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401 | 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. | You meet with the client after he requested an emergency appointment. The client says that he had a supervised visit with his children and he had used inhalants prior to the visit because he was anxious. The supervisor noted the intoxication and ended the visit early. The client says that this was 3 days ago and that he has used inhalants several times daily since the visitation. Due to his intoxication at the visit, all future visits have been canceled until the next hearing in court regarding visitations. The client says that he has been very depressed and that is why he is using inhalants. During the session, the client asks if he can go to the lobby to get water and you tell him that this is fine. The client returns, sits down, and appears listless because he is not displaying any emotion and has a very flat affect. You suspect that he is now intoxicated. Following this session, you determine that the client is not benefiting from therapy with you because he has used inhalants since at least your third week of sessions and almost daily since then | Following this session, you determine that the client is not benefiting from therapy with you because he has used inhalants since at least your third week of sessions and almost daily since then. Which of the following would be the most appropriate intervention for this client based on his recent inhalant use? | Case management from a local government agency | Psychiatric hospitalization | Referral to another counselor | Inpatient drug rehabilitation | (A): Case management from a local government agency
(B): Psychiatric hospitalization
(C): Referral to another counselor
(D): Inpatient drug rehabilitation | Inpatient drug rehabilitation | D | The client continues to use inhalants regularly despite counseling, and it is causing harm to his relationships and putting him and others at risk of harm. An inpatient drug rehabilitation facility might be a more appropriate level of care. A referral to another counselor would likely produce the same results because the counselor can only provide counseling twice weekly and cannot monitor or support him between sessions as well as an inpatient facility could. Psychiatric hospitalization may be helpful to stabilize the client quickly, but it would not provide the therapeutic level of support that the client needs to reestablish and maintain sobriety. Case management might be helpful; however, case management connects the client to services and supports functioning and this takes some time to set up and provide the funded services. The client needs more immediate support to keep him from causing further harm to his relationships and to decrease the risk that the client might pose to himself and others. Therefore, the correct answer is (C) | treatment planning |
402 | Initial Intake: Age: 26 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Private Practice Type of Counseling: Individual | The client appears his stated age and is dressed appropriately for the circumstances in clean jeans and a t-shirt. He identifies his mood as “anxious but a little excited” because he “is hopeful that he can finally let his anger go.” He tells you he is tired because he has difficulty falling asleep and staying asleep most nights. His affect is pleasant with emotional lability evident. He demonstrates appropriate insight and judgment, memory, and orientation. He reports never “seriously” having considered suicide but acknowledges that there were times when he wondered “if dying would make this pain go away.” He has never attempted suicide and states he would never consider harming himself or anyone else. | You are a counselor in a private practice setting. Your client is a 26-year-old male who presents for counseling at the request of his family and his employer, with whom he is close and who knows his history. The client tells you that he has been angry for the past 15 years, beginning a year after the death of his father from a heart attack. He says that his anger is triggered very quickly when frustrated by people or situations and that his “fuse is very short these days.” He states that he has been in some “loud arguments” with his mother, and later his stepfather. He admits that there have been times in the past when he and his stepfather have “almost come to blows” but his mother stepped in and made them stop. He admits to having hit or kicked walls at times in his anger, but has never hit a person. He tells you that he doesn’t want to feel this way because it interferes with his relationships and his former girlfriends have never understood that when the anniversary of his dad’s death comes around, he just wants to be alone for a couple days and not have to talk to anyone. He tells you that he has never had a long-term relationship with a woman because either he gets “depressed” for a few days during certain times of the year (i.e., father’s birthdate and death date) or because he is too quick to get angry and then says things he doesn’t mean. He says that he has been in a relationship with a woman now for eight months and really wants to get himself together because he feels “she’s the one.” | Family History:
The client reports a family history of being the youngest of three siblings born to his mother and father. He reports a “great life” with his family and that they regularly spent time together playing, camping, traveling, and “just being a family.” He tells you that he is sure there were occasional arguments but that he doesn’t remember anything significant, except that he had been mad at his dad the night he died because his dad wouldn’t let him stay up late, but that before the client went to bed, he had come down, apologized to his dad, and they had both said “I love you.” He states his parents had been married for 15 years prior to his father’s death, which occurred when the client was 11 years old. He states his dad died of a heart attack while sleeping, so while he did not see it, he knew something had happened because his mother woke him and his siblings and rushed them over to the next door neighbors’ house. He said that his mother went to the hospital with his father in the ambulance and came home that night to tell him and his siblings that their father had died. He tells you that he and his siblings are still very close and that they now have three much younger siblings born after his mother married his stepfather. He says that he is very close to his mother and stepfather, although he lives three hours away from them. He tells you that he tries to get home for big family events, like birthdays. He states that his stepfather adopted him and his siblings after the wedding and the client loves him very much. He tells you that he and his stepfather have gotten in what the client thinks are “typical teenager/parent” conflicts but that they have often been made worse by the client’s anger that seems to always be inside and erupts quickly. | Which of the following is not a symptom of post-traumatic stress disorder? | Derealization | Dissociative flashbacks | Depersonalization | Dissociative amnesia for everyday, non-traumatic events | (A): Derealization
(B): Dissociative flashbacks
(C): Depersonalization
(D): Dissociative amnesia for everyday, non-traumatic events | Dissociative amnesia for everyday, non-traumatic events | D | Dissociative amnesia for everyday, non-traumatic events is a symptom of Dissociative Identity Disorder (DID) and not of PTSD. Individuals may be diagnosed with DID and PTSD, but the two are different disorders. Both PTSD and DID often include symptoms of dissociative flashbacks in which the individual relives the traumatic event with a reduced awareness of the present. However, PTSD includes symptoms of depersonalization, in which the individual experiences feeling that they are not real; and derealization, in which the individual experiences the world around them as not real. DID does not include these two symptoms. Therefore, the correct answer is (C) | intake, assessment, and diagnosis |
403 | Name: Bianca Clinical Issues: Difficulty adjusting to life changes Diagnostic Category: V-codes Provisional Diagnosis: Z60.0 Phase of Life Problem Age: 62 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: Black Marital Status: Separated Modality: Individual Therapy Location of Therapy : Agency | The client is a 62-year-old female, wearing work attire. She appears to be in good hygiene and her dress is neat and appropriate for the situation. Her facial expression is sad and she has tear tracks on her cheeks. Her mood is noticeably depressed, anxious, and tearful. Her affect is constricted. She has coherent thought processes with appropriate content. She expresses feelings of sadness over her failed marriage and overwhelm about being alone. The client has intact memory and concentration. She has fair insight into her current situation and is able to verbalize her feelings in a coherent manner. | First session The client comes to the agency practice where you currently work as a licensed mental health therapist. She is a 62-year-old female who recently retired from an accounting firm employment. She is seeking treatment after her marriage recently failed. A few months ago, he husband filed for a legal separation and is currently romantically involved with another woman. The client looks at you tearfully and says, "I can't believe this is happening at my age. I am all alone. What am I going to do?" She continues to cry uncontrollably. You focus on providing a safe and secure environment. You assure her that she will not be judged or criticized in any way, and all of the conversations during the session will remain confidential. You gently let her know that it is okay to cry, and you are there to listen without judgement. You also tell the client that it is natural to feel lost and alone after a separation, especially since she and her husband have been together for such a long time. She says, "I just feel like such a fool. He cheated on me once before - that I know of - and now he's done it again. I stayed with him for over 30 years, and now I have nothing." She describes having mixed feelings of anger, sadness, fear, and confusion. She states, "There are moments where I'm so mad at him for leaving. Mad enough that I could break something! Our marriage wasn't perfect, but I thought he was committed to me. Well, obviously he wasn't. Then I start to question what's wrong with me that made him leave. And then I think about the future and how I'm going to live by myself. It's all so overwhelming." She further discloses that she is worried about having panic attacks again because "that's what happened the last time something of this magnitude happened to me." You reinforce the idea that it is important to focus on the fact that she is not alone and many people in similar situations feel overwhelmed and uncertain about their future. You let her know she is in a safe space to explore her feelings, work through her loss, and develop a plan for moving forward. You encourage her to reach out for support during this challenging time rather than isolate herself as she goes through this difficult change. Fifth session The client has been seeing you for individual therapy sessions every week. You have developed a strong rapport with her and collaborated on treatment goals, with her overall goal being to have a positive outlook on her life. During the last session, you gave her a homework assignment to begin keeping a journal, using the ABC model of rational emotive behavior therapy to identify self-defeating beliefs and understand how they are contributing to her emotional distress. You have also been working with her to process her feelings about her separation and develop coping skills. During today's session, she seems depressed, as she tells you her husband met with an attorney and officially filed for divorce. You explore her journal entries, noting one in particular in which she describes an experience in which she was driving and saw her husband sitting outside a café with "the other woman." She circled back a few times in her car, hoping he would see her. In her mind, she fantasized that he would leave his new girlfriend and drive away with her, and everything would return to normal. You ask her to tell you more about what "normal" means to her. She says, "I guess I just want things to go back to how it was before. When I mattered, when I felt loved, and when he was committed to our marriage." You acknowledge her feelings and explain that while it may not be possible to go back to exactly how things were, there is still hope for the future. You express compassion and understanding, emphasizing that there is no right or wrong way to feel. She states, "I just have mixed feelings about everything! I feel angry and betrayed by my husband, but sometimes I want him to come back. I start to feel lonely and realize the reality of my situation and that I have no purpose anymore and am alone. What's the point? My kids don't care; I have nothing in my life now. Things are so painful I'd be better off dead." You reassure her that you are here to support her as she works through all of her difficult emotions. Eighth session The client has been attending sessions weekly for two months. Today, you begin by reviewing the progress the client has made in therapy. She has joined a support group and has made some new friends but still feels anxious about her future. She has also joined a bridge group but is finding that she is having difficulty remembering what cards are being played. At your suggestion, she also made an appointment with a psychiatrist and was prescribed a low dosage of Paxil. She feels more positive and states that she may volunteer at a local animal shelter. The client also mentions that yesterday she received official divorce documents in the mail. As she tells you about this, you notice her mood shifts. She quietly shares, "On some level, I think I've known that my marriage has been over for a while, but when I got the legal papers, it made it feel real for the first time. My thoughts are all over the place. I'm still very hurt by all of this, but I know that I need to move forward with my life." The client tells you one of the friends she met in her support group suggested that she consider joining a dating app, and she asks if you could help her. She says, "Technology has changed so much since I first started dating my soon-to-be ex-husband. I don't know how any of this works!" You validate her feelings and offer her reassurance that these kinds of emotions are completely normal in this situation. You suggest she take some time to process and grieve the end of her marriage. You also remind her that it is important to focus on some of the positive aspects of starting a new chapter in her life. You talk about how she can use the skills she has learned in therapy to manage her negative emotions and focus on positive self-talk. Additionally, you suggest some healthy coping strategies for managing the stress of this transition including exercise, meditation, journaling, and spending time with her new friends. You then refocus on the topic of dating, and you provide some helpful tips such as creating a profile that accurately reflects her interests, making sure to be honest about who she is, and being mindful of safety when meeting people in person. Finally, you remind her that it is important to take things slow and enjoy the process of getting to know someone. You also encourage her to remember that relationships can take different forms and that it is okay if she is not ready for a romantic relationship right now. At the end of the session, you check in with her and ask how she is feeling. She tells you that while she still feels overwhelmed, she is feeling more prepared to move forward with her life. You end the session with words of encouragement and remind her that you are here to support her. | null | You respond to the client's statement of feeling hurt by saying, "I can see why you are feeling hurt. Healing takes time, and it's okay to feel that way. It's important that you recognize that even though you are hurting right now, you have made great progress." What did you do here? | Used constructive confrontation | Used an open-ended question | Reflection of meaning | Used listening/attending and reflection skills | (A): Used constructive confrontation
(B): Used an open-ended question
(C): Reflection of meaning
(D): Used listening/attending and reflection skills | Used listening/attending and reflection skills | D | You used skills which made the client feel heard while reflecting on how far she has come in the therapeutic process while simultaneously validating her feelings. Therefore, the correct answer is (D) | counseling skills and interventions |
404 | Name: Luna Clinical Issues: Developmental processes/tasks/issues Diagnostic Category: Neurodevelopmental Disorders Provisional Diagnosis: F81.0 Specific Learning Disorder, with Impairment in Reading Age: 13 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: Hispanic Marital Status: Not Applicable Modality: Individual Therapy Location of Therapy : School | The client is an average-built individual who is alert. The client is casually dressed and adequately groomed. Speech volume is quiet, and speech flow is slow. She has difficulty maintaining eye contact for extended periods and often looks down at her feet. She demonstrates irritability at times during the interview and sighs several times. Her thought process is logical. Her estimated level of intelligence is in the low average range, with limited abstract thinking. Concentration is intact. The client shows no problems with memory impairment. | First session As the mental health therapist working in a school setting, you welcomed your new client and her parents into your office. They explained their daughter's struggle with reading and how it caused her to freeze when faced with a spelling or math test. After listening to them closely, you asked the client why she did not enjoy reading. She said that words confused her and made no sense, so she found it difficult to remember what she read. You consider possible solutions for your client, who was having difficulty with schooling due to a lack of literacy skills. You proposed an idea: "Let's try incorporating creative activities as part of our therapy sessions." Doing so, we can develop strategies for improving written language comprehension and expression while making learning fun for your daughter." The parents were hesitant but agreed to try it after seeing their daughter's enthusiasm about trying something different than traditional methods like instruction books or worksheets, as those have not been effective in the past. During the session, you brainstormed ideas around stories, role-playing games, and drawing activities focusing on using everyday experiences as inspiration for creating unique narratives within each session – not only reinforcing literacy skills but also providing an opportunity for emotional growth through storytelling exercises. Fourth session The client came to her weekly session with you feeling discouraged and embarrassed about what happened in school earlier that day. She had been called on to read a paragraph from the science textbook in front of the whole class, and she could not get through it. Her classmates, who she usually gets along with, began to laugh at her, and she quickly excused herself to the clinic, saying she had a stomachache. It was the worst experience she had ever encountered, making her feel even more vulnerable. You offered comfort as you discussed strategies for the client's reading struggles. You also encourage the client not to give up and assure her that no matter what happens tomorrow, next week, or next month, she can reframe the fear and embarrassment she felt with being surrounded by support and people that will help her through these challenging times. After the client leaves, you talk with her parents over the phone. You suggest they meet at school with everyone involved with their daughter to discuss how best to implement an Individualized Education Plan (IEP). Your objective with this meeting is to review the areas where improvements and support could be given and determine if any changes need to occur for your client. Ninth session The client's parents were elated to see their daughter make significant progress in her reading at school. After careful consideration and collaboration between you, the client, her teachers, and the paraprofessional, the team has all devised a treatment plan tailored specifically to her needs. Incorporating a small group setting provided the client with the individualized attention she needed to become successful in her reading skills. As the session came to an end today, it was clear that both the client and her parents were satisfied with the results of their hard work. To ensure that they felt comfortable moving forward and everybody was on the same page, you asked them, "What I hear you saying is that you feel as though your daughter has met her educational goals and has the support to continue to succeed? Is that correct?" Both of them smiled knowingly and nodded affirmatively. With a sense of closure now achieved by this family team, the parents left feeling confident about continuing on this path towards helping their daughter reach success with reading deficits. Together they had created a practical plan which could be adapted as necessary along the way, one which would pave a brighter future for the client. | The client says she is only poor at reading and "good at everything else." She says that she feels stressed when she has to read. The client's IQ is 89. A reading specialist assessed her, and her reading skills are abnormally low. Throughout elementary school, teachers noted the client has difficulty reading and that, in turn, it has adversely affected the client's academic achievement. As a result, special needs are implemented in the client's school setting. The client has an active Individualized Education Plan (IEP). Pre-existing Conditions: The client has also been diagnosed with epilepsy and is on medication for seizures. The client had frequent seizures for many years until a medication that lessened the occurrence of her symptoms was prescribed. The client fell when she was eight, hit her head, and fractured her skull. She was not diagnosed with any traumatic brain injury, but she did need stitches. Additional Characteristics: The client portrays positive interactions with both staff and peers at school. The client does state she feels she is "stupid" when it comes to reading and wishes she could get better. The client's family is supportive and values education. They are hands-on in supporting the client in any way they can. | What action would be irrelevant as part of the termination process? | Ensuring the IEP is effective for the student | Check-in frequently with the client's parents | Discussing the client's progress with the principal | Following up with the client's teachers | (A): Ensuring the IEP is effective for the student
(B): Check-in frequently with the client's parents
(C): Discussing the client's progress with the principal
(D): Following up with the client's teachers | Discussing the client's progress with the principal | C | Connecting with the principal to discuss students' academic success is irrelevant as part of the termination process. Instead, you would discuss the client's progress with teachers, parents, and school psychologists. Therefore, the correct answer is (D) | professional practice and ethics |
405 | Name: Camron Clinical Issues: Worry and anxiety Diagnostic Category: Anxiety Disorders Provisional Diagnosis: F40.10 Social Anxiety Disorder Age: 20 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: White Marital Status: Never married Modality: Individual Therapy Location of Therapy : University Counseling Center | The client looks anxious and uneasy, presenting with a "nervous" laugh. He twirls his thumbs and shakes his legs while seated. Mood is anxious and frustrated. He feels isolated and misunderstood by his family and peers. Speech is soft and hesitant. Eye contact is sporadic. Thought process is concrete and linear. He has some difficulty with abstract concepts. Thought content reveals fear of social interactions, feeling judged by others, and feeling inadequate. He seems to recognize the negative consequences associated with his anxiety and behavior, but he has limited insight with regard to recognizing the source of his anxiety. He reports difficulty recalling past experiences or conversations due to anxiety levels. No suicidal or homicidal ideation noted. | First session Your client is a 20-year-old male who has been seeing your colleague at the university counseling center where you both work as mental health therapists. The client requested to be transferred to another therapist because his former therapist reminded him too much of his father and therapeutic progress could not be made. The client's former therapist contacted you as a referral, and you agreed to transfer the client to your caseload. When you meet with the client today, he seems very anxious and laughs nervously. You can see he is shaking his legs as he sits, twirling his thumbs, and making little eye contact with you. You explain the therapy process and that you need to go over some intake questions. You ask him who his ICE (in case of emergency) contact is, and he says it is his roommate. You continue with your assessment, gathering information about his presenting problem and what he would like to accomplish in counseling. He continues by telling you, "I thought that going to college would alleviate my social anxiety, but I'm not doing well here. I want to be social, but I can't." The client feels frustrated and overwhelmed by his fears of interacting with others. He tells you that when he is feeling anxious, he punches bathroom mirrors to try to distract himself from the anxiety. He notes that the anxiety is crippling, preventing him from doing the things he loves, and has resulted in him feeling isolated. He is afraid that others are judging him and is constantly worried that he will make a mistake and feel embarrassed. | The client grew up in an authoritarian house where all of his actions and behaviors were scrutinized by his father. His father demanded obedience from his son and would not accept anything but perfection from him. He graduated from high school at the top of his class and has been waiting to attend college to get out from "under the thumb" of his father. The client's parents are paying all of his college expenses. The client is experiencing difficulties adapting to college life. He states that he stays in his room because he believes he always says and does the wrong thing, and everyone can see what a "loser" he is. He further states that he rarely leaves his dorm room except to go to his work-study position. The client has experienced two panic attacks; one occurred when he was required to give a presentation in class, and the second happened when he was required to meet with a small group to discuss his input for their group project. The client has missed many classes in which he is expected to participate or present projects. He is currently failing three classes. The client is in danger of losing his work-study job on campus due to frequent absences. He is competent and conscientious when his job does not require customer interaction. Personal/Social Relationships: The client is interested in exploring social relationships but is anxious as his father never allowed him to interact with his peers. As a result, his level of social functioning is relatively low. He has talked with a few students in his dorm and classes when required, but he feels extremely uncomfortable and inept. The client has not developed any friendships because of his anxiety. | Which of the following areas would be addressed during a biopsychosocial interview? | Cognition, thought content, insight | Emotional history, appearance, mood | Problems during pregnancy, sensorium | Presenting problem, duration, family of origin | (A): Cognition, thought content, insight
(B): Emotional history, appearance, mood
(C): Problems during pregnancy, sensorium
(D): Presenting problem, duration, family of origin | Presenting problem, duration, family of origin | D | Presenting problem, duration, and family of origin are all areas on a biopsychosocial intake. Therefore, the correct answer is (A) | intake, assessment, and diagnosis |
406 | Initial Intake: Age: 48 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Divorced Counseling Setting: Acute Inpatient Psychiatric Hospital Type of Counseling: Individual | Sandy wandered into the ER waiting room asking for a police officer. After further conversation, it was clear that Sandy thought she was in a police station and repeatedly called once of the nurses Officer McKinney, as if she knew him.
