroke, but it wasn’t that big a deal I just had some bad indigestion.” He is now on a benzodiazepine regimen to help regulate his symptoms and stabilize his mood throughout his detox process until he can report a reduction in anxiety and be seen by the weekday psychiatrist. | Work History:
William has worked has a construction company manager for almost 30 years until just before reaching retirement he was let go due to COVID-related company downsizing. He attempted to file a legal case against his company for wrongful actions that would in William’s words “rob him of his hard-earned retirement” however they cited his daily alcohol use on the job as an additional reason he was fired. He was informed due to his longevity with the company that they would offer him a generous severance package and not pursue administrative actions against him for breaking company policies. He adds that he was not planning on stopping working when retiring from his company, saying “I’m too young to just stop. I was going to start my own business.” He also retorts that no one calls him William but his wife and insists that you call him “Bob.” | While conducting a lifetime C-SSRS, Bob admits to having active suicidal thoughts and breaks down in front of you. After guiding him through a few deep breaths and offering comforting support, you update his chart. Which factors should you have assessed prior to completing the assessment? | frequency and severity of active thoughts | if method and plan exist | history, frequency, severity, method, plan | history and past behaviors | (A): frequency and severity of active thoughts
(B): if method and plan exist
(C): history, frequency, severity, method, plan
(D): history and past behaviors | history, frequency, severity, method, plan | C | If this is the first C-SSRS you are completing with a client, it is assumed you will address a client's life history of thoughts and behaviors prior to assessing recent events. Then you must assess the client's ideation of method of suicide and if they have taken steps towards planning. Addressing the frequency of the thoughts as well as their severity using rating scales is significant in understanding level of debilitation and risk. Therefore, the correct answer is (B) | intake, assessment, and diagnosis |
324 | 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 | Risk factors for generalized anxiety disorder include? | Childhood experiences of physical and sexual abuse | History of separation anxiety | Genetic loading | Respiratory disturbance | (A): Childhood experiences of physical and sexual abuse
(B): History of separation anxiety
(C): Genetic loading
(D): Respiratory disturbance | Genetic loading | C | One third of the risk of developing general anxiety disorder is genetic. The other two thirds are a combination of temperamental and environmental factors. Respiratory disturbance is associated with panic disorder, as well as reports of negative childhood experiences such as physical and sexual abuse. There is no evidence that a history of separation anxiety can lead to generalized anxiety disorder later in life. Therefore, the correct answer is (A) | intake, assessment, and diagnosis |
325 | 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. After you finish talking with the client’s parents, you decide to go to the living room where the client is | After you finish talking with the client’s parents, you decide to go to the living room where the client is. What would assist you in building rapport with this client? | Engage the client in talking about the video game he is playing or play the game with him. | Encourage the client to return to the home office where the session was taking place. | Initiate a conversation about sports with the client to find a common interest. | Continue the intake session in the living room with the client because he seems more comfortable here. | (A): Engage the client in talking about the video game he is playing or play the game with him.
(B): Encourage the client to return to the home office where the session was taking place.
(C): Initiate a conversation about sports with the client to find a common interest.
(D): Continue the intake session in the living room with the client because he seems more comfortable here. | Engage the client in talking about the video game he is playing or play the game with him. | A | The client is resistant to the therapeutic process or is uninterested. The client may respond well to you showing interest in the game that he is playing because it is his preferred activity and topic. Although it may not feel therapeutic or clinical to talk about video games, this meets the client’s developmental needs to talk about or engage in preferred activities or play. Sports may create further conversation, but it cannot be assumed that the client enjoys sports, nor is establishing common interests a priority in the therapeutic relationship. Encouraging the client to return to the office or to continue the session in the living room may not be fruitful because the client is clearly uninterested in therapy at this moment. Therefore, the correct answer is (B) | counseling skills and interventions |
326 | 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. | ully. Family History: Several clients report coming from a single-parent home, whereas others are from a two-parent home. All clients report that they have siblings. Several clients reported having parents that were or are involved in the justice system | Which of the following would be the most appropriate short-term goal in the next month for the group? | The group will demonstrate the effective use of anger management strategies. | The group will build trust and cohesion. | The group will use assertive communication skills. | The group will demonstrate empathy in the group setting. | (A): The group will demonstrate the effective use of anger management strategies.
(B): The group will build trust and cohesion.
(C): The group will use assertive communication skills.
(D): The group will demonstrate empathy in the group setting. | The group will build trust and cohesion. | B | The group would most benefit from building trust and cohesion at this point in counselingbecause the correctional setting often encourages individuals to refrain from disclosure due to the fear of being targeted. Assertive communication skills, anger management strategies, and demonstrating affection will all be longer term goals as they work to develop these skills and implement them. Therefore, the correct answer is (A) | treatment planning |
327 | 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. Sixth session The wife presents for today's session without her husband. She reports that two nights ago, he was taken to the emergency room for pain. He had been drinking, and test results at the hospital liver indicated that his liver functioning was impaired. He continues to deny that he is drinking, but she knows this is untrue as she has been finding half-full liquor containers hidden around the house. She starts to cry, "I don't know what I will do without him. I had to call a babysitter and get a cab to come here. I'm worried about how I'll pay for the mortgage if my husband can't work. We'll end up losing the house and our health insurance! I'm going to have to sell off everything to make ends meet!" You respond to her fears with empathy and understanding. You are respectful of the client's thoughts and feelings and seek to understand her experience. You also explore the cognitive error that your client has made and how this is affecting her emotions. You continue the session by asking her what her most immediate concerns are at the moment and what she needs help with. She pauses for a moment and then starts to explain how she is feeling overwhelmed by the situation and feeling helpless in being able to help her husband. She expresses a lot of fear and anxiety about her family's financial security and the potential loss of the house and health insurance if her husband's drinking continues. She expresses a need for support and understanding and worries about how she will cope without her husband. She feels isolated and alone, stating, "I feel like my worst nightmare has come true. I've been worrying about my husband's drinking for a long time. I've heard horror stories about how addiction can ruin people's marriages, and I don't want that for us. I know it's hard for him, but it's hard for me, too." You offer her some resources that could help her with her financial situation and ask her to put together a list of a few people she feels she can talk to for emotional support. | 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. | What would you say to demonstrate a nonjudgmental stance towards the wife? | "It must be hard for you to watch your husband struggle with his addiction." | "It sounds like you're making many assumptions about what could happen in the future." | "It sounds like you're really struggling right now." | "You mentioned that your husband's drinking issues have been present for a long time. You must be feeling really frustrated with him." | (A): "It must be hard for you to watch your husband struggle with his addiction."
(B): "It sounds like you're making many assumptions about what could happen in the future."
(C): "It sounds like you're really struggling right now."
(D): "You mentioned that your husband's drinking issues have been present for a long time. You must be feeling really frustrated with him." | "It sounds like you're really struggling right now." | C | This response is affirming and shows the client that you are listening to her and understanding her pain. It also expresses sympathy and empathy without making any judgments. Therefore, the correct answer is (D) | counseling skills and interventions |
328 | 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. Fourth session It has been three weeks since the first counseling session, and you have agreed to meet for weekly sessions. You have been able to develop a positive rapport with the client, and he arrives to the scheduled session on time. When you ask him how he has been feeling, he tells you that he has been experiencing some anxiety. He has been having trouble sleeping and difficulty concentrating. He tells you that during his last cheerleading routine at a football game, he froze up and forgot what to do. You ask him if his anxiety may have anything to do with being bullied years ago. He tells you, "I don't wanna talk about that. My anxiety is about cheerleading. Ugh! Haven't you been listening to what I've been saying?" You remain calm and acknowledge the client's frustration. You reply, "You're angry with me because you feel that I'm not listening. Am I hearing you right?" He glares at you. You apologize, saying that you are sorry that something you said made him upset and ask him to tell you more about his anxiety. The client takes a few deep breaths and begins to tell you about the anxiety he feels towards cheerleading. He mentions that his mother used to be a cheerleader and she often tries to relive her glory days through him. He tells you he feels like his mother is always pushing him to do more and be better, but "she just doesn't get how hard it is for me." He also talks about feeling guilty when he fails to meet her expectations. You respond by saying, "It sounds like there's a lot of pressure on you from your mom. How do you cope with these expectations?" He says that he has been trying to distract himself from his feelings by watching television, playing video games, and eating. You take a moment to process this information and validate his feelings. You and the client agree to explore some healthier coping strategies, along with continuing to build a stronger connection between him and his mother. You also discuss the importance of having a support system of people who can lend an ear when he needs someone to talk to and provide emotional support. | 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. | Based on the client's presentation, what would be included as a short-term goal in his treatment plan? | Full remission | Decrease anxiety symptoms | Eliminate harmful eating behaviors | Improve self-esteem | (A): Full remission
(B): Decrease anxiety symptoms
(C): Eliminate harmful eating behaviors
(D): Improve self-esteem | Decrease anxiety symptoms | B | Decreasing anxiety symptoms is considered a short-term goal for the client through techniques and medications. Therefore, the correct answer is (A) | treatment planning |
329 | 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. | After additional sessions with the client, you are at the point of termination and would like to review the insights he has gained during therapy. After emphasizing that termination is a gateway to a new beginning, you ask the client to rate his progress. What is the intent behind asking the client this question? | To empower the client to recognize any future need for therapy should he begin destructive behavior. | To empower the client to assist others experiencing mood disorders and substance abuse issues by giving a testimonial | To empower the client by recognizing the accomplishments and changes that he has made in therapy | To empower the client to continue to work on unresolved issues which still need to be addressed | (A): To empower the client to recognize any future need for therapy should he begin destructive behavior.
(B): To empower the client to assist others experiencing mood disorders and substance abuse issues by giving a testimonial
(C): To empower the client by recognizing the accomplishments and changes that he has made in therapy
(D): To empower the client to continue to work on unresolved issues which still need to be addressed | To empower the client by recognizing the accomplishments and changes that he has made in therapy | C | You can link the client's insight to his personal growth and development and his continued areas of need. Through processing his overall value of treatment, the client can gain further insight into areas he has improved on and areas he needs to continue to examine. Sustainability is key. Therefore, the correct answer is (A) | counseling skills and interventions |
330 | Client Age: 30 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Married Counseling Setting: Counseling clinic Type of Counseling: Individual counseling Presenting Problem: The client is engaging in restrictive eating daily. The client engages in bingeing when her husband is away for business trips and engages in exercise as compensatory behavior. Diagnosis: Anorexia nervosa, binge eating/purging type, moderate (F50.02) | Mental Status Exam: The client is oriented to person, place, time, and situation. She reports no hallucinations or paranoia. The client was engaged in the session, but she had trouble accepting that her weight and self-talk were problem | You are a licensed counselor working in your own private practice, and you specialize in eating disorders. The client comes to counseling after her primary care physician (PCP) provided a referral to counseling due to restrictive eating that has led to a low body mass index of 16.5. The client says that she has lost about 30 pounds over the past 6 months and that she still feels that she is overweight. The client says that she usually consumes about 500 calories each day and that she fears that if she eats more, she will gain weight. The client’s mother, who was overweight, passed away at age 46 due to an aneurysm, which has contributed to the client’s perception that her mother’s death was weight related. The client expresses that she also has a fear that if she gains weight, then her husband will not love her. She describes experiencing anxiety resulting from the belief that she is currently overweight and is therefore already at risk of both her husband not loving her and of dying. The client says that she generally restricts eating when her husband is home, but when he is on business trips she binges and then forces herself to throw up. | You meet with the client, and she comes and sits down and appears happy because she is smiling and sitting with an open posture. The client’s food log shows improvement in engaging in healthier eating habits and minimal restriction. You and the client review her progress in treatment and agree that she has met all of the treatment goals. The client reports several situations in which she wanted to restrict, purge, and binge, but instead she engaged in cognitive reframing and was able to manage her reaction to the trigger. You praise the client and express that she should be proud of herself for her management of her symptoms. The client reports that she has gained weight and is in a healthy weight range at this point. She continues that her husband has made comments of concern about her weight gain and that the frequency of sex has decreased recently. The client says that she and her husband have been arguing about her eating recently and that she does not feel that he supports her in recovering from her eating disorder. You empathize with the client | All of the following are ethical considerations for termination, EXCEPT: | The client has not paid the agreed-upon counseling fees, so consideration of termination is appropriate. | It is apparent that the client no longer needs counseling. | You have different values than the client, so you consider termination and referral. | The therapist is at risk of harm by the client. | (A): The client has not paid the agreed-upon counseling fees, so consideration of termination is appropriate.
(B): It is apparent that the client no longer needs counseling.
(C): You have different values than the client, so you consider termination and referral.
(D): The therapist is at risk of harm by the client. | You have different values than the client, so you consider termination and referral. | C | Having different values is not a reason to terminate counseling because you must be able to provide counseling to others with different views and maintain objectivity. Rather, seeking counseling in the situation of different values is the appropriate consideration. When the client no longer needs counseling, termination is appropriate to consider because you are providing a service that is not needed. When the client cannot pay the agreed-upon fees, it is also appropriate to consider termination. If the counselor is at risk of harm by the client or by relationships that the client has, then termination is necessary. Therefore, the correct answer is (A) | professional practice and ethics |
331 | 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 | To help understand Mark's present functioning and safety risks, the counselor should first gather information on? | Previous hospitalizations | Length of time at job | History of mental illness in family | Duration of severity of symptoms | (A): Previous hospitalizations
(B): Length of time at job
(C): History of mental illness in family
(D): Duration of severity of symptoms | Duration of severity of symptoms | D | The duration and severity of symptoms helps to understand the client's present functioning and possible safety risks. After this is discussed, part of a comprehensive intake is gathering information on the history of mental illness in family members. There is a strong contribution for genetic factors in determining risk for schizophrenia. Previous hospitalizations are important to understand severity of illness and level of functioning. The length of time that Mark was at his job is not relevant to understand his psychological history. Therefore, the correct answer is (C) | intake, assessment, and diagnosis |
332 | 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 best describes the purpose of your interactions with the client during this session? | You are prompting and reinforcing each step of his treatment, strengthening all of the parts of the chain which move toward the desired behavior. | You are working to build a therapeutic alliance with the client, creating a safe place to learn to interact and build relationships. | You are observing distinct changes between the intake and this session as a result of your therapeutic interventions. | You are assessing this client's ability to work with others. His one-on-one aid will maximize his response time in adjusting to unforeseen changes. | (A): You are prompting and reinforcing each step of his treatment, strengthening all of the parts of the chain which move toward the desired behavior.
(B): You are working to build a therapeutic alliance with the client, creating a safe place to learn to interact and build relationships.
(C): You are observing distinct changes between the intake and this session as a result of your therapeutic interventions.
(D): You are assessing this client's ability to work with others. His one-on-one aid will maximize his response time in adjusting to unforeseen changes. | You are working to build a therapeutic alliance with the client, creating a safe place to learn to interact and build relationships. | B | This addresses the actions taken so far to establish a therapeutic alliance and a safe space. Therefore, the correct answer is (C) | counseling skills and interventions |
333 | Client Age: 74 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Divorced Counseling Setting: Community Mental Health Center Type of Counseling: Individual and psychoeducation Presenting Problem: Memory impairment Diagnosis: Mild Neurocognitive Disorder (MND) Unspecified with Behavioral Disturbance (apathy and mood disturbance) 799.59 (R41.9) | Mental Status Exam: The client is appropriately dressed and cooperative. She is tearful at times and often glances over at her daughter when she is unsure of how to respond to a question. The client denies suicidal and homicidal ideations. She is oriented to the day, month, and year, but she could not recall the date or place. She recalls the city with prompting. The client’s sleep is fair, and her appetite is normal. She reports feeling sad most of the day, every day. To date, medical procedures used to determine the etiology of the client’s cognitive impairment have been inconclusive. She awaits an appointment for a positron emission tomography (PET) scan, which can help determine the presence of brain activity associated with Alzheimer’s disease. She denies substance use and says that she is a social drinker. Her judgment and awareness are fair, and she denies audio and visual hallucinations. Fam | You work in a mental health center and are conducting an initial assessment on a 74-year-old Caucasian female. The client and her daughter arrive today with a copy of the client’s recent neuropsychological evaluation. The evaluation shows cognitive functioning deficits, and the neuropsychologist has diagnosed the client with mild neurocognitive disorder (MND). The client and her daughter fear that her memory issues could worsen and impact her independence. The daughter has seen a gradual decline in the client’s memory, which coincides with episodes of depression. The client expresses embarrassment over her memory issues and states, “remembering the simplest things—like doctor’s appointments or paying bills—has started to become more and more difficult.” She states that she no longer participates in things she once enjoyed, including her book club, church services, and fitness classes. | The client presents today with a blunted affect and an irritable mood. The daughter accompanies the client and states that the results of the client’s recent PET scan show changes in the brain that may indicate Alzheimer’s disease. You process the results with the client and her daughter and provide psychoeducation on cognitive impairment, including counseling risks, benefits, and limitations. The client would like to focus on improving psychosocial issues associated with her cognitive impairment. The client states, “People must think I’m so stupid when I can’t even remember whether or not I paid a bill.” You respond, “You feel embarrassed when you are unable to complete a task that you used to do with ease | The client states, “People must think I’m so stupid when I can’t even remember whether or not I paid a bill.” You respond, “You feel embarrassed when you are unable to complete a task that you used to do with ease.” This is an example of which of the following? | Empathetic reflecting | Reframing | Paraphrasing | Attending | (A): Empathetic reflecting
(B): Reframing
(C): Paraphrasing
(D): Attending | Empathetic reflecting | A | Empathetic reflecting or empathetic responding is used when a counselor responds to the client’s verbal expressions and underlying emotions. Paraphrasing is used when a counselor responds to the client’s main idea or literal meaning without using the client’s exact words. Counselors use attending by demonstrating listening and paying attention to the client. This occurs when making eye contact or assuming an attentive posture. Reframing is a communication skill that counselors use to help clients view things from a different and more positive perspective. Therefore, the correct answer is (D) | counseling skills and interventions |
334 | 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. Fifth session It has been a month and a half since you first met with the client and she has rescheduled multiple therapy appointments, continually citing a busy work schedule. The last time you met with her, she told you that the judge sentenced her to six months probation, provided that she follow through with Alcoholic Anonymous meetings and counseling sessions. She was also required to do 60 hours of community service. Though she was relieved to have the sentencing behind her, she remarked that she still felt shame and humiliation at having gone down that path. During that counseling session, she communicated to you that she tried to go one day without drinking but couldn't do it. She described the idea of quitting drinking as "impossible" because "I have never been strong enough." You explored the client's motivations and concerns about changing her behavior. You explained to her that while it was normal to feel overwhelmed by the thought of making changes, there were strategies that she could utilize in order to build a support system and make progress towards sobriety. Based on the client's behavior, you do not believe that outpatient treatment is the best fit for the client at this time, and you plan to discuss alternate options with her today. She is scheduled for an afternoon session but does not show. When you attempt to call her, her phone goes directly to voicemail. You continue to wait in your office even though the client does not respond to your calls or appear for the session. You are concerned about her because although she has rescheduled appointments before, she has always done so in advance and has never been a "no show." You take the appropriate ethical actions to check on her. | 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. | In consideration of the client's prior behavior of contacting you when she could not make an appointment, and given her status during today's session, what action would be most ethically appropriate for you to take at this time? | Contact the client's ex-boyfriend. | Contact the police. | Contact the client's mother. | Drive to the client's house to perform a wellness check. | (A): Contact the client's ex-boyfriend.
(B): Contact the police.
(C): Contact the client's mother.
(D): Drive to the client's house to perform a wellness check. | Contact the client's mother. | C | Since the client has indicated that she communicates with her mother weekly and you have a signed release to speak with her, this is an appropriate action for you to take. Therefore, the correct answer is (B) | professional practice and ethics |
335 | Name: Alex Clinical Issues: Hopelessness/depression Diagnostic Category: Depressive Disorders Provisional Diagnosis: F34.1 Persistent Depressive Disorder, Severe Age: 65 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: Multiracial Marital Status: Married Modality: Individual Therapy Location of Therapy : Private Practice | Appearance: The client is dressed in a manner that can be described as casual, suggesting that they might not have made any special effort to dress up for the session. Additionally, he is unshaven, which you note might indicate either personal preference, a decline in grooming habits, or possibly, decreased motivation and energy. Behavior: The client's overall behavior is withdrawn. Mood and Affect: His stated mood is depressed, implying feelings of sadness, hopelessness, or desolation. His affect, the observable manifestation of his feelings, is flat. Speech: His speech is both slowed and measured. Thought Process and Content: The client's thought process is tangential. He tends to veer off-topic and does not consistently answer questions directly or stay on point. The content of his thoughts is notably negative and self-defeating. Perceptual Disturbances: No delusions or hallucinations have been reported, indicating that the client has no gross misinterpretations of reality or perceptual disturbances. Orientation: The client is oriented to person, place, and time. Insight: It appears that the client has poor insight into his condition. Attitude: His attitude towards the evaluator is compliant and cooperative. | First session You are a licensed mental health therapist. Today you are seeing a 65-year-old male via distance counseling. You introduce yourself and ask him what prompted him to schedule an appointment to see you. He reports that he has felt "down in the dumps" for several years, and as he gets older, he feels more depressed and is in constant pain. As he is talking, he shifts around in his seat, appearing to have difficulty staying in a comfortable position. He continues by saying he feels depressed most of the time, has lost interest in activities that he once found enjoyable, feels hopeless, and is fatigued all the time. He also says he has lost his appetite and has difficulty sleeping. He states that "no one wants me around." Then he looks down and says, "I don't really blame them. I wouldn't want to be around me either." At work, he has difficulty concentrating and making decisions and is distressed that his co-workers see him negatively. When you ask him about his relationship with his wife, he says that while they live together, they have "not been close for a long time now." They both sleep in separate bedrooms and they lead separate lives. He explains, "We just kind of grew apart. We still love each other and would never get divorced, but now we're more like roommates. She's very social and involved in the community. I'm more of a homebody." After the client has shared why he is seeking counseling, you state, "I can hear that you are feeling very discouraged. It sounds like you have been going through a difficult time for quite some time now and it's taking a toll on your life. Let's explore what might be contributing to these feelings and how we can work together to help find solutions or ways to cope with the challenges you're facing." You use a solution-focused brief therapy technique and ask him visualize what successful treatment would look like. He contemplates it for some moments and says, "I'd feel better, I guess." You encourage the client to think more deeply about what successful treatment would look like and explain how this visualization process can help him gain clarity on his desired outcomes. He says, "Hmm, I'm not really sure. Can you give me some examples? This is my first time in therapy and I'm not really sure what to expect." You provide some examples of tangible goals that he might set for himself, such as improving sleep patterns, having better communication with family members and co-workers, and finding meaningful activities to engage in. The client is able to identify some areas that could be improved and formulates realistic, achievable goals. Together, you create an action plan for successful treatment, which includes specific steps he can take to reduce symptoms and increase positive outcomes. You schedule a follow-up appointment to meet with him next week. Fourth session It has been three weeks since your initial session with the client, and he has been keeping his weekly appointments. Last week you suggested he see a psychiatrist, and you begin today's session by discussing the results of his psychiatric referral. The client reports that he was prescribed antidepressant medication. He is not feeling much relief from his depressive symptoms now, but his psychiatrist told him that it could take a few months for the medication to reach maximum efficacy. Next, you discuss treatment options and the use of cognitive-behavioral therapy combined with his medication regimen. He is willing to try the combined approach, and together you create a treatment plan with both short-term and long-term goals. He mentions his job being a source of frustration. You spend some time discussing the client's job and his feelings about it. He expresses his desire to retire, but he worries about the financial burden it may place on his wife. He says, "My retirement benefits are not that great, and I lost a lot of money in the stock market last year. I just don't know how I can make this work. I'm not sure if retiring now is the right decision." You discuss other possibilities for him to consider for retirement, such as part-time work or freelancing in a field he enjoys. You also brainstorm with him about ways for him to transition out of his current job in a way that reduces conflict with his co-workers, such as taking scheduled breaks and speaking with his supervisor about his workload. You provide support and suggest that he speak with his wife about their financial situation before making any decisions about his retirement. He agrees and states he will bring it up with her this upcoming week. Toward the end of the session, the client reveals that he has been contemplating cutting back on his drinking, but he is worried that he will not have any friends if he stops drinking. He says, "I already feel like a failure at work and as a husband. If I lose the few friends that I still have, I'll be alone and will never be happy again." You utilize motivational interviewing strategies and suggest that if he stops drinking, it will not mean that he has to give up all of his friends, but rather that he may need to find new friends who do not drink alcohol or who can meet with him in an alcohol-free context. He nods his head and says, ""I hear what you're saying, but who is the world would want to be friends with someone like me? The only reason I've got any friends left is because I like to drink with them." You empathize with his feelings of self-doubt, but remind him that it is possible to find meaningful friendships without drinking. You give him a homework assignment to find at least one activity or group that seems interesting to him and create a plan to start building positive relationships with others. You reassure him that you will be there to support him through this process and set a date for his next appointment. 15th session You have been seeing the client regularly for the past four months. He states that he is feeling "better" these days, and he is doing better at work. He has been taking his antidepressant medication as prescribed and feels therapy has been helpful. You review the treatment plan and discuss the progress he has made and the termination process. Near the end of the session, he tells you, "Well, there is one more thing. I'm worried that my wife might be having an affair. I know it's probably crazy, but I can't help but think that she's seeing someone else. And you know what, I wouldn't blame her. I haven't been the best husband with my constant depression. I just think about her leaving me, and it makes me feel afraid." You express understanding and validate his feelings, noting that it's not uncommon for people to have affair-related thoughts when feeling insecure in their relationship. You inquire whether he has been spending time with his wife and how he and his wife have been communicating. He reports that they have been talking more and that he has been trying to be more present when he is with her. You remind him of his progress in therapy and how much better he has been feeling overall, which has likely contributed to him being able to engage more in his marriage. You suggest that as he continues to work on himself and generally feels better, his worries about his wife cheating on him will likely lessen. In the meantime, you caution against drinking to cope with his anxiety, as it can lead to further problems down the road. | The client reports that his relationships with family members were strained growing up, with his father often away for work and his mother struggling with her own mental health. He reports that his mother drank a lot, which the client defends saying, "I guess I'd drink a lot if I had 5 kids by the time I was 22 years old. The client grew up feeling unsupported and unimportant, which led to a disconnect from the rest of his family. Of his four siblings, the client keeps in touch with one brother, but "my other two brothers and sister live in different states and have different lives. I think they've struggled with depression, too. We don't talk much." Despite this difficulty in connecting, the client has an adult daughter whom he "loves very much and tries to stay in contact with. He wishes he could have done better for her during his parenting years, and despite their rocky past, has a deep desire to maintain a healthy relationship. He says, "I don't want her to think the same way I do about family and relationships. I want her to have good ones." The client is currently employed as a corrections officer and feels his job has no potential for advancement. He has been working there for 20 years and is ready to retire in less than a year. He expresses that it has been challenging and physically and mentally exhausting. In addition, he is tired of "dealing with both the inmates and the administration." He tells you his co-workers consider him a "slacker" because he is always tired and takes as many breaks as he can get away with. He is also worried about "word getting back to his co-workers" that he is in therapy. The client expresses that he has some drinks, especially after work, to calm down. He reports that he will drink in social settings as well. He states that his preferred drink of choice is whiskey. | Given the revelations within this session and considering your observations of the client during the subsequent sessions, which statement is most accurate to document in the client's therapy record? | The client and his wife are experiencing Folie à Deux, sharing jealous delusions. | The client's work conditions negatively affect his mental health, and he needs to retire earlier than planned. | Suicide risk factors have decreased, and he does not need to be screened for suicidal ideations, intent, and plan. | Suicide factors have increased, and he needs to be screened for suicidal ideations, intent, and plan. | (A): The client and his wife are experiencing Folie à Deux, sharing jealous delusions.
(B): The client's work conditions negatively affect his mental health, and he needs to retire earlier than planned.
(C): Suicide risk factors have decreased, and he does not need to be screened for suicidal ideations, intent, and plan.
(D): Suicide factors have increased, and he needs to be screened for suicidal ideations, intent, and plan. | Suicide risk factors have decreased, and he does not need to be screened for suicidal ideations, intent, and plan. | C | The client has a history of substance use and disclosed a new major life stressor with his wife, but he has learned coping mechanisms to deal with this new fear. Screening for suicidal ideations, intent, and plan is not necessary. Therefore, the correct answer is (B) | intake, assessment, and diagnosis |
336 | 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.” | History of Condition: The client first noticed symptoms of social anxiety when her family moved north during the summer of her 8th-grade school year. When she began high school, she received unwanted attention for being the “new girl.” She explains that she was often teased because of her Southern accent and was labeled “country” and “ignorant.” Before meeting her husband, the client remembers drinking before going on a date stating, “It just helped settle my nerves.” Her social anxiety lessened after becoming a stay-at-home mom to her two now-teenage children. However, she noticed a sharp increase in social anxiety after her divorce, particularly when attempting to reenter the job force and trying to find new social circles. She denies current drug use and states that she is a social drinker. Family History: The client’s parents both live out of town and run a business together. The client’s father has been treated for alcohol use disorder and is now in recovery. Her mother takes medication for anxiety and depression. The client has two teenage girls. Both girls have had a difficult time with the divorce. Her youngest child is seeing a therapist for depression. The client’s ex-husband is a prominent attorney in their town. This is the client’s first experience with counseling, and she asks many questions when filling out the intake paperwork. You and another counselor would like to start a group for individuals with social anxiety who tend to avoid performance situations (e\. g., talking in front of others, taking an exam, interviews, etc.) | You and another counselor would like to start a group for individuals with social anxiety who tend to avoid performance situations (e.g., talking in front of others, taking an exam, interviews, etc.). Which instrument would you use to help measure this? | Fear Questionnaire Social Phobia Subscale | Hamilton Anxiety Rating Scale | Liebowitz Social Anxiety Scale | Beck Anxiety Inventory | (A): Fear Questionnaire Social Phobia Subscale
(B): Hamilton Anxiety Rating Scale
(C): Liebowitz Social Anxiety Scale
(D): Beck Anxiety Inventory | Liebowitz Social Anxiety Scale | C | The Liebowitz Social Anxiety Rating Scale measures social anxiety; it provides measures for social anxiety and social avoidance, and there are also measures for performance anxiety and performance avoidance. Individuals with performance anxiety may also have negative performance-based appraisals leading to avoidance. Social anxiety disorder characteristics include fear of social situations fueled by cognitive distortions and reinforced by avoidance and other safety behaviors. Cognitive distortions include an underestimation of one’s performance in social situations. The Hamilton Anxiety Rating Scale is useful for measuring traits associated with GAD, including psychological distress and somatic complaints. The Beck Anxiety Inventory measures the severity of anxiety symptoms, specifically physiological and cognitive symptoms of anxiety. The Fear Questionnaire Social Phobia Subscale assesses the severity of specific phobias by focusing primarily on avoidance behaviors. Therefore, the correct answer is (B) | intake, assessment, and diagnosis |
337 | Name: Ruth and Dale Clinical Issues: Parenting/co-parenting conflicts Diagnostic Category: V-codes Provisional Diagnosis: Z63.0 Relationship Distress with Spouse or Intimate Partner Age: 41 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: White Marital Status: Married Modality: Couples Therapy Location of Therapy : Agency | Appearance: The client is casually dressed and adequately groomed. She appears healthy, and her age is consistent with her stated age. Behavior: The client's behavior is tense and purposeful. She is cooperative with adequate rapport. Speech: Speech volume is normal, and speech flow is normal and spontaneous. Mood: The client's mood is dysphoric and anxious. Thought Process: Thought process is logical. Thoughts are negative. Affect: The client's affect is broad and appropriate to the discussion. Cognition: The estimated level of intelligence is within average range with abstract thinking. Concentration is intact. The client shows no problems with memory impairment. Insight and Judgment: Insight is fair. Impulse control and judgment appear to be below average. | First session You are a therapist working at a marriage counseling agency. Ruth is a 41-year-old female who comes to your office with her husband. The couple has been married for seven years and have two children, ages five and one. The husband also has a 16-year-old daughter from a previous marriage who lives in the home. The client is a stay-at-home mom, and her husband works at a correctional institution. Their five-year-old has been removed from three separate daycare facilities because of her defiant behavior. In addition, the 16-year-old was recently arrested for shoplifting. At the end of the session, the client turns to her husband and says, "I'm the one who has to stay home with the kids all day. You just don't get it. You don't know what it's like having no time for yourself and no quiet place to relax. You think all this stuff with the kids is a normal phase and everyone will grow out of it. Well, I don't think it's normal, and I'm tired of it! I've been talking to my ex-husband lately because he listens to me, and I feel better after I talk to him." Ruth demonstrates elevated stress and anxiety levels, as evidenced by her verbalization of feeling overwhelmed by the demands of caring for their children and lack of personal time. She also expresses feelings of frustration with her husband, who she perceives as not understanding her struggles. Her husband's absence during the day and the children's challenging behaviors have likely contributed to the client's feelings of isolation and burnout. Ruth's decision to reach out to her ex-husband for emotional support may indicate that she is not receiving adequate support from her current partner. | Ruth's parents died in a boating accident while she was in college. She has two brothers and one sister, but they are not close, partially due to the strain of losing their parents. Her husband's first wife left him soon after their daughter was born. She does not discuss her place in the family's dysfunction but talks about other family members who need help. Ruth has been unable to heal her relationship with her sister and feels guilty about it. She also expresses concern for her husband's well-being after his first wife's divorce, which she was partly responsible for. Additionally, Ruth struggles with depression and anxiety due to trauma related to the death of her parents. Personal/Social Relationships: Ruth feels that her husband minimizes their children's problems and is to blame for their lack of improvement. Ruth feels her marriage is "on the rocks.'" Her husband knows his wife is unhappy but does not know what to do. Finally, you learn that Ruth recently reconnected with her ex-husband and is seriously considering having an affair. Previous Counseling: The client has been working on her low self-esteem through therapy but says she is not getting any better. Her husband says, "I know Ruth is unhappy. That much is obvious. She's stressed out all the time, and she's stopped talking to me. She gets in the car, is gone for hours, and isn't home when I arrive after work. I'm worried I will lose her, but I don't know what to do." | What data would be important in tracking Ruth's and Dale's progress? | The children's interactions and grades at school | Ruth's decrease or increase in contact with her ex-husband | The frequency of intimacy in the couple's relationship | How the couple respond to their children's behavior | (A): The children's interactions and grades at school
(B): Ruth's decrease or increase in contact with her ex-husband
(C): The frequency of intimacy in the couple's relationship
(D): How the couple respond to their children's behavior | How the couple respond to their children's behavior | D | If the client and her husband can respond as a cohesive unit to their children more appropriately, this would indicate that they are making progress in therapy. Therefore, the correct answer is (B) | counseling skills and interventions |
338 | Client Age: 41 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Divorced Counseling Setting: Behavioral Health Type of Counseling: Outpatient Presenting Problem: Fear and Panic Diagnosis: Agoraphobia 300.22 (F40.00) | Mental Status Exam: The client appears her stated age, and she is dressed in casual attire. Her affect and mood are anxious. She is tearful and seems extremely distressed when recounting her panic attacks. The client denies suicidal or homicidal ideations but does endorse feeling hopeless about her condition. She is unsure if she will benefit from counseling and expresses mixed feelings about seeking help. The client denies audio and visual hallucinations. Fam | You work in a behavioral health outpatient center. Your client is a 41-year-old Caucasian female presenting with symptoms of fear and panic. The client has a history of anxiety and depression but explains that her anxiety has worsened within the last year and that she has begun to experience panic attacks. She states that she has an “overwhelming fear” of elevators and stairwells. When exposed to these situations, she has trouble breathing, begins to feel dizzy, and hyperventilates. The client remembers having her first panic attack while staying at a hotel one weekend. She was taking the stairs and suddenly felt intense fear and panic. On the same trip, she had a similar experience when taking the elevator. The client quit her last job due to travel requirements, and she is currently unemployed. She stays away from stairwells and elevators as much as she possibly can. When unable to do so, she asks her son to accompany her. | The client’s son accompanies her to her appointment today. Since the initial intake, COVID-19 has become a global pandemic and has greatly impacted the client’s anxiety and fear. The client was visibly trembling when she spoke and requested that her son remain nearby. She explained that complying with the statewide mask mandate has been difficult, stating, “Wearing this mask makes me feel like I can’t breathe. It’s the same feeling I get when I’m walking up stairs or taking the elevator.” The client’s internist prescribes alprazolam (Xanax), which she has been taking for years. However, she thinks that it is no longer effective and asks if you can help her discontinue the medication. Given the COVID-19 outbreak, you discuss providing distance counseling to the client | The American Counseling Association (ACA) Code of Ethics (2014) guidelines for distance counseling, technology, and social media includes which of the following standards? | Counselors acknowledge the differences between synchronous and asynchronous communication and use synchronous communication whenever possible to avoid missed verbal and nonverbal cues. | Counselors take reasonable precautions to ensure the confidentiality of information transmitted through technology-based communication. | Counselors inform clients that only authorized individuals have access to confidential information. | Counselors verify their identity and the identity of the client (e.g., through the use of code words, numbers) each session. | (A): Counselors acknowledge the differences between synchronous and asynchronous communication and use synchronous communication whenever possible to avoid missed verbal and nonverbal cues.
(B): Counselors take reasonable precautions to ensure the confidentiality of information transmitted through technology-based communication.
(C): Counselors inform clients that only authorized individuals have access to confidential information.
(D): Counselors verify their identity and the identity of the client (e.g., through the use of code words, numbers) each session. | Counselors take reasonable precautions to ensure the confidentiality of information transmitted through technology-based communication. | B | Counselors adhering to the ACA Code of Ethics “take reasonable precautions to ensure the confidentiality of information transmitted through any electronic means” Section H3 states that counselors should take steps to verify the identity of the client, rather than their own identity and the client’s identity. This should occur “at the beginning and throughout the therapeutic process” Section H2b states that “Counselors acknowledge the limitations of maintaining the confidentiality of electronic records and transmissions. They inform clients that individuals might have authorized or unauthorized access to such records or transmissions (eg, colleagues, supervisors, employees, information technologists)” Finally, Section H4f states, “Counselors consider the differences between face-to-face and electronic communication (nonverbal and verbal cues) and how these may affect the counseling process. Counselors educate clients on how to prevent and address potential misunderstandings arising from the lack of visual cues and voice intonations when communicating electronically”. Therefore, the correct answer is (B) | professional practice and ethics |
339 | 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 | Brain abnormalities in those diagnosed with bipolar disorders occur in this area of the brain which controls cortisol levels? | Brain stem | Hippocampus | Hypothalamic-pituitary-thyroid axis | Thalamus | (A): Brain stem
(B): Hippocampus
(C): Hypothalamic-pituitary-thyroid axis
(D): Thalamus | Hypothalamic-pituitary-thyroid axis | C | The Hypothalamic-pituitary-thyroid axis is responsible for the production of cortisol. Abnormalities in thyroid function are frequently accompanied by changes in mood. The Thalamus communicated motor and sensory signals to the cerebral cortex. The hippocampus has a primary role in learning and memory. The brain stem is responsible for regulating some involuntary body actions. Therefore, the correct answer is (B) | intake, assessment, and diagnosis |
340 | 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. | 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. | As you develop a treatment plan, what long-term goal will you plan to work on with this client in therapy? | Increase rate of self-initiated verbal expressions with therapist and family members | Acquire fundamental language proficiency and the capacity for basic communication with others | Demonstrate significant improvement in sustained attention and impulse control | Increase frequency of positive social interactions with classmates at school | (A): Increase rate of self-initiated verbal expressions with therapist and family members
(B): Acquire fundamental language proficiency and the capacity for basic communication with others
(C): Demonstrate significant improvement in sustained attention and impulse control
(D): Increase frequency of positive social interactions with classmates at school | Acquire fundamental language proficiency and the capacity for basic communication with others | B | This is an appropriate long-term goal to work on with this client. Language proficiency and communication skills are essential to their development and social interaction. Without these skills, this client may struggle to interact with people around him, express himself, and understand what others are saying. Therefore, the correct answer is (D) | treatment planning |
341 | Initial Intake: Age: 14 Gender: Male Sexual Orientation: Heterosexual Race/Ethnicity: Hispanic - Mexican American Relationship Status: Single Counseling Setting: School-based Type of Counseling: Individual | Raul presents as irritable and anxious, with congruent mood and affect. Raul is casually dressed, appears to be overweight for his age and height, and is sweating with nervous hand motions. Raul has difficulty making eye contact, takes long pauses prior to answering questions, and often asks you to repeat the question after a long pause. Raul denies SI/HI or hallucination/delusion. He refers to an incident in his past he considers to be “trauma” but is uncomfortable discussing with you. When asked about his father, he sheds a tear which he immediately wipes away and returns to a scowl on his face with arms crossed, saying “there’s nothing to talk about.” Raul does admit to several instances of aggression with others such as “shoving a kid,” “kicking a desk” and “cursing out the principal.” You ask if he has ever been on medication for ADHD. He says, “No, I don’t think so. My doctor told my mom a few times to fill out some forms, but I don’t think she ever did.” | Diagnosis: Attention-deficit hyperactivity disorder, predominantly inattentive type (F90.0), Conduct disorder, unspecified (F91.9)
You are a counseling intern working for an agency that sends counselors into grade schools to work with their students on longer-term mental health issues. Raul is referred to you by his assistant principal for multiple in classroom infractions of interrupting, bullying, and being a “class clown.” In meeting with Raul and his mother, she shares that the principal accused Raul of bullying kids on the bus, and defacing property. She says, “Kids will be kids, they’re probably just too sensitive.” Raul’s mother works full-time and has an active social life, leaving Raul to stay at home alone frequently after school or on weekends. His mother appears very casual and does not seem concerned about Raul’s behaviors. She does mention Raul’s diagnosis of ADHD was given by his pediatrician, but he has never received psychiatric services. In front of his mother, Raul is quiet and acts well-behaved; after his mother leaves, he tells you he gets frustrated with her for leaving him alone but would never admit it to her directly. He refuses to state that he feels lonely, sharing that he spends most of his alone time playing live video games with other people across the country. He also denies bullying other kids. | Education History:
Raul’s teachers inform you of his behaviors throughout his freshman year in high school, that have according to them been ongoing since Raul’s middle school years. Raul is often reported for being inappropriate in class by making impulsive remarks to try and get others to laugh, disrupting the class, or falling asleep and appearing distracted. The school is concerned with his academic progress and has discussed moving his status up a higher-level Tier so he can be monitored further and made available to special programming geared towards students in jeopardy of failing.
Family History:
Raul lives with his mother and occasionally one of his mother’s boyfriends who come and go intermittently. Raul has one older sister who lives in the next town. Raul’s father lives in Mexico with several of his half and step siblings with whom Raul has minimal contact. Raul’s father is unable to enter the U.S. and has been absent most of Raul’s life. Raul reports his father is an alcoholic, but that where he lives, they “don’t think of things like that” because that is what his father told him. Raul’s grandmother also lives in Mexico but has been a continual presence in his life via phone calls, mail, and is his primary caretaker when he does visit Mexico, which has occurred twice. | Which of the following steps taken by you within Raul's school will most likely help improve his behavior over time? | Sit in Raul's classroom and observe behaviors | Set up a reward and consequences system | Periodically check in with his teachers | Review your clinical notes with his teachers | (A): Sit in Raul's classroom and observe behaviors
(B): Set up a reward and consequences system
(C): Periodically check in with his teachers
(D): Review your clinical notes with his teachers | Periodically check in with his teachers | C | Assuming there are appropriately signed releases of information in place, coordinating with Raul's teachers to learn more about his behaviors and whether there has been improvement is extremely helpful information in guiding your course of care. Sharing detailed clinical notes is inappropriate and unnecessary for helping Raul and breaks his confidentiality, as does sitting in his classroom to observe him. Additionally, the observation might not yield the intended results as Raul might modify his behavior if under observation. Becoming involved in a reward and consequence system for his corrective actions and behaviors in school transitions your role as a safe and unbiased helper into a disciplinarian, which may end up having detrimental implications on your therapeutic alliance. Therefore, the correct answer is (B) | treatment planning |
342 | Name: Dawn Clinical Issues: Maladaptive eating behaviors Diagnostic Category: Feeding and Eating Disorders Provisional Diagnosis: F50.01 Anorexia Nervosa, Restricting type Age: 17 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: White Marital Status: Single Modality: Individual Therapy Location of Therapy : University Counseling Center | The client presents as a female in her late teens who appears malnourished and underweight, dressed in loose, concealing clothing. She exhibits poor eye contact and a guarded, closed-off posture with arms protectively crossed. Her affect is tense and anxious. Speech is logical and goal-directed, with no evidence of hallucinations or delusions. She denies any suicidal or homicidal ideation. Cognition is grossly intact for person, place, and time. Her insight and judgment appear limited, as evidenced by unresolved conflict with her parents and changing college majors without considering long-term career goals. She reports a strained relationship with authoritarian parents who were often physically and emotionally absent, leaving her feelings of neglect. She exhibits low self-confidence and an inability to trust her thoughts and desires. She continues to seek parental approval but feels unable to assert her needs. Her mood is anxious and frustrated due to perceived external control and lack of autonomy. | First session You are a mental health counselor in a university counseling center. Dawn, a 17-year-old college student, is referred to you by her physician. The client's parents recently visited during their parents' weekend at the university campus and were very concerned when they saw their daughter, who appeared severely underweight. They had not seen her for several months and immediately contacted the family physician for guidance. After performing a complete physical exam, the physician could not determine any medical causes for the client's low weight. The physician noted, however, that the client expressed that she did not understand her parents' concern about her weight. During the physician's examination interview, she reported feeling intense anxiety about gaining weight and implied that she was unhappy with her appearance. Dawn reported feeling stressed and anxious about her schoolwork, friendships, and body image concerns. She explained that she often skips meals or severely restricts her food intake in an effort to maintain control. Dawn acknowledged that her eating habits have become more disordered over time and expressed openness to learning new coping strategies. While Dawn initially resisted her parents' efforts to intervene, their concern made an impression. She agreed to continue counseling to address the underlying issues driving her unhealthy behaviors. Dawn wants to improve her well-being despite lingering uncertainties. In today's initial counseling session, you focus on establishing trust and providing the client with a safe space to share her feelings without fear of judgment or reprisal. You begin by asking the client how she feels today and if there are any particular topics she would like to discuss. You also explore her feelings about her parents and brother and ask targeted questions to better understand the family dynamics and how they have impacted her self-esteem. You provide the client with psychoeducation regarding healthy eating habits, body image, and the consequences of not caring for oneself. Lastly, you discuss possible resources and referrals that may be helpful for the client during this time. Dawn seemed receptive to discussing her feelings and experiences in a judgment-free environment. She sometimes became emotional when describing her struggles but appeared relieved to openly share things she had kept private. Dawn stated the counseling session felt like a positive first step. After reviewing healthy coping tools and strategies, Dawn agreed to keep a daily food and feelings journal. She also committed to reaching out for support if feeling triggered or unable to care for herself. Dawn left the session with referrals for a nutritionist and an eating disorder support group. Fourth session You and the client have met twice weekly for therapy sessions on Monday and Thursday afternoons. This is your fourth session, and you begin to explore the client’s support network. She reports having a difficult time making friends at college and says that she feels very lonely. She shares a dorm room with two other female students who have been best friends since elementary school. The client says she feels like an “outsider” and struggles to share a living space with these two roommates. Dawn shared that she often spends time alone in her dorm room on weekends while her roommates go out together. She said this makes her feel even more isolated. Dawn explained that she has tried reaching out to her roommates to get to know them better, but they seem uninterested in including her in their plans. Dawn mentioned that her older brother is the only person she feels close with right now. However, since he lives so far away, they rarely see each other in person. Dawn said she misses having her brother around to talk to and confide in. One of her classmates invited her to have lunch on campus, but she was so anxious about eating in public that she declined the offer. Although she would like to have friends, she is worried that, eventually, she will end up in a social situation involving food; this idea creates intense anxiety for her. She believes that it is easier to avoid social situations altogether. The client begins to cry and says she often thinks about moving back home but does not feel like she belongs there anymore, especially since her parents repurposed her old bedroom. She continues crying and says, “I don’t have any friends at school, and I don’t even have a room at home. I feel like I don’t belong anywhere. I really miss my brother.” Dawn tearfully explained that she feels caught between missing her previous life and feeling unable to adjust to her new environment at college. She is longing for connection but finds it challenging to put herself out there socially. Crying, Dawn shared that she feels like she has no place where she truly belongs right now. She misses the security and familiarity of high school and being with her brother but also recognizes that things have changed there as well. Overall, Dawn conveyed profound feelings of loneliness and isolation. Eighth session You continue to work with the client in outpatient therapy. During a previous session, the client identified a few sources of support and was able to tell her parents that she switched her major. Today, the client arrives for her appointment 20 minutes early. She appears eager to see you and excited to talk with you. When she sits down, she pulls several cookbooks out of her backpack. She tells you that she plans to go home during spring break and has collected recipes for a large meal she wants to make for her family. During this session, while exploring the client's relationship with food, you discover that she spends many hours in the library reading through cookbooks and watching baking shows on her computer. She says that she has an apple for breakfast, picks up a small salad "to go" from the campus cafeteria every day at exactly 12:00 p.m., and bakes a sweet potato for dinner in the microwave in her room at 6:00 p.m. She looks forward to her meals and plans her day around them. She says she is envious of other people who "can eat anything whenever they want." She tells you she is worried that if she eats extra food, she will become obese overnight and never stop eating. You continue to explore the client's relationship with food by asking, "What do you think would happen if you ate whatever you wanted?" She replies, "I'm afraid that if I eat extra food, I'll gain weight and never be able to stop eating. I'll keep getting bigger and bigger and turn into a severely obese person." After taking a moment to think, the client shares, "I'm scared that if I gain weight, no one will love me or care about me. Then I'll be completely alone, and it will be all my fault because I couldn't control my eating!" You listen compassionately as the client shares her fear. You also emphasize that this is an extreme outcome and unlikely to occur. You encourage her to think realistically about the potential consequences of eating additional food and acknowledge that there may be some negative outcomes, but they are not guaranteed or irreversible. | The client has a 25-year-old brother who is a Navy Seal. The client's parents have government jobs and frequently travel to foreign countries for work. When the client moved away to live on campus, her parents immediately turned her old bedroom into a home gym, which the client found unsettling. The client says that while she knows her parents love her, they have never been very affectionate or spent much time with her. When she was younger, the client traveled with her family for a few weeks during the summer but was often left alone during their trips. She describes her relationship with her parents as "strained" but states that she does have a positive relationship with her brother. She plans to see him when he is on leave from the Navy. The client is a freshman at the university and has already changed her major from pre-med to music history. She is anxious about telling her parents that she switched majors and is worried they will be disappointed. She reports that she has always felt a lot of pressure from her parents to excel in school as her brother did. Since she was a child, her parents have expressed their desire to see her become a physician. Her parents have always set high expectations for her academic performance. Their authoritarian parenting style has left her doubting her confidence in her own capabilities. She is frustrated by this dynamic because she does not feel like she can think for herself or pursue her own goals without outside approval. | Based on the narrative, when would you specify that the client is “in partial remission” for the client's diagnosis? | When the criteria for low body weight are no longer met, and the client meets the requirements for an intense fear of gaining weight or disturbance in self-perception of body weight | When criteria for disturbance in self-perception of body weight and shape is no longer met | When criteria for Anorexia Nervosa are no longer met and have not been met for a significant amount of time | When the client ceases to talk about weight-related body image issues. | (A): When the criteria for low body weight are no longer met, and the client meets the requirements for an intense fear of gaining weight or disturbance in self-perception of body weight
(B): When criteria for disturbance in self-perception of body weight and shape is no longer met
(C): When criteria for Anorexia Nervosa are no longer met and have not been met for a significant amount of time
(D): When the client ceases to talk about weight-related body image issues. | When the criteria for low body weight are no longer met, and the client meets the requirements for an intense fear of gaining weight or disturbance in self-perception of body weight | A | The client is considered “in partial remission” for Anorexia Nervosa, Restricting Type, when criteria for low body weight are no longer met. The client still meets the criteria for either intense fear of gaining weight or disturbance in self-perception of body weight and shape, however. Therefore, the correct answer is (D) | intake, assessment, and diagnosis |
343 | Name: Alex Clinical Issues: Hopelessness/depression Diagnostic Category: Depressive Disorders Provisional Diagnosis: F34.1 Persistent Depressive Disorder, Severe Age: 65 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: Multiracial Marital Status: Married Modality: Individual Therapy Location of Therapy : Private Practice | Appearance: The client is dressed in a manner that can be described as casual, suggesting that they might not have made any special effort to dress up for the session. Additionally, he is unshaven, which you note might indicate either personal preference, a decline in grooming habits, or possibly, decreased motivation and energy. Behavior: The client's overall behavior is withdrawn. Mood and Affect: His stated mood is depressed, implying feelings of sadness, hopelessness, or desolation. His affect, the observable manifestation of his feelings, is flat. Speech: His speech is both slowed and measured. Thought Process and Content: The client's thought process is tangential. He tends to veer off-topic and does not consistently answer questions directly or stay on point. The content of his thoughts is notably negative and self-defeating. Perceptual Disturbances: No delusions or hallucinations have been reported, indicating that the client has no gross misinterpretations of reality or perceptual disturbances. Orientation: The client is oriented to person, place, and time. Insight: It appears that the client has poor insight into his condition. Attitude: His attitude towards the evaluator is compliant and cooperative. | First session You are a licensed mental health therapist. Today you are seeing a 65-year-old male via distance counseling. You introduce yourself and ask him what prompted him to schedule an appointment to see you. He reports that he has felt "down in the dumps" for several years, and as he gets older, he feels more depressed and is in constant pain. As he is talking, he shifts around in his seat, appearing to have difficulty staying in a comfortable position. He continues by saying he feels depressed most of the time, has lost interest in activities that he once found enjoyable, feels hopeless, and is fatigued all the time. He also says he has lost his appetite and has difficulty sleeping. He states that "no one wants me around." Then he looks down and says, "I don't really blame them. I wouldn't want to be around me either." At work, he has difficulty concentrating and making decisions and is distressed that his co-workers see him negatively. When you ask him about his relationship with his wife, he says that while they live together, they have "not been close for a long time now." They both sleep in separate bedrooms and they lead separate lives. He explains, "We just kind of grew apart. We still love each other and would never get divorced, but now we're more like roommates. She's very social and involved in the community. I'm more of a homebody." After the client has shared why he is seeking counseling, you state, "I can hear that you are feeling very discouraged. It sounds like you have been going through a difficult time for quite some time now and it's taking a toll on your life. Let's explore what might be contributing to these feelings and how we can work together to help find solutions or ways to cope with the challenges you're facing." You use a solution-focused brief therapy technique and ask him visualize what successful treatment would look like. He contemplates it for some moments and says, "I'd feel better, I guess." You encourage the client to think more deeply about what successful treatment would look like and explain how this visualization process can help him gain clarity on his desired outcomes. He says, "Hmm, I'm not really sure. Can you give me some examples? This is my first time in therapy and I'm not really sure what to expect." You provide some examples of tangible goals that he might set for himself, such as improving sleep patterns, having better communication with family members and co-workers, and finding meaningful activities to engage in. The client is able to identify some areas that could be improved and formulates realistic, achievable goals. Together, you create an action plan for successful treatment, which includes specific steps he can take to reduce symptoms and increase positive outcomes. You schedule a follow-up appointment to meet with him next week. Fourth session It has been three weeks since your initial session with the client, and he has been keeping his weekly appointments. Last week you suggested he see a psychiatrist, and you begin today's session by discussing the results of his psychiatric referral. The client reports that he was prescribed antidepressant medication. He is not feeling much relief from his depressive symptoms now, but his psychiatrist told him that it could take a few months for the medication to reach maximum efficacy. Next, you discuss treatment options and the use of cognitive-behavioral therapy combined with his medication regimen. He is willing to try the combined approach, and together you create a treatment plan with both short-term and long-term goals. He mentions his job being a source of frustration. You spend some time discussing the client's job and his feelings about it. He expresses his desire to retire, but he worries about the financial burden it may place on his wife. He says, "My retirement benefits are not that great, and I lost a lot of money in the stock market last year. I just don't know how I can make this work. I'm not sure if retiring now is the right decision." You discuss other possibilities for him to consider for retirement, such as part-time work or freelancing in a field he enjoys. You also brainstorm with him about ways for him to transition out of his current job in a way that reduces conflict with his co-workers, such as taking scheduled breaks and speaking with his supervisor about his workload. You provide support and suggest that he speak with his wife about their financial situation before making any decisions about his retirement. He agrees and states he will bring it up with her this upcoming week. Toward the end of the session, the client reveals that he has been contemplating cutting back on his drinking, but he is worried that he will not have any friends if he stops drinking. He says, "I already feel like a failure at work and as a husband. If I lose the few friends that I still have, I'll be alone and will never be happy again." You utilize motivational interviewing strategies and suggest that if he stops drinking, it will not mean that he has to give up all of his friends, but rather that he may need to find new friends who do not drink alcohol or who can meet with him in an alcohol-free context. He nods his head and says, ""I hear what you're saying, but who is the world would want to be friends with someone like me? The only reason I've got any friends left is because I like to drink with them." You empathize with his feelings of self-doubt, but remind him that it is possible to find meaningful friendships without drinking. You give him a homework assignment to find at least one activity or group that seems interesting to him and create a plan to start building positive relationships with others. You reassure him that you will be there to support him through this process and set a date for his next appointment. 15th session You have been seeing the client regularly for the past four months. He states that he is feeling "better" these days, and he is doing better at work. He has been taking his antidepressant medication as prescribed and feels therapy has been helpful. You review the treatment plan and discuss the progress he has made and the termination process. Near the end of the session, he tells you, "Well, there is one more thing. I'm worried that my wife might be having an affair. I know it's probably crazy, but I can't help but think that she's seeing someone else. And you know what, I wouldn't blame her. I haven't been the best husband with my constant depression. I just think about her leaving me, and it makes me feel afraid." You express understanding and validate his feelings, noting that it's not uncommon for people to have affair-related thoughts when feeling insecure in their relationship. You inquire whether he has been spending time with his wife and how he and his wife have been communicating. He reports that they have been talking more and that he has been trying to be more present when he is with her. You remind him of his progress in therapy and how much better he has been feeling overall, which has likely contributed to him being able to engage more in his marriage. You suggest that as he continues to work on himself and generally feels better, his worries about his wife cheating on him will likely lessen. In the meantime, you caution against drinking to cope with his anxiety, as it can lead to further problems down the road. | The client reports that his relationships with family members were strained growing up, with his father often away for work and his mother struggling with her own mental health. He reports that his mother drank a lot, which the client defends saying, "I guess I'd drink a lot if I had 5 kids by the time I was 22 years old. The client grew up feeling unsupported and unimportant, which led to a disconnect from the rest of his family. Of his four siblings, the client keeps in touch with one brother, but "my other two brothers and sister live in different states and have different lives. I think they've struggled with depression, too. We don't talk much." Despite this difficulty in connecting, the client has an adult daughter whom he "loves very much and tries to stay in contact with. He wishes he could have done better for her during his parenting years, and despite their rocky past, has a deep desire to maintain a healthy relationship. He says, "I don't want her to think the same way I do about family and relationships. I want her to have good ones." The client is currently employed as a corrections officer and feels his job has no potential for advancement. He has been working there for 20 years and is ready to retire in less than a year. He expresses that it has been challenging and physically and mentally exhausting. In addition, he is tired of "dealing with both the inmates and the administration." He tells you his co-workers consider him a "slacker" because he is always tired and takes as many breaks as he can get away with. He is also worried about "word getting back to his co-workers" that he is in therapy. The client expresses that he has some drinks, especially after work, to calm down. He reports that he will drink in social settings as well. He states that his preferred drink of choice is whiskey. | According to the DSM-5-TR, when would you revise the client's diagnosis to indicate that he is "in full remission"? | When the client has gone 6 months without any depressive episodes or symptoms | When the client reports that he is feeling better and occupational functioning has improved | When the client has achieved all short-term treatment objectives | When the client has been free of significant depressive symptoms for at least two months | (A): When the client has gone 6 months without any depressive episodes or symptoms
(B): When the client reports that he is feeling better and occupational functioning has improved
(C): When the client has achieved all short-term treatment objectives
(D): When the client has been free of significant depressive symptoms for at least two months | When the client has been free of significant depressive symptoms for at least two months | D | The DSM-5-TR states that a diagnosis of Persistent Depressive Disorder, Severe can be revised to "in full remission" when the symptoms of depression are absent for at least two months and any residual symptoms (if present) do not significantly interfere with social, occupational, or other important areas of functioning. Therefore, if the client has been symptom free for at least two months and is able to engage in activities without significant interference or distress, the diagnosis of Persistent Depressive Disorder, severe can be revised to "in full remission". This would need to be reassessed regularly, as symptoms may return. Therefore, the correct answer is (C) | intake, assessment, and diagnosis |
344 | Client Age: 45 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Divorced, single Counseling Setting: Private practice Type of Counseling: Individual counseling Presenting Problem: The client is experiencing difficulty in functioning in all areas of his life due to inhalant use. Diagnosis: Inhalant use disorder, severe (F18.20) | Mental Status Exam: The client is oriented to person, place, time, and situation. The client does not appear to be under the influence of inhalants because he does not display any symptoms of use. The client is friendly and engaged in the ses | You are a licensed counselor working in a private practice. You specialize in substance use disorders. The client comes into the session, is very friendly, and states that although his sessions are court ordered, he wants to get help with his inhalant use. The client spent the first half of the session explaining what happened to lead to him getting his third charge of driving under the influence of inhalants. The client says that he had twin sons 13 years ago and they both were in the ICU; one of his sons died after about a month. The client began drinking alcohol to excess daily for about 6 months, which then transitioned to inhalant use. The client says that he uses contact cement, model glue, paint, and permanent markers to become intoxicated. The client identified the following symptoms of inhalant use disorder: increase in frequency and amount of use over the past 5 years, several failed attempts at cessation of inhalant use, craving inhalants throughout every day, losing several jobs because of his inability to get to work on time due to inhalant use, use that has affected his ability to have visits with his children and maintain employment, use that increases the risk of harm to himself and others such as driving under the influence, increased tolerance, and continued use even when he knows it is negatively affecting his life. The client wants to become sober, improve his relationship with his children, and maintain employment. | sion. Family History: The client has three sons that are 11, 13, and 16 years old. The client is divorced as of 3 years prior and reports a contentious relationship with his ex-wife due to his difficulty following through with visits with their children. The client and his ex-wife were married for 17 years and dated for about 5 years before they were married. The client states that he loves his ex-wife but that she has currently been dating another man for the past 2 years and he knows they likely will not reconcile. He says that he understands why she does not want to be with him, and he thinks that he is not good for her or his children at this time. The client’s sessions are court ordered | The client’s sessions are court ordered. Which of the following is the most therapeutic course of action with regard to sharing information with the court? | Restrict access to the client’s records; even though therapy is court ordered, it does not mean that the court has access to all documentation. | Take steps to get written consent from the client, attempt to limit information given to the court, and/or prohibit the release of information if possible | Provide all of the information that the court requests per the legal requirements. | Provide minimal information to protect your counseling relationship with the client. | (A): Restrict access to the client’s records; even though therapy is court ordered, it does not mean that the court has access to all documentation.