During the intake, the nurse practitioner mentioned that she was running a temperature, had a rapid heartbeat and breath smelled foul. In addition, her hands were trembling as well as her tongue and lips. Sandy’s behavior was somewhat irritable and erratic. At one point she was seemed to be hallucinating and stated that that she saw rats.
| Sandy was sent to the inpatient psychiatric from the emergency department for symptoms of hallucinations, memory loss, and disorientation.
History:
Sandy currently lives alone and is unemployed. She has a history of alcohol abuse and has been admitted to the hospital before because of this. Sandy has gotten into trouble with the law and has alienated most of her family and friends because of her alcohol use. She currently attends alcoholics anonymous. | null | The memory deficit which Sandy experienced is result of? | Sedative withdrawal | Alcohol withdrawal | Alcohol poisoning | Psychosis | (A): Sedative withdrawal
(B): Alcohol withdrawal
(C): Alcohol poisoning
(D): Psychosis | Alcohol withdrawal | B | Sandy is showing signs of alcohol withdrawal as evidenced by disorientation of time and place, vivid hallucinations of fast-moving animals and perspiration, fever and rapid heartbeat. Alcohol poisoning may cause amnesia or mental confusion and is accompanied by physical symptoms such as difficulty remaining conscious, vomiting, seizure, trouble breathing, and slow heart rate. Psychosis and sedative withdrawal are ruled out since symptoms are caused by alcohol. Therefore, the correct answer is (A) | intake, assessment, and diagnosis |
407 | Clients Age: Husband: 45 Wife: 43 Sex: Husband: Male Wife: Female Gender: Husband: Male Wife: Female Sexuality: Heterosexual Ethnicity: Both Individuals Are Caucasian Relationship Status: Married Counseling Setting: Private Practice Counseling Clinic Type of Counseling: Couples Counseling Presenting Problem: Marital Distress Diagnoses: Couple Diagnosis: Adjustment Disorder with Anxiety (F43.22) and Relationship Distress with Spouse or Intimate Partner (Z62.898) Individual Diagnosis (Wife): Generalized Anxiety Disorder (F41.1) | Mental Status Exam: The husband and wife were both oriented to person, place, time, and situation. Both individuals were dressed appropriately for the season and appeared clean. The husband presented as angry, and the wife presented as remors | You are a licensed therapist working at a private practice. The couple comes to counseling in order to work on their relationship following an infidelity. The wife has difficulty expressing what happened, and the husband interrupts her and expresses that his wife had an affair with a coworker 3 weeks ago. The couple states that they are currently talking very little aside from conversations that involve their children. The wife states that she is regretful of what she did and that she does want her marriage “to be saved.” The husband explains that he is very hurt by her infidelity and that he is unsure if he can forgive her and continue being married to her. The couple has been married for 25 years and report that they both are in counseling to see if they can continue to be married following the affair. The husband expresses strong anxiety following the revelation of the affair and questions how he can be in a relationship with his wife following the infidelity. The wife is experiencing anxiety regarding her husband leaving her because she reports regretting the sexual interaction with her coworker and does not want to get divorced. | You meet with the couple for the third session, and they report that they continue to have minimal communication. The couple continues to process feelings regarding the affair and begin to yell and curse at each other. The wife reports that she has tried to engage in quality time with her husband and that he has ignored these attempts. Around 10 minutes into the session, the husband leaves the session and walks out and proceeds to sit in the waiting area of your practice. You desire to support both individuals | You desire to support both individuals. Which is the most ethical intervention to support the couple? | Meet with the wife and then meet with the husband in a separate, empty office in the practice to maintain confidentiality. | Encourage the wife to come to the lobby to process the situation with the husband because the door is closed to the practice and no one else is present. | Inform the husband of what the wife feels about him leaving because they are both clients and have access to information and no one else is present in the lobby. | Meet with the wife and then meet with the husband in the lobby because the practice door is closed and no one else is present in the practice setting. | (A): Meet with the wife and then meet with the husband in a separate, empty office in the practice to maintain confidentiality.
(B): Encourage the wife to come to the lobby to process the situation with the husband because the door is closed to the practice and no one else is present.
(C): Inform the husband of what the wife feels about him leaving because they are both clients and have access to information and no one else is present in the lobby.
(D): Meet with the wife and then meet with the husband in the lobby because the practice door is closed and no one else is present in the practice setting. | Meet with the wife and then meet with the husband in a separate, empty office in the practice to maintain confidentiality. | A | It would be most ethical to meet with the husband in a separate, empty office in the practice following the meeting with the wife. You want to protect both individuals’ right to confidentiality, and you do not know whether the wife would be listening in on your conversation with the husband in the lobby. Because both individuals are clients, it is important to ensure that they each have a safe space to express themselves. You should provide this safety by using separate spaces for self-expression prior to returning to the joint session. Therefore, the correct answer is (C) | professional practice and ethics |
408 | 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. | After the client has responded affirmatively to your last statement, which of the following would be the most appropriate to ask? | Is there a way that you can send your parents money and still have time to make your choices? | What scares you the most about not sending your parents money right now? | Is this something you would like to talk about together? | I wonder if it would help if we talked about some ways that you can work through this. | (A): Is there a way that you can send your parents money and still have time to make your choices?
(B): What scares you the most about not sending your parents money right now?
(C): Is this something you would like to talk about together?
(D): I wonder if it would help if we talked about some ways that you can work through this. | Is this something you would like to talk about together? | C | Asking the client if this is something that she wants to talk about with you is the most appropriate question. The counselor must demonstrate respect for the client and her culture. Cultural beliefs about discussing family matters with strangers vary. This client's original intent for counseling was to seek career help, not discuss family issues. It would be necessary for the counselor to allow the client to determine what topics will be discussed in sessions. Asking the client what scares her most makes the assumption that she wishes to discuss her family dilemma more deeply (as noted above) and that she feels scared. It is important for counselors to allow clients to identify their emotions rather than have the counselor assign emotions based on the counselor's own feelings. Asking the client if she can both send money and have time to choose a career demonstrates the counselor's countertransference and need to fix the client's problem, rather than allowing the client to choose her own solutions. Response d is less obtrusive but still does not take the client's culture into account nor allows the client to decide if this will be a topic of counseling. As well, the statement demonstrates the counselor's lack of awareness of her own need to fix the problem. Therefore, the correct answer is (B) | intake, assessment, and diagnosis |
409 | Age: 9 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Private practice Type of Counseling: Individual counseling Presenting Problem: The client has been engaging in behavior that has gotten him suspended from school several times over the past year, which also causes significant distress for the client’s family at home. Diagnosis: Conduct disorder, childhood-onset type, with limited prosocial emotions, severe (F91.1) | Mental Status Exam: The client was minimally engaged in the session. The client’s behavior was withdrawn, argumentative, and la | You are a professional counselor, and you specialize in working with children and adolescents. The client comes to this session with his parents. You review informed consent with the client and his parents and begin to ask the client about what brings him to counseling. The client responds by saying “shut the hell up” and leaves the room to go to the lobby. The client’s father gets up and follows him out, and after a few minutes they return. The client sits down and faces away from you. The client does not engage in the intake session aside from cursing at his parents when they report specific behavioral incidents and he disagrees with them about the facts of the events. The client’s parents say that he has had “bad behavior” over the past 2 years and that his behavior has “gotten worse” over the past 5 months. The parents outline the following behavioral problems that the client engages in, in all settings: bullying, physical fighting, kicking and throwing items at his dog, intentionally breaking others’ property, lying to others to get items or have access to activities, stealing items from others, truancy, and leaving the house at night without permission or supervision. | bile. Family History: The client has two younger brothers who are 6 and 7 years old. The client often engages in physical fights and arguments with his younger siblings and often will break or steal their toys. The client takes advantage of his 6-year-old sibling by conning him out of items and activities by convincing him that a certain trade or decision is better for him, when it is usually better for the client. The client’s parents report that these behaviors occur at school and that the client does not have any friends as far as they are aware. The client’s parents state that the client is adopted and that he was in foster care from when he was 2 until he was 4 years old. The client’s parents state that his basic needs were neglected because his birth mother was heavily using drugs | All of the following are part of the Mental Status Exam (MSE), EXCEPT: | Thought process | Insight | Memory | Diagnosis | (A): Thought process
(B): Insight
(C): Memory
(D): Diagnosis | Diagnosis | D | The MSE examines behavior and functioning during the present session. The client’s thought process (eg, coherent, grandiose, fleeting ideas, or delusional), insight, and memory are all part of MSE testing. You assess the client’s thought process throughout the session by noting his ability to communicate thoughts and feelings and to stay on topic during the session. Insight is the client’s awareness of the impact of mental health on functioning. This can be assessed by noticing if the client can identify if his behavior is problematic at home and in the school setting. Memory is assessed by noting if the client is able to recall events and remember what was talked about in this and previous sessions. Diagnosis is not part of the MSE. Therefore, the correct answer is (D) | intake, assessment, and diagnosis |
410 | 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. | What question would best help you to evaluate the client's current level of functioning? | "Do you attend a place of worship?" | "Do you volunteer in the community?" | "Do you spend excessive time on social media?" | "Can you describe the quality of your marital relationship?" | (A): "Do you attend a place of worship?"
(B): "Do you volunteer in the community?"
(C): "Do you spend excessive time on social media?"
(D): "Can you describe the quality of your marital relationship?" | "Can you describe the quality of your marital relationship?" | D | Assessing the client's relationship with his wife will provide you with information about his mental functioning. This question will specifically help elicit information about relational functioning, which is a subset of a client's overall mental functioning. Therefore, the correct answer is (A) | intake, assessment, and diagnosis |
411 | Initial Intake: Age: 43 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Married Counseling Setting: Private Practice Type of Counseling: Individual | The client presents appropriately dressed in a long-sleeved t-shirt and jeans and is well-groomed. Her weight appears appropriate to height and frame. Her movements and speech demonstrate no retardation and she is cooperative and engaged. The client reports her mood as anxious, however you note her to be relaxed in speech and appearance. She reports no recent suicidal ideations and demonstrates no evidence of hallucinations or delusions. The client reports that she is in good health and takes no medication except birth control. She reports she has difficulty falling asleep at night because she worries whether her husband finds her attractive. She states she also frequently worries about the children or situations that have happened during the day, but is often able to dismiss these after a few minutes. | You are a counselor in a private practice setting. During the intake session, you learn that your client has been married for 15 years and has four children and is currently struggling with her marital relationship. She states her husband does not want to attend counseling with her. Your client complains of occasional feelings of unhappiness, irritation, difficulty sleeping, as well as worrying. These have been present for the past 8 to 10 months, with the worry being almost daily. She states she feels alone in the marriage because her husband is an introvert and is often too tired after work to engage emotionally with her. She views the marriage as “good” and they engage in sex at least 5 times per week, where she is often the initiator. She reports that she repeatedly asks her husband and best friend to reassure her that she is still attractive. She tells you that her best friend is encouraging, but her husband tells her he is tired of her constant, daily questioning and says she must be in a midlife crisis. She confides that her husband frequently looks at pornography and sometimes they watch pornographic movies together prior to sex. | Family History:
Approximately 6 years ago, the client’s family doctor prescribed a short course of Valium, while she and her husband were building their house. She also was diagnosed with postpartum depression after her first child was born. She reports she did not seek counseling at the time but her obstetrician prescribed antidepressants, which she took for 10 months with good results. Her doctor then prescribed the same antidepressants for 12 months as a preventative against postpartum depression prior to each of her subsequent births. | Which of the following DSM-5 categories is most likely being represented by the client's currently expressed symptoms? | Anxiety Disorders | Bipolar and Related Disorders | Trauma- and Stressor-Related Disorders | Depressive Disorders | (A): Anxiety Disorders
(B): Bipolar and Related Disorders
(C): Trauma- and Stressor-Related Disorders
(D): Depressive Disorders | Anxiety Disorders | A | The client's current symptoms are most closely related to anxiety disorders, such as general anxiety, which includes symptoms of irritability, sleep disturbance, and worry. The client expresses some mild unhappiness, but this is occasional so does not meet the criteria for depressive disorders. While she has a history of postpartum depression, there is no evidence that she has experienced depression outside of those times. The client exhibits no manic symptoms such as risky behavior, inflated self-esteem, or racing thoughts. Additionally, the client has not reported any traumatic exposure, nor do her expressed symptoms include flashbacks, nightmares, or avoidance. Therefore, the correct answer is (B) | intake, assessment, and diagnosis |
412 | 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. Fourth session The client presents for his fourth session. You were able to work out a payment plan with him which has relieved his immediate concerns about paying for therapy sessions. However, he reports ongoing tension about finances and says that his his wife packed a bag to leave after a "big fight" about money. She told him she needs some space to see if she wants a divorce. The client breaks down and begins to cry and shaking uncontrollably. While looking at the ground he laments, "I don't know what to do. It wasn't always like this. We used to be happy, but now I'm just stressed and worried about everything. I'm never going to be able to make enough money to support my family." He tells you that he works hard to provide for his family, but his wife does not appreciate or support him. He has been drinking more but knows that it is not helping. He has decided he needs to make some lifestyle adjustments; he is ready to make changes and work on his issues. In the session, you provide a supportive environment, helping your client to see his anxiety from a place of self-awareness and empowerment. You offer him concrete strategies for managing anxiety including relaxation techniques, cognitive restructuring, and grounding exercises. You also explore how he can work towards building better communication with his wife by expressing himself in an assertive yet respectful way. You both discuss how alcohol serves as a distraction but ultimately leads to additional anxiety. Together you come up with a plan that includes reducing the amount of alcohol he consumes, engaging in positive self-talk, and scheduling weekly activities such as going on walks to help him reduce stress levels. At the end of this session, you encourage your client to continue making strides towards his goals and remind him of the progress he has already made. You assure him that anxiety is something that can be managed with regular practice and together you will continue to work towards positive change. Eighth session The client has been seeing you once a week for the last two months. Today, he appears calm, and his thoughts are coherent. The client tells you that he has not completely abstained from alcohol, but his use has significantly decreased. He reports that he went to a virtual AA meeting but did not find it helpful, so he signed off. The client opens up and states, "I think one of the reasons I am anxious is because I am having an affair. Ever since my wife hurt her back, we have not been intimate." The client's speech becomes more rapid, and he begins to lose eye contact as he discloses the details of his affair to you. Your client tells you, "I'm not happy with my wife, either sexually or emotionally. The new woman I'm seeing understands me, and I don't want to drink when I'm around her. She helps me forget everything that causes me stress." In response to your client focusing on the positives of his affair, you engage the client in a discussion to explore the issue from other perspectives. You ask questions like, "What do you think would happen if your wife found out about your affair?" Your client pauses for a moment and looks down, and then says, "I'm not sure. I care about my wife, but I don't know if she will ever be able to understand me in the way that this other woman does. I feel like I'm trapped." You listen empathically as your client expresses his feelings of anxiety, despair and confusion. You provide clarification when necessary and strive to help your client gain insight into his thoughts and behaviors. In the session, you explore the client's anxiety and how it has been related to his affair. You address underlying issues that may be contributing to the anxiety such as unresolved feelings of guilt or fear of being discovered. You emphasize that anxiety is often a sign of trying to avoid uncomfortable emotions and situations, but acknowledging them can help him understand anxiety in a different way. You also talk about the role alcohol has played in his anxiety and suggest strategies for reducing anxiety without relying on it as a coping mechanism. The conversation then turns to incorporating strategies to address these issues in his treatment plan, such as scheduling regular self-care activities and exploring the relationship between his thoughts and behaviors. Toward the end of this session, the client appears calmer and confident in his ability to make positive changes. As you are wrapping up the session, the client confides to you that ever since he started having an affair, he has found himself sexually attracted to his daughter. He says, "It's just kind of exciting to peek in the bathroom and watch her in the bathtub. But I would never touch her! It's just a passing thought. I know that I need to stop. The thrill of my affair is satisfying enough." | 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. | How do you proceed when the client confides in you at the end of the session about his recent thoughts and behavior toward his daughter? | Suggest a joint session with him and his wife in order to further assess the situation | Document his disclosure in his therapy record as a topic to discuss during the next session | Explore his sexual tension as an expression of anxiety resulting from having an affair | Notify the appropriate legal authorities about the client's behavior | (A): Suggest a joint session with him and his wife in order to further assess the situation
(B): Document his disclosure in his therapy record as a topic to discuss during the next session
(C): Explore his sexual tension as an expression of anxiety resulting from having an affair
(D): Notify the appropriate legal authorities about the client's behavior | Notify the appropriate legal authorities about the client's behavior | D | The client has disclosed that he is sexually attracted to his daughter (who is a minor) and has been watching her in the bathroom without her knowledge or consent. In the event that a client reports inappropriate behavior with a child, therapists must immediately notify the appropriate legal authorities to ensure safety of the minor. Therefore, the correct answer is (D) | professional practice and ethics |
413 | Initial Intake: Age: 20 Gender: Male Sexual Orientation: Homosexual Race/Ethnicity: African American Relationship Status: Single Counseling Setting: University counseling center Type of Counseling: Individual | Jonathan presents as anxious with congruent affect, evidenced by client self-report and therapist observations of fidgeting, inability to sit still, tearfulness and shallow breathing with rapid paced speech. Jonathan occasionally closes his eyes and takes deep breaths when he begins to cry in attempt to slow himself down and prevent what he calls “another emotional breakdown.” He has prior inpatient treatment history of a one-week episode where he was involuntarily committed at 17 for making comments about planning to kill himself in response to his stress over finishing high school. He admits to passive suicidal ideations in the past few weeks while studying for exams but does not report considering a method or plan. He reports that he has been losing sleep because of long study hours and feeling too keyed up to calm down. You assess him as having distress primarily associated with anxiety, which at times of abundant stress turns to episodes of depression and hopelessness. | Diagnosis: Anxiety disorder, unspecified (F41.9), Major depressive disorder, single episode, unspecified (F32.9)
You are a brand-new counseling intern in the counseling resource center of a local university. Jonathan is a junior in college and comes to speak with you, as you are his newly assigned college university counselor. Jonathan is concerned about finals that he feels unprepared for, stating he is “overwhelmed” and “under too much pressure” from his family to “allow himself” to fail. He is making disparaging, negative remarks about himself and his abilities, often repeating himself and talking in circles using emotional reasoning. He asks you for help in getting his teachers to modify his deadlines so that he can have enough time to accomplish all his assignments, mentioning that his last counselor did that and called it “playing the mental health card”. There are no previous records on file for this student, but when you ask him who he met with he just changes the subject and continues to express his worry that he will “never amount to anything or graduate” if he fails these exams. | Education and Work History:
Jonathan has a high academic performance history, despite short periods of time where he experiences heightened stress. Jonathan has never gotten in trouble in school or had any infractions at part-time jobs later as a teenager. He has worked after-school jobs at the grocery store, bowling alley, and local town library. Jonathan had only one work-related incident where he broke down emotionally when feeling overwhelmed and left work in the middle of his shift, but his supervisor was supportive and helped him.