(B): Take steps to get written consent from the client, attempt to limit information given to the court, and/or prohibit the release of information if possible
(C): Provide all of the information that the court requests per the legal requirements.
(D): Provide minimal information to protect your counseling relationship with the client. | Take steps to get written consent from the client, attempt to limit information given to the court, and/or prohibit the release of information if possible | B | The court can subpoena information if needed, and records must be provided in such cases. Therefore, it is best to gain consent from the client, if possible, so you are not sharing information against his wishes, while also explaining to the client certain limits in confidentiality that are unique to his circumstances. Limiting the amount of information provided to the court or attempting to restrict it altogether if it is best for the client is ideal because it protects your counseling relationship. The other answer options do not fulfill the counselor’s needs to meet court orders and to protect the counseling relationship. Sharing all information does not allow the client to have space to speak freely with you, yet you also cannot restrict all information from the court. Therefore, the correct answer is (A) | professional practice and ethics |
345 | Client Age: 60 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Married Counseling Setting: Private Practice Clinic Type of Counseling: Individual Counseling Presenting Problem: Unemployment; Anxiety; Depressed Mood Diagnosis: Adjustment Disorder with Mixed Anxiety and Depressed Mood (F43.23) | Mental Status Exam: The client appears to have a depressed mood as evidenced by his affect, slow speech pattern, and body posture. The client is dressed appropriately for the season and is in clean clothing. The client is oriented to person, place, time, and situa | You are a private practice therapist working in an outpatient clinic. Your 60-year-old male client comes into the intake session, sits down, and sighs deeply. You verbally acknowledge that the client looks as though he is carrying a big mental weight, and he nods. The client begins to talk about how he was let go from his job at an assembly plant a month prior due to budget cuts. The client says that he worked there for about 30 years and that he was most recently a plant manager for the past 10 years. The client states that the plant shut down because the automotive company moved their manufacturing to another country. The client expresses anxiety surrounding what he is going to do for work next. The client states that he worries that he does not have much to offer other employers due to the extent of time he spent at his last job and also that his age will make him unemployable. The client says that he has been isolating himself, feels down more often than not, and often worries about making ends meet. The client states that his wife is currently receiving cancer treatment and, because of this, they have significant, regular medical bills. | tion. Family History: The client has been married for 25 years. He has three children, a 23-year-old son, a 21-year-old son, and an 18-year-old daughter. The client reports a strong relationship with his wife and children and states that they regularly spend quality time together. The client does not currently have health insurance and says he will have difficulty continuing to pay for sessions at the current rate | The client does not currently have health insurance and says he will have difficulty continuing to pay for sessions at the current rate. Which of the following would be the most ethical method for determining your payment arrangement with this client? | You consider the client’s financial hardships and adjust your self-pay rate for the client. | You maintain the self-pay rate with the client because it is important to be compensated for the service you are providing. | You and the client set up a verbal agreement to trade the client’s garden produce and woodworking in exchange for counseling services. | You refer the client to another therapist who is willing to provide pro bono services. | (A): You consider the client’s financial hardships and adjust your self-pay rate for the client.
(B): You maintain the self-pay rate with the client because it is important to be compensated for the service you are providing.
(C): You and the client set up a verbal agreement to trade the client’s garden produce and woodworking in exchange for counseling services.
(D): You refer the client to another therapist who is willing to provide pro bono services. | You consider the client’s financial hardships and adjust your self-pay rate for the client. | A | Based on the ACA Code of Ethics, the most ethical method in dealing with this dilemma is to consider the possible hardships imposed on the client and adjust your rate for the client (ACA Governing Council, 2014). Bartering for services is appropriate, but it requires a written contract that both parties agree on (ACA Governing Council, 2014). Maintaining the self-pay rate does not consider possible hardships for the client and would not be the most ethical consideration. Providing a referral might be appropriate, but it is most ethical to first consider an adjustment in the fee prior to referring him to another therapist. Therefore, the correct answer is (C) | professional practice and ethics |
346 | 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. | There are several signs to cause you suspicion that Millie is high, which is not appropriate for your level of care and not permitted within your agency. What should you do? | Tell her you think she's high and that you must make a referral for higher level of care or call the police. | Continue to let her share because she might tell you on her own what is happening. | Present your observations of all concerning behaviors and ask her about them. | Remind her of your confidential relationship in hopes she admits to her using. | (A): Tell her you think she's high and that you must make a referral for higher level of care or call the police.
(B): Continue to let her share because she might tell you on her own what is happening.
(C): Present your observations of all concerning behaviors and ask her about them.
(D): Remind her of your confidential relationship in hopes she admits to her using. | Present your observations of all concerning behaviors and ask her about them. | C | At this stage, the most ethical choice moving forward is to present your concerns clearly and directly, and then give her an opportunity to address your observations. Millie has already broken company policies by not showing for her last appointment, arriving late, and is now presenting with reasonable suspicion of being intoxicated on the premises. Out of concern for Millie's best interest, waiting for her to share on her own or threatening her without discussing things with her first are both neglectful solutions as her counselor. You can always remind her of her confidentiality rights to support your therapeutic relationship, but this could be misleading when addressing her potential for illicit substance use or when preparing to make a referral. Therefore, the correct answer is (B) | professional practice and ethics |
347 | Name: Dave Clinical Issues: Worry and anxiety Diagnostic Category: Anxiety Disorders;Substance Use Disorders Provisional Diagnosis: F41.9 Unspecified Anxiety Disorder; F10.99 Unspecified Alcohol-Related Disorder Age: 42 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 presents at the intake session biting his nails and cannot keep his legs from shaking. He feels anxious about his wife and work. He continually places his hands on his head and complains of headaches and nausea. He admits to drinking a bit more than he should. He denies thoughts of self-harm but sometimes wishes that he could "disappear." | First session You are a counseling intern at an agency that works with clients from various socioeconomic backgrounds. Your client is a 42-year-old married male massage therapist who owns two therapeutic massage practices. Over the past nine months, his business has been reduced by fifty percent. He is having great difficulty paying the bills for the business, and he has exhausted his personal savings. His wife is currently not working due to a back injury. He has difficulty concentrating during the day and is irritable around his employees, friends, and family. He states that he drinks "too much" in order to relax at night and admits that his hangover adds to his anxiety the next day. His wife has begun to complain, and their relationship has been strained over the past three months. The client is concerned about paying for the sessions due to financial issues. He offers to exchange massage sessions for therapy. The client is aware that anxiety and alcohol use are impacting his work and family life negatively, but he does not know how to get a handle on them. He reports feeling overwhelmed with worry about the future of his business and whether he will be able to continue providing for his family. The client has been avoiding people lately, including old friends, and only sees his mother occasionally due to her health problems. In terms of self-care, the client acknowledges that he tends to put everyone else's needs before his own, which leads to feelings of exhaustion and anxiety. Additionally, he finds it difficult to recognize or accept compliments from others and has difficulty expressing gratitude for their help. During the intake session, you identify anxiety as one of the primary issues the client is seeking help with. You also discuss the role that alcohol is playing in his anxiety and suggest strategies for reducing anxiety without relying on it as a coping mechanism. The conversation then turns to developing a plan with the client for addressing these issues, such as scheduling regular self-care activities, limiting or eliminating alcohol use, and exploring cognitive behavioral therapy techniques for managing anxiety levels. | The client has been married for ten years. He and his wife have two children together, a son, age 10, and a daughter, age 12. The client does not speak to his father, who divorced his mother when he was four years old. The client and his mother have a good relationship. The mother lives 15 minutes away from the client and helps his wife with the children. During the past nine months, his massage therapy practice revenue has decreased by fifty percent, and it has been difficult to pay the bills. The client has exhausted all personal savings. The client is the sole income provider for his family, as his wife is not working while recovering from a back injury. | Your client finds you on Facebook and sends you a friend request. According to the ACA Code of Ethics, what would be the most appropriate course of action? | Use the request to explore and review boundaries regarding social media | Accept the client's friend request as a way of decreasing the client's level of anxiety as well as a way of building rapport | Modify your Facebook page by making private | Plan to address the friend request at a later time and continue with the session | (A): Use the request to explore and review boundaries regarding social media
(B): Accept the client's friend request as a way of decreasing the client's level of anxiety as well as a way of building rapport
(C): Modify your Facebook page by making private
(D): Plan to address the friend request at a later time and continue with the session | Use the request to explore and review boundaries regarding social media | A | Exploring and reviewing boundaries regarding social media is the correct answer. According to the ACA, as part of informed consent, counselors explain to their client's procedure benefits and limitations as well as boundaries while using social media. Therefore, the correct answer is (B) | professional practice and ethics |
348 | 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 participates in her last group therapy session today. You and the client review her treatment plan goals, and she reports an overall decrease in anxiety and says that she possesses a greater awareness of social anxiety disorder and the associated interventions. She has recently completed a job interview after previously scheduling and canceling two interviews. She plans to stay in touch with two group members. The client is ready to begin termination but is anxious about ending counseling. You and the client review the psychoeducation material reviewed in the group, including factors associated with social anxiety disorder and learned coping strategies. You previously measured the effectiveness of the group intervention by administering the same standardized instrument that was once used to measure social performance anxiety | You previously measured the effectiveness of the group intervention by administering the same standardized instrument that was once used to measure social performance anxiety. Which one of the following serves as your independent variable? | The instrument used in the posttest | The instrument used in the pretest | The group intervention | Social performance and anxiety | (A): The instrument used in the posttest
(B): The instrument used in the pretest
(C): The group intervention
(D): Social performance and anxiety | The group intervention | C | The group intervention serves as the independent variable. An independent variable is the variable that the experimenter manipulates. Social performance anxiety serves as the dependent variable. Dependent variables are what is observed or measured as being directly affected by the independent variable. In this scenario, you wish to determine the effectiveness of the group intervention (ie, the independent variable) on social performance anxiety (ie, the dependent variable). In this study, you use the same instrument for your pretest and posttest, neither one of which serves as the independent variable. Therefore, the correct answer is (A) | treatment planning |
349 | Name: Alex Clinical Issues: Hopelessness/depression Diagnostic Category: Depressive Disorders Provisional Diagnosis: F34.1 Persistent Depressive Disorder, Severe Age: 65 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: Multiracial Marital Status: Married Modality: Individual Therapy Location of Therapy : Private Practice | Appearance: The client is dressed in a manner that can be described as casual, suggesting that they might not have made any special effort to dress up for the session. Additionally, he is unshaven, which you note might indicate either personal preference, a decline in grooming habits, or possibly, decreased motivation and energy. Behavior: The client's overall behavior is withdrawn. Mood and Affect: His stated mood is depressed, implying feelings of sadness, hopelessness, or desolation. His affect, the observable manifestation of his feelings, is flat. Speech: His speech is both slowed and measured. Thought Process and Content: The client's thought process is tangential. He tends to veer off-topic and does not consistently answer questions directly or stay on point. The content of his thoughts is notably negative and self-defeating. Perceptual Disturbances: No delusions or hallucinations have been reported, indicating that the client has no gross misinterpretations of reality or perceptual disturbances. Orientation: The client is oriented to person, place, and time. Insight: It appears that the client has poor insight into his condition. Attitude: His attitude towards the evaluator is compliant and cooperative. | First session You are a licensed mental health therapist. Today you are seeing a 65-year-old male via distance counseling. You introduce yourself and ask him what prompted him to schedule an appointment to see you. He reports that he has felt "down in the dumps" for several years, and as he gets older, he feels more depressed and is in constant pain. As he is talking, he shifts around in his seat, appearing to have difficulty staying in a comfortable position. He continues by saying he feels depressed most of the time, has lost interest in activities that he once found enjoyable, feels hopeless, and is fatigued all the time. He also says he has lost his appetite and has difficulty sleeping. He states that "no one wants me around." Then he looks down and says, "I don't really blame them. I wouldn't want to be around me either." At work, he has difficulty concentrating and making decisions and is distressed that his co-workers see him negatively. When you ask him about his relationship with his wife, he says that while they live together, they have "not been close for a long time now." They both sleep in separate bedrooms and they lead separate lives. He explains, "We just kind of grew apart. We still love each other and would never get divorced, but now we're more like roommates. She's very social and involved in the community. I'm more of a homebody." After the client has shared why he is seeking counseling, you state, "I can hear that you are feeling very discouraged. It sounds like you have been going through a difficult time for quite some time now and it's taking a toll on your life. Let's explore what might be contributing to these feelings and how we can work together to help find solutions or ways to cope with the challenges you're facing." You use a solution-focused brief therapy technique and ask him visualize what successful treatment would look like. He contemplates it for some moments and says, "I'd feel better, I guess." You encourage the client to think more deeply about what successful treatment would look like and explain how this visualization process can help him gain clarity on his desired outcomes. He says, "Hmm, I'm not really sure. Can you give me some examples? This is my first time in therapy and I'm not really sure what to expect." You provide some examples of tangible goals that he might set for himself, such as improving sleep patterns, having better communication with family members and co-workers, and finding meaningful activities to engage in. The client is able to identify some areas that could be improved and formulates realistic, achievable goals. Together, you create an action plan for successful treatment, which includes specific steps he can take to reduce symptoms and increase positive outcomes. You schedule a follow-up appointment to meet with him next week. Fourth session It has been three weeks since your initial session with the client, and he has been keeping his weekly appointments. Last week you suggested he see a psychiatrist, and you begin today's session by discussing the results of his psychiatric referral. The client reports that he was prescribed antidepressant medication. He is not feeling much relief from his depressive symptoms now, but his psychiatrist told him that it could take a few months for the medication to reach maximum efficacy. Next, you discuss treatment options and the use of cognitive-behavioral therapy combined with his medication regimen. He is willing to try the combined approach, and together you create a treatment plan with both short-term and long-term goals. He mentions his job being a source of frustration. You spend some time discussing the client's job and his feelings about it. He expresses his desire to retire, but he worries about the financial burden it may place on his wife. He says, "My retirement benefits are not that great, and I lost a lot of money in the stock market last year. I just don't know how I can make this work. I'm not sure if retiring now is the right decision." You discuss other possibilities for him to consider for retirement, such as part-time work or freelancing in a field he enjoys. You also brainstorm with him about ways for him to transition out of his current job in a way that reduces conflict with his co-workers, such as taking scheduled breaks and speaking with his supervisor about his workload. You provide support and suggest that he speak with his wife about their financial situation before making any decisions about his retirement. He agrees and states he will bring it up with her this upcoming week. Toward the end of the session, the client reveals that he has been contemplating cutting back on his drinking, but he is worried that he will not have any friends if he stops drinking. He says, "I already feel like a failure at work and as a husband. If I lose the few friends that I still have, I'll be alone and will never be happy again." You utilize motivational interviewing strategies and suggest that if he stops drinking, it will not mean that he has to give up all of his friends, but rather that he may need to find new friends who do not drink alcohol or who can meet with him in an alcohol-free context. He nods his head and says, ""I hear what you're saying, but who is the world would want to be friends with someone like me? The only reason I've got any friends left is because I like to drink with them." You empathize with his feelings of self-doubt, but remind him that it is possible to find meaningful friendships without drinking. You give him a homework assignment to find at least one activity or group that seems interesting to him and create a plan to start building positive relationships with others. You reassure him that you will be there to support him through this process and set a date for his next appointment. | The client reports that his relationships with family members were strained growing up, with his father often away for work and his mother struggling with her own mental health. He reports that his mother drank a lot, which the client defends saying, "I guess I'd drink a lot if I had 5 kids by the time I was 22 years old. The client grew up feeling unsupported and unimportant, which led to a disconnect from the rest of his family. Of his four siblings, the client keeps in touch with one brother, but "my other two brothers and sister live in different states and have different lives. I think they've struggled with depression, too. We don't talk much." Despite this difficulty in connecting, the client has an adult daughter whom he "loves very much and tries to stay in contact with. He wishes he could have done better for her during his parenting years, and despite their rocky past, has a deep desire to maintain a healthy relationship. He says, "I don't want her to think the same way I do about family and relationships. I want her to have good ones." The client is currently employed as a corrections officer and feels his job has no potential for advancement. He has been working there for 20 years and is ready to retire in less than a year. He expresses that it has been challenging and physically and mentally exhausting. In addition, he is tired of "dealing with both the inmates and the administration." He tells you his co-workers consider him a "slacker" because he is always tired and takes as many breaks as he can get away with. He is also worried about "word getting back to his co-workers" that he is in therapy. The client expresses that he has some drinks, especially after work, to calm down. He reports that he will drink in social settings as well. He states that his preferred drink of choice is whiskey. | From a cognitive-behavioral perspective, what is the main factor contributing to the client's depression? | His family's history of depression | His drinking habits | Dissatisfaction with his job | His negative perception about himself and his environment | (A): His family's history of depression
(B): His drinking habits
(C): Dissatisfaction with his job
(D): His negative perception about himself and his environment | His negative perception about himself and his environment | D | CBT posits that depression is caused by distorted thoughts. Clients with depression tend to see themselves, their environment, and the future in a negative light. Therefore, the correct answer is (C) | counseling skills and interventions |
350 | 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. | The client informs you that she is upset because of a recent incident involving her two sons. She states that her teenage sons were walking in a neighborhood park when they came across a group of white men who used xenophobic slurs and threatened them. The boys said the men spit on them and told them to “go back to where they came from.” The client’s bouts of depression persist, and this is now coupled with the feeling that she has somehow failed to protect her sons. The client is also concerned that her husband is becoming increasingly intolerant of her inability to cook, clean, and care for their boys. The client states this makes her feel “worthless” and a “nobody.” She has also become more isolated and misses “having the energy” to connect with those in her community. You use behavioral activation to help the client with social isolation | You use behavioral activation to help the client with social isolation. Which treatment plan goal reflects this approach? | The client will identify two ways of reducing ambivalence and engaging in “change talk.” | The client will identify at least four individuals who fit into her “quality world.” | The client will engage in a minimum of two “values-based” activities each week. | The client will list a minimum of three faulty assumptions contributing to her “failure identity.” | (A): The client will identify two ways of reducing ambivalence and engaging in “change talk.”
(B): The client will identify at least four individuals who fit into her “quality world.”
(C): The client will engage in a minimum of two “values-based” activities each week.
(D): The client will list a minimum of three faulty assumptions contributing to her “failure identity.” | The client will engage in a minimum of two “values-based” activities each week. | C | Behavioral activation is a cognitive-behavioral approach for treating depressive symptoms, including those associated with social isolation. It works by positively reinforcing activities related to one’s values and enjoyment rather than waiting for depressive symptoms to diminish before engaging in these activities. Motivational interviewing is used to reduce ambivalence and elicit change talk. Identifying concepts and faulty assumptions contributing to one’s failure identity is associated with Adlerian therapy. Lastly, reality therapy suggests that one’s “quality world” is at the core of life. One’s quality world includes individuals we are closest to and those who supply us with satisfying experiences. Therefore, the correct answer is (A) | treatment planning |
351 | 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. | 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. | In which example are you demonstrating an empathic response toward the client's mother? | Share a summary of the Education Act of 1996 with the mother | Summarize her concerns about her son's behavior | Ask the client to look at you when you are interacting with him | Provide a psychoeducational session concerning the client's physical needs versus his social needs | (A): Share a summary of the Education Act of 1996 with the mother
(B): Summarize her concerns about her son's behavior
(C): Ask the client to look at you when you are interacting with him
(D): Provide a psychoeducational session concerning the client's physical needs versus his social needs | Summarize her concerns about her son's behavior | B | In this case, this is the best empathic response as it directly demonstrates that you understand the mother's emotions or motivations. Therefore, the correct answer is (B) | counseling skills and interventions |
352 | 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 | What type of treatment would not be beneficial for treating Mark? | Self-management strategies | Assertive community treatment | Supportive therapy with psychoeducation | Antipsychotic medications alone | (A): Self-management strategies
(B): Assertive community treatment
(C): Supportive therapy with psychoeducation
(D): Antipsychotic medications alone | Antipsychotic medications alone | D | Antipsychotic medication alone is not as effective for treating Schizophrenia. Effective treatment includes a combination of antipsychotic medication as well as wraparound services. These services include supportive therapy with a focus on psychoeducation to help the person better understand their diagnoses. Services also include assertive community treatment which includes a team of a psychiatrist therapist and peer advocate to help manage crises medication and community resources. Finally, self-management strategies are useful in helping the client with everyday life skills. Therefore, the correct answer is (A) | intake, assessment, and diagnosis |
353 | Initial Intake: Age: 9 Gender: Female Sexual Orientation: Heterosexual Race/Ethnicity: Caucasian/Non-Hispanic Relationship Status: Single Counseling Setting: Private Practice Type of Counseling: Individual | Lottie presents as excited, over-stimulated and hyperactive, unable to sit still and does not take breaks from talking. Her appearance is highly disheveled with stained clothes and unbrushed hair. Lottie nervously walks around your office touching and commenting on everything. You ask her nicely to ask you before she touches your things, but she refuses and continues to do so. Lottie deflects from every question posed in your assessment. She denies SI/HI, hallucination, or delusion, which you were surprisingly able to find out from her. |
Diagnosis: Attention Deficit Hyperactivity Disorder, predominantly hyperactive type (F90.1), Oppositional defiant disorder (F91.3), Reaction to severe stress (F43.9)
Lottie is a 9-year-old girl in the fourth grade who has been referred to you by officials in her elementary school. You are a counseling intern of a private practice that specializes in adult personality disorders, but your supervisor accepted Lottie as a new client because Lottie’s mother is a former client of her agency, and she requested her daughter be seen by your practice as opposed to a school-based counselor. Lottie’s mother does not want Lottie’s peers to know she is in therapy. Lottie has been doing well in school academically but has not been able to behave appropriately for years, according to the referral report. Lottie bounces up and down in her chair constantly, makes impulsive noises throughout the day, and engages in inappropriate behaviors daily. Some of the behaviors listed include invading the personal space of her peers, licking and eating school supplies to garner reactions from fellow classmates, hiding on the playground and refusing to emerge, and many other behaviors. Lottie follows basic classroom directions but needs constant reminding or guiding that the teacher does not have time for. Lottie breaks down into hysterical emotional fits when she does not get her way and her behaviors have been spreading the school staff too thin to be capable of managing without intervention. This session is conducted with only Lottie in the room; her mother insists on waiting in the car outside so she can make some phone calls. She mentions her Medicaid has just been reactivated to pay for sessions. | Family History:
Lottie lives at home with her mother and mother’s boyfriend, as well as their 1-year-old son Davie who is her half-brother. You learned from speaking with her mother beforehand that Lottie’s biological father was a drug addict and homeless, and he was recently shot and killed, about four months ago. Lottie knows and understands what happened. During the intake session you ask her to draw a picture of something important to her. She likes this assignment and draws you a picture of her father’s homeless camp where she last saw him. She explains to you the details surrounding his murder and mature, intimate details of her mother’s broken relationship with him. “How do you know all of this, Lottie?” you ask her, concerned. “Oh, my mother told me. She tells me everything.” | Speaking with Lottie's mother after session, you mention her comment about getting in trouble for admitting to feeling unsafe. Lottie's mother assures you she is safe, saying she has told stories in the past which led to unsubstantiated reports and cancelled investigations. What should you do? | Continue to monitor the situation. | Confront Lottie about the storytelling. | Ask to have a session at Lottie's house. | File a report anyway out of safety concerns. | (A): Continue to monitor the situation.
(B): Confront Lottie about the storytelling.
(C): Ask to have a session at Lottie's house.
(D): File a report anyway out of safety concerns. | Continue to monitor the situation. | A | Lottie's mother's explanation of storytelling is plausible, especially considering what you already know of Lottie's behaviors. However, it does not mean you should remove your attention from this factor while counseling Lottie. Continued safety questions, learning more about Lottie's traumatic past, and continual communication with her mother are all healthy and appropriate actions to take as you further assess their situation. Having a home visit is a clinical choice between you, your supervisor, and your client, but it does not yet seem warranted in this case as Lottie continues to be capable of coming into the office for sessions and you have not had many sessions yet with her. You still do not have enough information to substantiate any reporting. Confronting Lottie about storytelling is a choice you can make if you witness the storytelling yourself, however it seems Lottie's response to your safety question was her way of applying her own efforts to no longer tell stories. Therefore, the correct answer is (C) | counseling skills and interventions |
354 | 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. | The client enters the room and appears distracted when she sits down because she has a furrowed brow and is looking off to the side of the room. You ask her what is on her mind, and she reports that this morning she had a panic attack that led to her throwing up. You ask her to talk through the moments when she noticed it starting and how the panic attack progressed. She says that she woke up and was worried that she might have a panic attack because she typically has one on school days, and this turned into worry that she might be late for class, which compounded into worry about how it might affect her grades and eventually into certainty that she would fail. The client then experienced an increased heart rate, chest tightness, difficulty breathing, a feeling of impending doom, shaking, and finally vomiting. You empathize with the client and provide psychoeducation on the management of panic attacks. When this session is over, you check your online dating profile and notice that a past client’s sister reached out to you showing interest in going on a date. You and this past client terminated 3 years ago | When this session is over, you check your online dating profile and notice that a past client’s sister reached out to you showing interest in going on a date. You and this past client terminated 3 years ago. Which one of the following is aligned with the ethical guidelines of the American Counseling Association (ACA)? | You cannot date this person because she is related to a former client and 5 years have not passed since terminating the counseling relationship. | Document your decision and how the relationship is nonexploitative prior to going on a date with this client’s sister. | You did not have a counseling relationship with your past client’s sister, so this does not prohibit you from dating her. | You can proceed with a date because it has been 3 years since you worked with her sister. | (A): You cannot date this person because she is related to a former client and 5 years have not passed since terminating the counseling relationship.
(B): Document your decision and how the relationship is nonexploitative prior to going on a date with this client’s sister.
(C): You did not have a counseling relationship with your past client’s sister, so this does not prohibit you from dating her.
(D): You can proceed with a date because it has been 3 years since you worked with her sister. | You cannot date this person because she is related to a former client and 5 years have not passed since terminating the counseling relationship. | A | According to ACA ethical guidelines, dating a former client and/or someone related to that client cannot be considered until at least 5 years have passed since terminating the counseling relationship; therefore, you cannot date this individual. In a case in which 5 years had already passed, it is also necessary to provide supporting documentation that this would not be an exploitative relationship. Therefore, the correct answer is (D) | professional practice and ethics |
355 | Client Age: 30 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Agency Type of Counseling: Outpatient Presenting Problem: Recent Hospital Discharge Diagnosis: Borderline Personality Disorder (BPD) 301.83 (F60.3) | Mental Status Exam: The client is wearing a low-cut blouse and short shorts. Her affect and mood are labile, and her speech is pressured. She is fidgety at times and sits with her arms crossed. The client states that she has had three previous suicide attempts and has been cutting since her late twenties. Her last suicide attempt was an overdose, which resulted in her recent hospitalization. She stated that this was the result of her last boyfriend “ghosting” her. The client denies audiovisual hallucinations but states that she often feels that others are conspiring against her. She says that she continues to have suicidal thoughts but denies having a current plan. Fam | You are a mental health counselor in an outpatient setting. Your client is a 30-year-old white female who was released from the hospital 48 hours ago. The client presents today for a postdischarge follow-up appointment. The hospital clinician diagnosed the client with borderline personality disorder(BPD) and substance use disorder. The client has a history of suicidality, impulsivity, and relational instability. She explains that she has a “quick temper,” which occurs when she is feeling rejected. She explains that she has a long history of being treated poorly by others, including her last boyfriend, former employers, and family members. During these times, the client admits to substance misuse and self-mutilation (i.e., cutting). She states that there are times when she drinks to black out and that she is more inclined to do so when her feelings become intolerable. The client has had multiple hospital admissions and has been in the care of several counselors. She questions your credentials and your ability to “work with someone like (her).” | You are a mental health counselor in an outpatient setting. Your client is a 30-year-old white female who was released from the hospital 48 hours ago. The client presents today for a postdischarge follow-up appointment. The hospital clinician diagnosed the client with borderline personality disorder(BPD) and substance use disorder. The client has a history of suicidality, impulsivity, and relational instability. She explains that she has a “quick temper,” which occurs when she is feeling rejected. She explains that she has a long history of being treated poorly by others, including her last boyfriend, former employers, and family members. During these times, the client admits to substance misuse and self-mutilation (i\. e., cutting). She states that there are times when she drinks to black out and that she is more inclined to do so when her feelings become intolerable. The client has had multiple hospital admissions and has been in the care of several counselors. She questions your credentials and your ability to “work with someone like (her).” ily and Work History: The client attended 3 years of college and reports dropping out due to “depression, anxiety, and anger issues.” She has worked off and on as a server at several restaurants and says she usually quits after coworkers or employers “reject or betray her.” The client’s mother was a teenager when the client was born. Her mother is diagnosed with bipolar disorder, which first appeared after childbirth. She reports moving back and forth between caretakers when she was younger. Her maternal grandmother eventually became her legal guardian and died when the client was in her early twenties. The client reports that she constantly fears abandonment and has “never been successful in a relationship.” She has limited contact with her mother, and the identity of her father is unknown | Borderline personality disorder (BPD) is clustered with similar personality disorders characterized by which of the following traits? | Acute mood lability and social isolation | Fearful thinking and impulsive behavior | Dramatic and overly emotional behavior | Odd or eccentric behavior | (A): Acute mood lability and social isolation
(B): Fearful thinking and impulsive behavior
(C): Dramatic and overly emotional behavior
(D): Odd or eccentric behavior | Dramatic and overly emotional behavior | C | BPD is clustered with similar personality disorders characterized by dramatic and overly emotional behavior. The DSM-5-TR groups personality disorders into three clusters (ie, cluster A, cluster B, and cluster C). Cluster A includes paranoid, schizoid, and schizotypal personality disorders. Individuals with personality disorders in cluster A often exhibit odd or eccentric behavior. Cluster B personality disorders include borderline, histrionic, antisocial, and narcissistic personality disorders. Individuals with cluster B personality disorders can be described as dramatic, emotional, or erratic. Cluster C includes avoidant, dependent, and obsessive-compulsive personality disorders. Individuals in cluster C are characterized as anxious and fearful. Therefore, the correct answer is (C) | intake, assessment, and diagnosis |
356 | Name: Denise Clinical Issues: Hopelessness/depression Diagnostic Category: Bipolar and Related Disorders Provisional Diagnosis: F34.0 Cyclothymic Disorder Age: 38 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: White Marital Status: Divorced Modality: Individual Therapy Location of Therapy : Private Practice | The client is appropriately dressed. She is overweight and appears edgy and irritable. Her attention wanders during the intake. She is articulate and able to communicate her thoughts logically. The client focuses on the negative aspects of life and appears to have a strong external locus of control. Insight is low, and judgment is strong. | First session You are a mental health counselor in a community agency. The client is a 38-year-old White female teacher referred to you by her principal. The client is experiencing difficulty with her school colleagues. She wants to keep her job and is motivated to improve her social skills. Since she was a young adult, she has had tumultuous relationships with co-workers, friends, and family. She tells you she has periods of highs and lows. During the high periods, she is overly talkative, impulsive, and insensitive to others. However, during the low periods, she withdraws from social contact, feels hopeless and helpless, and has trouble concentrating. She expresses a desire to be liked, but people see her as an "emotional roller coaster" and avoid her. She is very talkative throughout the session and changes the topic frequently. You raise your hand periodically to summarize what she is telling you. Early on during the session, the client says, "Please help me. I know something is wrong, but I don't know what to do. Can you fix me?" You discuss the scope of your practice and explore options for treatment with her. You explain that one of your responsibilities as a therapist is to provide a safe space where she can express her thoughts and feelings without fear of judgement or criticism. You explain that through understanding and integrating different aspects of herself, she has the potential to develop healthier relationships both in and outside of work. You emphasize the importance of building self-awareness and developing effective coping skills as part of her journey towards healing. Ultimately, you focus on empowering the client by providing support, guidance, and skills that will enable her to make positive changes in herself so she can function more effectively in life moving forward. You discuss the importance of the client taking an active role in her treatment process and explore methods she can use to become more mindful of her thoughts, feelings, and behavior. You suggest that this will help her gain better insight into the sources of her distress, which will enable her to take more control over how she copes with difficult situations in the future. The client appears relieved that there is something constructive she can do. You end the session by scheduling another appointment for next week and encourage the client to focus on self-care in between sessions. You also reassure her that you will be there as a supportive resource throughout the therapeutic journey ahead. The client leaves feeling empowered and energized to take the first steps towards change. Fourth session During the previous two sessions, you spent the majority of the time listening to the client describing her conflicted relationships. You asked her to start keeping a mood diary, and while you review it together today, you notice that entries involving her father always precipitate a depressive mood. While you try to bring her attention to this trigger, she says, "I bet my dad enjoys watching this from the grave," and laughs. She tells you that she never felt like her father really loved her, and she believes that he blamed her for her mother's death. You demonstrate empathy and unconditional positive regard in response to her feelings. You begin to explore the client's thoughts about her father's suicide. Her demeanor changes, and she begins to talk about finding his body and the pain he must have gone through. She has "an epiphany" as she describes how she feels and realizes that he must have suffered a lot. Following the client's disclosure, you take the time to normalize her feelings and process her experience. You acknowledge the immense amount of pain and suffering she has endured, both from her father's death, as well as his emotionally distant behavior during life. Through your therapeutic dialogue, you emphasize that it is natural for a person to feel overwhelmed and disconnected in such circumstances, and that these feelings are not a source of shame or weakness. You prompt her to think of new ways in which she can build healthier relationships with others, including developing more meaningful connections through open and honest communication. Finally, you ask her to brainstorm different activities and interests that she finds joy in doing so she can incorporate them into daily life as a way for her to find balance amidst the chaos. At the end of the session, the client mentions that she is going to be visiting a friend who lives on the other side of the country. They are planning to explore one of the national parks for a few days and spend the remainder of the time "just chilling" at her friend's house. She tells you that she is looking forward to spending some time in nature. The client does not want to miss her weekly appointment with you and asks if you can meet with her for a virtual session next week instead of your usual in-person counseling session. | The client's mother was diagnosed with Bipolar I Disorder. The client's mother passed away ten years ago in a car accident. The client reported constant criticism from her father when she was growing up. When the client's mother was not depressed, she acted as a buffer between the client and her father. The client reports getting married immediately after graduating high school to an abusive man who was similar to her father in many ways. The couple divorced two years ago after the client wound up in the emergency room after reporting that she "slipped on the last step of the staircase and fell into a door jam." She got full custody of their son and went to live with her father until he passed away a year ago from suicide. He was chronically ill with cancer. The client is currently a science teacher. For the past three years, every school she has worked at has declined to renew her contract. The client's father left his house and all of his financial assets to her, so she does not have to make a mortgage payment. She has savings, but she is burning through it quickly. Previous Counseling: The client sought grief counseling at the time of her mother's death. She felt the therapist was "not spiritual enough" to deal with the client's beliefs. The client knew she needed help, and her pastor recommended a group. She attended four group sessions before leaving the group due to interpersonal conflicts with some of the group members. She tells you that she is not interested in participating in any group therapy. | How should you respond to her request to meet with her via telehealth for her next session? | As the client is still a resident in the same state in which you practice, you agree to meet with her for a virtual session. | Recommend postponing the next counseling session until after the client returns from her trip. | Ask her to complete a telehealth consent form prior to scheduling the session. | Prior to offering out-of-state services, you consult with your relevant governing agency or state laws. | (A): As the client is still a resident in the same state in which you practice, you agree to meet with her for a virtual session.
(B): Recommend postponing the next counseling session until after the client returns from her trip.
(C): Ask her to complete a telehealth consent form prior to scheduling the session.
(D): Prior to offering out-of-state services, you consult with your relevant governing agency or state laws. | Prior to offering out-of-state services, you consult with your relevant governing agency or state laws. | D | Depending on the area in which you practice, there may be certain restrictions and regulations related to providing telehealth services outside of the state. It is best for you to consult with your relevant governing agency before providing service in any other state. Therefore, the correct answer is (A) | professional practice and ethics |
357 | 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. Third session During last week's session, the client's mother accompanied her to the session. Throughout that session, the mother continued to talk about her own personal issues, and you could not gather information from her daughter's point of view. The client's mother presents with her daughter again to today's session. After a few minutes, you realize that the mother is monopolizing the counseling session by talking about her personal life and making snide comments aimed at her daughter. You suggest that it might be better for the client's mother to wait outside while you talk alone with the client. When the mother leaves, the client immediately relaxes and opens up about some of the struggles she has been going through. She shares that life at home has been difficult. She describes her mother as being "very mean" to her, and her grandmother makes fun of her. On the other hand, both adults are nice to her younger sister. The client states that she wishes she had never been adopted and that her life is "miserable." She expresses a desire to live with her father. Her behavior toward her parents has changed drastically since they started fighting in front of her, but she is not sure how to deal with their constant bickering. She has not told anyone at school about living in a "broken home" because she does not want any extra attention from her classmates. However, she has opened up more during therapy sessions, like today's meeting, telling you that music makes her feel better when upset. As homework, you ask the client to put together a playlist of music that is meaningful to her and bring it with her to the next session. Following today's session, the client's father calls you during off-hours to complain about his soon-to-be ex-wife. Sixth session You have seen the client every week since the initial intake. During today's session, the client tells you she has written a suicide note and left it in her room. Her mother is waiting in the lobby for the session to end. You tell the client you must bring her mother into the session and discuss the suicide note. You explain to the client that her mother's presence is necessary to explore and understand why the suicide note was written. The client expresses frustration and says, “You can’t bring my mom in here! She won’t understand why I wrote the note!” You empathize with her feelings, but also explain that it is important to discuss the reasons for writing the suicide note with her mother present. You reassure the client that you will guide the conversation to explore why she wrote the note and support her in addressing any underlying issues. You explain that understanding these reasons is an essential step toward moving forward and developing healthier coping strategies. The client reluctantly agrees, but insists on speaking with you alone first before bringing her mother into the session. You emphasize that it is important for her to be honest about her emotions and to talk about her experiences in order to identify the root cause of her distress. Throughout the conversation, you provide validation and affirmation in order to create a safe space for her to express her feelings. You remind her that she does not have to face the situation alone, and that you can work together to find a way forward. Once the client has had an opportunity to share her thoughts and feelings, you ask if she is ready for you to invite her mother in. She agrees, and the mother joins you in session. You explain to the mother that her daughter wrote a suicide note and that the two of you have been discussing the suicide note and why it was written. You emphasize that your goal is to better understand the circumstances leading up to this situation, so that you can work together to find a way forward. You state that your primary focus is on finding solutions, rather than assigning blame or judgment. The mother looks at you in disbelief and says, "What do you mean, she wrote a note saying she was going to kill herself? What are we doing here? I'm paying you to help my daughter, not make things worse!" She grabs her daughter's hand and storms out, after expressing her anger loudly the whole way to her car. You are unsure of how to proceed, so you discuss the case with your supervisor. Your supervisor listens and notes your concerns, offering advice and guidance on better handling the situation. He then suggests that you reach out to the client's primary care physician to discuss the possibility of hospitalization and other forms of support that might be available to the client. After further discussion, you call the client's physician and discuss the options. | 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. | What is the best strategy to de-escalate the mother's anger in session? | Explain that suicidal gestures are common with depression and that this is not a reflection of the client's progress or lack thereof in therapy | Explain that understanding the circumstances leading up to this situation is an essential step toward moving forward | Validate her feelings and emphasize that her daughter’s wellbeing is your primary focus | Employ therapeutic silence, to help the mother explore her own feelings. | (A): Explain that suicidal gestures are common with depression and that this is not a reflection of the client's progress or lack thereof in therapy
(B): Explain that understanding the circumstances leading up to this situation is an essential step toward moving forward
(C): Validate her feelings and emphasize that her daughter’s wellbeing is your primary focus
(D): Employ therapeutic silence, to help the mother explore her own feelings. | Validate her feelings and emphasize that her daughter’s wellbeing is your primary focus | C | An effective strategy would involve validating her feelings, listening to her perspective, and reassuring her that you are actively seeking solutions for her daughter's wellbeing. Therefore, the correct answer is (D) | counseling skills and interventions |
358 | 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. Your agency collects client satisfaction surveys that include a 5-point Likert rating scale. You notice that the client selected only neutral (i\. e., all 3s) answers | Your agency collects client satisfaction surveys that include a 5-point Likert rating scale. You notice that the client selected only neutral (i.e., all 3s) answers. This is most likely the result of which one of the following? | Central tendency bias | Primacy bias | The halo effect | Leniency bias | (A): Central tendency bias
(B): Primacy bias
(C): The halo effect
(D): Leniency bias | Central tendency bias | A | This is an example of central tendency bias. Central tendency bias occurs when a person rates items using only middle scores. This can happen when using a 5-point Likert scale and is prevented by instead using a 4-point Likert scale, which would force an individual’s score to fall to the left or right of the center. Leniency bias is when raters use only favorable ratings even though they believe that there is room for improvement. The halo effect is the tendency for a rater to allow one good trait to overshadow others. Individuals engaged in the primacy bias allow information received early on to take precedence over information received later. Therefore, the correct answer is (C) | professional practice and ethics |
359 | 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. | You meet with the client and review a log that he brings in that documents how often he masturbated over the past week. The client’s log showed that he masturbates about three to four times per day. The client appears to masturbate more when his roommates are not in the apartment and late at night when his time is less structured. The client reports that he has a job interview in a few days at a nonprofit agency that works with children to ensure that they have clothing. He feels that this will be meaningful work and is encouraged because he knows the supervisor there from a previous job, and he thinks that the supervisor is a respectful person. The client expresses worry that he will not be competent at the job based on how he is doing at his current place of employment. You support the client with reframing his anxious thoughts about the interview. The client often appears embarrassed when talking with you about masturbation | The client often appears embarrassed when talking with you about masturbation. All of the following could be helpful in increasing the client’s level of comfort with this conversation, EXCEPT: | Normalizing | Self-awareness | Immediacy | Summarizing | (A): Normalizing
(B): Self-awareness
(C): Immediacy
(D): Summarizing | Summarizing | D | Although summarizing shows that you are listening, it does not necessarily actively support the client in feeling more comfortable regarding a topic. Immediacy is when you address what you are seeing in the session, when you see it. This may induce some discomfort, but it will likely lead to talking through the anxiety, shame, and guilt that the client feels when talking about this topic. Self-awareness of the counselor applies to the verbal and nonverbal reactions that the counselor portrays while the client opens up about his struggles with masturbation. The counselor should maintain self-awareness when reacting to the client on this topic so as to create a safe environment of openness and to deepen therapeutic rapport. Although normalizing would likely not be helpful for the client in the sense of normalizing masturbation (because this is a religious and, therefore, internal struggle for him), it might be helpful to normalize the client’s humanity as an imperfect being who struggles with certain behaviors. Therefore, the correct answer is (D) | counseling skills and interventions |
360 | Name: Carter Clinical Issues: Developmental processes/tasks/issues Diagnostic Category: Neurodevelopmental Disorders Provisional Diagnosis: F90.0 Attention-Deficit/Hyperactivity Disorder, Predominately Inattentive Presentation; F81.2 Specific Learning Disorder with Impairment in Mathematics Age: 11 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Not Assessed Ethnicity: White Marital Status: Not Applicable Modality: Individual Therapy Location of Therapy : School | The client is of average build. He is dressed in a neat and appropriate manner for school. He is reluctant to engage in the conversation but does not display any hostility or aggression. The client displays a flat affect with occasional brief moments of animation which appear to be fueled by fleeting interests. His mood appears to be somewhat dysphoric as he often responds with a shrug or a one-word answer. The client’s thought process is non-linear and circumstantial. He is able to answer questions in a straightforward manner once he understands the topic being discussed. The client’s speech is of normal rate and volume for his age but it does contain some articulation errors due to his speech disorder. His memory appears intact as he can recall details from previous conversations with ease. | First session You are a mental health therapist in a public school. The client, an 11-year-old male, and his parents arrive at your office for the intake appointment per a referral from the committee on special education. The parents express concerns with their son's ongoing lack of concentration, being easily distracted, requiring multiple prompts and redirection throughout his day, and not following multi-step processes. The mother states that he tends to "drift off and is fidgety." He has trouble sitting still and cannot focus on anything for more than a few minutes. According to the parents, this behavior is present at both school and at home. As you progress with the intake session, you ask the parents to describe their current goals and any treatment barriers they have experienced up to this point. They state that they would like their son to be more focused throughout the day and be better able to follow instructions. They also mention that so far their efforts in trying to help him have been unsuccessful and he is still struggling. After gathering more insight into the client's home life, school performance, and developmental history from the parents, you turn your attention to the client. He has been looking around the room and has not been actively engaged in the conversation. When asked directly about his feelings about school, he shrugs and says, "It's okay." You ask him if there is anything that makes it hard for him to stay focused in class, and after a few seconds of reflection he admits that it is sometimes difficult because "there are too many things happening at the same time." He states that he cannot keep up with all of the activity going on around him and it is distracting. You inquire further as to what else may be contributing to his difficulty maintaining attention in school and he admits that sometimes he gets frustrated when tasks are too challenging for him. While he is answering your questions, he is looking at the small tabletop clock sitting on the corner of your desk. Once you feel that you have an accurate understanding of the current presenting issues, you discuss next steps with the parents. You discuss meeting with the client for individual weekly sessions to help him develop effective coping skills, build self-esteem, and manage emotions associated with frustration, failure, and low self-worth. You also suggest collateral sessions with the parents to check in with them about their son's progress and discuss strategies they can use at home to help him. They agree to this arrangement and ask if there are any tools or techniques they can try between now and the next time they meet with you. You suggest they start by creating a daily routine that will provide a sense of predictability and help to reduce chaos, and having a set time for homework, meals, and bedtime. You also mention that stimulant medication is often prescribed for children with ADHD, which can help to improve focus and concentration. Lastly, you let the parents know there is some evidence that certain foods can trigger or worsen ADHD symptoms, such as sugary, processed, or artificial foods. | The client is currently a fifth grader participating in the general education curriculum. He has a disability classification with his school district as learning disabled. He receives consultant teacher services via classroom support aide for English Language Arts (ELA) and Math. In addition, he attends the resource room daily for added support. The client arrives to class prepared with necessary materials and homework assignments but requires prompts throughout his day to stay on track. He is conscientious about his grades and doing well academically but is easily distracted by environmental factors surrounding him. Three years ago, the client's triennial evaluation report indicated a classification of Speech Language Disorder. To date, staff suggests that the client's speech deficits manifesting as notably impaired speech do not seem to cause concern in social situations. Additional Characteristics: The client is a very pleasant, quiet, shy, reserved boy. He tends to lack confidence in his academic abilities, which seems to cause him stress. Small glimpses of the client's good sense of humor can often be seen in small group settings. | Which best describes the legal requirements regarding your psychotherapy notes and reports for this client? | Even though you are a licensed psychotherapist, as an employee of the school system, you are not required to keep psychotherapy notes, since your final report is a public record. | Even though you are a licensed psychotherapist, as an employee of the school, your psychotherapy notes and reports are part of the student's record. | Even though you are an employee of the school, your psychotherapy notes are confidential. Your final report is part of the student's record. | Even though you are a school employee, all communication and notes regarding your client are confidential. | (A): Even though you are a licensed psychotherapist, as an employee of the school system, you are not required to keep psychotherapy notes, since your final report is a public record.
(B): Even though you are a licensed psychotherapist, as an employee of the school, your psychotherapy notes and reports are part of the student's record.
(C): Even though you are an employee of the school, your psychotherapy notes are confidential. Your final report is part of the student's record.
(D): Even though you are a school employee, all communication and notes regarding your client are confidential. | Even though you are an employee of the school, your psychotherapy notes are confidential. Your final report is part of the student's record. | C | Except for the usual exceptions of abuse and self-harm, therapy sessions follow rules of confidentiality. Therefore, the correct answer is (A) | professional practice and ethics |
361 | Initial Intake: Age: 28 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Married Counseling Setting: Private Practice Type of Counseling: Couple | The couple appear to be their stated ages with positive signs of self-care related to hygiene and dress. Both individuals appear overweight for height, and John appears to visually be categorizable as obese. Both individuals presented with congruent affect to their stated moods. Neither demonstrated retardation, spasticity, or hyperactivity of motor activity. The couple present as cooperative, open, and forthcoming, though each frequently looks at the other and confirms that the information they are presenting individually is accurate. Jane is noted to be caregiving of and highly empathetic to John. John is noted to respond appropriately to Jane’s statements. Neither presents with reports of suicidal ideations, thoughts of harm to self or others, or difficulties with memory, judgement, or concentration. | You are a counselor in a private practice setting. Your client, Jane, is 28 years old and presents with her spouse, John, a 24 year-old Hispanic male for “problems communicating.” The couple report that they have been married for one year after cohabitating for one year prior to marriage. Immediately after their marriage they began trying to become pregnant. They state they sought help from a specialist after several months and on learning that some degree of infertility existed, Jane began hormone therapy. Jane notes that it was soon after this time that the communication problems between them began. She tells you that it was at this point that she and John realized that they may not be able to have a biological child together. John acknowledges that Jane has tried many times over the last year to bring up this topic for discussion, but he chooses not to engage her. He tells you that he tends to believe that “if I don’t think about it, it will probably go away.” Jane agrees with John and reports that over time, the couple have talked less and spend much less time together. John agrees and says that sometimes “I may not say more than five words to Jane in a day.” Jane reports that they have not been intimate in over two months. When completing the intake paperwork, John endorsed no problems on any symptom criteria. Jane reported “serious” problems with “feeling sad, loss of interest in things she previously enjoyed, crying spells, and stress. She reported “moderate” problems with “feelings of worthlessness, anxiety, loss of appetite, and sleep disturbance. The couple states they were to sign divorce papers last week but made the decision to try counseling first. Neither has participated in counseling previously. | Family History:
The couple currently live with Jane’s 10 year-old son from her previous marriage and Jane’s 75 year-old grandfather, for whom the couple provide care. Jane owns and operates a small shop, is completing her bachelor’s degree, cares for her grandfather, and parents her son, who is heavily involved in baseball. She describes a history of hypothyroid disease though is no longer taking medication as her disease is now controlled with diet and exercise. She reports taking an antidepressant for two years, approximately seven years ago. She currently is taking Provera and Clomid for infertility and states these have had a noticeable effect on her mood. John reports this is his first marriage and he has no children from prior relationships. He was laid off two years ago and has been working in his uncle’s business, but the family has no insurance. He is actively involved in caring for Jane’s son and grandfather. He reports a history of high blood pressure. Prior to their wedding, John states he experienced irritability, agitation, difficulty sleeping due to “thinking about things” and worry. He was prescribed an SSRI and took this for six months. He tells you it seemed to help but he discontinued it 8 to 9 months ago. He reports that his doctor said his anxiety might have been because of his high blood pressure. | Using the information you have learned, which of the next steps is most appropriate? | Schedule John for a series of assessments to determine his mental status | Refer John to his family physician | Schedule John to meet with a support group | Refer John to a psychiatrist for evaluation and medical management of depression | (A): Schedule John for a series of assessments to determine his mental status
(B): Refer John to his family physician
(C): Schedule John to meet with a support group
(D): Refer John to a psychiatrist for evaluation and medical management of depression | Refer John to a psychiatrist for evaluation and medical management of depression | D | John is demonstrating physical signs of depression and has self-assessed his emotional state as depressed. The most appropriate action is to refer him to psychiatry to have him evaluated and determine whether antidepressants are warranted. Only medical providers are allowed to dispense antidepressants. John took an SSRI previously with good results and his mood has decreased since stopping them 6-8 months ago. A psychiatrist will use this information to determine John's treatment for depression. You could refer him to his family physician but his doctor's previous linkage of his affective state with his blood pressure may influence how his doctor approaches the issue. Psychiatry specialists are experts in initial diagnosing and prescribing medication for depression. Once an effective level is achieved, John should follow up with his family doctor. Scheduling John for testing is unnecessary as you are observing depressive symptoms, John is affirming he feels depressed, and moving into treatment is the next step. Having John attend a support group may be helpful for him once his depression is controlled. This will provide a safe place for him to practice communication skills and vulnerability in sharing his thoughts and feelings. Therefore, the correct answer is (D) | treatment planning |
362 | Initial Intake: Age: 58 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Married Counseling Setting: Private Practice Type of Counseling: Individual | The client reports that in the past six months she has lost 40 pounds, which leaves her looking thinner than seems appropriate for her 5’8” frame. Her hair is combed and neat, but looks thin and lacks a healthy shine. Her clothes, while clean, appear rumpled as if they have been slept in. She is cooperative and engaged, but moves slowly and pauses in her speech, causing you to wonder if she is lost in thought or if speaking is too painful. She reports she has difficulty falling asleep at night and never feels like she has any energy, though she does go to work each day. She denies any suicidal thoughts but states she feels sad all the time and “can’t wait to see him again.” She admits she blames herself for not keeping him home that evening, which would have prevented his death. | You are a counselor in a private practice setting. You receive a telephone call from an attorney that would like to refer their client, who is engaged in a civil suit, to you for counseling treatment. The attorney provides you with a detailed description of a traumatic event, death of her son, and expresses concerns about the client’s well-being. The attorney requests that you work with their client and be prepared to testify in court when the case goes to trial. | Family History:
During the intake session, the client reports that her youngest son was killed in a car accident eighteen months ago, which was caused by an impaired driver. Her son was the youngest of her five children and while she said she loves them all equally, she reported that her children have always said their youngest brother was her favorite. | Which of the following counseling skills or interventions should be employed during this session? | Open-ended questions | Reflection | Self-disclosure | Exploring family of origin patterns related to loss | (A): Open-ended questions
(B): Reflection
(C): Self-disclosure
(D): Exploring family of origin patterns related to loss | Reflection | B | Reflections of feelings or affect allow the client to feel heard and understood. This is particularly important when a client feels others are not listening to them. Open-ended questions and family patterns can be helpful in treating loss but are not effective without a strong therapeutic bond. Self-disclosure focuses on the counselor's experience, rather than on the client's experience. Therefore, the correct answer is (A) | counseling skills and interventions |
363 | Client Age: 25 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: In a Relationship Counseling Setting: Private Practice Clinic Type of Counseling: Individual Counseling Presenting Problem: Premature Ejaculation Diagnosis: Provisional | Mental Status Exam: The client is oriented to person, place, time, and situation. The client appears comfortable in the session as evidenced by his openness, congruent affect, and verbal express | You are a counseling resident at an outpatient clinic. Your 25-year-old male client reports he was in a bicycle accident a year ago and that, resultingly, he had reconstructive surgery to his penis. The client identifies that it takes approximately 30 seconds to a minute to ejaculate following vaginal penetration. The client reports that the symptoms occur every time he engages in sexual activities with his girlfriend. The client is a car salesman and also reports anxiety about performance at work and other areas of life. You suspect that the client may also have generalized anxiety disorder. The client reports that his girlfriend does not seem to mind that sex does not last long, but he feels bad because he also wants her to feel good during sex. | The client comes to the session reporting that he and his girlfriend attempted to have sex the past week, and he wrote down some thoughts he was having on his CBT thought log. The client and the clinician reviewed his thoughts and engaged in cognitive reframing to support him in creating new scripts to use when engaging in sex. The client also wrote down physical responses to anxiety that he was experiencing before and during sex that included muscle tension and increased heart rate. You ask the client what his life would be like if he did not feel that he can’t satisfy his significant other, and he does not respond immediately | You ask the client what his life would be like if he did not feel that he can’t satisfy his significant other, and he does not respond immediately. All of the following are important aspects of the use of silence EXCEPT: | The client appears uncomfortable with the silence, so you provide him with a prompt to say whatever is coming to his mind. | Your client may provide a meaningful response as a result of the silence, so you maintain the silence. | After providing a period of silence, you use attending skills to let the client know it is his turn to speak. | The client is not responding to the silence, so you continue talking to try to elicit more information. | (A): The client appears uncomfortable with the silence, so you provide him with a prompt to say whatever is coming to his mind.