Current Living Situation:
Jonathan lives in the college dormitory with a peer and is supported by his mother. His mother is a single mom who works full-time in Jonathan’s hometown, which is almost a full day’s worth of driving from where Jonathan goes to college. Jonathan mentions that his friends call him “Jonny.” He adds that the food available to him is not very healthy and he has poor eating habits due to prioritizing studying and his involvement in extra-curricular activities. | You ask how Jonny has been feeling living in the dorms for years on his own. He becomes emotional and admits he misses when his mom took care of him. What approach should you take to have Jonny elaborate? | Share anecdotes in congruence so he feels connected. | Lean in closer with a quiet smile and maintain eye contact. | "I'm so sorry, Jonathan" and hand him a box of tissues. | Ask if he wants to call his mom in session. | (A): Share anecdotes in congruence so he feels connected.
(B): Lean in closer with a quiet smile and maintain eye contact.
(C): "I'm so sorry, Jonathan" and hand him a box of tissues.
(D): Ask if he wants to call his mom in session. | Lean in closer with a quiet smile and maintain eye contact. | B | This skill offers Jonathan to continue sharing in his own timing without feeling pressured, which is the priority of counseling. Self-disclosure or calling his mother are not necessary here and apologizing as if Jonny is a victim of having feelings while providing tissues which can signify "wipe the tears away" is not the best approach in encouraging Jonny to elaborate as it changes the focus from his train of thought to believing his memories or feelings are inherently "sad". Therefore, the correct answer is (D) | counseling skills and interventions |
414 | 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. | 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 would you say to demonstrate an accurate reflection of the client's feelings? | "I'm hearing that it seems like you're feeling a bit overwhelmed and out of control." | "I'm hearing that you're feeling really angry and resentful." | "I'm hearing that you feel helpless and frustrated with your family situation." | "I'm hearing that you're feeling a little bit sad and lost." | (A): "I'm hearing that it seems like you're feeling a bit overwhelmed and out of control."
(B): "I'm hearing that you're feeling really angry and resentful."
(C): "I'm hearing that you feel helpless and frustrated with your family situation."
(D): "I'm hearing that you're feeling a little bit sad and lost." | "I'm hearing that you feel helpless and frustrated with your family situation." | C | The client has mentioned feeling "miserable," wanting to never have been adopted, and being "very mean" to her. She is also overwhelmed by her parents' bickering and does not feel like she can turn to anyone for help. This answer reflects a combination of helplessness and frustration in her family situation. Therefore, the correct answer is (C) | counseling skills and interventions |
415 | Initial Intake: Age: 45 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Married Counseling Setting: Private Practice Type of Counseling: Individual | The client appears his stated age and is dressed appropriately for the circumstances. He rates his mood as “happy” and this is congruent with his affect. He demonstrates some social awkwardness in presentation and conversation both in missing social cues and oversharing. He demonstrates some motor hyperactivity, indicated by fidgeting, shifting in his seat, and upon entering the office, is invited to sit as he was touching items on the bookshelf. He presents as very talkative, distractible, and tangential in his conversation. It is necessary to redirect him often as his explanations and responses include excessive and irrelevant details, and provides responses before the question is completely stated. He demonstrates limited insight into his presentation or the concerns others have shared with him. He demonstrates appropriate judgment, memory, and orientation. He reports no substance use, no sleep or waking problems, and does not smoke. He is emphatic in his negative responses to questions related to suicidal or homicidal thoughts and intentions. | You are a counselor in a private practice setting. Your client is a 45-year-old male who reports that his wife of two years suggested he seek help for what she says is “OCD.” The client says that several months after their marriage, his wife began complaining that the client had so many expectations for her and her children that they are overwhelmed and feel unable to please him. The client tells you that he has had friends tell him in the past that he is “OCD” and sometimes his employees make fun of him because he wants everything done a certain way. He says that they sometimes call him “the eye” because they say he is always watching to make sure they do things correctly. Some of his closer friends will “test me” sometimes by moving something to see if the client notices it. He tells you they are doing it in fun, and he doesn’t really mind because he automatically notices things, whether they moved something or it has accidentally got put in the wrong place. He admits that he is concerned that things are done well because he owns his own business and needs it to be managed correctly, but he doesn’t really understand his wife and stepchildren’s concerns. He tells you that he would like to know if he “is the problem” and if so, how he can make changes to help his marriage. He tells you that he doesn’t see a problem with how he runs his business and thinks that his employees are just “complainers.” | Family History:
The client reports being the youngest of two sons born to his parents. His parents have been married for 40-plus years. He tells you that his mother did complete high school with some difficulty and has never been employed. His father is now retired but was an accountant previously. He says his older brother had a difficult time several years ago with holding a job and going through a divorce, but is now doing much better. The client tells you that his family is still very close, his parents come over to visit often, and prior to buying his business, he often vacationed with family. He says that while growing up, their mother has always been overprotective of him and his brother and has always made sure that they did things the right way. The client states that until his marriage, he continued to live in his parent’s home in his childhood bedroom. He says that even though he took care of his own things, his mother still checked behind him every day to make sure the bed was made correctly and that nothing needed cleaning up. The client says that his parents were constantly frustrated with his brother because he didn’t take care of his room and things. The client reports that he completed a college degree in business and chose to open his own franchise business so that he could work for himself. He has owned his business for six years and enjoys it, although he rarely has time off. He tells you that his father and mother stop by the store frequently “just to help out.” He says his mother likes to help with cleaning and his father helps with the accounting. | Which of the following is the most effective approach when working with a client who has OCPD? | Remind him to look at others' perspectives | Use a feelings wheel or list with the client to identify his emotions | Use prolonged exposure techniques to help the client delegate tasks | Warn the client that at some point you will behave in a way that upsets him | (A): Remind him to look at others' perspectives
(B): Use a feelings wheel or list with the client to identify his emotions
(C): Use prolonged exposure techniques to help the client delegate tasks
(D): Warn the client that at some point you will behave in a way that upsets him | Warn the client that at some point you will behave in a way that upsets him | D | Warning the client that you will eventually behave in a way that upsets him is one of the most important things a therapist can do with a client who has OCPD. The client's tolerance for lack of perfection in others will be triggered when at some point the counselor, like others in the client's life, will behave or say something that violates the client's rigid standards or expectations for perfection. Violating the client's expectation for perfection from the therapist is frequently the cause for OCPD clients to terminate counseling. Forewarning the client of this provides the opportunity to talk about how staying in the therapeutic relationship can help him learn to manage the conflict. Using a feeling wheel or list will not be helpful with the OCPD client because increasing his self-awareness and insight will be needed before he is able to begin working through emotions. Likewise, looking at and understanding others' perspectives may be attempted but the client will eventually need to challenge his own perspectives of his way being the only right one, rather than focusing on others. Prolonged exposure is an effective treatment for OCD, but is not effective in treating OCPD. Therefore, the correct answer is (D) | counseling skills and interventions |
416 | Client Age: 54 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Multiracial Relationship Status: Divorced Counseling Setting: Local Government Mental Health Agency Type of Counseling: Individual Presenting Problem: Opioid Use Diagnosis: Opioid Use Disorder, Severe (F11.20), Homelessness (Z59.0) | Mental Status Exam: The client has not maintained hygiene, as evidenced by him not smelling clean and wearing clothes that are visibly dirty. He appears to have bilateral tremors in his hands. The client is oriented to person, place, situation, and time. The client appears malnourished because he is very thin and f | You are a mental health counselor working at a local government mental health agency, specializing in substance use counseling. An individual came in today to become a client for mental health case management and was encouraged to meet with a counselor to begin receiving therapy. The 54-year-old male client is currently living in a tent in the woods behind a local grocery store and reports that he lost his job a year ago following a divorce from his wife of 26 years. The client stated that about 3 years ago he had a back injury and following surgery was prescribed oxycodone. The client continued that he had difficulty stopping his use of the medication when the prescription ran out and connected with a friend to get fentanyl. He reports that he spends a lot of time on a street corner asking for money to get fentanyl and that he cannot seem to go a day without it. The client feels that he cannot sleep or function without the use of fentanyl and that this has affected his housing, marriage, employment, and social life. He acknowledges that fentanyl has negatively affected his life and that he is not sure if he wants to stop using it because he knows it would be hard to deal with life without it. | The client discusses how his case manager has gotten him into a shelter and is currently working on securing housing for him. The client processes feelings surrounding the shelter and has begun a detox program for his fentanyl addiction. The client verbalizes that he is experiencing anxiety surrounding being at meetings with the case manager, talking with other residents, reintegrating into a “more normal life,” and worrying about whether he can ever have a relationship with his kids or ex-wife if he gets sober. Through processing, you realize that this anxiety was present prior to drug use and that he has experienced anxiety throughout his life | Based on the transtheoretical model of intentional behavior change, which stage would the client be in if he is beginning to analyze the pros and cons of his current behavior and situation? | Action | Contemplation | Precontemplation | Preparation | (A): Action
(B): Contemplation
(C): Precontemplation
(D): Preparation | Contemplation | B | This client is in the contemplation phase of the transtheoretical model of intentional behavior change because he is analyzing the risks and rewards of changing his current situation. The precontemplation phase involves little or no thought about changing current behaviors. The client is not in the stage of taking actions yet. The client has not made a commitment to change and is therefore not yet in the preparation phase. Therefore, the correct answer is (A) | counseling skills and interventions |
417 | 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 information are you lacking that would be helpful for completing your assessment? | copies of court documents | family history | relationship history | consent to release information from ex-wife | (A): copies of court documents
(B): family history
(C): relationship history
(D): consent to release information from ex-wife | family history | B | Family history information would support your increased knowledge and understanding of contributing factors to Davone's presentation, including his upbringing and how this triggers him, family dynamics, possible trauma, even hereditary conditions. Answers b) through d) are not necessary in completing your initial assessment and may not be needed throughout treatment. Therefore, the correct answer is (A) | intake, assessment, and diagnosis |
418 | Client Age: 27 Sex: Female Gender: Female Sexual Orientation: Heterosexual Ethnicity: Caucasian Relationship Status: Married Counseling Setting: Career Counseling Center Type of Counseling: Individual Presenting Problem: Employment-related Stress; Anxiety Diagnosis: Adjustment Disorder with Anxiety 309.24 (F43.22) | Mental Status: The client was well-groomed and dressed appropriately. She appears nervous and jittery and quickly places her hands under the table when she notices them shaking. The client states that she is not sleeping well and says it is difficult making it to work each day knowing that “things rarely go as planned.” She explains that she has irritable bowel syndrome, which is exacerbated by stress. The client reports that there are no known medical conditions that would cause her chronic headaches. The client denies homicidal or suicidal ideations but remarks that she has felt like this in the past. Wor | You work in a career counseling center, and your intake is a 27-year-old white female employed as a fourth-grade elementary schoolteacher. The client has been a teacher for 3.5 years and has become increasingly dissatisfied with her job. The client explains that she is “at her breaking point” and relays that her stress level has increased sharply within the past 3 months. This is her first school year with a newly hired principal who has been “unreasonably demanding and unsupportive.” The client states that she was already second-guessing her career choice and explains that disruptive students and a lack of parental involvement have made teaching incredibly challenging. She reports “stress-induced physical symptoms,” which include acute stomach distress and chronic headaches. She worries that her skill set is nontransferable. | k and Family History: The client obtained her bachelor’s degree in teaching and is currently a certified teacher. She comes from a family of educators, with her mother working as a teacher and her father as a high school guidance counselor. Before college graduation, she worked odd jobs, including waiting tables and working in a public library with preschool groups. She remembers enjoying her student teaching position but states that the class was “nothing like” what she has now. She explains that her student-teaching classroom contained 16 students and that she now struggles to stay on top of her current class of 24. She plays on a tennis team and serves as a “big sister” to a child through a local nonprofit organization. The client is married, and she and her husband do not have children. She reports that her husband has a high-stress job working as an attorney. The client says that he has “little patience with me when I complain about my job stress.” You would like your treatment goals to reflect elements of John Krumboltz’s learning theory of career counseling | You would like your treatment goals to reflect elements of John Krumboltz’s learning theory of career counseling. Which assessment instrument would help you accomplish this? | Vocational Preference Inventory | Vocational Interest Inventory | Career Orientations Inventory | Career Beliefs Inventory | (A): Vocational Preference Inventory
(B): Vocational Interest Inventory
(C): Career Orientations Inventory
(D): Career Beliefs Inventory | Career Beliefs Inventory | D | The Career Beliefs Inventory is based on John Krumboltz’s learning theory of career counseling. It is designed to identify problematic beliefs that interfere with career decision making, including indecision and high aspirations. The Vocational Preference Inventory is used to identify an individual’s Holland type, which is based on John Holland’s theory of vocational personalities and work environments. The Career Orientations Inventory is used to determine the motives, values, and skills associated with Edgar Schein’s career anchors. The Vocational Interest Inventory is based on Roe’s personality theory of career choice. Therefore, the correct answer is (D) | intake, assessment, and diagnosis |
419 | 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. | 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 client’s diagnosis, what immediate objective would you focus on with this client? | Participate in a group focusing on positive body image. | Identify unhealthy weight control behaviors | Increase the client's understanding of the risks associated with Anorexia Nervosa | Restore healthy eating patterns | (A): Participate in a group focusing on positive body image.
(B): Identify unhealthy weight control behaviors
(C): Increase the client's understanding of the risks associated with Anorexia Nervosa
(D): Restore healthy eating patterns | Increase the client's understanding of the risks associated with Anorexia Nervosa | C | The immediate objective that would be most appropriate to focus on first with this client is to increase her understanding of the physical, emotional, and psychological health risks associated with her anorexia nervosa. This could be done by educating her about the disorder, exploring her feelings and beliefs about her body, and discussing how her behavior is impacting her life. Additionally, the counselor could explore the client's motivation to make changes and develop a personalized treatment plan to help her reach her goal. Therefore, the correct answer is (A) | treatment planning |
420 | Client Age: 35 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Hispanic Relationship Status: Divorced Counseling Setting: Private Practice Clinic Type of Counseling: Individual Counseling Presenting Problem: Anxiety; Depressed Mood, Difficulty with Changing Relationship Roles Diagnosis: Adjustment Disorder with Mixed Anxiety and Depressed Mood (F43.23) | Mental Status Exam: The client presents as oriented to person, place, time, and situation. The client appears anxious because he avoids eye contact often and expresses that he has never been in counseling and is ner | You are a licensed counselor in Texas in a private practice. A 35-year-old male client comes to counseling for support during a recent divorce. The client says that he and his wife separated a year ago and had to wait a year for divorce per state law; therefore, they finalized the divorce recently. The client says that his wife decided she married him because she was lonely and that, after 8 years of being married, she wanted to find someone she loved. The client states that he still loves his ex-wife and that he has a hard time with his new relationship with her because he shares custody of his children and still has to communicate with her regularly. He continues saying that his wife often calls him for emotional support and he does not know how to respond when this happens because he loves her and wants to support her, but this is confusing for him. The client says that he knows he “shouldn’t be with someone who doesn’t want to be with him and that things won’t go back to how they were.” The client identifies that anxious and depressive symptoms are present and that they affect his ability to engage socially, engage with his children, and perform at work. The client wants to work on navigating his new relationship with his ex-wife, his relationship with his children, and being single again. | vous. Family History: The client was married for 8 years, has been separated for a year, and was divorced within the past month. The client reports a good relationship with his family of origin and with his ex-wife’s family. He has two children, a 5-year-old son and a 6-year-old daughter. The client’s children stay at his house every other week | When completing a mental status exam, which one of the following would be the most appropriate term to define this client’s affect? | Constricted | Flat | Blunted | Congruent | (A): Constricted
(B): Flat
(C): Blunted
(D): Congruent | Congruent | D | The client’s affect is best described as congruent because he is demonstrating anxious behavior, which is consistent with being in counseling for the first time. Congruence is demonstrated when a client’s verbalized emotions match their body language and expressions. People with constricted affect show evidence of restrained emotion, displaying much less explicit emotion than the typical person. A flat affect is defined by almost no emotional expression even in the presence of strong stimuli. A blunted affect is similar to a flat affect but involves mild expressions of emotion in the presence of strong stimuli. Therefore, the correct answer is (D) | intake, assessment, and diagnosis |
421 | 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. | Based on your theoretical orientation, what strategy would be the most efficient in aiding the client to effectively manage their anger? | Allow the client to express his anger without becoming physically threatening. | Offer the client bibliotherapy resources focused on anger management. | Directly present the client with the negative consequences of his behavior | Begin exploring the client’s triggers to anger by analyzing transference. | (A): Allow the client to express his anger without becoming physically threatening.
(B): Offer the client bibliotherapy resources focused on anger management.
(C): Directly present the client with the negative consequences of his behavior
(D): Begin exploring the client’s triggers to anger by analyzing transference. | Begin exploring the client’s triggers to anger by analyzing transference. | D | Transference has occurred as the client has responded to you as though you are his wife/mother. Through an analysis of transference, the client can uncover his unconscious emotions, which might be driving his anger in the here-and-now. Therefore, the correct answer is (D) | counseling skills and interventions |
422 | Client Age: 7 Grade:2nd Sex: Male Gender: Male Ethnicity: African American Counseling Setting: Community Mental Health, School-Based Services Type of Counseling: Individual and Collateral Presenting Problem: Impulsivity; Inattention; Hyperactivity Diagnosis: Attention-Deficit Hyperactivity Disorder (ADHD) 314.01 (F90.2) | Mental Status: The client is dressed appropriately, and he is well groomed. His affect is bright when engaged in an activity of his choice, but he becomes irritable when asked to comply with a direct request (e.g., pick up the toys, walk in the hallway). He is energetic, eager to please, and interrupts your conversation with the mother, as evidenced by the client stating multiple times, “Watch this! Hey! Watch! Look what I can do!” The client has difficulty transitioning from your office and back to his classroom. He runs ahead of you in the hallway and does not respond to redirection. The client has not voiced suicidal or homicidal ideation. Developmenta | You are a clinical mental health counselor providing on-site school-based services in a public elementary school. Your client is a 7-year-old African American male enrolled in the 2ndgrade. The client is accompanied by his mother, who states that she is here because the school “requested an ADHD assessment.” The school reports that the client is disruptive, refuses to follow directions, disturbs others, and has difficulty staying on task. The mother describes the client as “energetic” and “strong-willed”—behaviors that she believes are “just typical for a boy.” She is upset that the school wants to conduct a formal evaluation to determine if the client qualifies for a more restrictive classroom setting. The school’s population is predominantly white, and the mother believes that her son is being treated unfairly because of his race. | Mental Status: The client is dressed appropriately, and he is well groomed. His affect is bright when engaged in an activity of his choice, but he becomes irritable when asked to comply with a direct request (e\. g., pick up the toys, walk in the hallway). He is energetic, eager to please, and interrupts your conversation with the mother, as evidenced by the client stating multiple times, “Watch this! Hey! Watch! Look what I can do!” The client has difficulty transitioning from your office and back to his classroom. He runs ahead of you in the hallway and does not respond to redirection. The client has not voiced suicidal or homicidal ideation. Developmental and Family History: The client’s mother and father are married, and the client has a sister who is 3 years old. The mother denies drug or alcohol use during pregnancy. She is a smoker but states that she cut down when she discovered she was pregnant with the client. The client was delivered at 34 weeks and weighed 5 pounds and 6 ounces. He stayed in the newborn intensive care unit for 10 days after delivery. The client was toilet trained at 24 months, walked at 12 months, and talked at 18 months. The client’s paternal grandmother has been treated for bipolar disorder. His maternal uncle has a history of substance abuse, which his mother cites as the reason why she is opposed to the client going on medication. You find several ADHD interventions consistent with EBP and would like to narrow down your search | You find several ADHD interventions consistent with EBP and would like to narrow down your search. Research methodologies with the highest level of evidence include which of the following? | Randomized control trials | Quasiexperimental studies | Correlational research designs | Ex post facto designs | (A): Randomized control trials
(B): Quasiexperimental studies
(C): Correlational research designs
(D): Ex post facto designs | Randomized control trials | A | Randomized control or clinical trials (RCTs) are associated with the highest level of evidence. The highest level of evidence (ie, strength) refers to methodologies that are less likely to have biases or confounds. However, experts caution clinicians from using RCTs as the sole determination for EBP because application to clinical practice must also be considered. Correlational research designs, which are less rigorous than RCTs, determine if there is a relationship between two factors. Experimenters conducting quasiexperimental studies manipulate the independent variable but do not randomly assign subjects to a control group or an experimental group. Ex post facto (ie, “after the fact”) designs are quasiexperimental designs involving subjects who are not randomly assigned to groups. Additionally, the experimenter cannot manipulate the independent variable because it was a condition present before the study was conducted. Therefore, the correct answer is (C) | professional practice and ethics |
423 | Initial Intake: Age: 4 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: African American Relationship Status: Single Counseling Setting: Community Clinic Type of Counseling: Individual | Destiny was engaging with the counselor throughout the interview although her affect was flat. She played by herself while the counselor spoke to Darlene and Tony. She did not look up at her parents or engage with them during the entire session. | Destiny is a 4-year-old who was referred for therapy by her preschool teacher. Destiny arrived at the intake session with her adoptive parents, Darlene and Tony Mase. Darlene and Tony shared that they were concerned about Destiny because she never wants to interact with other children, rarely smiles or laughs, and has mood fluctuations with little or no pattern or trigger. Reactions include irritability, sadness, and tearfulness.