(B): Your client may provide a meaningful response as a result of the silence, so you maintain the silence.
(C): After providing a period of silence, you use attending skills to let the client know it is his turn to speak.
(D): The client is not responding to the silence, so you continue talking to try to elicit more information. | The client is not responding to the silence, so you continue talking to try to elicit more information. | D | You should continue to maintain silence instead of continuing talking because you are missing the opportunity to use silence by continuing silence. Maintaining silence, providing a prompt to respond to the silence, and the use of attending skills to encourage silence are all helpful skills to prompt a response to the use of silence. Therefore, the correct answer is (B) | counseling skills and interventions |
364 | 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 | By conducting extensive research, the counselor is demonstrating | Multicultural sensitivity | Non-judgmental stance | Unconditional positive regard | Empathetic Attunement | (A): Multicultural sensitivity
(B): Non-judgmental stance
(C): Unconditional positive regard
(D): Empathetic Attunement | Multicultural sensitivity | A | Culture encompasses many things that make the client unique such as gender. By the counselor taking the time to do extensive research on a topic they are not familiar with, they show multicultural sensitivity. Unconditional positive regard is warmth and acceptance towards the client while not focusing on past transgressions. Empathetic attunement is the ability to put oneself in the shoes of another. Having a non-judgmental stance in not judging in comparison to personal standards. Therefore, the correct answer is (D) | intake, assessment, and diagnosis |
365 | Client Age: 30 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Agency Type of Counseling: Outpatient Presenting Problem: Recent Hospital Discharge Diagnosis: Borderline Personality Disorder (BPD) 301.83 (F60.3) | Mental Status Exam: The client is wearing a low-cut blouse and short shorts. Her affect and mood are labile, and her speech is pressured. She is fidgety at times and sits with her arms crossed. The client states that she has had three previous suicide attempts and has been cutting since her late twenties. Her last suicide attempt was an overdose, which resulted in her recent hospitalization. She stated that this was the result of her last boyfriend “ghosting” her. The client denies audiovisual hallucinations but states that she often feels that others are conspiring against her. She says that she continues to have suicidal thoughts but denies having a current plan. Fam | You are a mental health counselor in an outpatient setting. Your client is a 30-year-old white female who was released from the hospital 48 hours ago. The client presents today for a postdischarge follow-up appointment. The hospital clinician diagnosed the client with borderline personality disorder(BPD) and substance use disorder. The client has a history of suicidality, impulsivity, and relational instability. She explains that she has a “quick temper,” which occurs when she is feeling rejected. She explains that she has a long history of being treated poorly by others, including her last boyfriend, former employers, and family members. During these times, the client admits to substance misuse and self-mutilation (i.e., cutting). She states that there are times when she drinks to black out and that she is more inclined to do so when her feelings become intolerable. The client has had multiple hospital admissions and has been in the care of several counselors. She questions your credentials and your ability to “work with someone like (her).” | You are a mental health counselor in an outpatient setting. Your client is a 30-year-old white female who was released from the hospital 48 hours ago. The client presents today for a postdischarge follow-up appointment. The hospital clinician diagnosed the client with borderline personality disorder(BPD) and substance use disorder. The client has a history of suicidality, impulsivity, and relational instability. She explains that she has a “quick temper,” which occurs when she is feeling rejected. She explains that she has a long history of being treated poorly by others, including her last boyfriend, former employers, and family members. During these times, the client admits to substance misuse and self-mutilation (i\. e., cutting). She states that there are times when she drinks to black out and that she is more inclined to do so when her feelings become intolerable. The client has had multiple hospital admissions and has been in the care of several counselors. She questions your credentials and your ability to “work with someone like (her).” ily and Work History: The client attended 3 years of college and reports dropping out due to “depression, anxiety, and anger issues.” She has worked off and on as a server at several restaurants and says she usually quits after coworkers or employers “reject or betray her.” The client’s mother was a teenager when the client was born. Her mother is diagnosed with bipolar disorder, which first appeared after childbirth. She reports moving back and forth between caretakers when she was younger. Her maternal grandmother eventually became her legal guardian and died when the client was in her early twenties. The client reports that she constantly fears abandonment and has “never been successful in a relationship.” She has limited contact with her mother, and the identity of her father is unknown. After reviewing the client’s hospital records, you conduct an unstructured interview to confirm and retain the diagnosis of substance use disorder | After reviewing the client’s hospital records, you conduct an unstructured interview to confirm and retain the diagnosis of substance use disorder. Your clinical judgment may have been influenced by which of the following? | The Hawthorne effect | Affect heuristic | Overconfidence bias | Confirmation bias | (A): The Hawthorne effect
(B): Affect heuristic
(C): Overconfidence bias
(D): Confirmation bias | Confirmation bias | D | Individuals subject to confirmation bias seek information that confirms an initial hypothesis while rejecting information that does not fit the theory. An unstructured interview consists of open-ended questions used to arrive at a diagnosis, whereas structured interviews use a standardized list of questions. Semistructured assessments offer flexibility between the two. Unstructured interviews are subject to bias, particularly for an unseasoned clinician. Overconfidence bias, a form of hindsight bias, occurs when counselors overestimate their ability to make sound clinical decisions. Overconfidence bias occurs when answers to difficult clinical decisions seem apparent when viewed retrospectively. Affect heuristic is used when counselors base clinical decisions on the feelings experienced when interacting with a client. For example, if a client becomes angry or irrational during a diagnostic assessment, which produces countertransference, the counselor may be quick to assign a BPD diagnosis. The Hawthorne effect is the tendency for individuals to change their behavior in response to knowing they are being monitored or observed. Therefore, the correct answer is (A) | intake, assessment, and diagnosis |
366 | Initial Intake: Age: 68 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Widow Counseling Setting: Community Agency Type of Counseling: Individual | The client presents appearing thin for height and older than her stated age. She is dressed in jeans and a shirt, no make-up and appropriate hygiene. Her mood is identified as euthymic and her affect is congruent. She is talkative and tells stories about herself and others, although she appears very distractible and changes subjects easily. She demonstrates appropriate insight, judgment, memory, and orientation using mental status exam questions. She reports never having considered suicide and never consider harming herself or anyone else. | You are a counselor in a community agency and your client presents voluntarily, though at the request of her family members. She tells you that her stepson and daughter-in-law told her they are concerned about her because she lives alone and they don’t believe that she can take care of herself at her home. She tells you that she is very happy living alone and is never lonely because she has over 20 indoor and outdoor cats that she feeds and they keep her company. During the intake, the client tells you that her husband of 33 years died five years ago from lung cancer. When asked why her family wanted her to come to counseling, your client says that she gets along well on her own; however, she believes that her stepson is looking for ways to take over her property. She tells you she owns a large section of land that includes two trailer homes, one of which is in better shape than the other so that is where she lives; ten or eleven vehicles, some that run and some that do not; and five large carports that hold the items that she and her husband used to sell at the daily flea market before it closed 15 years ago. She tells you that she sometimes finds uses for some of these items around her house but keeps all of them because they may “come in handy” at some point. She currently has no help on her property for mowing or upkeep, unless a neighbor or her son-in-law volunteers to help. | Family History:
The client reports that her parents divorced when she was a young teenager and she did not see her father again after that time. She reports he was an alcoholic as was her mother and they often argued. She relates that her mother did not work and she grew up with government assistance for food and shelter. She tells you that several years after the divorce, her mother’s mobile home was destroyed in a fire and the two of them lived in a friend’s trailer until they were able to buy another one to put on their property. She reports that she quit high school in 10th grade after having trouble reading for many years, married at age 16, had one daughter, and then divorced at 19 due to her husband’s continuing drug use. She tells you that her daughter has not been around for the “past few years” because she lives in another state and has some “mental problems, like bipolar something.” She tells you that she married again at age 20 and remained married to her husband until his death. She tells you her husband was a “good man” though he had many problems related to his military service in Vietnam and health problems due to smoking. She reports he had lung cancer and lived for 20 years although the doctors did not expect him to live so long. This was a second marriage for both of them and she tells you that her husband had one son. The client tells you she has not been close with her stepson because he has never helped them out and it has been worse since she stopped letting him keep his hunting dogs on her property. She tells you that he never took care of them and she had to feed them every day because he did not. The client tells you that she is close to her stepdaughter-in-law and that she trusts her much more than she does her stepson. The client tells you that she and her husband worked at the local flea market for many years selling things they had collected, but since the flea market closed 15 years ago, they lived on Social Security and the money her husband made doing “odd jobs” around town. | Using the information you have learned, which of the following will not be helpful in focusing on change? | Help the client practice visualizing her home and yard without clutter | Help the client identify barriers to making the changes she would like to make | Help the client identify strengths that she possesses that can help her make changes | Help the client practice relaxation exercises to relieve anxiety | (A): Help the client practice visualizing her home and yard without clutter
(B): Help the client identify barriers to making the changes she would like to make
(C): Help the client identify strengths that she possesses that can help her make changes
(D): Help the client practice relaxation exercises to relieve anxiety | Help the client practice visualizing her home and yard without clutter | A | Helping the client visualize her home and yard without the clutter is most likely to cause the client higher anxiety. Hoarding represents an attachment to possessions and visualizing her possessions gone may upset her. It will be more helpful for the counselor to help the client identify the strengths that she possesses and can draw on as she tries to make changes in the way she thinks about things. Identifying barriers to her success will be helpful as these are areas that can be proactively processed and rehearsed for so that the client has a plan in place when they occur. Using relaxation exercises will be helpful when barriers are encountered and particularly when the client and her support system begin clearing her home and yard. Therefore, the correct answer is (A) | counseling skills and interventions |
367 | Name: Jackson Clinical Issues: Behavioral problems Diagnostic Category: Depressive Disorders Provisional Diagnosis: F34.8 Disruptive Mood Dysregulation Disorder Age: 11 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Not Assessed Ethnicity: White Marital Status: Not Applicable Modality: Individual Therapy Location of Therapy : Private Practice | Appearance: The client is dressed in clothes associated with anime. He is well groomed and appears to be a few years younger than his chronological age. Orientation: The client is oriented X3. Mood: The client's mood is dysphoric. Affect: The client's affect is restricted. Speech: The client's speech is soft and hesitant. Thought Process: The client's thought process is slow and labored. Thought Content: The client's thought content is pessimistic and focused on negative themes. Perception: The client's perception is intact. Insight: The client's insight is poor. | First session You are a therapist in private practice specializing in working with children. The client is an 11-year-old male. His mother brought him to therapy because of the "latest incident at school," wherein he had an angry outburst and threatened to come to school with a gun and shoot everyone, including himself. The mother states that the police were notified, and the client was suspended from school for a week. The client was unwilling to discuss his emotions or the incident at school. He became agitated and defensive whenever the topic was brought up and now will not talk to you. He seemed to be in a state of denial, minimizing the impact of the incident at school. You observe a bald spot on the top of the client's head, indicating that the client has been pulling his hair out. The client was evasive when asked about the bald spot on his head and became increasingly anxious. He could not articulate why he was pulling his hair out and seemed embarrassed, avoiding the topic. He has difficulty identifying and expressing emotions outside of anger. His mother reports that he lashes out at home with family and classmates at school, aggressively arguing and making threats. He had difficulty engaging in self-reflection and could not make meaningful connections between his behavior and the consequences that may follow. His mother is extremely frustrated and worried that this school will also expel him. She is upset with the lack of progress his previous therapist made with her son and is now considering residential treatment options. The mother has been receiving conflicting diagnoses from previous therapists and is seeking a definitive diagnosis from you. Halfway through the session, you ask to speak with the client by himself for a few minutes. The mother exits the room, leaving you alone with the client. You take notice of his anime shirt and ask him more about anime. He quickly starts talking and making eye contact. | The client's biological father was diagnosed with Bipolar I Disorder. The biological father is unaware of the client's existence although the client knows that his step-father is not his biological father. The client has transitioned from school to school. Each time his behavioral problems have escalated. This is his third school. The client's issues have become so severe that his parents have been called to the school multiple times. They have been unable to get him to listen to them or follow directions. His outbursts are becoming more frequent and aggressive, and his refusal to do work or cooperate has become a problem for his teachers. The school has tried various approaches to try and help the client, but he has been resistant to them. He has been put on a behavior plan but has not followed through. The administration has also tried talking to him on multiple occasions to try and get him to open up, but he has been unresponsive. The administration has now exhausted all of its options and is at a loss as to what to do. They are willing to give him one more chance, but they will be forced to find another solution if he does not improve. Previous Counseling: The client has been seeing a pediatric psychiatric nurse twice a month for two years for his frequent temper outbursts at home and school. His irritable and angry mood is a daily occurrence, with verbal rages and physical aggression occurring three or more times a week. He is currently taking Respidol for emotional regulation. The medication affects his appetite and energy level. | When you see that the client likes anime, you pull out your Nintendo Switch and ask him if he wants to play Dragon Ball FighterZ. Which explanation is appropriate, given he just threatened to kill his classmates and himself this week? | The client's past threat to harm himself and others should be addressed first before providing rewards. | Using gaming would only be appropriate in subsequent sessions after therapeutic goals have been established. | Playing games with the client minimizes the severity of his actions and reinforces his denial. | Engaging in a therapeutic activity that engages the client helps establish rapport, which is paramount at this stage. | (A): The client's past threat to harm himself and others should be addressed first before providing rewards.
(B): Using gaming would only be appropriate in subsequent sessions after therapeutic goals have been established.
(C): Playing games with the client minimizes the severity of his actions and reinforces his denial.
(D): Engaging in a therapeutic activity that engages the client helps establish rapport, which is paramount at this stage. | Engaging in a therapeutic activity that engages the client helps establish rapport, which is paramount at this stage. | D | As indicated, the client became agitated and defensive whenever the topic of him threatening to kill his classmates and himself was brought up, and he is now unwilling to talk to you. Unless you can establish rapport with the client, you will not be able to work with him regarding the incident at school. If he were willing to work with you, you would first address his threat to harm himself and others. Therefore, the correct answer is (A) | counseling skills and interventions |
368 | 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. | Which of the following is the least appropriate way to demonstrate cultural sensitivity to Malik? | Ask her to tell you more about her heritage and its importance to her. | Discuss with her the similarities and differences about Hawaiian and mainland culture. | Share with her your extensive knowledge of Hawaii and how you loved vacationing there. | Conduct interventions that increase her self-esteem in her heritage. | (A): Ask her to tell you more about her heritage and its importance to her.
(B): Discuss with her the similarities and differences about Hawaiian and mainland culture.
(C): Share with her your extensive knowledge of Hawaii and how you loved vacationing there.
(D): Conduct interventions that increase her self-esteem in her heritage. | Share with her your extensive knowledge of Hawaii and how you loved vacationing there. | C | Personal anecdotes about your connection to her culture that do not adequately reflect or support your client's concerns are not useful in counseling. It is also insensitive to present yourself as "expert" in the topic of their heritage. As a counselor it is your responsibility to help your client feel safe and secure so they can share about themselves and how their thoughts, beliefs, cultural attitudes, and experiences shape and affect their moods, behaviors, and reactions to different situations. Not everyone from the same culture feels and thinks the same way about their acculturation stress, so working with Malik to learn more about how she specifically feels is paramount in understanding how to help her. Interventions b, c and d are all effective and positive ways of addressing her heritage, learning more about her feelings, and helping her overcome her anxiety. Therefore, the correct answer is (A) | core counseling attributes |
369 | 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. You have been diagnosed with ADHD and experience similar struggles that you want to share with the client | You have been diagnosed with ADHD and experience similar struggles that you want to share with the client. Which one of the following is the most helpful description of effective self-disclosure? | Sharing personal experiences can enrich the counseling relationship. | You use self-disclosure when it is beneficial for displaying your empathetic understanding and when it benefits the counseling relationship. | You use self-disclosure in order to develop rapport with your client. | No level of self-disclosure is appropriate because you are counseling the client and do not want to risk them having to support your emotional needs. | (A): Sharing personal experiences can enrich the counseling relationship.
(B): You use self-disclosure when it is beneficial for displaying your empathetic understanding and when it benefits the counseling relationship.
(C): You use self-disclosure in order to develop rapport with your client.
(D): No level of self-disclosure is appropriate because you are counseling the client and do not want to risk them having to support your emotional needs. | You use self-disclosure when it is beneficial for displaying your empathetic understanding and when it benefits the counseling relationship. | B | The use of self-disclosure is a helpful therapeutic tool in demonstrating empathy and can benefit the counseling relationship when used appropriately. Self-disclosure should only occur when it would be beneficial to the therapeutic process; it should be used discriminately. Completely refraining from using self-disclosure prevents the counselor from access to a potentially helpful tool. Therefore, the correct answer is (D) | counseling skills and interventions |
370 | Name: Bianca Clinical Issues: Difficulty adjusting to life changes Diagnostic Category: V-codes Provisional Diagnosis: Z60.0 Phase of Life Problem Age: 62 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: Black Marital Status: Separated Modality: Individual Therapy Location of Therapy : Agency | The client is a 62-year-old female, wearing work attire. She appears to be in good hygiene and her dress is neat and appropriate for the situation. Her facial expression is sad and she has tear tracks on her cheeks. Her mood is noticeably depressed, anxious, and tearful. Her affect is constricted. She has coherent thought processes with appropriate content. She expresses feelings of sadness over her failed marriage and overwhelm about being alone. The client has intact memory and concentration. She has fair insight into her current situation and is able to verbalize her feelings in a coherent manner. | First session The client comes to the agency practice where you currently work as a licensed mental health therapist. She is a 62-year-old female who recently retired from an accounting firm employment. She is seeking treatment after her marriage recently failed. A few months ago, he husband filed for a legal separation and is currently romantically involved with another woman. The client looks at you tearfully and says, "I can't believe this is happening at my age. I am all alone. What am I going to do?" She continues to cry uncontrollably. You focus on providing a safe and secure environment. You assure her that she will not be judged or criticized in any way, and all of the conversations during the session will remain confidential. You gently let her know that it is okay to cry, and you are there to listen without judgement. You also tell the client that it is natural to feel lost and alone after a separation, especially since she and her husband have been together for such a long time. She says, "I just feel like such a fool. He cheated on me once before - that I know of - and now he's done it again. I stayed with him for over 30 years, and now I have nothing." She describes having mixed feelings of anger, sadness, fear, and confusion. She states, "There are moments where I'm so mad at him for leaving. Mad enough that I could break something! Our marriage wasn't perfect, but I thought he was committed to me. Well, obviously he wasn't. Then I start to question what's wrong with me that made him leave. And then I think about the future and how I'm going to live by myself. It's all so overwhelming." She further discloses that she is worried about having panic attacks again because "that's what happened the last time something of this magnitude happened to me." You reinforce the idea that it is important to focus on the fact that she is not alone and many people in similar situations feel overwhelmed and uncertain about their future. You let her know she is in a safe space to explore her feelings, work through her loss, and develop a plan for moving forward. You encourage her to reach out for support during this challenging time rather than isolate herself as she goes through this difficult change. Fifth session The client has been seeing you for individual therapy sessions every week. You have developed a strong rapport with her and collaborated on treatment goals, with her overall goal being to have a positive outlook on her life. During the last session, you gave her a homework assignment to begin keeping a journal, using the ABC model of rational emotive behavior therapy to identify self-defeating beliefs and understand how they are contributing to her emotional distress. You have also been working with her to process her feelings about her separation and develop coping skills. During today's session, she seems depressed, as she tells you her husband met with an attorney and officially filed for divorce. You explore her journal entries, noting one in particular in which she describes an experience in which she was driving and saw her husband sitting outside a café with "the other woman." She circled back a few times in her car, hoping he would see her. In her mind, she fantasized that he would leave his new girlfriend and drive away with her, and everything would return to normal. You ask her to tell you more about what "normal" means to her. She says, "I guess I just want things to go back to how it was before. When I mattered, when I felt loved, and when he was committed to our marriage." You acknowledge her feelings and explain that while it may not be possible to go back to exactly how things were, there is still hope for the future. You express compassion and understanding, emphasizing that there is no right or wrong way to feel. She states, "I just have mixed feelings about everything! I feel angry and betrayed by my husband, but sometimes I want him to come back. I start to feel lonely and realize the reality of my situation and that I have no purpose anymore and am alone. What's the point? My kids don't care; I have nothing in my life now. Things are so painful I'd be better off dead." You reassure her that you are here to support her as she works through all of her difficult emotions. | null | What concurrent referral might you consider for this client? | Support group | Behavior analyst | Clinical hypnotist | Career counselor | (A): Support group
(B): Behavior analyst
(C): Clinical hypnotist
(D): Career counselor | Support group | A | A support group specific to individuals entering a new phase of life (such as singleness after a recent divorce) may benefit this client. Therefore, the correct answer is (A) | treatment planning |
371 | 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. | Client Age/Gender: Sexuality: Both Heterosexual Ethnicity: Both Caucasian Relationship Status: Married Counseling Setting: Outpatient Behavioral Health Type of Counseling: Couples Counseling Marital Discord Diagnoses: You are a certified counselor providing couples therapy in an outpatient behavioral health setting. The wife serves as the primary client due to the complexity of her clinical and diagnostic presentation. She is a 34-year-old female seeking marital counseling with her 44-year-old husband of 18 months. The client explains that shortly after returning from the couple’s honeymoon, she began having chronic, debilitating migraines causing her to remain bedridden, sometimes for days on end. She reports that she no longer engages in activities that she once enjoyed and feels chronically tired and depressed. Despite being treated by several neurologists, her chronic migraines persist, and she is now on long-term leave from her job. The client’s husband is a chief financial officer for a large hospital system and works long hours. The couple has joint custody of the husband’s 12-year-old son from a previous marriage. The client thinks that there is an unfair amount of burden placed on her to parent her stepchild, which has caused conflict among the client, her husband, and the husband’s ex-wife. The husband admits to growing impatient with the chronic nature of his wife’s illness and says she is not the same person that she was when they met nearly 3 years ago. The client and the husband are both well dressed. The client is wearing sunglasses and explains that her migraines cause her to be light sensitive. It is the middle of the husband’s workday, and he is dressed in a suit and tie. The client reports daytime sleepiness, which she attributes to her migraine medication. Her appetite is fair. She denies current suicidal or homicidal ideations. However, the client does report that she has previously had thoughts of not wanting to live. Her mood is depressed, and her affect is congruent with her mood. The client is tearful when discussing how her illness has affected the marriage and states that she receives little support from her husband. When the client begins to cry, the husband responds by sitting silently, crossing his arms, shaking his head, and looking around the room. The client states, “See! This is what I’m talking about! Whenever I need his support, he checks out.” Family History and History of The client’s parents were never married. The client was placed in foster care at age 3 due to parental neglect. She remained in foster care until age 6, when the courts granted her paternal grandmother full custody. The client’s husband has two younger brothers and was raised by his biological mother and father. He describes his father as “hardworking” and his mother as a stay-at-home mom. Approximately 5 years ago, the husband was treated for alcohol use disorder. He states that he stopped drinking independently and “didn’t have to rely on a 12-step program to get sober.” The couple met when the husband was married, which contributed to a drawn-out and acrimonious divorce | During the initial session, which of the following would you use to create a therapeutic alliance with the couple? | Encourage the use of “I” statements and teach effective problem solving. | Empathize with and validate the client’s physical and emotional pain. | Explain your clinical approach to help define the treatment focus. | Summarize the couple’s concerns and assess readiness for change. | (A): Encourage the use of “I” statements and teach effective problem solving.
(B): Empathize with and validate the client’s physical and emotional pain.
(C): Explain your clinical approach to help define the treatment focus.