History:
Destiny arrived at the Mases’ when she was two years old and was nonverbal at the time. Destiny also showed cognitive delays in her early intervention screening. Darlene and Tony noticed Destiny’s lack of interest in playing with other children when Destiny arrived and she did not want to interact with the other children in the home. The irritability and mood fluctuations began over a year ago. Darlene and Tony were hopeful that once Destiny started preschool that she would start interacting with others, however this is not the case. | null | Which of the following is a projective test that can be administered to Destiny to assess representation of significant relationships? | Sentence Completion Test | Story Stem Assessment Profile | Draw a Family Picture Test | Strengths and Difficulties Questionnaire | (A): Sentence Completion Test
(B): Story Stem Assessment Profile
(C): Draw a Family Picture Test
(D): Strengths and Difficulties Questionnaire | Draw a Family Picture Test | C | The Draw-a-Family-Picture-Test is a projective test instrument developed to determine children's attitude, fears, needs, maturity level, stressors, gender tendencies and self-perception in relation to their family and significant others. The Strengths and Difficulties Questionnaire (SDQ) is a brief behavioral screening questionnaire for individuals aged 3- 16 which measures emotional symptoms, conduct problems, hyperactivity, peer relationship problems and prosocial behavior. It is not a projective test. Sentence completion test is appropriate for individuals ages 12 and older so it would not be appropriate for Destiny. The Story Stem Assessment Profile uses a narrative base measure of internal representations for children between the ages of 4 and 11. Therefore, the correct answer is (D) | intake, assessment, and diagnosis |
424 | 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. | Which cluster of symptoms is most representative of Oppositional Defiant Disorder? | Mania, argumentativeness, and vindictiveness | Irritability, depressed mood, and spitefulness | Being annoying, depressed mood, and vindictiveness | Negative mood, argumentative, and vindictiveness | (A): Mania, argumentativeness, and vindictiveness
(B): Irritability, depressed mood, and spitefulness
(C): Being annoying, depressed mood, and vindictiveness
(D): Negative mood, argumentative, and vindictiveness | Negative mood, argumentative, and vindictiveness | D | This is the most correct cluster grouping for ODD as ALL three of these symptoms are hallmarks of this disorder. Therefore, the correct answer is (A) | intake, assessment, and diagnosis |
425 | 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. | What, if any, ethical issue did you create by responding to the client's parents asking if there are any tools or techniques they could learn from you to work with their son? | No ethical issue was violated by mentioning medication is prescribed for children with ADHD. | A behavioral analyst should be responsible for scheduling and creating a daily routine for the client. | Mentioning that medication is often prescribed for children with ADHD is not within your scope of practice as a therapist. | A qualified dietician should be the only provider mentioning this treatment modality. | (A): No ethical issue was violated by mentioning medication is prescribed for children with ADHD.
(B): A behavioral analyst should be responsible for scheduling and creating a daily routine for the client.
(C): Mentioning that medication is often prescribed for children with ADHD is not within your scope of practice as a therapist.
(D): A qualified dietician should be the only provider mentioning this treatment modality. | No ethical issue was violated by mentioning medication is prescribed for children with ADHD. | A | Giving the client's parents options does not create an ethical issue. If you indicated that their son should be on medication, that would be outside the bounds of your clinical practice. Therefore, the correct answer is (B) | professional practice and ethics |
426 | Client Age: 19 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Private Practice Type of Counseling: Individual Presenting Problem: Suicidality related to body image Diagnosis: Body Dysmorphic Disorder 300.7 (F45.22), with absent insight/delusional beliefs | Mental Status Exam: The client’s mood is sad and irritable. His speech is pressured when discussing his appearance but is otherwise normal. He is appropriately groomed and wears a beanie covering his ears. He admits to repetitively dissecting his face in the mirror several hours a day. The client offers that he cannot hide his ears with his hair because “it is too thin.” He denies audio/visual hallucinations. The client’s thought content is organized and coherent, but he shows poor insight and delusional thinking about how he and others regard his appearance. The client avoids social settings and reports that sometimes, an entire week goes by where he doesn’t leave the house. He denies suicidality and currently does not have a plan or intent to harm himself or others. Appetite and sleep are fair. The client denies drug use and states he consumes alcohol occasionally. You provide an in-depth suicide assessment, and you and the client work together to create a suicide safety | You are working in private practice and conducting an initial intake session with a 19-year-old male who presents today with his mother. The client was recently admitted to a psychiatric hospital for suicidality and was discharged four days ago. His mother reports that the client tried to commit suicide by overdosing. The client reports feeling increasingly hopeless following a “failed” cosmetic surgery procedure. He explains that he had an otoplasty performed to change the proportion and position of his ears. He states he has always hated his ears and is convinced people are staring and laughing at his “deformity.” His mother reports that she reluctantly consented to the surgery a year and a half ago, despite believing it was unnecessary. The client does not leave the house without wearing a beanie or hoodie. He has completed high school with no interest in attending college. He is unemployed due to shame and embarrassment over his “defective” appearance. Two weeks ago, the hospital psychiatrist changed his medication and placed him on a selective serotonin reuptake inhibitor (SSRI). | plan. Family History: The client’s parents are divorced and he lives with his mother and two younger siblings. There is a history of child protective services (CPS) involvement due to reports of domestic violence between his parents. The client witnessed these incidents between that ages of 10 and 12. His parents subsequently divorced and the client has had minimal contact with this father since. The client’s maternal aunt is diagnosed with obsessive-compulsive disorder. His mother previously attended therapy for anxiety and other trauma-related symptoms. The client began experiencing symptoms of body dysmorphic disorder at age 13, with symptoms worsening after starting high school | Which of the client’s following symptoms is NOT listed as a DSM-5-TR diagnostic criterion for body dysmorphic disorder (BDD)? | Occupational distress and impairment primarily due to BDD symptoms | Repetitive mirror checking in response to appearance concerns | Self-oriented perfectionism regarding performance, appearance, and routine | Appearance-related preoccupation with flaws that others don’t see | (A): Occupational distress and impairment primarily due to BDD symptoms
(B): Repetitive mirror checking in response to appearance concerns
(C): Self-oriented perfectionism regarding performance, appearance, and routine
(D): Appearance-related preoccupation with flaws that others don’t see | Self-oriented perfectionism regarding performance, appearance, and routine | C | Of the symptoms listed, self-oriented perfectionism regarding performance, appearance, and routine is not a diagnostic criterion of body dysmorphic disorder. Instead, this rigid perfectionism is a pathological personality trait associated with obsessive-compulsive personality disorder. While there is an element of perfectionism with BDD, it is limited to one’s appearance rather than an aspect of extreme conscientiousness, which insists that all things must be perfect. According to the DSM-5-TR, the diagnostic criteria for BDD include “A. Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others. B. At some point during the course of the disorder, the individual has performed repetitive behaviors (eg, mirror checking, excessive grooming, skin picking, reassurance seeking) or mental acts (eg, comparing his or her appearance with that of others) in response to the appearance concerns. C The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. D The appearance preoccupation is not better explained by concerns with body fat or weight in an individual whose symptoms meet diagnostic criteria for an eating disorder (APA, 2022)”. Therefore, the correct answer is (B) | intake, assessment, and diagnosis |
427 | 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 | What would be an area to focus on? | Hopelessness | Gender Identity Development | Recommitment | Behavioral Problems | (A): Hopelessness
(B): Gender Identity Development
(C): Recommitment
(D): Behavioral Problems | Recommitment | C | Both Tony and Kathleen felt hurt by the other to the point where they questioned the future of their relationship. However, after some exploration they both decided on working things out. Recommitment to the relationship would be an area of focus. Gender identity is not an issue as transvestic disorder is not an indication that one is not happy with the gender with which they were born. Tony and Kathleen have not expressed feelings of hopelessness individually or as a couple system. There are no behavioral issues to be addressed as a couple system. Therefore, the correct answer is (B) | intake, assessment, and diagnosis |
428 | 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. | Which of the following is a long-term goal as opposed to a short-term objective? | Parents set firm, consistent limits and maintain appropriate parent-child boundaries | Parents and the client demonstrate increased knowledge about ADHD and its treatment | Consult with school personnel to implement behavioral classroom management interventions | Complete psychological testing to measure the nature and extent of ADHD | (A): Parents set firm, consistent limits and maintain appropriate parent-child boundaries
(B): Parents and the client demonstrate increased knowledge about ADHD and its treatment
(C): Consult with school personnel to implement behavioral classroom management interventions
(D): Complete psychological testing to measure the nature and extent of ADHD | Parents set firm, consistent limits and maintain appropriate parent-child boundaries | A | Working with the parents on developing and maintaining consistent boundaries at home is an important factor in the effectiveness of your treatment of Avery and would be considered a longer-term goal as it will involve several objectives and interventions delivered over the length of your counseling relationship. Answer a) is a short-term objective that would be paramount in this treatment plan for Avery. Answer b) is an intervention underneath the banner of a short-term objective, and answer d) is also a short-term objective, however it is better conducted by a psychologist. Therefore, the correct answer is (C) | treatment planning |
429 | Name: Amy Clinical Issues: Hopelessness/depression Diagnostic Category: Depressive Disorders Provisional Diagnosis: F34.1 Persistent Depressive Disorder (Dysthymia), Severe Age: 15 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: White Marital Status: Not Applicable Modality: Individual Therapy Location of Therapy : Private Practice | The client appears in your office with loose clothing and a thin physical frame. She has inconsistent eye contact and portrays a drowsy level of consciousness. Her speech rate is slow, her volume is soft yet monotone, and her fluency and rhythm are unclear and hesitant at times. She talks about how much she hates her life. Her mood is depressed and discouraged, while her affect is flat and sad. The client has been previously hospitalized for suicidal ideation. Her thoughts are slowed, and she is easily distracted. Her concentration is impaired with frequent lapses in attention. She is unable to follow a long line of thought or argument. She also reports difficulty making decisions. Her insight and judgment are limited. The client's emotional state is characterized by a pervasive sadness, irritability, and feelings of hopelessness. She exhibits difficulty in concentrating, making decisions, and expressing herself coherently. Additionally, she is experiencing disrupted sleep patterns, including insomnia and excessive daytime sleepiness, and has reported a diminished appetite with subsequent weight loss | First session You are licensed as a mental health therapist working on a post-doctoral thesis related to depression and have been working with several clients diagnosed with Persistent Depressive Disorder. One of your new research participants is a 15-year-old client who arrives at your office with her mother after being released from the hospital. Before beginning the session, you ask to talk with the mother and daughter separately. When interviewing the mother, she tells you about her daughter's ongoing behavioral difficulties, experimenting with drugs and alcohol, and getting involved with a "bad group of kids." The client's academic performance has also been affected, with teachers reporting a notable decline in grades and participation in class. This behavior has been ongoing for approximately six months and appears to be intensifying. The strained familial relationships that the client is experiencing are a constant irritation to the entire family. The father's instability may have contributed to the client's current emotional distress, exacerbating her depressive symptoms. The client's mother, while providing primary care, struggles to maintain any bond with her daughter due to the increasing social withdrawal and lack of communication Next, you interview the daughter. You ask her questions about school, friends, and activities she enjoys. She states that she is picked on daily at school, has no "real" friends, and hates her life. The client sighs heavily, saying, "Some nights I go to bed hoping that I won't wake up in the morning. There's nothing to look forward to. School is horrible. She explains that she feels like she is "stuck in a dark hole" and that she cannot get out. She reports feeling hopeless, helpless, and alone. You summarize what she has told you, and she confirms your understanding of her feelings. After completing your interview with the daughter, you invite the mother to join you in your office. You continue to gather information about the client's personal and family history, symptoms of depression, and risk factors contributing to her current state. You explore potential triggers for her suicidal ideation and any protective factors in place. The mother reports that her daughter has been struggling with a lack of self-confidence and low self-esteem. You also discuss her current support system and any potential areas for improvement. Through the assessment, you can comprehensively understand the client's challenges and strengths. At the end of the intake, you check to ensure that both mother and daughter clearly understand what you have discussed today. You plan to meet with the client on a weekly basis, and you schedule a session for the following week. Third session As the client enters your office, you notice she has been crying. She states that she does not want to be here and feels like she has "no say" in what happens to her. She says that she wants to start attending a virtual school, but her mother "forced" her back to a physical school. The client says, "I can't stand it anymore. My mom yells at me every day about how I'm doing something wrong. Yesterday she blew up at me about leaving my shoes and backpack in the living room. It's my house, too. She's such a control freak." You respond to her with empathy and understanding. You ask her to tell you more about how she has felt since the argument. She explains that in addition to feeling like she has no control over her life, she feels guilty and confused because she loves her mother but does not understand why she is so controlling and demanding. You let her know that it is natural to have complicated feelings in this situation and that you are here to help her work through them. You create a plan with her, outlining different goals and activities she can do on her own or with the support of her mother. Through further exploration, you discover that she has an interest in drawing and is used to create characters for stories. She admits she feels calm when creating these drawings but that it does not take away from her depressive symptoms. You explain that having a creative outlet and developing it further can give her a healthy outlet for her emotions. The client appears to be receptive to this idea, expressing that she is willing to try it. She leaves your office feeling hopeful and slightly less overwhelmed. You make an appointment for the following week and suggest she come with a piece of art or design to share. She nods in agreement before leaving. Seventh session It has been almost two months since you began therapy with the client. You suggested a session in which both she and her mother were present to discuss the client's progress. She presents to today's session with her mother. The client followed up with your referral from a previous session for her to see a psychiatrist and has provided you with a release of information to communicate with her psychiatrist. The client has been prescribed an antidepressant and says she does not feel any notable change yet but the psychiatrist told her it would take a few weeks to know if the medication was working. The mother states that since her daughter started taking the antidepressant, she is sleeping more than usual and struggles to get out of bed. She has been late to school several times. She is also having trouble with motivation. You reflect the client's current state and suggest she establish a daily routine to gain a sense of control in her life. You discuss the importance of making small achievable goals and explain that taking on too much can be overwhelming, so it is more beneficial to focus on one task at a time. The mother begins listing off potential activities that her daughter should take part in. The client closes her eyes and begins to sigh. When you ask her about her reaction, she says, "See, yet another example of my mom trying to control everything." The mother responds by saying, "I'm not trying to control you. Believe it or not, I just want what's best for you!" Understanding the tension between them, you suggest a compromise. You explain that if the client completes one activity each day, her mother will not pressure her to do more. The client appears hesitant but agrees to try it out. You then turn to the mother, thanking her for being willing to compromise and understanding. You encourage them to be patient with one another and remind them that progress takes time. You suggest they continue to have regular check-ins so that each party is aware of how the other is doing in following through on the agreement. You end the session by summarizing what was discussed, reinforcing the importance of communication between the client and her mother. | The client's mother reports that the client's father has a history of depression. The client's mother is her primary caregiver, as her father is in and out of psychiatric facilities. When the client was a child, she had a positive relationship with her mother, but as a teenager, she has been withdrawing from her mother and spending most of her time alone in her room. The client has missed many days of school in the past few months. She feels that no one at school likes her; she has tried to fit in by experimenting with alcohol and marijuana, controlling her weight, and staying out late at night. The client is struggling academically and lacks concentration in the classroom. At home, the client is withdrawn and spends most of her time in her room pretending she is doing homework but is actually scrolling through social media posts for several hours. In addition, she is having trouble sleeping and stays up late. | Using a cognitive-behavioral approach, how would you use reframing to help the client see her mother's "controlling" behavior from a different perspective? | "Take this opportunity to take control over your life and show your mother that you are capable of making responsible decisions." | "I understand the tension between you and your mother. It sounds like you feel she is trying to control everything, and you're overwhelmed by her expectations." | "It seems clear that your mother's suggestions are aimed at helping you to gain better control, doesn't it?" | "It sounds like your mother is trying to support you and help you make positive changes. Perhaps she has different ideas about how to get there." | (A): "Take this opportunity to take control over your life and show your mother that you are capable of making responsible decisions."
(B): "I understand the tension between you and your mother. It sounds like you feel she is trying to control everything, and you're overwhelmed by her expectations."
(C): "It seems clear that your mother's suggestions are aimed at helping you to gain better control, doesn't it?"
(D): "It sounds like your mother is trying to support you and help you make positive changes. Perhaps she has different ideas about how to get there." | "It sounds like your mother is trying to support you and help you make positive changes. Perhaps she has different ideas about how to get there." | D | Reframing involves helping the client and her mother to view the situation from a new perspective. Instead of viewing the mother's requests as controlling, the client can instead view them as an expression of care and concern. Therefore, the correct answer is (B) | counseling skills and interventions |
430 | 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 in your office 1 week after the intake session. The client reports that her husband was out of town for half of the past week and she engaged in bingeing and purging. You review the client’s food log with her and can see the difference between when her husband is home and when he is gone based on her documentation. The log included the client’s thoughts following bingeing, purging, and restricting, and you and the client work on creating new scripts for the thoughts that have led to unhealthy eating and compensatory behaviors in the past. You want to demonstrate congruence with the client when she begins to cry, and you feel the urge to sit beside her and put your hand on her shoulder to comfort her | You want to demonstrate congruence with the client when she begins to cry, and you feel the urge to sit beside her and put your hand on her shoulder to comfort her. Which of the following is the most important consideration? | The appropriateness of this action depends on the sexual orientation and identified gender of you and the client, so as to not send the wrong message to the client. | Physical comfort is a typical human reaction, and this can build therapeutic rapport. | You must first consider if you want to comfort the client physically for your own needs or for the client’s needs. | Handshakes are the only appropriate physical touch with a client. | (A): The appropriateness of this action depends on the sexual orientation and identified gender of you and the client, so as to not send the wrong message to the client.
(B): Physical comfort is a typical human reaction, and this can build therapeutic rapport.
(C): You must first consider if you want to comfort the client physically for your own needs or for the client’s needs.