(D): Summarize the couple’s concerns and assess readiness for change. | Summarize the couple’s concerns and assess readiness for change. | D | Summarizing shared concerns and assessing readiness for change can help create a therapeutic alliance with the couple. During the initial stage of treatment, building a therapeutic alliance can be accomplished by assisting the couple in conceptualizing the presenting problem. This can be done by using core counseling techniques, including, but not limited to, summarization, empathy, attending, encouraging, genuineness, and congruence. In addition, counselors can use a motivational enhancement approach to determine a couple’s readiness for change. Assessing a couple’s readiness to change contributes to the therapeutic alliance by fostering hope. Explaining your clinical approach to define the treatment focus is not the best option because it does not elicit the couple’s input for what they need and hope to get out of therapy. Empathizing and validating the client’s pain addresses the client’s needs, but this does not address the couple’s needs. Further, this response may alienate the husband and potentially deprive him of the opportunity to later express this sentiment to his wife. Encouraging “I” statements and problem solving are helpful interventions, but this is not the best option for creating a collaborative therapeutic alliance. Therefore, the correct answer is (C) | counseling skills and interventions |
372 | 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. | What assessment tool should be used to evaluate Millie's risk of suicidality? | Beck Depression Inventory | Mental Status Examination | Columbia Suicide Severity Rating Scale | Hamilton Depression Rating Scale | (A): Beck Depression Inventory
(B): Mental Status Examination
(C): Columbia Suicide Severity Rating Scale
(D): Hamilton Depression Rating Scale | Columbia Suicide Severity Rating Scale | C | Using the Columbia Suicide Severity Rating Scale, you will learn Millie's history of actual suicidal ideation or behaviors and her current level of risk based on several factors contributing to a severity score. The Hamilton Rating Scale for Depression measures depression in individuals before, during and after treatment, and the Beck Depression Inventory is useful to measure behavioral manifestations and severity of depression across one's lifespan. You can conduct a mental status exam to screen for suicide risk, however in the mental status exam presented here, Millie is denying active suicidal ideation and is also presenting with incongruent affect causing difficulty with discernment of her actual condition. Therefore, the correct answer is (C) | intake, assessment, and diagnosis |
373 | Client Age: 26 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Community Mental Health Agency Type of Counseling: Individual Presenting Problem: Hallucinations and Delusions Diagnosis: Schizophrenia 295.90 (F20.9) | Mental Status Exam: The client displays an angry affect, and his mood is irritable. His speech is disorganized and pressured. He is oriented to person, place, time, and situation. He reports audiovisual hallucinations, which include seeing “the shadow man” and hearing voices others cannot hear. The client exhibits tangential and disconnected thinking. He is firm in his conviction that he is being poisoned and says he is exhausted from constantly trying to maintain vigilance. The client’s insight and judgment are poor. He denies suicidal ideation, homicidal ideation, and command hallucinations. The client first experienced symptoms of schizophrenia in his late teens but was misdiagnosed with bipolar disorder until rece | You are a counselor working in an outpatient community mental health center serving clients with severe psychiatric disorders. A 26-year-old male, accompanied by his caseworker, presents for counseling due to symptoms of schizophrenia. The caseworker reports that the client was doing well until he stopped taking his prescription medication. He resides in assisted living, where he was placed after being discharged from the hospital last month. The client claims someone he calls “the shadow man” is following him and putting poison in his food. The caseworker reports that the client has been more agitated recently and has engaged in verbal altercations with other residents. The client is refusing to take his medication because of the side effects. He had an initial therapeutic response to Haldol, an antipsychotic, but stopped taking it because it made him restless and nervous. He explains, “I felt like I constantly had to keep moving.” The client is adamant about his desire to stay off medication and becomes angry when his caseworker mentions the possibility of going back into the hospital. | ntly. Family History: The client has an older brother who transports the client to appointments and periodically checks in with the client. Hospital records indicate that the client becomes increasingly agitated during visits with his parents. The hospital social worker noted that his father was critical and dismissive toward the client during family therapy. The client’s mother is diagnosed with generalized anxiety disorder and had to quit her job due to the overwhelming burden of the client’s care. The father blames the client for the excessive toll his illness has placed on the family | How would you classify the type of delusion the client is experiencing? | Grandiose | Nihilistic | Persecutory | Somatic | (A): Grandiose
(B): Nihilistic
(C): Persecutory
(D): Somatic | Persecutory | C | The client’s delusions are persecutory. The DSM-5-TR recognizes the following types of schizophrenic delusions: persecutory, grandiose, somatic, erotomania, and jealousy. Subtypes are determined by the client’s primary symptoms and can change over time. Persecutory delusions involve the fixed belief that someone intends to harm the individual. For this client, it is the shadow man. Nihilistic delusions are thoughts that center around the belief that complete devastation or catastrophe is soon approaching. Grandiose delusions occur when there is a preoccupation with believing that one is of great significance, is famous, or has other exceptional talents or traits. Somatic delusions are fixed beliefs concerning one’s health or organ functioning. Therefore, the correct answer is (A) | intake, assessment, and diagnosis |
374 | Client Age: 32 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Counseling Setting: Community Mental Health Agency Type of Counseling: Individual Presenting Problem: Depressed Mood Diagnosis: Bipolar II 296.89 (F31.81), current episode depressed | Mental Status Exam: The client is dressed casually and is somewhat disheveled. She avoids eye contact and displays a flat affect. The client admits to having suicidal thoughts in the past but currently denies both suicidal and homicidal ideations. Her speech is soft in volume and tone. She tends to provide one-word responses but is cooperative when asked to elaborate. The client denies audio-visual hallucinations, and her thought content is coherent. The client’s mood is depressed, and her affect is flat. She appears tired and reports she has insomnia at night and is sleeping most of the day. The client has experienced depression off-and-on, beginning in late adolesc | You work at a community mental health agency providing outpatient services to adults. Today, you are meeting with a 32-year-old female who presents with her husband for an initial intake session. The client’s husband is concerned about his wife’s depressive symptoms. She is experiencing sadness, decreased appetite, and hypersomnolence. The client also expresses hopelessness and has lost interest in doing the things she once enjoyed. Until recently, the client worked at an art gallery. When employed, she reports that she, “just couldn’t get out of bed” and was eventually let go due to excessive absences. After her employment ended, her depressive symptoms worsened. The client was able to recall a time nearly one year ago when she felt “almost the opposite” of how she feels now. During this time, she experienced increased energy and felt more inspired and creative. The client explains that she and her husband used to travel selling their art at juried art exhibitions most weekends, but it has been awhile since she has joined him. | ence. Family History: The client is married and has a 10-year-old daughter from a previous marriage. The client explains that her father was “distant and quiet unless he was drinking.” She remembers hearing that her paternal grandfather declared bankruptcy “at least once” due to gambling losses. The client’s mother has been diagnosed with bipolar disorder, with acute episodes requiring hospitalization. The client indicates that a former therapist also diagnosed her with bipolar disorder, but she rejects the diagnosis stating her symptoms are “nothing like my mother’s | Which intervention would you select to help the client process grief related to her job loss? | Acceptance and commitment therapy (ACT) | Reality therapy (RT) | Solution-focused brief therapy (SFBT) | Interpersonal psychotherapy (IPT) | (A): Acceptance and commitment therapy (ACT)
(B): Reality therapy (RT)
(C): Solution-focused brief therapy (SFBT)
(D): Interpersonal psychotherapy (IPT) | Interpersonal psychotherapy (IPT) | D | Interpersonal psychotherapy (IPT) is an evidence-based practice for bipolar II disorder that addresses interpersonal deficits, including life transitions, conflict at home or in the work environment, and managing grief and loss. Grief and loss can pertain to losing another person or losing a healthy sense of self. IPT is beneficial for individuals with bipolar II disorder because psychosocial stressors can exacerbate diagnosis-specific symptoms. William Glasser is credited with developing reality therapy, which is based on the assumption that individuals are responsible for appropriately choosing behaviors to meet their goals, desires, and needs. Solution-focused therapy, or solution-focused brief therapy, is grounded in the assumption that individuals can make positive choices and can adopt workable solutions to problems. Acceptance and commitment therapy combines mindfulness and behavioral therapy elements to assist individuals with greater self-acceptance of uncomfortable feelings. Therefore, the correct answer is (D) | treatment planning |
375 | Name: Candy Clinical Issues: Anxiety and relationship distress Diagnostic Category: Personality Disorders Provisional Diagnosis: F60.03 Borderline Personality Disorder Age: 29 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: Black Marital Status: Married Modality: Individual Therapy Location of Therapy : Private Practice | The client presented as a well-groomed female who appeared her stated age. She was appropriately dressed in casual attire. Her speech was marked by a slow rate and low volume overall, though, at times, her rate and loudness increased spontaneously. Her tone was muffled and difficult to hear clearly at times. The client's mood appeared depressed and confused. She displayed emotional lability during the evaluation, with shifts between expressing elation, fear, and distrust of this clinician and the treatment environment. Despite her affective instability, she was oriented to person, place, and time. Her attention and concentration waxed and waned throughout the session, with some difficulty tracking questions and sustaining focus on topics. She denied current homicidal ideation or intent. However, the client endorsed chronic passive suicidal ideation that intensifies during times of high personal stress. She also reported a remote history of hospitalization due to engaging in self-injurious cutting behaviors when feeling extremely distressed. | First session You are a clinical mental health counselor working in a private practice setting. The client, a 29-year-old female, presents to the intake session expressing that she has trouble controlling impulsive acts and is constantly worried. She speaks about her marriage, describing it as up and down. She looks down tearfully and says, "I keep hurting him. One day I love him, and the next day I can't look at him." She pauses and asks, "What if he leaves me? I can't deal with that." She further reveals that after she fights with her husband, she goes into their bedroom and cuts her thighs. At first, she feels relief, but this is followed by profound sadness and a feeling of worthlessness. The client's lack of a stable parental figure resulted in her having difficulty forming healthy attachments with others. She feels isolated and disconnected from the world around her and has difficulty appropriately expressing her emotions. Her relationships are often strained, and she finds it difficult to trust others or herself. She has difficulty setting healthy boundaries and repeatedly emotionally abuses herself and others. She reports feeling overwhelmed by her emotions and finds it difficult to regulate them. She states that she experiences intense guilt and shame following her impulsive acts and is often worried that her husband may leave her due to her behaviors. The client has struggled to control her emotions, which has been a source of significant distress in her life. The client's self-destructive behavior has become increasingly frequent and intense. She has been unable to find a way to cope with her emotions and has resorted to self-harm as a way to manage her distress. She has become increasingly isolated and withdrawn, and her relationships have suffered as a result. She has become increasingly dependent on her husband, and her fear of abandonment has become a source of significant distress. Third session You are in your office waiting for the client to arrive for her weekly session when suddenly you hear screaming. You run out into the hallway and see the client crying hysterically. After guiding her into your office, she lies on the couch, crying. She begins to punch the pillows on the sofa. You indicate you are here to listen when she is ready to talk. The client is in a heightened emotional state and says, "He. Left. Me." You maintain a calm demeanor and encourage the client to tell you what happened. She said she arrived home after work and noticed her husband's car was gone. He had left her a note indicating he was leaving and wanted a divorce. The client expresses feelings of shock and betrayal as she discusses how she had been blindsided by her husband's sudden decision to end the marriage. She reports feeling overwhelmed by a range of emotions, including fear, anger, sadness, and confusion. The client expresses hopelessness and despair, believing her situation is beyond repair. She ruminates on the idea that her marriage is irrevocably broken and that her life will never be the same. She expresses feelings of helplessness and fear of the unknown, feeling overwhelmed by the magnitude of the situation. The client struggles to make sense of her husband's decision and appears overwhelmed by the potential consequences. She is particularly concerned about how her husband's decision will affect their children and their family's future. The client stares at you with a blank expression and states, "I might as well give up. There's no point anymore." You further assess her current mental health state and determine that she is suffering from an acute stress reaction. You provide empathy and validation while creating a safe space for the client to process her thoughts and feelings. You encourage her to talk openly and honestly about her experience, allowing her to express her emotions without judgment. | The client's father died when she was very young. She describes her mother as having a "difficult time raising me and my brother as a single mother." The client's mother worked three jobs and could not spend much time with her children. The client remembers having several babysitters as a child, but they never lasted long. Currently, the only relative the client speaks with is her mother. She lists her husband and mother as her emergency contacts on the intake form. The client reports feeling isolated and alone, especially since her father's death. Personal/Social Relationships: The client has a long history of attempting suicide. She has been in and out of emergency rooms nearly every week. She is persistently angry, needs attention and recognition, and has difficulty trusting others. She has had numerous affairs in an attempt to feel worthy. The client compensates for her guilt by buying her husband expensive gifts. She grapples with maintaining healthy relationships and controlling her rage and violent behaviors when she feels threatened. She has struggled to form meaningful relationships with her peers and has few friends. Although she does not lack socialization skills, the client finds it difficult to get close to people. Previous Counseling: The client is currently taking Paxil for her underlying depressive symptoms. She has expressed concern about her ability to manage her mental health with her current treatment. She worries that her erratic adherence to her medication regimen and lack of follow-up with her psychiatrist could lead to a termination of services. She has reported increased anxiety and stress as a result of this fear. She reports that her mood swings are more extreme, and she is having difficulty concentrating and staying focused. She reports that her friends and family have noticed her behavior change and expressed concern. | After assessing the client, you determine that her "feeling of giving up" does not require hospitalization or will lead to self mutilation. You do need to address her current emotive crisis. What feelings do you identify as the most significant to address in this session? | Grief | Shock and betrayal | Sadness and anger | Fear of the future | (A): Grief
(B): Shock and betrayal
(C): Sadness and anger
(D): Fear of the future | Shock and betrayal | B | It is important to address the feelings of betrayal and abandonment the client feels, as these will have a much more significant impact on the client's emotional state. Betrayal can devastate a person's emotional state, particularly when it comes to the dissolution of a marriage. The client in question has been dealt a heavy blow, as her husband has unexpectedly left her without warning. For the client, the betrayal of trust and feeling of abandonment can be overwhelming and deeply painful. The client already has trust issues and may find it difficult to trust anyone again or to see relationships in the same light as before. Therefore, the correct answer is (A) | counseling skills and interventions |
376 | Initial Intake: Age: 37 Gender: Female Sexual Orientation: Heterosexual Race/Ethnicity: Caucasian/non-Hispanic Relationship Status: Married Counseling Setting: Mental health counseling agency Type of Counseling: Individual telemedicine | Leah is casually dressed, presenting with anxious mood and affect. Speech is of fast rate but with normal tone. Breathing is shallow from speaking fast, you note she stops to take deep breaths before continuing. Leah denies SI/HI, reports many protective factors, and admits that nothing in her life is “really that wrong.” Leah demonstrates good insight and judgment into the nature of her concerns. | Diagnosis: Generalized Anxiety Disorder (F41.1), Adjustment disorder with mixed anxiety and depressed mood (F43.23)
Leah is referred to your counseling agency by the U.S. Department of Veterans Affairs (VA) mental health program due to their inability to accommodate her because of their high caseloads. Leah is a 37-year-old married woman with a 2-year-old child and is a disabled combat veteran who served 8 years in active-duty Air Force service. Both you and Leah work full-time as mental health counseling interns in your respective practices. Leah struggles to manage her own anxiety which causes both interpersonal and professional problems for her. Leah reports experiencing trauma related to deployments, past divorce, death of a pet and birth trauma with her daughter. Leah tells you she needs someone to process everything with regularly as she does not want to exhaust members of her family with her stress. Leah’s biggest problem, she shares, is that she knows how to resolve her negative thoughts that lead her to act impulsively but cannot apply her skills when she feels overwhelmed. |
Education and Work History:
Prior to military life Leah worked several different jobs since the age of 13. Leah joined the Air Force at age 21, worked overseas as well as in the states, and had several deployments including one year in Kabul, Afghanistan as a Staff Sergeant during her fifth year of service. Leah obtained her bachelor’s degree right after separation, and then returned to Afghanistan as a contractor. Following this experience, she completed her master’s degree in counseling. She admits she is “skeptical” working with someone who has the same amount of experience as herself.
Family History:
Leah grew up with two younger siblings, and her parents divorced when she was 11. Due to joint custody, her and her siblings moved back and forth weekly every Friday until she originally left home for college at 18. Both of Leah’s parents remarried; her father having three more children with her stepmother, and Leah inheriting a stepsister when her mother married her stepfather. Leah was also previously married to an Army Sergeant while active duty, but her husband had an affair and left her prior to her military separation. | Leah decides to share about her traumatic divorce that occurred at the same time as her separation from the military. She explains that she pushes away the people who show concern for her, and understands it is likely due to fear of abandonment. What would help her learn more about this? | Myers-Briggs Type Indicator | BPD checklist | Adult Separation Anxiety Questionnaire | Schema Therapy | (A): Myers-Briggs Type Indicator
(B): BPD checklist
(C): Adult Separation Anxiety Questionnaire
(D): Schema Therapy | Schema Therapy | D | Schema therapy combines elements of CBT, psychoanalysis, attachment theory, and emotion-focused therapy, which aims to teach you how to ensure your emotional needs are met in a healthy way that does not cause distress. To understand this in Schema therapy, one must take the Young Schema Questionnaire which leads you to identify your Early Maladaptive Schemas. Abandonment is one of the issues focused on and assessed for using the YSQ. Regarding answer b), Leah does not meet criteria for BPD solely because she is afraid of abandonment. A disorder checklist will not help her learn more about the connection between her trauma and active behaviors. The Adult Separation Anxiety Questionnaire is a 27-item self-report that examines symptoms of separation anxiety experienced after 18 years of age, but also does not apply to this situation as the two phenomena may be linked but are different clinical presentations. The Myers-Briggs Type Indicator is an introspective self-report that indicates different psychological preferences in how people perceive the world and make decisions, often used for professional development purposes. Therefore, the correct answer is (A) | counseling skills and interventions |
377 | Name: Roger Clinical Issues: Physical/emotional issues related to trauma Diagnostic Category: Neurocognitive Disorders Provisional Diagnosis: F02.81 Major Neurocognitive Disorder Due to Traumatic Brain Injury, with Behavioral Disturbance Age: 36 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: White Marital Status: Married Modality: Individual Therapy Location of Therapy : Outpatient clinic | The client presents as tired. He reports a mild headache at the intake appointment, which he says is likely due to coming in from the bright day outside. Memory is slightly impaired. Mood is depressed, though he says this is impermanent, and his mood changes within a day, though the depressed mood is more prevalent and longer-lasting. | First session The client returned home from Afghanistan last month after separating from the Navy after 12 years of service. He states he is tired of trying to get an appointment at the VA Hospital, so he Googled locations that treat brain injuries, and your office was on the results page. He called to arrange a consultation with you. You have been practicing as a licensed mental health therapist at the outpatient clinic for over a decade, and you have worked with many clients diagnosed with traumatic brain injury. The client complains about difficulty sleeping, bad headaches, and feeling like he is on a roller coaster - feeling happy one minute and then down in the dumps the next. He states that the happy times don't last long, and he is "down in the dumps" most of the time. When asked why he left the Navy, he replies: "Toward the end of my last deployment, I just got sick and tired of everything and couldn't deal with it anymore. I couldn't sleep, was jumpy all the time, and didn't even want to go outside during the day." Now, I'm finally back home, but things only seem worse. My wife keeps nagging me to get a job, my kids look at me like I'm a monster, and nobody understands how I feel. I want to lay in bed all day and drink a couple of beers. I think something isn't right, and I can't take it anymore." Near the end of the session, the client asked what he could expect if a medical professional recommended medication management to treat NCD. The client discloses experiencing a highly distressing and psychologically damaging event during his military service in Afghanistan. While on patrol with his unit, their convoy was ambushed, and a fellow soldier directly next to the client was seized by insurgents. The client painfully witnessed his peer and friend being brutally beheaded, describing the horrific sight and sounds as permanently seared into his memory. Helplessly observing the brutal murder firsthand left him stunned and overwhelmed with grief and terror at the moment. The grotesque violence and knowing that could have just as quickly been his fate continues haunting him years later. The constant stress of combat and imminent danger already had the client in a perpetual state of hypervigilance and anxiety during his deployment. He shares that coming to terms with the abrupt, unfair loss of life was a daily reality there. While transporting supplies between bases in a standard jeep convoy, his vehicle triggered an IED explosion or was directly hit by artillery fire. The client was violently jolted and knocked completely unconscious as the blast disabled their jeep. He remained in and out of consciousness for over 24 distressing hours, being evacuated while critically injured to a military hospital. Once stabilized, he was thoroughly examined and diagnosed with a traumatic brain injury concussion along with other shrapnel wounds. Fourth session You and the client decided to meet for weekly sessions based on his current needs. You have established a trusting relationship with him, and he feels more comfortable knowing that you have experience in working with military populations. You provided psychoeducation regarding the effects of traumatic brain injuries and what he can expect from the counseling process. You were able to instill hope that he could recover emotionally following his injury and learn new skills along with coping mechanisms. He presents for today's session in a depressed mood which he states began the previous night. He reports that his family appears to now better understand what he is going through and they are getting along better. He is still drinking three beers at night to help him fall asleep, and his headaches have decreased in intensity due to finally getting a medication consult from the VA. However, he is still sensitive to light. He shares that he is ready to look for work but is concerned about finding a job and performing due to his ongoing symptoms. Ninth session Rober arrives elated at the session, appearing happy, talkative, and smiling. He states that he has felt this way for four days now, which has not been the typical length of time or the intensity of his positive mood episodes. He reports that his family relationships are satisfactory, and he has been somewhat successful at his part-time job at the local lumberyard. However, he is angry with his manager, who says he has been too distracted this past week and spends more time talking with customers than working. He is still drinking three beers at night to sleep but reports that he has not had to sleep much this past week and feels "wide awake." He says he is ready to open his own business but isn't sure what he wants to do yet. Roger reports feeling energized, creative, and motivated over the past several days. He has come up with many new business ideas that he is eager to pursue, including opening a restaurant, starting a landscaping company, and developing a crypto blockchain. Roger stays up late into the night brainstorming ideas and making extensive plans. He feels compelled to act on his ideas immediately and has already taken steps to register business names and research loans. However, the next day, Roger often changes course, dropping previous ideas for new ones that seem even more exciting. His friends notice his frenzied pace in bouncing from idea to idea, worrying he has taken on too much. But Roger reassures them this surge of creativity allows him to see endless possibilities for his future business success. Though well-intended, their skepticism only pushes him to work harder to bring his visions to life. Roger also mentions experiencing increased sociability and talkativeness lately. He says he has frequently called and texted friends and family to share his business ideas and other excited thoughts. Roger speaks rapidly, his thoughts racing as he tries to get loved ones as enthused as he feels. Though some gently try to interject realistic concerns, he remains unchecked in his ambitious optimism. A few close friends have expressed concern over Roger's intensified pace and plans, but he brushes them off, feeling very optimistic and self-assured about his ideas. Roger's confidence borders on grandiose as he envisions an incredibly successful entrepreneurial future. Attempts by caring friends and family to restrain his inflated self-assurance are met with irritation, as Roger feels unable to focus on anything but chasing his next big idea. He's optimistic that his new crypto blockchain will rival and surpass Bitcoin in a matter of months. | The client drinks three beers every night before bed to help him fall asleep. He started this pattern a few years ago after struggling with insomnia and finding it challenging to relax his mind. Though effective at first in inducing drowsiness, he has built up a growing tolerance and now needs to drink three beers minimum to feel any sedative effects. He discloses that he knows consuming alcohol regularly can be unhealthy, but he feels dependent on having those beers to wind down from the stresses of his day and quiet his anxious thoughts enough to get adequate rest. During his time serving in the military, the client reported smoking cannabis on occasion when it was available. However, he did not enjoy the experience or feel compelled to use it. He mainly partook when offered by peers to be social. Since his discharge five years ago, he states he has not had any cannabis. The client currently smokes approximately one pack of cigarettes per week, a habit he picked up during his military service as a way to cope with boredom and nerves. He expresses some interest in trying to cut back for health reasons but also shares smoking provides a sense of relief and routine. | When a client presents in a hypomanic state, what is the initial determination that a therapist must make? | Is the client suitable for starting a physical workout to channel excess energy? | Is the client under the influence of substances? | Is the client going to require hospitalization? | Is the client able to safely make decisions for themselves and are they a risk to other's around them? | (A): Is the client suitable for starting a physical workout to channel excess energy?
(B): Is the client under the influence of substances?
(C): Is the client going to require hospitalization?
(D): Is the client able to safely make decisions for themselves and are they a risk to other's around them? | Is the client able to safely make decisions for themselves and are they a risk to other's around them? | D | This will allow a therapists to respect a client's autonomy while still upholding the duty to protect. Therefore, the correct answer is (B) | intake, assessment, and diagnosis |
378 | 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. | Why would you give the client a referral to his pediatrician? | For advice on anxiety-specific nutrition | For a medical second opinion | For a more thorough psychological exam | For anti-anxiety medication evaluation | (A): For advice on anxiety-specific nutrition
(B): For a medical second opinion
(C): For a more thorough psychological exam
(D): For anti-anxiety medication evaluation | For anti-anxiety medication evaluation | D | There are age-appropriate medications which can lend short-term help in cases of anxiety disorder in youths. Therefore, the correct answer is (B) | treatment planning |
379 | 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. | Based on the interactions you observe in this session and the client's family history, what new objective would you consider incorporating into the treatment plan? | Addressing client anger issues | Identifying alternative ways of coping with family stress | Developing effective communication strategies for managing difficult conversations | Exploring ways in which the client can adjust to the requests of others | (A): Addressing client anger issues
(B): Identifying alternative ways of coping with family stress
(C): Developing effective communication strategies for managing difficult conversations
(D): Exploring ways in which the client can adjust to the requests of others | Developing effective communication strategies for managing difficult conversations | C | This objective is important because it encourages the client and her family to express their feelings in a constructive way, allowing them to come together in support of the client's health and well-being. This will help reduce tension and foster more positive relationships among family members. Additionally, it can provide the client with tools for managing conversations that may trigger negative emotions or behaviors. Therefore, the correct answer is (C) | treatment planning |
380 | 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 | Theodore made positive changes in a short amount of time because? | The goals were attainable | Both b and c | The goals were made by Theodore | The goals were agreed upon by Theodore and the counselor | (A): The goals were attainable
(B): Both b and c
(C): The goals were made by Theodore
(D): The goals were agreed upon by Theodore and the counselor | Both b and c | B | It is evident that Theodore made a tremendous amount of progress in a short amount of time. Since the goals were made by Theodore, he was able to focus on something he was motivated to work on. Although some goals may seem small and short term, early successes build confidence in the ability to change. Whether or not a counselor agrees with a goal does not determine the likelihood for success. A counselor can discuss possible outcomes or barriers, but ultimately, the goal setting is up to the client. Therefore, the correct answer is (D) | counseling skills and interventions |
381 | 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 | A theoretical approach that may work for Darrel is? | Person-Centered therapy | Family systems therapy | Psychoanalysis | Cognitive Behavioral therapy | (A): Person-Centered therapy
(B): Family systems therapy
(C): Psychoanalysis
(D): Cognitive Behavioral therapy | Cognitive Behavioral therapy | D | Cognitive behavioral therapy provides a structured, focus-active approach which seems congruent with Darrel's request to learn coping skills and assertiveness training. A psychoanalytic or person-centered approach would be too passive and long term. Family Systems therapy focuses on dysfunctional family relationship problems which are not evident currently. Therefore, the correct answer is (C) | counseling skills and interventions |
382 | Client Age: 14 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Asian-American (Karen) Grade: 8th Counseling Setting: Child and Family Services Agency Type of Counseling: Individual and Family Presenting Problem: Substance Misuse and Acculturation Difficulties Diagnosis: Substance Use Disorder, Moderate (F2.911 ); Acculturation difficulty (V62.4 Z60.3) | Mental Status Exam: The client is polite and cooperative. He is neatly dressed and is the only member of his family who is not wearing traditional Karen clothing. His affect is restricted, and his eye contact is poor. The client denies suicidal and homicidal ideation. He reports feeling anxious and sad frequently. He expresses that he is particularly worried at school and has had a difficult time adjusting. The client states that he lived in outdoor homes and buildings before coming to the United States. He explains, “Here, I feel like I’m trapped in a c | You are working as a counselor in a child and family mental health agency. A 14-year-old Asian-American male presents with family members who are concerned about the client’s drug use. The family is part of an ethnic population from Southeast Asia who resettled in the United States just under two years ago. The client is fluent in English and interprets for the family. The client goes to a public school specifically designed to improve English proficiency and has, until recently, done well academically. The parents have limited English proficiency (LEP). The parents provide a letter from his school stating the client was suspended after administrators found marijuana and amphetamines in the client’s locker. The client expresses remorse and says he became highly anxious and fearful when the school resource officer became involved. He explains, “Where I come from, the police are not there to protect or help.” The client willingly completes a substance use screening assessment, and the results indicate he is at risk for meeting the diagnostic criteria for substance use disorder. | The client is now attending family therapy with his parents and has made progress. His last four drug screens have been negative, and the client is beginning to show insight into his problem. The parents have improved with limit setting and are learning how to help the client achieve a healthy sense of identity. The parents are becoming better acclimated to the United States and have developed stronger connections within their church and community. The client has met his treatment plan goals, is pleased with his progress, and is ready to end therapy. The client and his parents have also made therapeutic gains in family therapy; however, his parents are not prepared to end treatment and would like to keep seeing you without the client | The client has met his treatment plan goals, is pleased with his progress, and is ready to end therapy. The client and his parents have also made therapeutic gains in family therapy; however, his parents are not prepared to end treatment and would like to keep seeing you without the client. After providing pretermination counseling, how should you proceed? | Encourage the client to continue therapy and continue working with all parties. | Terminate with all parties after referring the parents to another provider. | Terminate with all parties. | Terminate with the client and continue working with the parents. | (A): Encourage the client to continue therapy and continue working with all parties.
(B): Terminate with all parties after referring the parents to another provider.
(C): Terminate with all parties.