(D): Handshakes are the only appropriate physical touch with a client. | You must first consider if you want to comfort the client physically for your own needs or for the client’s needs. | C | It is most important to first consider your own motives for any personal reaction, similar to self-disclosure, because you want to make sure that you are responding for the client’s benefit and not for your own management of emotional response or emotional needs. Although handshakes are generally acceptable, clients may also respond well to other types of physical touch and may benefit from a comforting hand on the shoulder. Sexual orientation and the client’s identified gender are important considerations; however, your motives are the first filter in assessing the benefits of physical touch. Although physical touch is a typical and accepted human response, you should be careful about the impacts of this response. Therefore, the correct answer is (C) | core counseling attributes |
431 | Initial Intake: Age: 35 Sex: Male Gender: Male Sexuality: Gay Ethnicity: African American Relationship Status: Married Counseling Setting: Private Practice Type of Counseling: Individual | The client presents appropriately dressed and is well-groomed. His stated mood is congruent with stated affect but you note a limited range of emotions. He appears to be cooperative and forthcoming. He endorses no use of illegal or inappropriately prescribed drugs and a 20-year history of alcohol abuse, with one driving citation at age 21. He currently drinks 3 to 4 beers per day and 16 or more on the weekend. He acknowledges using alcohol to relieve emotional discomfort and feels the need to cut down. He is able to offer insight into his thoughts and behaviors, and demonstrates appropriate memory and judgement. | You are a counselor in a private practice setting. During the intake session, you learn that your client and his spouse have been married for 7 years and together for 10 years. He states they have 2 children and he is their primary caregiver from early afternoon until evenings; this includes transportation, preparing dinner and homework. He states his spouse and he moved their family here earlier this year to be closer to his husband’s family. He works as a high school teacher. He presents relationship issues as his main concern and rates these as “very difficult,” and has been told that he and his husband “may be heading for divorce.” He states he often feels “suspicious” because his husband has multiple friendships with other males, online and face-to-face, including old boyfriends. The client tells you he feels this is inappropriate but that his husband disagrees and will not end these friendships. He admits being stressed, overwhelmed, sad, having little energy, and experiencing crying spells, irritability, and angry outbursts. He says he feels like a failure. He says his husband said he has not been “emotionally available” since their marriage. The client notes that during the year they married, he finished his teaching credentials, the couple adopted their first child, and he began working as a first year teacher in a high school with tenure requirements. | Family History:
The client states he has three siblings. He relates he has a “pretty good” relationship to his brother, a moderate connection to his younger sister, and a tenuous connection to his older sister. He says he has cut himself off “emotionally and physically” from his own parents and his husband’s family due to “conflicts.” He describes his mother as manipulative and attributes the lack of many extended family relationships to her. He describes the relationship between his parents as conflictual but that his father “goes along with her” and has cut off relationship with the client’s older sister, his father’s twin sister and her spouse. The client says his mother has never liked the client’s spouse. He said she was not happy he married a man, but was even more upset that his husband is White. During one family visit, his mother left a derogatory email about his husband in a visible place so he would find it. | Which of the following interventions should be taken as you work with the client and his husband to help them resolve their relationship issues? | Focus on conflict resolution skills | Focus on active listening skills | Have each individual set personal goals for change | Teach them how to use "I" statements | (A): Focus on conflict resolution skills
(B): Focus on active listening skills
(C): Have each individual set personal goals for change
(D): Teach them how to use "I" statements | Have each individual set personal goals for change | C | Couple's counseling is most effective if each individual is able to determine their own goal for how they would like to change themselves in the relationship. Individuals are not able to change another person but can facilitate changes within the relationship when focusing on changing themselves. Each of the other interventions are important skills for clients to learn to improve communication and interpersonal relationships but are not as important as setting one's own personal change goal. For example, the use of "I" statements when discussing conflicts (eg, "I feel sad" vs "You make me sad") is an important part of communication, but will be most effective once the individuals have recognized their own issues within the relationship. Therefore, the correct answer is (B) | treatment planning |
432 | Name: Alberto Clinical Issues: Sexual functioning concerns Diagnostic Category: Sexual Dysfunctions Provisional Diagnosis: F51.22 Erectile Disorder, Situational Age: 43 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: White Marital Status: Married Modality: Individual Therapy Location of Therapy : Agency | The client is dressed in casual clothing and appears to be clean and well-groomed. He is of average height and build, with short black hair. He is noticeably tense and avoids eye contact when describing his symptoms. His speech is audible and clear. He is able to express himself clearly and articulately. The client reports feeling frustrated, embarrassed, and confused concerning issues with his wife. He denies any suicidal or homicidal ideation. His mood is anxious and affect is flat. He is able to recall pertinent events and information. He has no difficulty understanding the session process or comprehending instructions. He appears to be alert and oriented to person, place, and time. The client displays average insight into his current situation and expresses willingness to explore relevant issues in more depth with the therapist. He displays average judgment when answering questions. | First session The client, a 43-year-old male, presents for his first Telehealth session through the agency where you are an intern, finishing your final hours for licensure under clinical supervision. You begin the session by striving to create a safe, comfortable, and non-judgmental environment. You provide the client with an introduction to yourself, your qualifications, and your approach to therapy. You also explain how Telehealth works and provide the client with an opportunity to ask questions about the process. Next, you review his informed consent and other paperwork that was filled out prior to the session. You explain the policies and procedures for confidentiality within your agency. He nods his head and verbally acknowledges understanding. You then begin to explore the client's presenting issues and goals for therapy. You ask what prompted him to schedule an appointment for counseling, and he responds saying, "I don't know what is wrong with me, but lately, I've been having trouble with my wife....on an intimate level. It's been very frustrating and embarrassing, and it's causing a lot of tension between us. My wife is getting frustrated and accusing me of cheating on her. We have two children. I never thought this would happen to me." The client has seen a urologist and has no sign of prostate cancer but is in poor health. The client appears anxious when describing his symptoms. He is fidgeting and has trouble maintaining eye contact as you explore the issue more deeply. This is your first client who presents with this particular issue, and you are not entirely sure of how to proceed. You take a few moments to pause and reflect on what he has said while also noting his body language. As you consider the best way forward, you remember the importance of validation in establishing rapport. You nod your head and say, "I can see how this has been difficult for you and your wife. It's understandable why it might be causing tension between the two of you." Fourth session It has been a month since you began therapy with the client. You have been meeting with him weekly. Today, the client states he and his wife attempted to have sex last week, and he could not maintain an erection. He says she called him "a lousy cheat with a beer belly who can't satisfy her." He lets you know that this remark triggers him as it reminds him of his relationship with his mother. He reports that sex feels like a "chore," and it is not fun anymore. "Sometimes, I fantasize about being with an ex-girlfriend of mine just to get an erection." The client seems sad and looks down at his feet. You and the client discuss his wife's comments, and he expresses feeling overwhelmed and helpless. You ask him to reflect on how he feels about his wife's reaction, and he reports feeling "hurt and rejected." You then discuss the possibility of exploring underlying issues that may be impacting his ability to find pleasure in sex. You then ask if he is able to recall any past experiences or traumas contributing to his difficulty with erectile dysfunction. He has never felt anxious about past experiences with erectile dysfunction, but now he sees to be struggling with feelings of guilt and shame. You then discuss strategies for improving communication with his wife and ways to build trust within their relationship. You encourage the client to explore his feelings and identify potential triggers impacting his ability to enjoy sex. Lastly, you role-play a scenario in which the client communicates his feelings to his wife in a non-confrontational manner. At the end of the session, he tells you that he is beginning to understand how he can relate better to his wife. He states, "I guess it's important to tell each other what we need and want." | The client is an only child. As he grew up, he reports that his father was often vocal about his dissatisfaction with his sex life. The client also reports that his mother often expressed resentment toward him from the day he was born. This has left him with a deep-seated dislike of his mother, as well as resentment of women in general. Currently, his parents are facing health issues, with his father drinking heavily and his mother having lung cancer. The client feels overwhelmed and stressed due to his job and family responsibilities. He is worried about his parents' health and is not happy about the potential of having to take care of his mother if his father passes away. After a decade of working as an illustrator designing greeting cards, the client has recently been promoted to creative director of his department. Because of his introverted nature, he is now feeling overwhelmed with the new responsibilities and having to communicate with other departments within the company. The client drinks weekly and occasionally smokes marijuana. The client drinks at least one beer every other night after work with dinner. He will finish two six-packs on some weekends if they have company over to watch football. He says he rarely drinks hard liquor. The client has reported that his alcohol use or smoking marijuana is not causing any impairments in his ability to carry out his daily responsibilities, but he is overweight because of his inactivity and indicates he would like to return to his normal weight. He also says that he has never experienced any adverse physical or psychological effects due to his substance use. | The client appears to have no significant colleagues at work or friends at home. What is the best method to assess the client's support system? | Ask the client to create a diagram of his relationships with colleagues and friends. | Ask the client to describe his relationships with colleagues and friends. | Ask the client to draw a picture representing his relationships. | Ask the client to list all of his colleagues and friends. | (A): Ask the client to create a diagram of his relationships with colleagues and friends.
(B): Ask the client to describe his relationships with colleagues and friends.
(C): Ask the client to draw a picture representing his relationships.
(D): Ask the client to list all of his colleagues and friends. | Ask the client to create a diagram of his relationships with colleagues and friends. | A | As indicated, the client has been in art for over a decade. The client's mode of communication is more haptically oriented, so asking him to draw his relationships with colleagues and friends would be the preferred method in assessing his support system. Therefore, the correct answer is (C) | intake, assessment, and diagnosis |
433 | Initial Intake: Age: 48 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Private Practice Type of Counseling: Individual | The client appears to be his stated age and overweight for his height. He is dressed professionally and appropriately to the circumstances as he tells you he will see clients after your appointment. The client lays on the office couch with his hands behind his head and his feet on a cushion. He answers questions without pauses and often replies very casually with “sure” or “I don’t know,” demonstrating little insight into his thoughts, behaviors, and emotions. He estimates his mood as dissatisfied and unhappy though his affect suggests ambivalence. He presents with some complaints of forgetfulness but is oriented to time and place, and endorses no delusions or hallucinations. He acknowledges frequently feeling suspicious, especially when he’s feeling really stressed. He says he questions other people’s motives and what they are doing or saying when he’s not present. The client acknowledges using alcohol on weekends, and has used marijuana and cocaine regularly over the past ten years but admits it has increased over the last two years. He assures you he only drinks and uses drugs when not seeing clients. He has a prescription for pain medicine and states he uses it appropriately. | You are a counselor in a private practice setting. Your client presents with complaints of not meeting his own expectations in his licensed, health care profession, and dealing with the business aspect of his work, difficulty meeting financial obligations, difficulty getting along with others, and problems with his ability to concentrate. He says his business partner used to be his best friend but now he can’t stand him because he sees the clients more often and leaves your client to do all the work. He tells you his concentration issues have always been present but have become progressively worse over the past eighteen months, as have his feelings of irritability, failure, fatigue, and lately he has pains in his chest and shoulder. He tells you that he thinks sometimes about what would happen if he died, but only as far as wondering how others would react. Later in the session, he says he is not suicidal and does not have a plan, but occasionally he just “gets tired of it all.” He tells you that sometimes he feels like “ending it” and has said that to women when the relationship isn’t going well and once or twice during breakups. He asserts that he has not actually tried to kill himself. He summarizes his relationships with others as “if they like me, they lose interest” and says that he finds himself “almost being manipulative” in how he chooses his words in his relationships with women and sometimes takes them on spontaneous “wildly expensive vacations” so they will not lose interest in him. The client tells you he has been in several relationships with women over the years, beginning with his high school sweetheart, then with his college sweetheart, but none of them have “worked out.” He states he was engaged to his college sweetheart at 24 for 6 months and then she married someone else. He tells you that another girlfriend was married and didn’t tell him, one “went crazy and threatened him with a gun,” and one broke up with him saying that he was “too needy” and “almost obsessive” in wanting to see her every day. He tells you that “all in all, I’m unhappy with how things are going and I need to make changes, but I just have no motivation to do it and I don’t know why I should have to.” | Family History:
He states he is close to his sister who has never married but “always likes the deadbeat guys.” He tells you his father and mother never showed affection to him while growing up, were always bickering, and his mother was always obsessive about saving money and always complaining. He acknowledges loving his parents but sometimes getting so angry at them that he wishes he could just ignore them forever. He tells you both his maternal and paternal grandfathers were “mean as snakes,” while his paternal grandmother was a “saint.” He reports that one of his uncles committed suicide several years ago and that his cousin, whom he was very close to, committed suicide last year. He also says his best friend died five years ago due to a drug overdose. | Which of the following actions will be most challenging when working with this client? | Empathic responding | Developing a safety plan | Setting and maintaining strong boundaries | Using active listening and attending skills | (A): Empathic responding
(B): Developing a safety plan
(C): Setting and maintaining strong boundaries
(D): Using active listening and attending skills | Setting and maintaining strong boundaries | C | Counselors who work with clients diagnosed with BPD are often challenged to set and maintain strong personal and professional boundaries with their client. The client's personality patterns include frantic efforts to avoid any imagined abandonment so changes in appointment times, not allowing the client to stay longer than their appointment time, or holding them to therapeutic discussion rather than casual conversation can appear as rejecting the client. Counselors working with this population are challenged to set, explain, and maintain their boundaries, often needing to repeat these to the client or set new boundaries as new circumstances occur with the client. Developing a safety plan for this client is important so that the client has a plan as well as allowing the counselor to maintain boundaries when not in the office or "on call". Empathic responding and active listening/attending skills are foundational counseling interventions that are used with all clients and should not be a challenge. Therefore, the correct answer is (B) | counseling skills and interventions |
434 | 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 | You administer the Scale for the Assessment of Positive Symptoms (SAPS) to determine the severity of which of the following? | Diminished speech | Avolition | Agitation | Social withdrawal | (A): Diminished speech
(B): Avolition
(C): Agitation
(D): Social withdrawal | Agitation | C | The Scale for the Assessment of Positive Symptoms (SAPS) is a standardized testing instrument used to measure the severity of positive symptoms associated with schizophrenia. Positive symptoms include hallucinations, delusions, bizarre behavior, and positive formal thought disorder. Aggressive and agitated behaviors are considered bizarre behavior. Avolition, diminished speech, and social withdrawal are all negative symptoms of schizophrenia. Avolition is characterized by an inability to pursue goal-oriented activities. Diminished speech, or alogia, involves reduced speech output and decreased verbal fluency. Social withdrawal, or asociality, includes limited social interactions or a lack of interest in socializing. Therefore, the correct answer is (C) | intake, assessment, and diagnosis |
435 | 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.” | . Family and History: The client is an only child and has never been married. She describes her relationship with her parents as “close until recently.”She and her family belong to a Christian evangelical church, and her family does not accept the client’s sexual orientation\. Her father is an accountant without any known mental illness. The client’s mother has been diagnosed with depression and anxiety. When growing up, the client states her parents placed a strong emphasis on how things looked on the outside. She feels she has failed her parents and carries shame and guilt over her body weight and sexual orientation | Which is included in the DSM-5-TR criteria for binge-eating disorder (BED)? | Dietary restrictions between binging to influence body shape | Dissociation during or following binge eating episodes | Marked distress associated with binge eating | Recurrent compensatory behavior (e.g., purging) | (A): Dietary restrictions between binging to influence body shape
(B): Dissociation during or following binge eating episodes
(C): Marked distress associated with binge eating
(D): Recurrent compensatory behavior (e.g., purging) | Marked distress associated with binge eating | C | The DSM-5 criteria for BED include marked distress regarding binge eating. Dietary restrictions and recurrent compensatory behaviors are criteria associated with bulimia nervosa. Some individuals report dissociation during or immediately after binge eating, but this is not a criterion for BED. According to the DSM-5, “Binge-eating disorder has recurrent binge eating in common with bulimia nervosa but differs from the latter disorder in some fundamental respects. In terms of clinical presentation, the recurrent inappropriate compensatory behavior (eg, purging, driven exercise) seen in bulimia nervosa is absent in binge-eating disorder. Unlike individuals with bulimia nervosa, individuals with BED typically do not show marked or sustained dietary restrictions designed to influence body weight and shape between binge-eating episodes. They may, however, report frequent attempts at dieting (APA, 2013)”. Therefore, the correct answer is (C) | intake, assessment, and diagnosis |
436 | 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 | The diagnosis of depressive disorder due to another medical condition (migraine headache) can be assigned when the disturbance is caused by which of the following? | The biopsychosocial effects of migraine headache and/or migraine medication | The pathophysiological effects of migraine headache | The psychocultural effects of migraine headache | The physiological effects of migraine medication | (A): The biopsychosocial effects of migraine headache and/or migraine medication
(B): The pathophysiological effects of migraine headache
(C): The psychocultural effects of migraine headache
(D): The physiological effects of migraine medication | The pathophysiological effects of migraine headache | B | According to the DSM-5-TR, Criterion B for the diagnosis of depressive disorder due to another medical condition (migraine headache) states that the diagnoses can be made if there is supporting clinical evidence that the psychological disturbance is the direct pathophysiological consequence of another medical condition. When making this determination, the possibility of medication-induced or substance-induced disruption must also be considered, in which case both diagnoses (ie, depressive disorder due to another medical condition and substance/medication-induced depressive disorder) may be given. Lastly, psychological and cultural effects are considerations for all diagnoses and are not stipulated criteria for this diagnosis. Therefore, the correct answer is (B) | intake, assessment, and diagnosis |
437 | Initial Intake: Age: 20 Gender: Male Sexual Orientation: Homosexual Race/Ethnicity: African American Relationship Status: Single Counseling Setting: University counseling center Type of Counseling: Individual | Jonathan presents as anxious with congruent affect, evidenced by client self-report and therapist observations of fidgeting, inability to sit still, tearfulness and shallow breathing with rapid paced speech. Jonathan occasionally closes his eyes and takes deep breaths when he begins to cry in attempt to slow himself down and prevent what he calls “another emotional breakdown.” He has prior inpatient treatment history of a one-week episode where he was involuntarily committed at 17 for making comments about planning to kill himself in response to his stress over finishing high school. He admits to passive suicidal ideations in the past few weeks while studying for exams but does not report considering a method or plan. He reports that he has been losing sleep because of long study hours and feeling too keyed up to calm down. You assess him as having distress primarily associated with anxiety, which at times of abundant stress turns to episodes of depression and hopelessness. | Diagnosis: Anxiety disorder, unspecified (F41.9), Major depressive disorder, single episode, unspecified (F32.9)
You are a brand-new counseling intern in the counseling resource center of a local university. Jonathan is a junior in college and comes to speak with you, as you are his newly assigned college university counselor. Jonathan is concerned about finals that he feels unprepared for, stating he is “overwhelmed” and “under too much pressure” from his family to “allow himself” to fail. He is making disparaging, negative remarks about himself and his abilities, often repeating himself and talking in circles using emotional reasoning. He asks you for help in getting his teachers to modify his deadlines so that he can have enough time to accomplish all his assignments, mentioning that his last counselor did that and called it “playing the mental health card”. There are no previous records on file for this student, but when you ask him who he met with he just changes the subject and continues to express his worry that he will “never amount to anything or graduate” if he fails these exams. | Education and Work History:
Jonathan has a high academic performance history, despite short periods of time where he experiences heightened stress. Jonathan has never gotten in trouble in school or had any infractions at part-time jobs later as a teenager. He has worked after-school jobs at the grocery store, bowling alley, and local town library. Jonathan had only one work-related incident where he broke down emotionally when feeling overwhelmed and left work in the middle of his shift, but his supervisor was supportive and helped him.
Current Living Situation:
Jonathan lives in the college dormitory with a peer and is supported by his mother. His mother is a single mom who works full-time in Jonathan’s hometown, which is almost a full day’s worth of driving from where Jonathan goes to college. Jonathan mentions that his friends call him “Jonny.” He adds that the food available to him is not very healthy and he has poor eating habits due to prioritizing studying and his involvement in extra-curricular activities. | During the second session, you respond quite impulsively, albeit out of concern for Jonny, exclaiming "Oh, Jonny, you can't quit everything you've worked for because of a boy you just met!" What mistake have you just made? | Being overly honest in a way that might hurt his feelings | Breaking counselor code of ethics | Sharing your opinion without being asked | Letting your professional guard down | (A): Being overly honest in a way that might hurt his feelings
(B): Breaking counselor code of ethics
(C): Sharing your opinion without being asked
(D): Letting your professional guard down | Sharing your opinion without being asked | C | There is nothing unprofessional about being honest with your client or letting your guard down in a discussion about feelings. It also does not break counselor code of ethics to share your opinions with your clients. However, Jonny did not ask you for your input before you provided it, which has now potentially affected the entire course of your session moving forward since he now knows your disapproving perspective on his choices. You are expected to be a safe, non-judgmental advocate for Jonny, a position which you have now compromised. Therefore, the correct answer is (A) | counseling skills and interventions |
438 | 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. 11th session As the session begins, you sit calmly in your office, virtually watching as the client pounds her fists on her desk and speaks angrily. The client informs you that she is "not happy" with you as a therapist. "You therapists are all the same!" she yells. She accuses you of being responsible for her break-up, saying that her boyfriend left her because she had been hospitalized on your recommendation. Her facial expressions convey feelings of hurt and disappointment, and you attempt to normalize her reaction. You remain calm, opting to validate the client's feelings rather than respond defensively or deny responsibility for what has happened between the client and her partner. As the session continues, you take a deep breath and give yourself a moment to gather your thoughts. You recognize that the client's emotional pain and distress have created a lens through which she now views your professional relationship. Reflecting on the session and past interactions, you remember your concerns that prompted the recommendation for hospitalization. The client had exhibited signs of severe emotional distress and potential self-harm. As a therapist, you prioritized her safety and well-being. You understand her feelings of abandonment from her partner and try to determine who represents both care and potential harm in her life. However, no matter how much empathy you try to show or how many times you attempt to normalize the client's feelings of anger, she refuses any further discussion on the topic; instead, she declares firmly that she does not want to see you again and abruptly logs out of the session. You make a note to reach out to the client in a few days to check in on her well-being and see if she's open to discussing her feelings further. Given the intensity of her reaction, it's crucial to ensure that she has a support system during this challenging time. While she might not be receptive to your outreach initially, she needs to know that she is not alone and that help is available should she seek it. Later, you discuss the situation with your supervisor, seeking guidance on best handling her response and processing your feelings about the matter. The supervisor reminds you that therapeutic relationships can mirror many aspects of clients' other relationships. The anger and feelings of betrayal the client is experiencing could have been elicited by any number of events in her life. The most important thing is to continue offering support while respecting her boundaries. | 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 is the most likely reason for the client's aggressive and blaming behavior towards the therapist? | The client is aggressive as a coping mechanism base on her background and life experiences | The client is stuck in the ego "critical parent state" in exhibiting her behaviors. | Projection of her frustrations about the breakup | The client is justified in her anger as you are responsible for her breakup. | (A): The client is aggressive as a coping mechanism base on her background and life experiences
(B): The client is stuck in the ego "critical parent state" in exhibiting her behaviors.
(C): Projection of her frustrations about the breakup
(D): The client is justified in her anger as you are responsible for her breakup. | Projection of her frustrations about the breakup | C | The client's reaction may indicate projection, a psychological defense mechanism where individuals attribute their unacceptable thoughts or feelings to another person. Here, the client might feel intense disappointment and anger due to the breakup and could be projecting these feelings onto the therapist. This could be because accepting her own role in the situation might be too emotionally challenging. Therefore, the correct answer is (B) | counseling skills and interventions |
439 | Initial Intake: Age: 70 Gender: Female Sexual Orientation: Heterosexual Race/Ethnicity: Caucasian/Non-Hispanic Relationship Status: Widowed Counseling Setting: Private Practice Telemedicine Type of Counseling: Virtual Individual | Mary presents with anxious mood and congruent affect. Speech is normal rate and tone, motor movements within normal limits. Denies hallucinations, delusions, suicidal or homicidal ideation. Mary is well-dressed, adorned with makeup, jewelry, and stylish hairstyle. Mary frequently resists the urge to cry as evidenced by smiling and deflecting when becoming tearful. She tells you she wants to work on herself but appears mildly offended whenever given feedback or asked a personal question and then changes the subject. | Diagnosis: Anxiety disorder, unspecified (F41.9), Adjustment disorder, unspecified (F43.20)
You are an associate counselor and receive a new referral for a virtual client through your company’s telehealth practice. Mary is a 70-year-old widow who lives alone with her dog in a 55+ active living community. Mary moved to her town to live closer to her daughter and son-in-law when she lost her husband suddenly to cancer four years ago. Mary is struggling with feeling comfortable leaving the house or engaging in any social gatherings outside of being with her children. She wants to make friends her age and take local activity classes, but her anxiety prevents her from committing to plans. Mary has been widowed for four years but has not yet committed to counseling or attendance in grief support groups. She has felt insecure socially since her husband died, but reports being a “social butterfly” before his passing. She admitted to only visiting her husband’s grave on his birthday but is unable to do so any other time. Also, since the COVID-19 outbreak, Mary’s fears and concerns have increased as she is immunocompromised. She asks you for counseling but cannot define what she wants to get out of it. |
Family History:
Mary was married to her children’s father for 25 years until he had an affair and left her for the other woman. After a few years, Mary met her late husband and was married another 20 years until he became diagnosed with lymphoma and died within three months of being diagnosed. Mary has three older sisters, all of whom live in different states but come to visit seasonally. She celebrates her late mother’s birthday annually, expressing symptoms of grief each year, and becomes inconsolable on the anniversaries of her late husband’s passing. She tells you only country music calms her down.
Work History:
Mary was a stay-at-home mother and wife for both of her marriages, working several jobs in-between marriages as a children’s dental receptionist and an antiques shopkeeper. She opened her own shoppe after meeting her late husband where she sold and displayed southern home décor. She had to close her store down when her husband moved for work. She spent much of her free time making greeting cards and crafts at home, until her hands developed arthritis and she lost enjoyment of her hobbies. She now lives off social security and her late husband’s estate that he left for her. | It is clear after your second session with Mary that she will continue to struggle with debilitating anxiety symptoms until she is willing to address her unresolved grief. How should you approach this? | motivational interviewing process | do not address it unless Mary brings it up herself | caring confrontation out of ethical responsibility | education on the long-term effects of unresolved grief | (A): motivational interviewing process
(B): do not address it unless Mary brings it up herself
(C): caring confrontation out of ethical responsibility
(D): education on the long-term effects of unresolved grief | motivational interviewing process | A | Using motivational interviewing in your counseling with Mary will help you address your primary treatment goal with her, but without using a confrontational style that might cause her to be defensive or resistant. MI can provide a non-judgmental, supportive, and client-led environment for a discussion centered around the client's desired change and factors that increase motivation. Waiting for Mary to work on her grief is a different strategy than waiting for an appropriate time to begin MI interventions. It can be empathic to wait for a future session to address her problem, however waiting for Mary indefinitely is not helpful as she has already suffered for four years without improvement to her condition. Providing education on unresolved grief disorders is useful and can be part of the process; but not used as a means for approaching her unwillingness to engage in the topic. Therefore, the correct answer is (D) | counseling skills and interventions |
440 | 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. Your time-limited group is coming to an end | Your time-limited group is coming to an end. During this final phase, you and the group members process key elements EXCEPT which of the following? | Resolving any conflicted relationships | Identifying members in need of a future “booster” session | Identifying individual changes in anxiety-related beliefs, attitudes, and behaviors | Generalizing the skills learned in group | (A): Resolving any conflicted relationships
(B): Identifying members in need of a future “booster” session
(C): Identifying individual changes in anxiety-related beliefs, attitudes, and behaviors
(D): Generalizing the skills learned in group | Identifying members in need of a future “booster” session | B | You attend to all of the key elements listed except identifying members in need of a booster session. According to the American Group Psychotherapy Association (AGPA) Practice Guidelines for Group Psychotherapy (AGPA, nd), factors listed in answer options A, B, and C summarize the responsibilities of group leaders during the final phase of group therapy. Empirical evidence shows that scheduling booster sessions for all group members helps prevent symptom relapse. Identifying candidates in need of a booster session is rarely processed with the group as a whole. Therefore, the correct answer is (D) | counseling skills and interventions |
441 | Initial Intake: Age: 23 Gender: Male Sexual Orientation: Heterosexual Ethnicity: Indian American Relationship Status: Single Counseling Setting: Private Practice Type of Counseling: Individual | Shawn is slightly unkempt, completes ADLs and has good hygiene. His motor movements are fidgety and tense, and he consistently averts eye contact and darts his eyes around the room and towards the door every time he hears a noise. He appears to be sensitive to the lighting in the office as evidenced by fluttering his eyes when he looks up and commenting about its brightness. Shawn speaks within normal rate and tone, however low volume and often mutters under his breath. He denies any past suicidal or homicidal ideation and denies hallucinations or delusions. Shawn also denies history of trauma. | Diagnosis: Social Phobia, unspecified (F40.10) provisional; Alcohol Use Disorder, moderate, in early remission (F10.10)
Rishaan is a 23-year-old heterosexual male of Indian origin and is being referred to you by his parents for counseling in your private practice who are telling you Rishaan is at risk for going back to his drinking because he “never does anything constructive.” Further complaints by Rishaan’s parents include that “all he does is play video games and watch TV,” that he “never has money to pay for anything himself” and is constantly asking them for money. His parents offer to self-pay for Rishaan’s sessions. You welcome Rishaan to your office for an initial assessment. He respectfully requests that you refer to him as “Shawn,” which he explains is his preferred American name, and remarks that his parents really want him to talk to you. Shawn has agreed to counseling because he shares with you that he “has stuff to talk about anyway” and does not think he can go to his parents. | Substance Use History:
Shawn entered treatment and rehabilitation five months ago after his ex-girlfriend’s family had an intervention with him about his abusive drinking and he has now been through all phases of treatment for Alcohol use disorder. Shawn tells you he is ashamed that his parents found out about his problem through his ex-girlfriend’s parents, because he had been lying to his own parents about his well-being for several years since he left home for college at 18 years old. Shawn is currently five months sober but is not engaged in any post-treatment recovery program nor has he continued counseling.
Family History:
Shawn has two older siblings, both of whom he shares are “successful and have families.” Shawn says, “my parents always want me to be like them and are constantly comparing me to them, it’s so annoying.” Shawn’s father is a dermatologist, and his mother is his father’s secretary in their medical practice. Both parents observe traditional Indian cultural practices in their social lives and with respect to Hinduism.
Work History:
Shawn has attempted part-time work following his graduation from his alcohol rehabilitation treatment program but was unable to make his shifts on time and was let go from his job. He tried another job selling products by cold calls but could not keep up with the volume required to make a viable salary. When asked what Shawn would like to do for a living, he says “I’d like to be a gaming coder or tester, something like that.” | Which list of symptoms most accurately relates to Social Phobia? | Depressed mood, dissociation, fear of going outside | Avoidant personality, shyness, anhedonia | Inability to make friends, speech problems, explosions of anger | Avoidance disorder, performance anxiety, fear of eating in public | (A): Depressed mood, dissociation, fear of going outside
(B): Avoidant personality, shyness, anhedonia
(C): Inability to make friends, speech problems, explosions of anger
(D): Avoidance disorder, performance anxiety, fear of eating in public | Avoidance disorder, performance anxiety, fear of eating in public | D | Social anxiety is characterized by intense, irrational fears of one or more social or performance situations in which a person believes they will be scrutinized by others. Exposure to social situations immediately provokes an anxiety response to an excessive or unreasonable degree. A diagnosed person may or may not experience several of the other factors listed in answers a, c or d, but each one of those answers has a combination of factors that indicate a co-occurring disorder other than social phobia alone. Therefore, the correct answer is (B) | intake, assessment, and diagnosis |
442 | Client Age: 20 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: African American Relationship Status: Single Counseling Setting: College Campus Counseling Clinic Type of Counseling: Individual Counseling Presenting Problem: Depression and “Odd Behavior” Diagnosis: Bipolar 1 Disorder, Current Episode Manic Without Psychotic Features, Moderate (F31.12) | Mental Status Exam: The client states that she slept for 4 hours the night before, which was the most she has slept in one night in the past week and that she now feels tired for the first time. The client had dark circles around her eyes and was wearing sweatpants and a t-shirt with stains on it. The client is oriented to person, place, time, and situation. The client’s affect and speech are | You are a licensed therapist working on a college campus in the counseling center. A 20-year-old female client comes to counseling following 8 days of experiencing the following symptoms: little to no sleep most nights with the longest stretch of sleep being 2 hours, several middle-of-the-night shopping sprees, and distractibility. She reports that some of her college professors have called on her to stop talking during class and that she has not been doing very well in school this semester. The client identifies that she has felt this way before over the past 2 years and that this last time scared her because she was more aware of the negative impact it is having on her schooling. The client continues to relate that she also experiences depression at times and that she does not understand where it comes from but that it happens for a few weeks at a time every few months. When in a depressive episode, the client experiences a depressed mood more often than not, decreased enjoyment of activities, hypersomnia, fatigue, and a significant decrease in appetite. | flat. Family History: The client says that she and her family moved to the United States from Kenya when she was 5 years old. The client is the first member of her family to go to college, and she reports significant pressure from her parents to succeed. She feels that she has a good relationship with both of her parents. Her sister is 2 years younger than her, and they talk on the phone on a daily basis. The client identifies no other close family members because most are still living in Kenya | Which of the following is the most effective form of treatment for bipolar disorders? | Medication management | CBT and medication management | Dialectical behavior therapy | CBT | (A): Medication management
(B): CBT and medication management
(C): Dialectical behavior therapy
(D): CBT | CBT and medication management | B | The most effective form of treatment for bipolar disorders is a combination of medication management and psychotherapy (Mayo Foundation, 2021). Medication and CBT together are an effective treatment combination for this lifelong disorder that requires cognitive adjustments that can be supported by medication. Therapy alone, although it can be helpful, is more effective when combined with medication. Medication alone would address the behavioral and cognitive changes needed to create the lasting changes that are not impacted by medication. Dialectical behavior therapy is useful in treating mood disorders and substance use and is not proven to be beneficial for treatment of bipolar disorder. Therefore, the correct answer is (B) | treatment planning |
443 | 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 imago intentional dialogue technique with couples consists of three steps | The imago intentional dialogue technique with couples consists of three steps. In step 2, you encourage the message receiver to respond by stating, “You make sense because …” or “I can see where …” This is an example of which of the following? | Empathizing | Attending | Validating | Summarizing | (A): Empathizing
(B): Attending
(C): Validating
(D): Summarizing | Validating | C | This is an example of validating. Imago relationship therapy, developed by Dr Harville Hendrix and Dr Helen LaKelly Hunt, uses imago dialogue, or an imago intentional dialogue, which is a technique used with couples to facilitate meaningful dialogue rather than unproductive discussions that fuel criticism, judgment, and contempt. There are three steps to an imago dialogue: (1) mirroring (ie, “what I hear you say is …”), in which the sender’s message is reflected by using methods such as paraphrasing, summarizing, and clarification; (2) validating (ie, “you make sense because …”), which conveys to the sender that the receiver has accurately understood the message and conveys how it made sense to them; and (3) empathizing, (ie, “I imagine this feels …”), which involves processing the message sender’s underlying feelings. Attending is a listening skill used throughout the process. Couples demonstrate attending using eye contact, facing their partner, and remaining focused. Therefore, the correct answer is (D) | counseling skills and interventions |
444 | 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 | Which of the following would be considered a negative attending behavior? | Consistently matching the client’s posture and repeating her statements throughout the session | Leaning forward | Turning your body 30 degrees in relation to the client throughout the session to present a less aggressive posture | Using hand gestures for emphasis | (A): Consistently matching the client’s posture and repeating her statements throughout the session
(B): Leaning forward
(C): Turning your body 30 degrees in relation to the client throughout the session to present a less aggressive posture
(D): Using hand gestures for emphasis | Consistently matching the client’s posture and repeating her statements throughout the session | A | Overusing mirroring with your posture and reflection can present as unnatural or manipulative to clients (Sommers-Flanagan & Sommers-Flanagan, 2015) and would therefore be considered a negative attending behavior. Leaning forward, using hand gestures, and turning your body about 30 degrees in relation to the client are typically not a negative experience for the client unless they are excessive. Overturning your body (past 45 degrees), can be considered a negative attending behavior (Sommers-Flanagan & Sommers-Flanagan, 2015). Therefore, the correct answer is (B) | counseling skills and interventions |
445 | 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. | her. Family History: The client says that she has a good relationship with her parents. She says that they are encouraging and supportive of her. The client says that she has a younger brother who is 6 years old and an older brother who is 16 years old. The client states that she has a good group of friends and spends time with them regularly. You noted that the client is withdrawn and appears uncomfortable | null | Ask the client what she does for fun. | Ask the client to talk about anything she wants. | Ask about the musical group depicted on the client’s t-shirt. | Ask open-ended questions to provide the client with the opportunity to answer in a way that she chooses to. | (A): Ask the client what she does for fun.
(B): Ask the client to talk about anything she wants.
(C): Ask about the musical group depicted on the client’s t-shirt.