(D): Terminate with the client and continue working with the parents. | Terminate with all parties. | C | After providing pretermination counseling, you should terminate with all parties. Per the ACA Code of Ethics (2014), “Counselors terminate a counseling relationship when it becomes reasonably apparent that the client no longer needs assistance, is not likely to benefit, or is being harmed by continued counseling” Termination with clients is an ongoing process that begins with informed consent at the outset of treatment. Since the client has met his treatment goals, he no longer needs assistance. Regarding multiple roles, the ACA Code of Ethics (2014) states, “When a counselor agrees to provide counseling services to two or more persons who have a relationship, the counselor clarifies at the outset which person or persons are clients and the nature of the relationships the counselor will have with each involved person. If it becomes apparent that the counselor may be called upon to perform potentially conflicting roles, the counselor will clarify, adjust, or withdraw from roles appropriately. […] Counselors provide pretermination counseling and recommend other service providers when necessary” Since the identified client’s goals have been met, the counselor should continue with pretermination counseling and go forward with the planned termination. The parents would not require an outside referral because treatment plan goals have been met. Church and community connections also serve as ongoing support for the family. Therefore, the correct answer is (A) | professional practice and ethics |
383 | Name: Alexei Clinical Issues: Substance use/addiction issues Diagnostic Category: Substance Use Disorders Provisional Diagnosis: F10.99 Unspecified Alcohol-Related Disorder Age: 32 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: German American Marital Status: Married Modality: Individual Therapy Location of Therapy : Private Practice | A 32-year-old German American man confidently enters your office. He is tall and slender and appears older than his stated age. His physical appearance is unkempt. The client's voice quality is strong and loud, and his command of English is minimal. His posture and gait are limp and unsteady at times. He is slurring his words and appears to be actively intoxicated. He portrays no accountability or responsibility for his actions with substance use. He denies any current thoughts of homicidal ideations. The client lacks insight, and his thought processes are not logical or appropriate. | First session You are a psychoanalytic therapist in private practice and often work with clients who struggle with substance use issues. You believe these issues often arise from unresolved conflicts and the inability to manage emotions. Today, you are seeing a 32-year-old German American male named Alexei, who was referred to you due to occupational disciplinary issues related to alcohol use. Alexei was referred to you by his employer, where he works in a manufacturing plant in the Midwest. His supervisor noticed marked changes in his behavior and productivity over the last few months and was concerned that Alexei might be dealing with a drinking problem. The supervisor initially suggested an employee assistance program, but Alexei was adamantly opposed to talking to anyone involved in his workplace. You introduce yourself and explain to Alexei that this is a safe and confidential space where he can discuss whatever is troubling him. You reassure him that the only people who will know about the details of this session are himself and yourself. Then, you begin to ask open-ended questions to assess Alexei's current state of mind and identify his current challenges. You are particularly interested in understanding his thoughts and feelings about his substance use and the occupational problems it has created. You notice that Alexei seems excessively relaxed as you establish the confidentiality of the session. As you delve deeper into his thoughts and feelings, you ask him to describe his relationship with substances, particularly how they have affected his daily life and work performance. Alexei hesitantly opens up, admitting that his substance use has become a coping mechanism to deal with mounting stress and anxiety. You listen empathetically and validate his emotions while gently probing into the factors that have contributed to this pattern of behavior. Alexei tells you that his boss has never liked him and is trying to get him fired. He reports that he sees nothing wrong with having a few drinks in the morning and after lunch. He has been late to work "only a few times" because of a hangover. Alexei states that he needs help finding a new job. You ask Alexei if he can tell you more about his drinking habits. He says he usually starts drinking around 9 am and has been drinking more in the past few weeks. He also admits to drinking at work a couple of times. He looks at you suspiciously, wondering why you need to know this. You explain that it is important to understand his drinking habits and the context of his behavior to provide the best care. As the session continues, you observe that Alexei's cognitive functioning appears impaired, as he struggles to maintain focus and has difficulty recalling important details. He expresses frustration and anger when discussing his work situation but minimizes the impact of his alcohol consumption on his professional life. Alexei's denial of his alcohol-related problems and the escalating pattern of his drinking behavior indicate a potential substance use disorder. Furthermore, his physical symptoms, such as sweating and slurred speech, suggest that he may be experiencing acute effects of alcohol during the session. It becomes evident that addressing Alexei's alcohol use and its consequences is crucial to provide appropriate care and support for him in his current situation. Fourth session You completed a risk assessment in the last session and worked on safety planning with Alexei. He arrives 15 minutes late to today's session. When you mention his tardiness, he begins yelling in German. When you appear confused, he switches over to English, saying you are harassing him just like his wife. You respond by acknowledging his feelings and gently reminding him that you are there to help him process his emotions in a safe and productive way. Once he is calm, you explore what it is about your presence that he may be perceiving as hostile or threatening. He takes a breath, apologizes to you for his outburst, and begins to talk about his wife and her disparaging comments. He explains that, when you asked why he was late, it felt like a reminder of how his wife often disregards his needs and makes him feel worthless. "She makes some negative comment like 'you're late' or 'you never do this right'. It make me just want to give up!" He begins talking about wanting to take a break from home and go back to Germany where he can "start fresh". He says that his wife's constant harassment is unbearable. Lately, he has been hoping that she will leave him. You spend the rest of the session planning with Alexei ways he can express his feelings of frustration in productive ways. | The client grew up in Germany and recently immigrated to America with his wife and mother. Both parents have a history of alcohol abuse and divorced when he was five. After his father left, his mother's enmeshment with her son intensified. She made him spend time with her rather than his school friends and used the threat of leaving him in an orphanage to control his behavior. Whenever he became upset or anxious, she would cuddle him and give him sips of whatever alcohol she consumed. The client was recently arrested for driving under the influence. The client's wife is contemplating separating because of her husband's continued drinking. He identifies a couple of bartenders as "friends" but cannot recall anyone he knows in an alcohol-free context. He has also been late or missed work due to hangovers and will likely lose his job. His co-workers have often complained that he smells of alcohol. Previous Counseling: The client has had suicidal thoughts thrice, all of which were recent. The initial occurrence was after a DUI incident, followed by a write-up at work, and the third after his wife proposed a separation. The client has shared that he has a specific plan in mind for ending his life, which involves either ingesting pills or cutting his wrists. | You noted the client stating that he hoped his wife would leave him. From a psychoanalytic perspective, what underlying theme does this comment suggest is prevalent in his thought process? | Fear of abandonment or rejection | Unresolved grief from past relationships and losses | Sense of helplessness and desperation regarding his marriage | An approach-avoidance syndrome | (A): Fear of abandonment or rejection
(B): Unresolved grief from past relationships and losses
(C): Sense of helplessness and desperation regarding his marriage
(D): An approach-avoidance syndrome | Sense of helplessness and desperation regarding his marriage | C | From a psychoanalytic perspective, Alexei's statement suggests an underlying sense of helplessness and desperation regarding his marriage. His desire for his wife to leave him reflects a deep-seated wish to escape the power imbalance in the relationship, where he feels powerless and unable to effectively manage her anger or criticism. This is likely linked to his feelings of inadequacy and worthlessness, which are likely rooted in other early experiences. Therefore, the correct answer is (D) | counseling skills and interventions |
384 | Name: Gary Clinical Issues: Behavioral problems Diagnostic Category: Disruptive/Impulse-Control/Conduct Disorders Provisional Diagnosis: F91.3 Oppositional Defiant Disorder Age: 10 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Not Assessed Ethnicity: White Marital Status: Not Assessed Modality: Individual Therapy Location of Therapy : Agency | The client reluctantly enters the session accompanied by his mother. He is slightly overweight for his age and is wearing clothes that appear too small for his physique. He is sitting in the chair with his arms crossed, refusing to make eye contact with you. His mood is angry, and his affect is irritable. His attitude during the initial part of the examination is defiant. Speech characterized by short responses and refusal to engage in conversation. Client refuses to discuss feelings or issues. He appears to have difficulty focusing. He lacks insight into his behavior and impact on others. Judgment and impulse control are poor. He denies suicidal or homicidal ideation. | First session You are a mental health therapist in an agency, and a 10-year-old male is referred to you due to behavioral issues. The client and his mother arrive at your office, and you note that he has an irritable look on his face. The two are arguing with each other. His mother threatens him with punishment if he does not cooperate with you and says that this is his "last chance". He glares at her and then stares at the floor. You introduce yourself and explain what you do as a therapist. The client barely says a word and keeps his head down with his arms crossed over his chest. You ask the mother to describe the issues that prompted her to seek help and she begins to tell you the story. She explains that her son has difficulty listening to adults and gets into verbal altercations with his peers. She informs you that he got suspended again from school because he lost his temper in the cafeteria when the student in front of him in the lunch line "wasn't moving fast enough". When you ask about how often his temper outbursts occur, the mother pauses for a moment to think and says, "It seems like he's always losing it, but I guess maybe a few times a month? The rest of the time, he's just angry, mostly at me and other adults. No matter what I do, he seems like he hates me." As she tells you this, you notice that the client is not paying attention and continues to look down at the floor, appearing disinterested in the conversation. His mother goes on to say that the school is threatening expulsion if her son's behavior does not improve. After thanking the mother for sharing this information with you, you look toward the client who has been sitting quietly the entire time. You explain that you understand it must be hard for him to be here and that you are not here to judge or criticize him. He looks up at you with a surprised expression on his face. He slowly nods and mumbles something under his breath. You let him know that you want to help him find ways to better manage his emotions so he can get along better with the people in his life. He looks away again, but this time there is a hint of curiosity in his eyes. You sit in silence for a moment. The client finally looks up at you and says, "It's just...everyone's always telling me what to do and they never listen to me. They think they know everything, but they don't. I can't help it if I get angry, but then everyone looks at me like I'm a monster. It's not fair." His mother looks away, tears in her eyes. You thank the client for expressing his feelings and explain that it is normal to feel upset when things are unfair. You further emphasize that you are here to help him find positive ways to handle his anger and other emotions. You then address the mother, "Parenting can be challenging, especially when it feels like your child is angry or upset with you. I'd like to work with both of you to improve your communication and relationship. It might be helpful to schedule separate sessions for you and your son, as well as joint sessions, so we can address individual concerns and work on improving your relationship together." The mother agrees, and you proceed to discuss a plan of action, including setting up regular weekly therapy appointments and providing resources to help support the family. Fifth session It has been over one month since you first began working with the client. You've been meeting with him for individual therapy and have implemented parent training with his mother. During previous counseling sessions, you focused on building rapport with the client and talked about different triggers for his outbursts. He said that he often gets angry when people do not listen to him or when they try to tell him what to do. You also discussed strategies for managing these triggers and the importance of communicating his needs in a respectful way. Last week, as part of your parent management training approach, you assigned the mother homework to read from a parent training handbook. When the client arrives for today's session, he is clearly upset, saying that he does not want to be here. His facial expression is one of anger and frustration. His mother is exasperated and apologetic. You calmly remind her that it is all right, that this is a normal part of the process. You ask if she would like to accompany them into your office, but she declines, saying that she needs some time to herself and she would like to wait in the waiting room for the first half of her son's session. Once inside your office, you start by asking the client why he does not want to be here. He says that he is tired of talking about his problems and he does not think it will make any difference. When you ask him to tell you more, he glares at you and says, "Why do you care? You're only asking because you want to get paid." You acknowledge how difficult it can be to keep coming back, but emphasize that whatever feelings he is having in this moment are valid and important. The client then looks away and sighs. He slowly says, "I don't know why I have to keep coming here...it feels like no matter what I do, nothing changes. I still get mad, my mom and teachers still get mad at me, and the school still threatens to kick me out." After a few moments of silence, you ask the client if he remembers what goals were set for the session today. He looks away and mumbles something under his breath. You gently remind him that you want to help him learn how to manage his emotions in a healthier way so he can get along better with the people in his life. He gradually relaxes and you ask him what strategies he has been using in the past week to work toward this goal. He thinks for a few moments before recounting an incident at school where instead of getting angry, he took a deep breath and walked away from the situation. You use behavioral modification techniques to encourage this positive behavior. You then move into today's activity, which is a role-play exercise. Once you have completed your planned tasks with the client, you invite his mother in to your office to provide her with feedback on her son's progress and discuss next steps with parent training. Eighth session The client and his mother arrive for today's session. You begin by meeting with the client alone and plan to speak with his mother afterwards. You ask the client how he has been doing since last week. He is quiet and shrugs his shoulders. You take a moment to notice his non-verbal cues and then gently ask him, "It looks like something is on your mind. Do you want to tell me about it?" He hesitates for a moment and then says, "I don't know. My mom told me that I have to stop playing video games so much. She said it's getting in the way of my homework. But I don't have any friends and video games are the only thing that makes me feel better. It's not fair. My mom gets to do whatever she wants." You listen attentively and validate his feelings. You explain to him that it is important to have a balance between recreational activities and taking care of responsibilities, like doing your homework. You say, "Your mom has a job, right? Sometimes she has to take care of things like going to work or paying bills, and it's the same when we have responsibilities at school. It takes time and effort, but if we do it, then it can free up some time for fun activities like playing video games." He shrugs and says, "Yeah, I guess." You continue the session by discussing his behavior in school and ask him if he can think of any positive experiences he has had since the last session. He thinks for a moment, then starts to shout excitedly, "Yes! There was something!" You intervene by giving him a choice of writing down his feelings or starting over with a quieter tone. He stops, takes two breaths, then proceeds to tell you about his experience in the school playground, where he managed to stay calm when he was provoked by a classmate. He said that his teacher was watching and praised him for staying calm. She gave him a sticker and told him that he could choose the game they would play at recess. You congratulate him on his success and praise him for his efforts. After you conclude the session with him, you invite his mother to your office and direct the client to wait in your waiting room. You talk to his mother to determine how her home parent training is going and review the client's treatment plan with her. His mother states that when she tried to set boundaries on gaming time, he had a "melt down". You suggest that she could consider increasing the amount of time he can play his video games in increments if he meets certain goals, such as completing all of his homework or cleaning up his room. She agrees to try this during the upcoming week. She also mentions that her son continues to struggle socially. When she told him that he could invite a friend over for pizza, he said, "What friend? Making friends is dumb. Who needs them anyway?" Following the session, you receive a phone call from the client's father who states that he has recently reconnected with his family. He says, "My wife told me that you've been working with my son. I know he's got some issues. I'm trying to get back in his life and make things right. What should I do?" | The client's father left the family two years ago. The mother, still married to him, retains sole legal custody of the client. Since his father left, the client will not help out around the house, seems angry, and sometimes loses his temper when he does not get his way. The client receives frequent but inconsistent corporal punishment from his mother. His mother made the appointment with you but did not tell him where they were going. The relationship between the client and his mother has been strained as the mother does not know how to handle the abandonment of the father. The client is in fifth grade and has been skipping school for the last six months and refuses to do any homework. His school records were released to you and show A's and B's through third grade, but C's and D's during the past two years. His decline in grades coincides with his truancy. He is also known as a "bully" at school and has been suspended and given detention a few times due to his behavior. He has a history of walking out of classrooms, running down the hallways, refusing to sit in his chair, and running away from the school counselor or anyone in an authoritative position. Personal/Social Relationships: The client does not have friends his age in the neighborhood, and parents do not want their children playing with him because they believe he is a "troublemaker". In addition, children in school avoid him because they are afraid of upsetting him. He does not seem interested in making friends and does not care to engage in any play time with the neighborhood children. Instead, he spends most of his time alone playing video games. | What statement is strength-based to empower the client to continue to achieve his goals? | "I'm proud of you for being able to stay calm in the playground. Showing that kind of self-control takes practice and effort, so keep up the terrific work." | "I know you're feeling frustrated. If you continue to work hard on staying calm when you feel angry, your mom will let you have more time to play video games." | "It's great that your teacher noticed that you have been practicing staying calm. I bet she's really proud of you!" | "Your mom told me that you're having some trouble following her rules for video gaming. Can you think of another activity that you like to do instead?" | (A): "I'm proud of you for being able to stay calm in the playground. Showing that kind of self-control takes practice and effort, so keep up the terrific work."
(B): "I know you're feeling frustrated. If you continue to work hard on staying calm when you feel angry, your mom will let you have more time to play video games."
(C): "It's great that your teacher noticed that you have been practicing staying calm. I bet she's really proud of you!"
(D): "Your mom told me that you're having some trouble following her rules for video gaming. Can you think of another activity that you like to do instead?" | "I'm proud of you for being able to stay calm in the playground. Showing that kind of self-control takes practice and effort, so keep up the terrific work." | A | This response acknowledges the progress he has made and encourages him to keep going. Therefore, the correct answer is (C) | counseling skills and interventions |
385 | Initial Intake: Age: 68 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Widow Counseling Setting: Community Agency Type of Counseling: Individual | The client presents appearing thin for height and older than her stated age. She is dressed in jeans and a shirt, no make-up and appropriate hygiene. Her mood is identified as euthymic and her affect is congruent. She is talkative and tells stories about herself and others, although she appears very distractible and changes subjects easily. She demonstrates appropriate insight, judgment, memory, and orientation using mental status exam questions. She reports never having considered suicide and never consider harming herself or anyone else. | You are a counselor in a community agency and your client presents voluntarily, though at the request of her family members. She tells you that her stepson and daughter-in-law told her they are concerned about her because she lives alone and they don’t believe that she can take care of herself at her home. She tells you that she is very happy living alone and is never lonely because she has over 20 indoor and outdoor cats that she feeds and they keep her company. During the intake, the client tells you that her husband of 33 years died five years ago from lung cancer. When asked why her family wanted her to come to counseling, your client says that she gets along well on her own; however, she believes that her stepson is looking for ways to take over her property. She tells you she owns a large section of land that includes two trailer homes, one of which is in better shape than the other so that is where she lives; ten or eleven vehicles, some that run and some that do not; and five large carports that hold the items that she and her husband used to sell at the daily flea market before it closed 15 years ago. She tells you that she sometimes finds uses for some of these items around her house but keeps all of them because they may “come in handy” at some point. She currently has no help on her property for mowing or upkeep, unless a neighbor or her son-in-law volunteers to help. | Family History:
The client reports that her parents divorced when she was a young teenager and she did not see her father again after that time. She reports he was an alcoholic as was her mother and they often argued. She relates that her mother did not work and she grew up with government assistance for food and shelter. She tells you that several years after the divorce, her mother’s mobile home was destroyed in a fire and the two of them lived in a friend’s trailer until they were able to buy another one to put on their property. She reports that she quit high school in 10th grade after having trouble reading for many years, married at age 16, had one daughter, and then divorced at 19 due to her husband’s continuing drug use. She tells you that her daughter has not been around for the “past few years” because she lives in another state and has some “mental problems, like bipolar something.” She tells you that she married again at age 20 and remained married to her husband until his death. She tells you her husband was a “good man” though he had many problems related to his military service in Vietnam and health problems due to smoking. She reports he had lung cancer and lived for 20 years although the doctors did not expect him to live so long. This was a second marriage for both of them and she tells you that her husband had one son. The client tells you she has not been close with her stepson because he has never helped them out and it has been worse since she stopped letting him keep his hunting dogs on her property. She tells you that he never took care of them and she had to feed them every day because he did not. The client tells you that she is close to her stepdaughter-in-law and that she trusts her much more than she does her stepson. The client tells you that she and her husband worked at the local flea market for many years selling things they had collected, but since the flea market closed 15 years ago, they lived on Social Security and the money her husband made doing “odd jobs” around town. | Using the information provided, which of the following would not be the best choice for determining the client's current status and potential mental health needs? | Structured Interview for Adult ADHD | Beck's Depression Inventory-II (BDI-II) | Yale-Brown Obsessive Compulsive Scale (YBOC) | Minnesota-Multiphasic Personality Inventory-2 (MMPI-2) | (A): Structured Interview for Adult ADHD
(B): Beck's Depression Inventory-II (BDI-II)
(C): Yale-Brown Obsessive Compulsive Scale (YBOC)
(D): Minnesota-Multiphasic Personality Inventory-2 (MMPI-2) | Minnesota-Multiphasic Personality Inventory-2 (MMPI-2) | D | The MMPI-2 is used to assess personality traits and psychopathology and has over 500 questions at an 8th grade reading level. Because the client states that she had reading difficulties for years prior to quitting school in 10th grade, this would be the least helpful assessment for this client. The BDI-II measures the client's current level of depression, which is often correlated with symptoms of hoarding. The potential for this client to be experiencing a hoarding disorder is noted in the number of animals she keeps, the amount of vehicles, and other items kept without letting them go. Additionally, hoarding is often related to OCD and ADHD, making the YBOC and Structured Interview for Adult ADHD tests to consider for this client. Therefore, the correct answer is (A) | intake, assessment, and diagnosis |
386 | 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. | The client reports having several concerns about the antidepressants she has been prescribed by her psychiatrist and asks for your help in switching medications or modifying her dosage. Which of the following is the best choice for responding to the client's concerns? | Before or after using techniques described in answer c, refer her back to her psychiatrist to discuss her medication changes. | Offer alternative solutions for different medicinal regimens that are not known to have the same side effects. | Validate the client's feelings and lead client into further discussion about symptoms through Socratic questioning. | Confront deflection from addressing core issues and re-direct her to discussing negative core beliefs. | (A): Before or after using techniques described in answer c, refer her back to her psychiatrist to discuss her medication changes.
(B): Offer alternative solutions for different medicinal regimens that are not known to have the same side effects.
(C): Validate the client's feelings and lead client into further discussion about symptoms through Socratic questioning.
(D): Confront deflection from addressing core issues and re-direct her to discussing negative core beliefs. | Before or after using techniques described in answer c, refer her back to her psychiatrist to discuss her medication changes. | A | Only psychiatrists, registered mental health nurse practitioners, and in some cases primary care physicians are qualified to make recommendations or adjustments to a client's mental health medications. While it is preferrable for a counselor to have knowledge of psychiatric medications and their effects, it is outside of the scope of practice and must be deferred to the appropriate professional. The approach in answer b) does not adequately validate the client's psychiatric or medical problem, which should be prioritized initially over cognitive behavioral therapy (CBT) approaches until a client has stabilized. Using these techniques will be optimally effective in conjunction with the correct medication and in later stages of treatment once the therapeutic relationship has been more established. It is most often the case that a client demonstrates the need for CBT to show improvement; but the approach in answer b) is also needlessly confrontational during an intake session, which may disrupt the trust-building and information gathering phase. In this case, the client has already been working with the agency's Psychiatrist, therefore it would be best practice to have her discuss with her doctor directly. Neglecting to address the client's reported issues with her psychiatric medications can also be deemed a liability and thus it is important to follow up with the client to ensure her needs are being addressed despite the counselor's opinion that the client has preoccupation with the psychiatric portion of her care. Therefore, the correct answer is (D) | counseling skills and interventions |
387 | 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. | Avery has a history of multiple medication switches with his psychiatrist. Which of the following steps would not be necessary to do for your treatment planning? | Inquire about which medications he was on and their effectiveness | Provide education on stimulants and other prescriptive regimens | Ask the parents to provide a copy of Avery's Psychiatric records | Help the parents identify and explore patterns of behavior and root causes | (A): Inquire about which medications he was on and their effectiveness
(B): Provide education on stimulants and other prescriptive regimens
(C): Ask the parents to provide a copy of Avery's Psychiatric records
(D): Help the parents identify and explore patterns of behavior and root causes | Ask the parents to provide a copy of Avery's Psychiatric records | C | Answers b) through d) are all appropriate ways to better understand Avery's journey with mental health medications and addressing each of these items can support the parents in their decision making going forward. While you can view the records of other providers with parental consent of your minor client (whether the parents provide them to you, or you submit a release of information and request them from the provider directly) it is not necessary for your treatment planning considerations. Therefore, the correct answer is (A) | professional practice and ethics |
388 | Name: Gregory Clinical Issues: Behavioral problems Diagnostic Category: Disruptive/Impulse-Control/Conduct Disorders Provisional Diagnosis: F91.3 Oppositional Defiant Disorder Age: 14 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Not Assessed Ethnicity: Black Marital Status: Not Assessed Modality: Individual Therapy Location of Therapy : Private Practice | The client appears obese and his clothing is unkempt. His behavior is uncooperative. He finds people "annoying" and can at times be vindictive toward people he finds "annoying." His mood is angry and affect is irritable. His flow of thought is coherent and goal-directed. His overall responses at times show themes of low self-esteem. He denies any current thoughts of suicide or homicide. He does not display any signs of hallucinations or delusions. His vocabulary is age-appropriate, but his speech is at times sarcastic. He answers questions coherently. Thought process is linear and coherent. He is oriented X3. Memory is intact for recent, remote, and immediate. Insight and judgement are poor. | First session You are a mental health counselor working in private practice. Gregory, a 14-year-old male, presents to the initial session with his mother. She reports that her son has been skipping school, hanging out with a negative peer group, and his grades are starting to slip. He refuses to listen to his mother, saying she is "strict and unfair." Gregory, who up to this point has been sitting quietly with his arms crossed, rolls his eyes and says, "She should be in therapy, not me." Gregory's mother continues on to express concern over his decline in school performance, noting that "he is having problems with some teachers and staff." Last week, he got up in the middle of class and when told to sit down, he said, "I have to go to the bathroom." He walked out and slammed the door behind him. He was sent to the principal's office as a consequence. He has also become vindictive toward certain classmates. When asked why, he states, "because they think they're better than me." His mother reports that at home, Gregory has become increasingly isolated, spending most of his free time alone in his room or out with a group of teenagers she does not recognize. He has has become increasingly hostile and verbally abusive toward his mother and brothers, resulting in frequent arguments. He routinely ignores his curfew and refuses to participate in family activities. You thank the mother for sharing her concerns and ask to speak with Gregory alone to give him a chance to express himself freely. You want to obtain his assent to join in therapy and understand what is causing him to act out. Third session Today is your third session with Gregory and you are meeting him on a weekly basis. Last week, you met with him alone and explored his feelings about his family and triggers for his anger and irritability. He reiterated that his mother and brothers were the problem, not him. You recommended meeting with Gregory and his mother for today's session to develop a treatment plan to address Gregory's issues. As you prepare for his appointment, you hear yelling in the waiting room and find Gregory screaming at his mother. She is sitting in the chair, shaking her head. You call them both into your office. His mother yells, "I've had enough of you today! This time, I'm going to talk!" Gregory rolls his eyes and mocks her. According to his mother, Gregory was "caught by the school resource officer today with a vape on him." She chokes back tears, saying, "I don't know who my son is anymore." Gregory responds, "You're overreacting. That's all you do. Big deal. It's just a vape. Get over it." His mother looks at you and says, "He's not getting better even with therapy. He won't listen to anyone, and dealing with him is a constant pain. He's spiteful and working against me. How do I get my son back?" Gregory has been exhibiting increasingly concerning behaviors since he began using a vape. He has become easily frustrated, struggles to regulate his emotions, and often resorts to aggressive outbursts. He continues to be defiant and uncooperative, straining his relationship with his mother. Despite her best efforts, Gregory remains uninterested in following your guidance, further complicating his mother's efforts to help him. 10th session You have been seeing Gregory for therapy every week for the past three months. You have worked to improve the parent-child relationship and incorporated parent-management training into his treatment plan. You have taught Gregory's mother techniques to improve his behavior and support his emotional functioning. Also included in Gregory's treatment plan is improving impulse control, learning problem-solving skills, and improving social skills. You have used CBT interventions, structured activities, games, and role-playing exercises with Gregory to achieve these goals. Today, Gregory begins the session by taking a paper from his backpack and handing it to you. You see that he received a high grade on his mid-term in Global Studies. You praise him for his hard work. Then, you ask him how it felt to get his grades back up. There is a long silence. Gregory is fidgeting with the string on his backpack. He turns, looks out the window, and whispers, "Good, I guess." You notice the client has tears in his eyes. You draw his attention to his behavior and affect and ask, "Why are you upset after being successful with your exam?" He shrugs his shoulders, looks at you, says, "Would you stop asking me so many questions?" and walks out of the office. You follow him into the waiting room and hear him tell his mom, "I'll be in the car." His mom looks confused. You say to her, "Is something going on or did something happen with Gregory that I should know about? He seemed upset after showing me his good exam grades." She thinks for a moment and tells you that he found a box of old family pictures and has been going through them. She wonders if this is related to his reaction today. | The client resides with his mother and three older brothers. He describes his brothers and mother as "annoying" and tells you that none of them listens to him. 18 months ago, his father passed away after a long illness. The client says that his dad was the only family member who understood him. The client feels he has no one to talk to and does not get along with his family members. He reports difficulty trusting others and is guarded in his relationships. He has become more irritable and vindictive since his father's death. The client denies drug or alcohol use and responds to your question, saying, "What? Are you an idiot? Do I look like someone that would be stupid enough to do drugs?" The client scoffed and continued, "Why would I waste my time and energy risking my future for something so pointless." He then crossed his arms and stared defiantly, clearly not interested in discussing the matter further. | Given your overall understanding of the client's situation, what is the best adjunct service to suggest at this time? | Group therapy | Grief support group | Family therapy | Problem-solving skills training | (A): Group therapy
(B): Grief support group
(C): Family therapy
(D): Problem-solving skills training | Family therapy | C | Considering the current family dynamics, family therapy may be useful to address multiple issues that may be impacting Gregory and the family as a whole. Therefore, the correct answer is (B) | treatment planning |
389 | 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. Fifth session It has been a month and a half since you first met with the client and she has rescheduled multiple therapy appointments, continually citing a busy work schedule. The last time you met with her, she told you that the judge sentenced her to six months probation, provided that she follow through with Alcoholic Anonymous meetings and counseling sessions. She was also required to do 60 hours of community service. Though she was relieved to have the sentencing behind her, she remarked that she still felt shame and humiliation at having gone down that path. During that counseling session, she communicated to you that she tried to go one day without drinking but couldn't do it. She described the idea of quitting drinking as "impossible" because "I have never been strong enough." You explored the client's motivations and concerns about changing her behavior. You explained to her that while it was normal to feel overwhelmed by the thought of making changes, there were strategies that she could utilize in order to build a support system and make progress towards sobriety. Based on the client's behavior, you do not believe that outpatient treatment is the best fit for the client at this time, and you plan to discuss alternate options with her today. She is scheduled for an afternoon session but does not show. When you attempt to call her, her phone goes directly to voicemail. You continue to wait in your office even though the client does not respond to your calls or appear for the session. You are concerned about her because although she has rescheduled appointments before, she has always done so in advance and has never been a "no show." You take the appropriate ethical actions to check on her. | 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. | In light of the client's admissions to you, as well as her regularly missing therapy, which recommendation would you make to ensure that the client's level of care matches her current needs? | Recommend participation in SMART Recovery | Refer the client to a Rational Recovery Program | Recommend to the court that she be court-ordered into residential care. | Refer the client to an alcohol and mental health rehabilitation center | (A): Recommend participation in SMART Recovery
(B): Refer the client to a Rational Recovery Program
(C): Recommend to the court that she be court-ordered into residential care.