(D): Ask open-ended questions to provide the client with the opportunity to answer in a way that she chooses to. | Ask open-ended questions to provide the client with the opportunity to answer in a way that she chooses to. | D | Open-ended questions were not helpful during the intake session; therefore, you need to take a different approach. If you ask the client about the musical group depicted on her t-shirt or what she does for fun, you show interest in the client and what she values, which could lead to building rapport. It can be helpful to open things up and allow the client to identify whatever goals she wants or to start talking about whatever is easiest for her to start talking about. This gives the client control and lets her lead with what she is most comfortable talking about. Therefore, the correct answer is (A) | counseling skills and interventions |
446 | Name: Jeanne Clinical Issues: Fear and panic Diagnostic Category: Anxiety Disorders Provisional Diagnosis: F41.9 Unspecified Anxiety Disorder Age: 35 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: Latin American Marital Status: Married Modality: Individual Therapy Location of Therapy : Community Center | The client appears tearful and overwhelmed. Her affect is mood congruent with her reported symptoms of panic, stress, and guilt. The client has a poor sense of control over her current mental state, leading to ideas and fears of not being able to cope with her current circumstances. She reports having panic attacks and expresses feeling overwhelmed by the demands of motherhood and home life. The client has difficulty concentrating on tasks, as well as changes in her eating habits, sleeping patterns, and overall mood, leading to worries about managing her responsibilities as a mother. She expresses an understanding of her situation and an awareness that her current mental state is not sustainable in the long-term. She has also expressed a desire to seek counseling as a first step towards managing her anxiety. | First session You are a therapist at a community center. The client is a married, 35-year-old mother of two young children. She is a stay-at-home mother, and the family is financially dependent on her husband's income. He works long hours and is very tired when he finally gets home, leaving most of the household tasks and childrearing to the client. She tells you, "About eight months ago while driving my car, I began having hot flushes, sweating, and feeling like I was going to die. It has happened multiple times since then. What if my kids are with me, and it happens again while I'm driving? I can't stop thinking about it." She states that her husband drove her to the session today because she has been afraid to drive since her first panic attack. She describes another incident two weeks ago while getting her hair cut. She began feeling like she had a heart attack. She tells you, "I sat straight up in the middle of having my hair shampooed and just ran out the door. The room felt so small all of the sudden and I couldn't stand it. It's so embarrassing. It doesn't make any sense." As she wipes tears from her eyes, she shares, "I'm becoming more and more afraid to leave my house by myself. I'm not even going to church anymore. The idea of being in a closed room full of people freaks me out. I'm terrified I'm going to have another 'attack.' I can't tell when another one will come on, and I don't even know how long it will last. Please, help me. I'm no good to anyone right now - not me, my kids, or my husband." She tells you that she had a "bad experience" with medications in the past and wants to try counseling before considering medications again. She expresses feeling afraid that she will never "get better." She also states she feels like a "bad wife and mother" because she cannot control her anxiety. You discuss the principles of panic-focused CBT and mindfulness-based stress reduction to effectively treat her. Fourth session At the start of today's session, the client hands you a copy of a hospital discharge form. She went to the emergency room two days ago with severe dyspnea and fear of dying from a myocardial infarction. Upon arrival at the hospital, the client reported paresthesia, pounding heart, and chest pain. She appears "frazzled" and disheveled during today's session. She describes the circumstances leading up to her trip to the hospital. She reports that her husband has been emotionally distant and is becoming increasingly frustrated with her anxiety. Finally, he told her that "this has been going on long enough" and that she needed to "get her act together." After this conversation, the client experienced a panic attack and stated that she was "terrified" that she was dying. Her husband arranged for their neighbor to watch the kids and drive her to the hospital. You tell the client that she must stop thinking she will die or progress in therapy will be unlikely. You reassure her that the physical sensations she feels during a panic attack are not life-threatening, even though they may feel that way. You discuss the importance of her bringing compassion and attention to her body rather than jumping into "fight, flight, or freeze" mode. The client appears anxious and has poor eye contact with an averted gaze. She is continuously wringing her hands together and bouncing her legs. She has trouble concentrating, as evidenced by her asking you to repeat questions. The client tearfully states, "I'm ruining my family. What if I die? Who will take care of the kids?" You provide empathy and walk her through a relaxation technique. | The client has two young children, ages four and six, both of whom have been diagnosed with ADHD. She has been married for ten years. Her husband is 47, twelve years her senior. He works full-time, and she is a stay-at-home mom. For the past year, the client has reported feeling overwhelmed with the demands of motherhood and home life. She feels that her husband does not understand her struggles, nor does he contribute enough to their household responsibilities. This lack of support from her husband has caused her to feel a deep sense of resentment. She is also concerned that her children are not receiving the support they need from their father, as his involvement in their lives appears to be minimal. The client expresses frustration with her lack of motivation and has become increasingly more anxious and irritable over the past several months. She reports difficulty concentrating on tasks. She feels her stress levels are rising and she is having recurrent panic attacks. In addition, she has noticed changes in her eating habits, sleeping patterns, and overall mood. These changes have caused the client to worry about managing her responsibilities as a mother. The client has been a full-time stay-at-home mother since the birth of her older child. Before that, she was a salesperson and shift manager at a local women's clothing boutique for several years. Since becoming a stay-at-home mom, the client has felt increasingly isolated and disconnected from the outside world. She fears she has lost her ability to successfully manage conversations with strangers, her skills in sales and marketing have eroded, and she no longer feels as confident in herself. Previous Counseling: The client has been hospitalized as she feared she was having a heart attack which turned out to be a panic attack. According to he client, her husband (her designated emergency contact person) was responsible for creating the conditions that resulted in her being hospitalized. | Upon arrival at the hospital, the client reported paresthesia, pounding heart, and chest pain. What would be the most likely manifestation of her paresthesia? | Tremors | Paralysis | Numbness | Dysphasia | (A): Tremors
(B): Paralysis
(C): Numbness
(D): Dysphasia | Numbness | C | Paresthesia is a type of abnormal skin sensation characterized by tingling, burning, pricking, itching, or numbness. It commonly affects the hands and feet but can occur anywhere on the body. It is caused by damage to nerve endings caused by trauma, medical conditions such as stroke or diabetes, localized pressure on a nerve, vitamin deficiency, or drugs and alcohol use. Therefore, the correct answer is (B) | intake, assessment, and diagnosis |
447 | Initial Intake: Age: 48 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Divorced Counseling Setting: Acute Inpatient Psychiatric Hospital Type of Counseling: Individual | Sandy wandered into the ER waiting room asking for a police officer. After further conversation, it was clear that Sandy thought she was in a police station and repeatedly called once of the nurses Officer McKinney, as if she knew him.
During the intake, the nurse practitioner mentioned that she was running a temperature, had a rapid heartbeat and breath smelled foul. In addition, her hands were trembling as well as her tongue and lips. Sandy’s behavior was somewhat irritable and erratic. At one point she was seemed to be hallucinating and stated that that she saw rats.
| Sandy was sent to the inpatient psychiatric from the emergency department for symptoms of hallucinations, memory loss, and disorientation.
History:
Sandy currently lives alone and is unemployed. She has a history of alcohol abuse and has been admitted to the hospital before because of this. Sandy has gotten into trouble with the law and has alienated most of her family and friends because of her alcohol use. She currently attends alcoholics anonymous. | null | The name of the activated system central to the neurochemical process underlying addiction is? | None of the above | Mesocorticolimbic pathway | Norepinephrine pathway | Serotonin pathway | (A): None of the above
(B): Mesocorticolimbic pathway
(C): Norepinephrine pathway
(D): Serotonin pathway | Mesocorticolimbic pathway | B | The mesocorticolimbic pathway is the sometimes called the "pleasure pathway" and is central to the release of dopamine and is activated by drugs. Serotonin pathway stabilizes our mood, feelings of well-being and happiness. The norepinephrine pathway is activated during stressful events and causes our fight or flight response. Therefore, the correct answer is (B) | intake, assessment, and diagnosis |
448 | Initial Intake: Age: 19 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: African American Relationship Status: Single Counseling Setting: Group home run by the Office of Children and Family Services Type of Counseling: Individual | Elaina has little insight into her behaviors and is currently involved in an abusive relationship. Staff members are concerned for her safety, as well at the safety of her child. She is not functioning well socially or academically. | Elaina is a 19-year-old female who is living in a residence for pregnant teens in foster care. She has been displaying risk taking behaviors such as running away and fighting.
History:
Elaina has an extensive history of abuse and neglect. She entered foster care at the age of 5 when her mother was incarcerated for prostitution and drugs. Since then, she has been in and out of foster care homes and had several failed trial discharges back to her mother’s care. Elaina ran away from her foster homes multiple times. Another trial discharge date is set for the near future, after the baby is born.
Elaina never finished high school. She had difficulty focusing on her classes and was often teased because the other children knew that she was in foster care. Elaina would frequently get into fights, resulting in suspensions. She has a tumultuous relationship with the father of her child, and she recently told her case planner that he sometimes hits her.
Elaina walked into the counselor’s office, sighed, and stated, “Great- someone new- I have to tell my story again?”
The counselor responded “It sounds like you have told your story many times. I can imagine how that feels for you.”
Elaina stated, “It is very frustrating and annoying.” To which the counselor responded, “I like to hear from clients, their history in their own words as opposed to reading it on paper. When we make your goals, I would like you to be involved as well.”
Elaina visibly relaxed and began to tell the counselor about her history and current challenges. Elaina agreed to think about what she wanted her goals to be and agreed to discuss it next session. | null | Elaina has experienced several ACEs which stands for? | Adverse childhood experiences | Adverse community experiences | Avoidant childrearing entities | Ambivalent caregiver experiences | (A): Adverse childhood experiences
(B): Adverse community experiences
(C): Avoidant childrearing entities
(D): Ambivalent caregiver experiences | Adverse childhood experiences | A | Adverse childhood experiences (ACEs) are negative experiences throughout the lifespan such as child abuse or caregiver mental illness which can lead to toxic stress. The more ACEs a person experiences, the more likely they are to have mental health and physical complications later in life. Therefore, the correct answer is (C) | intake, assessment, and diagnosis |
449 | 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 is responding well to your therapeutic interventions. School has ended, and her summertime athletic and academic commitments have lessened. The client reports that she is happy to be out of school and spoke again about not fitting in with her peers. She states that there are limited opportunities for sustaining friendships and worries that she will never find a romantic interest. She reports that her mother has suspended her social media account because the client was overly consumed by the number of “likes” that she received for her online posts. You explain that you will be starting a 12-week group of diverse teens who also experience anxiety and would like her to join. She agrees and is eager to participate | The preaffiliation, or forming, stage of group development is characterized by which of the following? | Dependency and inclusion | Structure and trust | Separation | Power and control | (A): Dependency and inclusion
(B): Structure and trust
(C): Separation
(D): Power and control | Dependency and inclusion | A | Dependency and inclusion describe the preaffiliation, or forming, stage of group development. This initial phase of group development is marked by apprehension and tentative exploration. The group leader’s involvement is most pronounced during this stage. Healthy time-limited or closed groups have distinct beginning, middle, and end stages (ie, forming, storming, norming, performing, and adjourning). Power and control describe the middle stage of group development. Other descriptors for this stage include storming, counterdependency, and flight. Competition and the struggle for control emerge as the authority of the group leader is challenged during this stage. Structure and trust describe the norming stage, which transpires during the working stage of development. The leader’s role is less pronounced during this stage, and the group members form closer connections. Separation, or adjourning, is associated with the last stage of group development. Therefore, the correct answer is (B) | professional practice and ethics |
450 | Initial Intake: Age: 28 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Married Counseling Setting: Private Practice Type of Counseling: Couple | The couple appear to be their stated ages with positive signs of self-care related to hygiene and dress. Both individuals appear overweight for height, and John appears to visually be categorizable as obese. Both individuals presented with congruent affect to their stated moods. Neither demonstrated retardation, spasticity, or hyperactivity of motor activity. The couple present as cooperative, open, and forthcoming, though each frequently looks at the other and confirms that the information they are presenting individually is accurate. Jane is noted to be caregiving of and highly empathetic to John. John is noted to respond appropriately to Jane’s statements. Neither presents with reports of suicidal ideations, thoughts of harm to self or others, or difficulties with memory, judgement, or concentration. | You are a counselor in a private practice setting. Your client, Jane, is 28 years old and presents with her spouse, John, a 24 year-old Hispanic male for “problems communicating.” The couple report that they have been married for one year after cohabitating for one year prior to marriage. Immediately after their marriage they began trying to become pregnant. They state they sought help from a specialist after several months and on learning that some degree of infertility existed, Jane began hormone therapy. Jane notes that it was soon after this time that the communication problems between them began. She tells you that it was at this point that she and John realized that they may not be able to have a biological child together. John acknowledges that Jane has tried many times over the last year to bring up this topic for discussion, but he chooses not to engage her. He tells you that he tends to believe that “if I don’t think about it, it will probably go away.” Jane agrees with John and reports that over time, the couple have talked less and spend much less time together. John agrees and says that sometimes “I may not say more than five words to Jane in a day.” Jane reports that they have not been intimate in over two months. When completing the intake paperwork, John endorsed no problems on any symptom criteria. Jane reported “serious” problems with “feeling sad, loss of interest in things she previously enjoyed, crying spells, and stress. She reported “moderate” problems with “feelings of worthlessness, anxiety, loss of appetite, and sleep disturbance. The couple states they were to sign divorce papers last week but made the decision to try counseling first. Neither has participated in counseling previously. | Family History:
The couple currently live with Jane’s 10 year-old son from her previous marriage and Jane’s 75 year-old grandfather, for whom the couple provide care. Jane owns and operates a small shop, is completing her bachelor’s degree, cares for her grandfather, and parents her son, who is heavily involved in baseball. She describes a history of hypothyroid disease though is no longer taking medication as her disease is now controlled with diet and exercise. She reports taking an antidepressant for two years, approximately seven years ago. She currently is taking Provera and Clomid for infertility and states these have had a noticeable effect on her mood. John reports this is his first marriage and he has no children from prior relationships. He was laid off two years ago and has been working in his uncle’s business, but the family has no insurance. He is actively involved in caring for Jane’s son and grandfather. He reports a history of high blood pressure. Prior to their wedding, John states he experienced irritability, agitation, difficulty sleeping due to “thinking about things” and worry. He was prescribed an SSRI and took this for six months. He tells you it seemed to help but he discontinued it 8 to 9 months ago. He reports that his doctor said his anxiety might have been because of his high blood pressure. | Which of the following policies builds trust specifically when working with couples in counseling? | The counselor's policy on counseling attendance | The counselor's policy on who is responsible for payment | The counselor's policy on information provided to the counselor by one individual without the knowledge of their partner | The counselor's policy on mandated reporting for domestic violence between adults | (A): The counselor's policy on counseling attendance
(B): The counselor's policy on who is responsible for payment
(C): The counselor's policy on information provided to the counselor by one individual without the knowledge of their partner
(D): The counselor's policy on mandated reporting for domestic violence between adults | The counselor's policy on information provided to the counselor by one individual without the knowledge of their partner | C | When working with couples, the counselor's policy of holding or not holding secrets must be determined and communicated to the couple in the informed consent. Many counselors choose not to hold secrets for individuals in a couple so as not to become triangulated in the relationship. A counselor's policy on payment responsibility and attendance is communicated to all clients regardless of whether it is couples counseling or individual counseling. Counselors are mandated reporters for suspected abuse of a child, elderly person, or a vulnerable adult, but not of adults who do not meet these criteria. Therefore, the correct answer is (B) | treatment planning |
451 | Initial Intake: Age: 40 Sex: Female Gender: Female Sexuality: Lesbian Ethnicity: African American Relationship Status: Partnered Counseling Setting: Community Agency Type of Counseling: Individual | The client appears to be slightly older than stated and demonstrates positive signs of self-care in her hygiene and dress. She states her mood fluctuates between “sad and okay.” Her affect is labile and mirrors topics discussed in session. She smiles when describing her children and her relationship with her former oncology team. She cries easily when discussing cancer, moving, instability, and fears. The client is cooperative and forthcoming, with easily understood speech. She offers insight into her thoughts and behaviors, is attentive, and shows no difficulties with memory or judgement. She acknowledges one episode of suicidal ideation, without plan, during her adolescence when she desperately missed her mother while on a custodial visit with her father. She has had no thoughts of harming herself since then and has no thoughts of harming others. | You are a counselor in a community agency. Your client presents with concerns about her lifelong history of being “anxious and emotional” since her parent’s divorce when she was 12. She tells you her feelings of “anxiety and feeling badly about myself” intensified when she was diagnosed with breast cancer four years ago and then again when her family moved to the area last year. She tells you that she thinks she managed her emotions well during her treatment because her focus was on getting through the crisis. She also was taking Klonopin twice a day for anxiety. She says she feels that she has let her family down by having cancer because it costs them monetarily and emotionally; she wonders sometimes if her cancer is a punishment for something she’s done. She reports that she does not discuss these concerns and emotional fears with her partner because “she has become the breadwinner and I feel like I need to protect her from my negativity.” On intake forms, she endorses crying daily, trouble sleeping, concentrating on things, has been losing weight without trying, and constantly worrying about her health and the family’s finances. She tells you that her partner says she “runs around like a chicken with my head cut off because I start stuff like cleaning or cooking and then stop right in the middle of it. I just get restless and sometimes I just can’t stop fidgeting when I should be paying attention.” She notes that she is in menopause due to her cancer treatments, which included a removal of her ovaries three years ago and a hysterectomy one year ago. She tells you people often refer to her as a “cancer survivor” but she doesn’t feel like she has survived it because every surgery makes her feel like she “is losing another piece of me.” Additionally, she says that having to have body scans every six months and not being able to look in the mirror and see a “complete woman” makes her feel that she is still trying to survive, rather than putting it in the past. | Family History:
Your client reports a four-year history of treatment for breast cancer. She has had 16 months of chemotherapy and 27 rounds of radiation, as well as a double mastectomy three years ago. She has completed reconstructive surgery for her breasts but has not yet added nipple tattooing for a more realistic image. She reports that she has three close female relatives with breast cancer, but no relapses after treatment. She states that she has been in a relationship with her partner for 17 years and they share two children, ages 12 and 8. She describes her partner as a “good person” and the relationship as “good.” She tells you that they moved to the area one year ago when her partner had an unexpected promotion. She reports this has been good but that their oldest child is “anxious, emotional, and just angry sometimes.” | Based on the information provided, which of the following diagnoses is most appropriate for the client at this time? | General Anxiety Disorder | Major Depressive Disorder | Anxiety Disorder Due to Another Medical Condition | Somatic Symptom Disorder | (A): General Anxiety Disorder
(B): Major Depressive Disorder
(C): Anxiety Disorder Due to Another Medical Condition
(D): Somatic Symptom Disorder | Major Depressive Disorder | B | The client meets six criteria for diagnosis with major depressive disorder. She cries daily (Criterion A1), difficulty sleeping (A4), weight loss without trying (A3), psychomotor agitation observable by others (A5), difficulty concentrating (A8), and feelings of inappropriate guilt for having cancer (A7). The client has been treated for anxiety and names her emotional state as anxiety, but her symptoms most closely indicate depression. She does worry about finances and her health, but these are normal worries given her circumstances and do not qualify as anxiety. For these reasons, she does not qualify for a general anxiety disorder. The client does not meet criteria for an anxiety disorder due to a medical condition because this requires that her medical condition, cancer, is physiologically causing her current physical or emotional symptoms and no evidence is provided to support this. Additionally, the client does not complain of somatic symptoms (most commonly pain) that is debilitating and significantly disrupts the client's life. Therefore, the correct answer is (B) | intake, assessment, and diagnosis |
452 | 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 would be the most effective “homework assignment” for the client before the next session? | Create a wall collage of her son's photos for the home | Write about her son and her feelings in a daily journal | Choose one day a week for family members to discuss the loss | Talk with her husband about her counseling session | (A): Create a wall collage of her son's photos for the home
(B): Write about her son and her feelings in a daily journal
(C): Choose one day a week for family members to discuss the loss
(D): Talk with her husband about her counseling session | Write about her son and her feelings in a daily journal | B | Writing in a journal provides space for the client to express her feelings. These can be shared with the counselor if desired. The artwork and family interactions represent ways to require the family to engage with the client's pain, which is not serving the client effectively at this time. Therefore, the correct answer is (C) | treatment planning |
453 | Client Age: 48 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Separated Counseling Setting: Private practice Type of Counseling: Individual Presenting Problem: Alcohol use Diagnosis: Alcohol Use Disorder, Moderate, Provisional (F10.20) | Mental Status Exam: The client’s hands tremble, and she becomes tearful on several occasions. There is mild perspiration on her forehead. She endorses feeling hopeless about the future but denies suicidal ideation. The client shows no signs of intoxication or impairment. She presents as well-dressed with good hygiene. Both affect and mood are dysphoric. She apologizes several times for crying and states she has been “a mess” lately due to not sleeping for the last several days. Her demeanor becomes somewhat defensive when asked about her drinking, and she appears to minimize the impact this has had on her life. Fam | You are a counselor working in private practice evaluating a 48-year-old female with a history of alcohol misuse. Three weeks ago, the client was hospitalized due to alcohol poisoning. She explains that she was in a blackout before waking up in the hospital and was told her BAC was 0.26, just over three times the legal limit. This occurred on the evening she discovered that her husband was having an affair. The client briefly attended a drug and alcohol intensive outpatient program (IOP) but felt she was not improving with group therapy and would like to try individual therapy instead. She admits that there are times in her life when she has abused alcohol but does not believe she is an alcoholic. The client experiences frequent anxiety and admits to using alcohol “just to take the edge off” and to help her fall asleep. Her alcohol intake increased nearly six months ago when her youngest child left for college. During this time, her husband of 25 years announced he was leaving and filing for divorce. She struggles with being an “empty nester” and is mourning the loss of the life she and her husband built together. | ily and Work History: The client worked briefly as an office manager but became a stay-at-home mom once she had kids. As a devout Catholic, she reports feeling heartbroken and ashamed that her husband is filing for divorce. The couple frequently entertained guests at their home, which abruptly stopped after their separation. Her oldest daughter is not speaking to her and is “taking her father’s side,” which has caused her great sadness and resentment. Her middle child, who lives locally, is married with children but does not allow the client to visit her grandchildren unsupervised. She believes her children’s father has spread lies about her alcohol use and feels he “drinks just as much” but appears to do so with impunity. The client’s mother was addicted to pain pills, and her father was diagnosed with bipolar disorder. The client witnessed interpersonal violence between her parents as a child and often felt unsafe growing up. History of Substance Use and Addictive Behavior: The client first started drinking at the age of 14. Her drinking increased significantly while in college and in her early 20’s. The client was able to stop drinking through her three pregnancies but began to drink daily when her children became school-aged. She acknowledges that drinking during the day first started while waiting in the school’s carpool line and increased when her husband returned home from work. She has received three DUIs and had the third offense expunged. After the third DUI, she was court-ordered to attend Alcoholics Anonymous. She stated she resented having to “get a piece of paper signed” and being asked to attend 90 meetings in 90 days. The client denies substance use beyond experimenting with marijuana in college. She concedes that alcohol has been problematic in the past but feels she can successfully control her intake | null | On more than one occasion, the client has been arrested or had other legal problems because of alcohol use. | The client has continued to consume alcohol, even though it causes difficulties with her family or friends. | Adverse consequences associated with alcohol consumption have increased in severity within the last 6 months. | The client sees or hears things that others do not. | (A): On more than one occasion, the client has been arrested or had other legal problems because of alcohol use.