(D): Refer the client to an alcohol and mental health rehabilitation center | Refer the client to an alcohol and mental health rehabilitation center | D | An alcohol and mental health rehabilitation center is an on-site detox with twenty-four hour supervision support. This setting provides evidence-based treatment programs customized to the client's co-occurring mental health needs. Therefore, the correct answer is (A) | professional practice and ethics |
390 | 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. | What do the terms circumstantiality, tangentiality, and coherence reference when conducting a Mental Status Exam? | Speech | Perception | Affect | Thought process | (A): Speech
(B): Perception
(C): Affect
(D): Thought process | Thought process | D | Circumstantiality, tangentiality, and coherence are referencing thought process. Therefore, the correct answer is (A) | intake, assessment, and diagnosis |
391 | Name: Gregory Clinical Issues: Behavioral problems Diagnostic Category: Disruptive/Impulse-Control/Conduct Disorders Provisional Diagnosis: F91.3 Oppositional Defiant Disorder Age: 14 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Not Assessed Ethnicity: Black Marital Status: Not Assessed Modality: Individual Therapy Location of Therapy : Private Practice | The client appears obese and his clothing is unkempt. His behavior is uncooperative. He finds people "annoying" and can at times be vindictive toward people he finds "annoying." His mood is angry and affect is irritable. His flow of thought is coherent and goal-directed. His overall responses at times show themes of low self-esteem. He denies any current thoughts of suicide or homicide. He does not display any signs of hallucinations or delusions. His vocabulary is age-appropriate, but his speech is at times sarcastic. He answers questions coherently. Thought process is linear and coherent. He is oriented X3. Memory is intact for recent, remote, and immediate. Insight and judgement are poor. | First session You are a mental health counselor working in private practice. Gregory, a 14-year-old male, presents to the initial session with his mother. She reports that her son has been skipping school, hanging out with a negative peer group, and his grades are starting to slip. He refuses to listen to his mother, saying she is "strict and unfair." Gregory, who up to this point has been sitting quietly with his arms crossed, rolls his eyes and says, "She should be in therapy, not me." Gregory's mother continues on to express concern over his decline in school performance, noting that "he is having problems with some teachers and staff." Last week, he got up in the middle of class and when told to sit down, he said, "I have to go to the bathroom." He walked out and slammed the door behind him. He was sent to the principal's office as a consequence. He has also become vindictive toward certain classmates. When asked why, he states, "because they think they're better than me." His mother reports that at home, Gregory has become increasingly isolated, spending most of his free time alone in his room or out with a group of teenagers she does not recognize. He has has become increasingly hostile and verbally abusive toward his mother and brothers, resulting in frequent arguments. He routinely ignores his curfew and refuses to participate in family activities. You thank the mother for sharing her concerns and ask to speak with Gregory alone to give him a chance to express himself freely. You want to obtain his assent to join in therapy and understand what is causing him to act out. | The client resides with his mother and three older brothers. He describes his brothers and mother as "annoying" and tells you that none of them listens to him. 18 months ago, his father passed away after a long illness. The client says that his dad was the only family member who understood him. The client feels he has no one to talk to and does not get along with his family members. He reports difficulty trusting others and is guarded in his relationships. He has become more irritable and vindictive since his father's death. The client denies drug or alcohol use and responds to your question, saying, "What? Are you an idiot? Do I look like someone that would be stupid enough to do drugs?" The client scoffed and continued, "Why would I waste my time and energy risking my future for something so pointless." He then crossed his arms and stared defiantly, clearly not interested in discussing the matter further. | What is the best assessment instrument for Oppositional Defiant Disorder? | Eyberg Child Behavior Inventory | Child Behavior Checklist (CBCL) | New York Teacher Rating Scale for Disruptive and Antisocial Behavior | The adolescent version of Home and School Situation Questionnaires (AHSQ) | (A): Eyberg Child Behavior Inventory
(B): Child Behavior Checklist (CBCL)
(C): New York Teacher Rating Scale for Disruptive and Antisocial Behavior
(D): The adolescent version of Home and School Situation Questionnaires (AHSQ) | The adolescent version of Home and School Situation Questionnaires (AHSQ) | D | Of the options, the AHSQ is the best assessment tool for ODD as it assesses the child in multiple settings. Therefore, the correct answer is (D) | intake, assessment, and diagnosis |
392 | Name: Camron Clinical Issues: Worry and anxiety Diagnostic Category: Anxiety Disorders Provisional Diagnosis: F40.10 Social Anxiety Disorder Age: 20 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: White Marital Status: Never married Modality: Individual Therapy Location of Therapy : University Counseling Center | The client looks anxious and uneasy, presenting with a "nervous" laugh. He twirls his thumbs and shakes his legs while seated. Mood is anxious and frustrated. He feels isolated and misunderstood by his family and peers. Speech is soft and hesitant. Eye contact is sporadic. Thought process is concrete and linear. He has some difficulty with abstract concepts. Thought content reveals fear of social interactions, feeling judged by others, and feeling inadequate. He seems to recognize the negative consequences associated with his anxiety and behavior, but he has limited insight with regard to recognizing the source of his anxiety. He reports difficulty recalling past experiences or conversations due to anxiety levels. No suicidal or homicidal ideation noted. | First session Your client is a 20-year-old male who has been seeing your colleague at the university counseling center where you both work as mental health therapists. The client requested to be transferred to another therapist because his former therapist reminded him too much of his father and therapeutic progress could not be made. The client's former therapist contacted you as a referral, and you agreed to transfer the client to your caseload. When you meet with the client today, he seems very anxious and laughs nervously. You can see he is shaking his legs as he sits, twirling his thumbs, and making little eye contact with you. You explain the therapy process and that you need to go over some intake questions. You ask him who his ICE (in case of emergency) contact is, and he says it is his roommate. You continue with your assessment, gathering information about his presenting problem and what he would like to accomplish in counseling. He continues by telling you, "I thought that going to college would alleviate my social anxiety, but I'm not doing well here. I want to be social, but I can't." The client feels frustrated and overwhelmed by his fears of interacting with others. He tells you that when he is feeling anxious, he punches bathroom mirrors to try to distract himself from the anxiety. He notes that the anxiety is crippling, preventing him from doing the things he loves, and has resulted in him feeling isolated. He is afraid that others are judging him and is constantly worried that he will make a mistake and feel embarrassed. Fourth session It has been three weeks since the initial counseling session with your client. The client comes to your office for his weekly session and says, "I tripped on my way here when I got off the subway, and I felt so embarrassed. I'm going to take a cab back to campus. What if people who saw me fall are still in the subway by the time we finish?" You ask your client to explain this embarrassment and why he thinks people who saw him fall this morning would still be in the station an hour later. He tells you that when he was little, his father always told him, "Don't do this, don't do that. People are going to think you're stupid. I still hear his voice in my head, telling me what to do. I've spent my whole life trying to live up to his expectations, and I'm tired of it!" You explore this with your client and use guided imagery to ask him to return to that little boy in his memory. He tells you, "I can't concentrate right now. The anxiety of remembering my childhood is stressing me out." You switch to using behavioral techniques as a way to help him manage his anxiety. You explain that it is important for him not only to challenge his anxieties but also recognize his successes. To ensure that he feels successful and rewarded, you come up with a plan so he can realize progress and be able to measure it. In order for you and your client to monitor his progress, you create charts that will document any positive changes he experiences during the therapy sessions. As part of the plan, your client will commit to engaging in activities outside of the counseling session which are designed with the purpose of calming him down and helping him practice his newly-acquired skills to manage his anxiety. Eighth session It has been seven weeks since the client presented for the initial interview. Today, the client returns to your office for his weekly session. He admits that he has not been following through with any of the activities you have assigned as part of his systematic desensitization plan, and he continues to feels overwhelmed by anxiety. His facial expressions reveal a sense of defeat and disappointment as he shares his struggles with making progress. He says, "I just want to be a normal guy. What's wrong with me?" The client expresses feeling overwhelmed with fear and shame at being unable to make any changes. He asks if you know of anyone else who has experienced social anxiety before and if there is any hope for him to get better. You normalize his experience and briefly share a story about being afraid to wear glasses in high school out of fear that your classmates would make fun of you. You then explain to him that even though it may feel like he is alone in his experience and feels discouraged, recovery is possible. You emphasize the importance of being patient with himself and expressing self-compassion as he works through the process. During the session, the client also mentions that his parents are having a difficult time in their relationship which has been causing additional distress for him. You explain that this could cause extra feelings of worry and insecurity, even when he is away from them. He acknowledges the connection between his parents’ relationship dynamics and his own struggles with anxiety. In order to address the additional stressors created by the distress in the client's parents' relationship, you explore ways he can work on managing his own emotions and reactions. You explain that building self-awareness of his feelings and responses may help empower him to have greater control over his anxiety symptoms. You discuss mindful breathing and visualization techniques. Afterwards, you provide examples of cognitive reappraisal strategies that can be used to challenge any irrational beliefs related to fear of failure or embarrassment that might be driving his avoidance behaviors. You explain the importance of consistently doing the practice in order for it to be effective and positive changes can be expected with consistent effort. You also give the client a homework assignment to read about social anxiety. Toward the end of the session, you summarize what you have discussed during today's session, and you address his feelings of disappointment in his perceived lack of progress by saying, "I understand your frustration. It can seem like things are not changing but in reality, even small changes are a sign of progress. The most important thing for you to remember is that it takes time and effort to learn how to manage your anxiety and make meaningful change in your life. As you continue working on the strategies we have discussed, I want you to recognize any successes or moments of improvement as they occur; no matter how small they may be. This will help keep you motivated and encourage further growth." | The client grew up in an authoritarian house where all of his actions and behaviors were scrutinized by his father. His father demanded obedience from his son and would not accept anything but perfection from him. He graduated from high school at the top of his class and has been waiting to attend college to get out from "under the thumb" of his father. The client's parents are paying all of his college expenses. The client is experiencing difficulties adapting to college life. He states that he stays in his room because he believes he always says and does the wrong thing, and everyone can see what a "loser" he is. He further states that he rarely leaves his dorm room except to go to his work-study position. The client has experienced two panic attacks; one occurred when he was required to give a presentation in class, and the second happened when he was required to meet with a small group to discuss his input for their group project. The client has missed many classes in which he is expected to participate or present projects. He is currently failing three classes. The client is in danger of losing his work-study job on campus due to frequent absences. He is competent and conscientious when his job does not require customer interaction. Personal/Social Relationships: The client is interested in exploring social relationships but is anxious as his father never allowed him to interact with his peers. As a result, his level of social functioning is relatively low. He has talked with a few students in his dorm and classes when required, but he feels extremely uncomfortable and inept. The client has not developed any friendships because of his anxiety. | What treatment plan objective are you seeking to accomplish by discussing the use of mindful breathing and visualization techniques with the client? | The client will learn and implement calming strategies when experiencing anxiety | The client will identify 3 triggers for anxiety and learn coping skills to decrease distress | The client will develop a sense of self-compassion when working through the therapeutic process | The client will identify and challenge irrational beliefs that fuel anxiety-related avoidance behaviors | (A): The client will learn and implement calming strategies when experiencing anxiety
(B): The client will identify 3 triggers for anxiety and learn coping skills to decrease distress
(C): The client will develop a sense of self-compassion when working through the therapeutic process
(D): The client will identify and challenge irrational beliefs that fuel anxiety-related avoidance behaviors | The client will learn and implement calming strategies when experiencing anxiety | A | This answer accurately reflects the goal of discussing mindful breathing and visualization techniques with a client, which is to help them become more aware of their emotions, physical sensations, and thoughts in order to better manage anxious and intrusive feelings. By developing this mindfulness and awareness, clients can begin to explore their reactions to anxiety-provoking situations in a safe space. Therefore, the correct answer is (A) | treatment planning |
393 | Client Age: 20 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Asian Relationship Status: Single Counseling Setting: College counseling clinic Type of Counseling: Individual counseling Presenting Problem: Panic attacks Diagnosis: Provisional diagnosis: panic disorder (F41.0) | Mental Status Exam: The client is oriented to person, place, time, and situation. The client does not appear anxious or depressed and was friendly and eng | You are a counselor working in a college counseling department. The client comes in after being late to class several times over the last month due to reported “freak-outs” in the morning. The client experiences the following panic symptoms: accelerated heart rate, sweating, shaking, shortness of breath, and a feeling of impending doom. The client reports a feeling of impending doom when she wakes up on days when she has classes, and this anxiety tends to escalate into fear of having a panic attack on a daily basis, often making her late to her first class. The client is worried that she will have panic attacks every day for the rest of her life. She says that her parents have put a lot of pressure on her to get a high grade point average at college. The client is worried about how this pressure and the panic attacks are going to affect her doing well at college and engaging socially. | aged. Family History: The client reports that she is close with her parents but that they often have high expectations of her and that she worries about disappointing them. The client has an older brother who is 25 and is a lawyer. The client says some of the pressure is wanting to be as successful as her brother because she thinks her parents are really proud of him | All of the following are short-term goals for treatment for the first month of therapy, EXCEPT: | Processing aspects of the client’s relationship with her parents | Implementing calming and coping strategies for panic symptoms | Providing psychoeducation on cognitive reframing | Reducing the frequency and intensity of anxiety and panic attacks | (A): Processing aspects of the client’s relationship with her parents
(B): Implementing calming and coping strategies for panic symptoms
(C): Providing psychoeducation on cognitive reframing
(D): Reducing the frequency and intensity of anxiety and panic attacks | Reducing the frequency and intensity of anxiety and panic attacks | D | A panic attack is a triggered fight-or-flight response, and this response takes time to reduce when triggered. Reducing the frequency and intensity of panic attacks is a longer-term goal because some psychoeducation and practice with coping skills need to occur first. At this point, the client would be prepared to learn and implement coping skills and cognitive reframing. It would also be helpful for the client to begin processing the thoughts, feelings, and experiences related to her relationship with her parents. Therefore, the correct answer is (C) | treatment planning |
394 | 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 following diagnostic cues, which specific information or observed symptoms would most strongly align with and support a definitive diagnosis of Anorexia Nervosa, Restricting Type? | Low body weight and poor body image | Use of compensatory behavior to prevent weight gain | Interpersonal relationship difficulties | Eating until feeling uncomfortably full | (A): Low body weight and poor body image
(B): Use of compensatory behavior to prevent weight gain
(C): Interpersonal relationship difficulties
(D): Eating until feeling uncomfortably full | Low body weight and poor body image | A | Individuals with Anorexia Nervosa present as underweight and have a poor body image. Therefore, the correct answer is (A) | intake, assessment, and diagnosis |
395 | 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 participates in her last group therapy session today. You and the client review her treatment plan goals, and she reports an overall decrease in anxiety and says that she possesses a greater awareness of social anxiety disorder and the associated interventions. She has recently completed a job interview after previously scheduling and canceling two interviews. She plans to stay in touch with two group members. The client is ready to begin termination but is anxious about ending counseling. You and the client review the psychoeducation material reviewed in the group, including factors associated with social anxiety disorder and learned coping strategies | Which of the following is true of factors related to social anxiety? | Postevent rumination helps accurately evaluate feared outcomes. | Individuals with social anxiety underestimate how negatively others judge them. | Relaxation and other safety behaviors are helpful for managing social anxiety. | In feared social situations, avoidance behaviors help maintain anxiety. | (A): Postevent rumination helps accurately evaluate feared outcomes.
(B): Individuals with social anxiety underestimate how negatively others judge them.
(C): Relaxation and other safety behaviors are helpful for managing social anxiety.
(D): In feared social situations, avoidance behaviors help maintain anxiety. | In feared social situations, avoidance behaviors help maintain anxiety. | D | Individuals with anxiety disorder typically try to manage anxiety by engaging in avoidance behaviors, such as not making eye contact or not participating in conversations. Avoidance creates a positive feedback loop that reinforces anxiety and leads to additional self-defeating thoughts and behaviors. Relaxation is not an example of a safety behavior. Relaxation techniques are helpful for the long-term management of anxiety, whereas safety behaviors are not. Safety behaviors are used with and without avoidance behaviors. Safety behaviors include things used to protect individuals from perceived “catastrophic” consequences and include inappropriate giggling or stereotypical movements when performing. Like avoidance behaviors, safety behaviors are not effective for the long-term management of social anxiety. Individuals with social anxiety tend to overestimate rather than underestimate how negatively others judge them. Finally, postevent rumination, a cognitive factor associated with social anxiety, leads to inaccurate evaluations of feared outcomes. Postevent rumination occurs when aspects of the encounter are repeatedly mentally reviewed, thus fueling anxiety and confirming negative perceptions. Therefore, the correct answer is (C) | intake, assessment, and diagnosis |
396 | 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 interventions would be the most effective in helping the client with her anxiety about the holidays? | Have the client invite her friend to a counseling session for better communication. | Teach the client a grounding technique for when her anger overwhelms her. | Provide the client with a book on setting boundaries. | Role play conversations between the client, her in-laws, and her friend. | (A): Have the client invite her friend to a counseling session for better communication.
(B): Teach the client a grounding technique for when her anger overwhelms her.
(C): Provide the client with a book on setting boundaries.
(D): Role play conversations between the client, her in-laws, and her friend. | Role play conversations between the client, her in-laws, and her friend. | D | Roleplay provides an opportunity for the client to observe the counselor communicating in a way that models the ideas that the client wishes to communicate to others. By playing the role of the in-laws and friend, the client can listen to new ways of responding to those individuals so that she can feel comfortable imitating the counselor in actual conversations. Providing the client with a book on boundaries can be very helpful, if the client follows through with the reading. Clients do not always complete homework, so assigning a book to read may not provide the outcome that the counselor had hoped. Having the client invite her friend to a session may or may not be effective. While it can provide an opportunity for the client to feel safe confronting her friend, her friend may feel uncomfortable and a rupture in the relationship may occur. Teaching the client a grounding technique when her anger overwhelms her is a good intervention to use when the client's emotions are out of control. In most situations, it is best to help clients be proactive in working on their issues rather than concentrating on reactive remedies. Therefore, the correct answer is (C) | counseling skills and interventions |
397 | 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." | 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. | Which of the following assessments is most appropriate to assess suicidality and plan for treatment around suicide risk? | The Behavior Assessment System for Children (BASC) | The Beck Depressive Inventory-II (BDI-II) | The Columbia Suicide Severity Rating Scale (CSSRS) | Collaborative Assessment and Management of Suicidality (CAMS) | (A): The Behavior Assessment System for Children (BASC)
(B): The Beck Depressive Inventory-II (BDI-II)
(C): The Columbia Suicide Severity Rating Scale (CSSRS)
(D): Collaborative Assessment and Management of Suicidality (CAMS) | Collaborative Assessment and Management of Suicidality (CAMS) | D | The CAMS is considered to be the best tool to assess suicidality and plan treatment around suicide risk. The collaborative nature of the CAMS allows extensive coordination of treatment between the client and therapist, which is important for this client. Therefore, the correct answer is (C) | intake, assessment, and diagnosis |
398 | Initial Intake: Age: 16 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: African American Relationship Status: Single Counseling Setting: Community Health Type of Counseling: Individual | The client presents as a thin young woman, whose weight is appropriate for her age. Her clothing is appropriate for her age and to the situation. She identifies her mood as happy and her affect is congruent. The client shows some retardation in movement but no spasticity or physical or abnormal movements. The client appears open and honest in her responses, though responses are short. She responds to closed questions without pause but appears to struggle to answer open-ended questions as evidenced by staring and smiling without speaking or saying “I don’t know.” On examination, the client shows little insight into her mother’s concerns and uses childlike judgement when responding to hypothetical questions. The client denies suicidal or homicidal ideations or intent, delusions, or hallucinations, but does admit to playing a game with children at her maternal grandmother’s house where they attempt to see ghosts in the bathroom mirror. | You are a counselor in a community health setting which includes in-office sessions as well as home visits. Your client is a 16 year-old female who presents with a history of academic difficulties, problems following rules at home, and fighting with her sister, which recently included threatening to cut her sister with a kitchen knife. Her mother tells you that the client has always had some problems in school but they are getting worse. Her teachers say that she doesn’t pay attention and struggles with simple concepts, but is always polite and friendly to others. When asked to tell you how she thinks things are going, she answers “good” and smiles. You notice that she often smiles while her mother is talking but when her mother talks about the problems at home, the client looks away from both of you and stares out the window. The client’s mother reports that the client does not clean her room, has to be told to attend to her hygiene, and does not complete chores when they are assigned, such as cleaning out the refrigerator or vacuuming the living room. Mother reports that the client stays at home alone or with her two younger sisters when her mother or mother’s boyfriend are at work or away from home during the day. | Family History:
The client is the oldest of three children born to her mother. Her siblings have different fathers and her youngest sister’s father currently lives in the home and is identified as “mom’s boyfriend” or “Robert.” Client’s mother reports no family history of mental health disorder or substance abuse. The client reports that she often spends several nights a week with her grandmother “to give Mom a break” and plays games and spends time with the neighborhood children. The client states that her grandmother “makes me sit and she reads the Bible to me” for several hours each day. She reports that she likes spending time at her grandmother’s house because she and her sister watch “scary movies” including movies about monsters, murders, and witchcraft. | Which of the following is not part of the termination process? | Review company policies for uses and limits of social media | Provide contact information in case the client or her mother have questions for you | Provide the new clinician with a copy of your notes | Introduce the client and her mother to the clinician who will be working with them | (A): Review company policies for uses and limits of social media
(B): Provide contact information in case the client or her mother have questions for you
(C): Provide the new clinician with a copy of your notes
(D): Introduce the client and her mother to the clinician who will be working with them | Provide contact information in case the client or her mother have questions for you | B | Termination is often as hard on counselors as it is on clients. However, the counselor is responsible for terminating ethically, legally, and professionally. Relationships with clients after counseling are discouraged by the ACA Code of Ethics. The counselor should provide only contact information for the new clinician and for the agency as the current counselor will no longer be involved with this client. It will be helpful to use some of the current session to introduce the new clinician and help the client and her mother begin building a relationship with that counselor. Reviewing company policies about social media is important as the counselor should not accept or allow the client access or expectations of access to the counselor through social media. It is appropriate for the retiring counselor to provide a copy of notes to the new clinician to facilitate continuity of treatment. Therefore, the correct answer is (B) | treatment planning |
399 | 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. | The client appears to be more comfortable with you as he greets you at the door and starts talking with you about his favorite TV show as you walk back to the office. The client talks about how his parents give different consequences to him than his younger sister and that they also give her more attention than they give him. You empathize with the client about this because it must be frustrating being treated differently. You assist the client with processing further, and he identifies feeling like he is “bad.” But because he gets attention, he continues to push back against their authority. During this session, the client curses at his parents and they punish him by removing access to video games for the next week. You are using the rational emotive behavior therapy ABC model with the client during this session. You want to challenge the client’s belief that “my parents don’t like me” following their punishment of him | You are using the rational emotive behavior therapy ABC model with the client during this session. You want to challenge the client’s belief that “my parents don’t like me” following their punishment of him. All of the following statements would be a disputation of that belief EXCEPT: | “My parents do like me, and that is why they’re punishing me.” | “My parents don’t want me to be mean, so they made me take time to calm down.” | “My parents don’t like me right now, so they made me take time to calm down.” | “My parents don’t like what I’m doing, so they punished me.” | (A): “My parents do like me, and that is why they’re punishing me.”
(B): “My parents don’t want me to be mean, so they made me take time to calm down.”
(C): “My parents don’t like me right now, so they made me take time to calm down.”
(D): “My parents don’t like what I’m doing, so they punished me.” | “My parents don’t like me right now, so they made me take time to calm down.” | C | The purpose of disrupting beliefs is to challenge thoughts that are harmful or unhelpful. The answer that states “my parents don’t like me right now, so they made me take time to calm down” is still unhelpful because it validates that the client is not liked by his parents. The other options promote the idea that the parents care about him and want him to do and feel better. Therefore, the correct answer is (D) | counseling skills and interventions |
400 | Name: Shelly Clinical Issues: Emotional dysregulation Diagnostic Category: Personality Disorders Provisional Diagnosis: F60.3 Borderline Personality Disorder Age: 41 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: Black Marital Status: Never married Modality: Individual Therapy Location of Therapy : Telehealth | The client's clothes are clean but her hair and make-up seem unkempt. She wears long sleeves but you notice some scarring on her left wrist when she steeples her hands together in front of her computer screen to answer a question. The client remains alert throughout the interview, though sometimes you have to repeat questions. She seems to be distracted by something off screen at times. She fidgets with a cigarette lighter. The client appears irritable and her affect is labile. The client is coherent. Her speech is unpressured though at times slightly slow. She is oriented to person and place but not time or situation. She is unsure of what day of the week it is and she does not seem to understand the significance of being court-ordered. Her thinking is mostly linear and goal-directed but at times tangential and unfocused. She displays persecutory thought content. Insight and judgment are poor. | First session You are a mental health therapist delivering telehealth therapeutic services. Your 41-year-old Black female client is sitting on her sofa with her arms crossed and an annoyed look on her face. When you first see the client, you are immediately attracted to her as she reminds you of your first wife. She has been mandated to therapy by the Court as part of the terms of her probation. She begins by telling you about her difficulties with her acting career. She recently auditioned for a new role but was turned down because the directors wanted to "go in a different direction." She also mentions relationship distress and tells you she has been dating a high-profile plastic surgeon on and off for two years. She tells you, "We just had a big fight. He said I was 'too high maintenance' and he was tied of 'all my drama' and left. Can you believe it? I was obviously upset and stopped for a drink on the way home and met a very nice gentleman who bought me a few more drinks. But I don't know they think I have a drinking problem." As the intake progresses, it becomes evident that the client's frustration and agitation stem from a deep feeling of abandonment. She expresses her distress over feeling overlooked and not validated in her acting career. She reveals her struggle with the expectations placed upon her as a Black woman in the entertainment industry, believing that systemic biases may be limiting her opportunities. This realization amplifies her anger and resentment, fueling her resistance to therapy and perceiving it as a means of forced compliance rather than genuine support. As you continue to gather information about her presenting problem, you notice that the client is becoming increasingly agitated. Her tone turns angry, and it becomes clear that she resents being in therapy, especially when she says you are "no more than hired help." You attempt to ease tensions and build rapport by sharing with her the names of two famous actors you have counseled. However, this does not change her demeanor or attitude toward you. You detect a recurring theme of self-sabotage that manifests in the client's relationships. She complains about her relationships with the high-profile surgeon and other men. You note the client's lack of trust in men as well as casual female acquaintances who she sometimes sees as "competition." Her relationships appear strained due to her unresolved issues, leading to conflicts and feelings of worthlessness. As you continue your assessment, it becomes apparent that a complex interplay of societal pressures, past traumas, and a deep-seated fear of abandonment negatively impacts her self-perception. You also learn that she worries about her precarious financial situation, which adds to her insecurity and instability. The fear of being unable to meet her basic needs is an artifact of her unstable childhood. You suggest that during the next session, you begin to explore what might be contributing to her current feelings and behaviors beyond just focusing on her career issues, mainly her emotional dysregulation and fears of being abandoned. She says, "I'm an actress and have auditions. How long is this going to take?" You reinforce that the client has been court-ordered to therapy and that therapy will continue for as long as it takes to address the mandated objectives in the court order. You schedule a follow-up appointment to meet with the client again next week. Sixth session The telehealth session starts like any other; you log in and wait for the appointment to begin. However, after several minutes of waiting, you are concerned that something is wrong with the client. When she eventually logs on, she is 15 minutes late and crying uncontrollably. When prompted about what happened, the client begins pouring out her anguish over her boyfriend's recent departure from town on business. She explains how he will not be coming home this weekend like they had planned - leaving her feeling empty and alone. Then, with tears streaming down her cheeks, she says, "I see no reason to go on if he will only cause me grief." At this point, you realize your client might be at risk of self-harm or worse. You spend the remainder of the session developing a safety plan together, which involves finding alternative ways to cope with loneliness and reaching out to friends and family members who can support the client during distress. Despite your best efforts in the session to establish a safety plan, you perceive her adherence to it as shaky. Her body language and verbal feedback clearly show that she struggles to accept the idea of seeking help from her network of friends and family. She confesses feeling like a burden to others, reflecting a deep-seated inferiority complex that seems central to her emotional distress. This, coupled with her inability to visualize the situation from a holistic perspective, implies that she might be caught in the throes of an existential crisis, unable to see beyond the immediate emotional turmoil. Tackling this crisis from an Adlerian lens, you gently challenge her self-defeating beliefs and attempt to imbue her with a sense of belonging and community. However, her tearful responses indicate a sense of discouragement and isolation, suggesting she perceives herself as alone in her struggle. It is apparent her social interest is significantly diminished. You note that this disconnection isolates her emotionally and poses a potential risk to her overall well-being. Despite your attempts to reassure her, she repeatedly questions her self-worth and viability without her boyfriend, mirroring feelings of inferiority and an over-reliance on external validation. In the face of such severe emotional turmoil and potential risk, you recognize that her current mental state may require a more intensive approach beyond the scope of telehealth sessions. This solidifies your intent to seek a higher level of care and immediate intervention for her, emphasizing the severity of the situation and your dedication to safeguarding her well-being. After the client leaves the session, you call her emergency contact and discuss your concerns. You tell the client you are considering referring her for further assessment by a psychiatrist or hospitalization to ensure her safety. You request the client's emergency contact person to call you if they see any indications that the client is decompensating. | The client shared significant details about her familial history, particularly on her father's side. She conveyed that her paternal relatives have contended with various mood disorders, although she could not provide specific diagnostic categories. As a result of her father's authoritarian parenting style of strict adherence to his rules and restrictions, she has rejected any limitations from any authority figures. Notably, she also revealed several severe distressing incidents within her family, including suicide attempts, multiple instances of divorce, and hospital admissions. According to the client, these incidents often emerged due to relational difficulties, culminating in elevated levels of emotional distress. Furthermore, the client reported a history of hospitalization, although her recollection of the admission circumstances was somewhat nebulous. She said that she was feeling "distraught" during that period. You determine that exploring this episode more thoroughly in future sessions when the client feels ready and comfortable could provide valuable insights into her emotional coping mechanisms and resilience. The client was recently arrested for driving under the influence (DUI). This was not her first encounter with law enforcement regarding such a matter, as she has been charged with three DUIs over the past five years. However, this recent incident was markedly different and considerably more severe. She lost control of her vehicle and collided with a residential building, resulting in physical injury to a child. She underwent legal proceedings after her involvement in this accident and was found guilty. As part of her sentence, she was placed on probation under the court's oversight and mandated to attend therapy. The client disclosed that her consumption of alcohol is primarily social in nature. However, she also appears to use alcohol to self-medicate in times of emotional dysregulation. Despite these circumstances and her ongoing encounters with the law, she maintains the belief that her alcohol use does not pose a significant problem. | What potential positive or negative effects could the client's profound sense of inferiority and reliance on her boyfriend have on her recovery process? | The client's emotions of inferiority and dependency would provide motivation for her to persist in therapy, thus facilitating her recovery process. | The client's feelings of inferiority and dependency could motivate her to work on strengthening her bond with her boyfriend, potentially expediting her recovery journey. | The client's experience of inferiority and dependency could compel her to pursue self-reliance and independence, thereby accelerating her recovery process. | The client's experience of inferiority and dependence may impede her recovery as it could discourage her from seeking support from alternative avenues, thus intensifying her feelings of isolation and loneliness. | (A): The client's emotions of inferiority and dependency would provide motivation for her to persist in therapy, thus facilitating her recovery process.
(B): The client's feelings of inferiority and dependency could motivate her to work on strengthening her bond with her boyfriend, potentially expediting her recovery journey.
(C): The client's experience of inferiority and dependency could compel her to pursue self-reliance and independence, thereby accelerating her recovery process.
(D): The client's experience of inferiority and dependence may impede her recovery as it could discourage her from seeking support from alternative avenues, thus intensifying her feelings of isolation and loneliness. | The client's experience of inferiority and dependence may impede her recovery as it could discourage her from seeking support from alternative avenues, thus intensifying her feelings of isolation and loneliness. | D | Feelings of inferiority and dependency can cause an individual to have a narrow perspective on who or what can provide support or relief. In this case, the client's heavy reliance on her boyfriend for validation might deter her from seeking or accepting help from others, thereby leaving her emotionally isolated and increasing her risk. Therefore, the correct answer is (A) | counseling skills and interventions |
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