(B): The client has continued to consume alcohol, even though it causes difficulties with her family or friends.
(C): Adverse consequences associated with alcohol consumption have increased in severity within the last 6 months.
(D): The client sees or hears things that others do not. | The client has continued to consume alcohol, even though it causes difficulties with her family or friends. | B | This question addresses the client’s reported symptoms and the diagnostic criteria for Alcohol Use Disorder (AUD). AUD is diagnosed in individuals who meet at least 2 of 11 criteria in the same 12-month period, as outlined in the DSM-5-TR. The client admitted to continuing to consume alcohol even though it was causing family difficulties (eg, divorce, estrangement from her oldest child, and supervised visits with her grandchildren). This criterion is one out of the 11 criteria recognized in the DSM-5-TR. Individuals who see, feel, or hear things that others don’t are symptoms of alcohol-induced psychosis, which the client did not experience. The client did have negative consequences associated with alcohol consumption, and those consequences did increase in severity within the last 6 months; however, that is not a characteristic of AUD. The client’s 3 DUIs would qualify as legal troubles; however, this criterion was recognized in the DSM-IV and not included in the DSM-5 or DSM-5-TR. Therefore, the correct answer is (D) | intake, assessment, and diagnosis |
454 | Name: Jill Clinical Issues: Depression and recent death of a close friend Diagnostic Category: Depressive Disorders;Substance Use Disorders Provisional Diagnosis: F34.1 Persistent Depressive Disorder, with Anxious Distress, and F10.99 Unspecified Alcohol-Related Disorder Age: 26 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: Eastern European Marital Status: Never married Modality: Individual Therapy Location of Therapy : Agency | The client is a 26-year-old female who appears slightly disheveled and unkempt with bags under her eyes, suggesting recent lack of sleep. Her affect is flat and her behavior is withdrawn. She speaks in a quiet monotone and is tearful at times. Her speech is coherent, though her thoughts are sometimes diffuse. She exhibits difficulty in focusing on topics and has some difficulty in supplying relevant details. The client reports that she has difficulty concentrating and recalling information, as well as making decisions. No perceptual distortions are reported. The client has limited insight into the cause of her distress, but appears to understand that her drinking is a problem. Her judgment appears impaired due to her drinking, as evidenced by her blackout episodes. The client expresses feeling overwhelmed and states that if counseling does not help, she is not sure she wants to go on living. She has also had thoughts of death and dying. | First session You practice as a mental health therapist at an agency. A 26-year-old female presents for therapy following a recent incident involving the death of her close friend. The client elaborates on her friend's death by saying, "He was beaten to death because he was transgender." The attack occurred a week ago, but the client states she has felt depressed for as long as she can remember. She says, "He was the only person who could actually put up with me. Now that he's gone, I feel like I have no one." She tells you that during the past few years, she has been drinking as a way to cope with her feelings. She states that she is usually able to control her drinking, but admits that lately it has "gotten out of hand." After her friend was killed, she went to a party and blacked out after drinking. She states that she cannot seem to find joy in anything and cannot stop thinking about her friend. You continue your assessment by exploring the client's history and current symptoms. After gathering more information, you determine that the client is experiencing a major depressive episode which has been compounded by her friend's death. When asked what she is hoping to gain from therapy, she responds, "I just want to stop feeling so awful all the time." You validate her feelings and applaud her willingness to seek help. You share information about the counseling process and treatment options, including potential risks and benefits. You tell her that it is important to be open and honest during therapy and that she may need to talk about some difficult topics to make progress. After explaining the importance of developing a trusting relationship, you encourage her to ask questions and ask if she has any concerns. She asks if she can contact you outside of your counseling sessions. You review your agency's policies with her, including information about therapist availability. | The client grew up in a very chaotic household with five siblings. The client is a first-generation Eastern European whose family immigrated to the United States before her birth. Her parents never adapted to the culture. Her father committed suicide when she was in high school. She says, "It was like my dad leaving us just made everything worse." The client says she has no patience with her siblings when they call and has little desire to keep in touch with them. After completing her associate's degree, the client immediately started her job as a paralegal. She is a paralegal at a law firm where she has worked for two years. She describes her work as "okay, but not something I'm passionate about." She says that she has been feeling increasingly overwhelmed and stressed out. At work, she becomes easily annoyed, has trouble concentrating, and feels tense. She has difficulty getting along with her colleagues and tries to avoid them when she can. | What do your observations of the client during the initial session suggest in terms of establishing primary treatment goals? | The primary treatment goals should focus on exploring her childhood experiences and how they may be contributing to her current symptoms. | The primary treatment goals should address thoughts of dying, coping with loss, and her drinking behaviors. | The primary treatment goals should focus on examining the client's past relationships and how they are impacting her current emotional state. | The primary treatment goals should focus on helping the client develop better social skills and increase her social connections. | (A): The primary treatment goals should focus on exploring her childhood experiences and how they may be contributing to her current symptoms.
(B): The primary treatment goals should address thoughts of dying, coping with loss, and her drinking behaviors.
(C): The primary treatment goals should focus on examining the client's past relationships and how they are impacting her current emotional state.
(D): The primary treatment goals should focus on helping the client develop better social skills and increase her social connections. | The primary treatment goals should address thoughts of dying, coping with loss, and her drinking behaviors. | B | These issues should be the initial focus of treatment in order to address the client's immediate psychological needs. Therefore, the correct answer is (A) | treatment planning |
455 | Initial Intake: Age: 20 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Married Counseling Setting: Community Mental Health Agency Type of Counseling: Individual | The client presents appropriately dressed with evidence of positive self-care related to hygiene and appearance. Her mood is stated as anxious about being labeled as “crazy” though you note her affect appears to be angry. Her movements and speech demonstrate no retardation; she is cooperative, engaged, and forthcoming. She reports past suicidal attempts using alcohol or pills when she was extremely angry at her boyfriend or her parents, but emphasizes she has no current suicidal ideations. She also states she has had past thoughts of hurting others but emphasizes she does not desire to or think about hurting others now. Her short- and long-term memory appear to be intact, but demonstrates poor insight and judgement in choices. | You are a counselor in a community mental health agency. The client presents for “an evaluation,” which she states is required by her parents before she is allowed to move back into their home. During the intake session, you learn that your client was married for 18 months and has been divorced for two years. The client states that her husband had an affair during their marriage, which led to the divorce. She states she has a daughter who is five years old and shares custody with her ex-husband, who is now remarried. She reports that she was living with her parents until recently and is now sleeping on a friend’s couch. The client acknowledges that she has had several traffic incidents related to driving while intoxicated in the past few months. She reports she “totaled” her new car last week but was not arrested, likely because her companion had a felony warrant and the police arrested him at the scene and not her. It was at this time that she says her parents insisted she move out of the house and cannot return until she has sought counseling. She states she wants to “move on from my past,” she misses how things used to be, and wishes that her parents understood her better. The client reports that she drinks at least 20 alcoholic drinks per week and uses marijuana intermittently. She states she takes Adderall to help her clean the house quickly, uses cocaine, and has used Klonopin in the past, but stopped due to a “back experience.” She states she does not have a problem with substance use but acknowledges it is a stressor in her relationship with her parents. She reports that using substances are the “only way to get to know people” and has found herself angry when attending parties where others were having fun but she was not drinking or high. | Family History:
Client reports that she is the youngest of two children and that her family relationships were terrific until she turned 14 years old and then her parents “went crazy” when her grades in school declined and she was often grounded. She tells you that her parents didn’t like her after that and were always angry at her. On further discussion, the client says that she began dating a 19-year-old male when she was 14 but her parents decided he was too old for her and would not allow her to see him. She admits being furious at him for not taking her out after that and she called him daily to try to change his mind for over two months. She says she can’t stand him now and that he is currently in prison for aggravated assault on a police officer. She also tells you that at 15 years old, she began a long-term relationship with another man, who is now in prison for attempting to shoot someone. She states that he got involved with another girl and your client ended up getting arrested after she started a fight with the girl. Her third relationship was with her husband and with whom she became pregnant. At that time, her parents “kicked me out of the house and I couldn’t even come back inside to get my things.” They divorced two years ago after he called the police after “he said I attacked him when I found out he was cheating on me.” | Which of the following will the counselor need to be most aware of when helping this client set treatment length expectations and prognosis? | Skill building through DBT is helpful but cannot create lasting change | Addiction is a cycle that include relapse | Addiction in conjunction with BPD is not treatable | BPD characteristics tend to diminish in late adulthood so therapy may be long-standing | (A): Skill building through DBT is helpful but cannot create lasting change
(B): Addiction is a cycle that include relapse
(C): Addiction in conjunction with BPD is not treatable
(D): BPD characteristics tend to diminish in late adulthood so therapy may be long-standing | BPD characteristics tend to diminish in late adulthood so therapy may be long-standing | D | Research shows that clients with BPD tend to experience more distress in young adulthood but may gradually experience fewer symptoms in late adulthood and this can be improved with treatment. Therapy is frequently long-term and may be needed for years to modify ingrained personality characteristics. Skill building with DBT is an effective treatment and some studies show that clients may not qualify for a BPD diagnosis after completing long-term DBT therapy. The addiction cycle does include relapse but this is incidental to BPD. Addiction is often a way that individuals with BPD medicate their distress and is treatable with substance abuse therapy. Therefore, the correct answer is (B) | counseling skills and interventions |
456 | 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 types represent the client's ISA code? | Intellectual, Structured, Analytic | Investigative, Social, Artistic | Intuitive, Sedentary, Abstract | Inventive, Scientific, Active | (A): Intellectual, Structured, Analytic
(B): Investigative, Social, Artistic
(C): Intuitive, Sedentary, Abstract
(D): Inventive, Scientific, Active | Investigative, Social, Artistic | B | The Holland RIASEC types are Realistic, Investigative, Artistic, Social, Enterprising, and Conventional. The client's type ISA shows that her personality type is Investigative, Social, and Artistic so a counselor would facilitate exploration of occupations and work environments that meet the ISA, IAS, SIA, SAI, AIS, and ASI codes. Therefore, the correct answer is (B) | intake, assessment, and diagnosis |
457 | Initial Intake: Age: 16 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: African American Relationship Status: Single Counseling Setting: Community Health Type of Counseling: Individual | The client appears older than his stated age, with weight appropriate for height. He demonstrates positive signs of self-care in his hygiene and dress. He appears to be open and cooperative, with some hesitancy noted in his speech pattern, due to age or possible alcohol use. The client endorsed several positive responses to alcohol dependence but states he has not used alcohol prior to this session. He states he does not take any medication. He identifies his mood as ambivalent and his affect is congruent with little lability. His responses to questions demonstrate appropriate insight, judgement, memory, concentration, and orientation. He does state that he has never considered harming himself, but acknowledges passive ideas such as, “what’s the point,” he would be “better off dead,” or he should “drink a lot of wine and go to sleep.” He acknowledges these as previously unrecognized suicidal ideations and states he does not have a wish or plan to follow through or harm himself. | You are a counselor in a private practice setting. Your client is a 68-year old male who presents with difficulties stemming from his role as a caregiver to his wife of 26 years and who now has Parkinson’s disease and requires his full attention. He tells you that he has been providing care for the past 40 years, first for his parents and now for his wife. The client endorses feelings of sadness, anger, guilt, irritability, and being overwhelmed. He states that he has difficulty concentrating, anxious, losing things, and having unwanted thoughts like that he might be better off dead. He tells you also that he has difficulty sleeping and can’t enjoy any hobbies or social activities because of caring for his spouse. The client states that he distracted himself from his negative feelings last year by preparing for the move to their new home and then getting settled in. The client and his wife moved into an assisted living facility, but live in independent housing. The client endorsed a history of alcohol use that includes drinking more than he intends, feeling the need to cut down, being preoccupied with drinking, and using alcohol to relieve emotional pain. He states he drinks one to two bottles of wine daily and has done so for the past 6 years. He acknowledges that he has not admitted the extent of his alcohol use to others and works diligently to hide it. He reports he is unwilling to attend AA or other alcohol support groups, but “lurks” on an online support group for alcoholics. The client tells you that he attended counseling twice: 15 years ago, related to depression about his wife’s diagnosis and 10 years ago related to depression and anxiety related to caregiving. On both occasions, he was prescribed antidepressants but said he refused to fill the prescriptions because he doesn’t like to take medicine. | Family History:
The client describes his family history as containing a significant number of family members who use alcohol in great quantities and multiple, maternal, close relatives diagnosed with schizophrenia. Client states that two of his aunts have male children with schizophrenia and that one of these aunts has been diagnosed with Bipolar I disorder. The client’s father was diagnosed with Parkinson’s disease and was in an assisted living facility prior to his death while the client’s mother remained in their family home. The client was the main caregiver for both of his parents until their deaths. The client reports two siblings, one with an alcohol and drug use history who is a paraplegic following a motorcycle accident and one who identifies as “gay” with a history of alcohol dependence and hospitalizations for “nerves.” | Which of the following is the best approach to help you determine the client's current readiness for counseling? | Use Motivational Interviewing | Use the client's goals as indicators | Use the Motivation Assessment Scale | Use Prochaska and DiClemente's Transtheoretical Model | (A): Use Motivational Interviewing
(B): Use the client's goals as indicators
(C): Use the Motivation Assessment Scale
(D): Use Prochaska and DiClemente's Transtheoretical Model | Use Prochaska and DiClemente's Transtheoretical Model | D | Prochaska and DiClemente's Transtheoretical Model includes five stages of change and allows the client and counselor to determine the client's current status in their readiness for change, from precontemplation to maintenance. This allows the counselor to tailor the treatment plan to the stage in which the client currently resides. Motivational Interviewing is an effective way of moving a client into action when they are less motivated to do so or are experiencing resistance. Motivational Interviewing is a good intervention to use after the client's stage of change has been determined. The Motivation Assessment Scale does measure motivation but is used for clients with developmental disabilities. The client's goals may show desires for change but particularly as the client has been in counseling for these same issues in the past, it is not likely that the goals will provide evidence of the client's readiness for change. Therefore, the correct answer is (B) | intake, assessment, and diagnosis |
458 | Client Age: 7 Grade:2nd Sex: Male Gender: Male Ethnicity: African American Counseling Setting: Community Mental Health, School-Based Services Type of Counseling: Individual and Collateral Presenting Problem: Impulsivity; Inattention; Hyperactivity Diagnosis: Attention-Deficit Hyperactivity Disorder (ADHD) 314.01 (F90.2) | Mental Status: The client is dressed appropriately, and he is well groomed. His affect is bright when engaged in an activity of his choice, but he becomes irritable when asked to comply with a direct request (e.g., pick up the toys, walk in the hallway). He is energetic, eager to please, and interrupts your conversation with the mother, as evidenced by the client stating multiple times, “Watch this! Hey! Watch! Look what I can do!” The client has difficulty transitioning from your office and back to his classroom. He runs ahead of you in the hallway and does not respond to redirection. The client has not voiced suicidal or homicidal ideation. Developmenta | You are a clinical mental health counselor providing on-site school-based services in a public elementary school. Your client is a 7-year-old African American male enrolled in the 2ndgrade. The client is accompanied by his mother, who states that she is here because the school “requested an ADHD assessment.” The school reports that the client is disruptive, refuses to follow directions, disturbs others, and has difficulty staying on task. The mother describes the client as “energetic” and “strong-willed”—behaviors that she believes are “just typical for a boy.” She is upset that the school wants to conduct a formal evaluation to determine if the client qualifies for a more restrictive classroom setting. The school’s population is predominantly white, and the mother believes that her son is being treated unfairly because of his race. | You have been working with the client weekly and are meeting with the mother today to discuss interventions that she can use at home. She relays that her husband does not support the diagnosis of ADHD and has reached out to their faith community instead. The mother is conflicted about counseling and explains that it is viewed as a sign of weakness in her community. She continues to voice concern over the school’s lack of diversity and her belief that the client is being treated differently because of his race | Which of the following would help you engage the client’s mother in treatment? | Explore the influence of her biases toward the school’s majority culture. | Denote the incongruence between historical trauma and here-and-now experiences. | Refute the core cultural beliefs surrounding mental health stigma. | Recognize the impact of the intersectional contexts of privilege and marginalization. | (A): Explore the influence of her biases toward the school’s majority culture.
(B): Denote the incongruence between historical trauma and here-and-now experiences.
(C): Refute the core cultural beliefs surrounding mental health stigma.
(D): Recognize the impact of the intersectional contexts of privilege and marginalization. | Recognize the impact of the intersectional contexts of privilege and marginalization. | D | Recognizing intersectional contexts of privilege and marginalization would best help engage the mother in treatment. Intersectionality considers each individual’s privileged and marginalized status in terms of all intersecting sociocultural contexts (eg, race, ethnicity, religion, socioeconomic background, education). Culturally responsive therapists consider the client and the counselor’s intersectional identity’s impact on the client’s presenting problem, treatment engagement, and treatment adherence. Validating rather than refuting core cultural beliefs surrounding mental health stigma can enhance the therapeutic relationship. Exploring the influence of the biases toward the school’s majority culture is not conducive to engaging the mother in treatment. Finally, it is essential to validate historical trauma (and not denote its incongruence), particularly the trauma’s connection to here-and-now experiences, values, and assumptions. Therefore, the correct answer is (B) | counseling skills and interventions |
459 | Name: Michael Clinical Issues: Separation from primary care givers Diagnostic Category: Anxiety Disorders Provisional Diagnosis: F93.0 Separation Anxiety Disorder Age: 10 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Not Assessed Ethnicity: Guatemalan American Marital Status: Not Applicable Modality: Family Therapy Location of Therapy : Agency | Michael appears clean and dressed in appropriate clothing. He often fidgets with his hands and insists on sitting next to his father during the session. Speech volume is low, and pace is fast. He has a slightly flattened affect. He exhibits minimal insight consistent with his age. | First session You are a licensed mental health counselor at a pediatric behavioral health center. Michael, a 10-year-old male, presents along with his father. You conduct a thorough psychological exam, including a mental status examination. During the initial interview, you take note of Michael's behavior. He sits very close to his father and looks fearfully around the room. The father tells you Michael has been having trouble at school and home for the past few months and it has been getting worse. When you ask how Michael is doing in school, the father tells you there have been several incidents, including difficulty waking up for school, crying in the morning, and refusal to get dressed and ready. The father also tells you that Michael has been showing signs of frustration with his teachers and classmates. On the home front, the father mentions that his son has become "a nuisance for his babysitter, especially during bedtime." Both parents are paramedics on a 24-on/48-off shift rotation. Michael often calls his parents while at work, complaining that he feels sick and cannot fall asleep. He worries that someone might break into the house or that "something bad will happen" to his parents. The father reports that he and his wife have tried to reassure Michael, but their efforts have been unsuccessful. They are perplexed as to what is causing Michael's distress. The father tells you that Michael has always been a bright and energetic child, but now he seems overwhelmed and anxious. You conduct a more detailed interview with Michael alone, focusing on his current environment and daily routines. You ask him how he feels about school, and Michael denies having any issues. He tells you that he does not want to go because his new school is "boring." However, when you probe further, he admits to feeling scared and alone. He does not want to be away from his parents, and he imagines "all the ways they could be hurt" while they are not with him. You say, "I can understand why you might be feeling scared and anxious, Michael. It sounds like a lot has been going on recently. I'm here to help you and your parents understand what's causing your worries so you can start to feel better." You reconvene with Michael's father and provide a brief summary of your findings. You explain that you suspect Michael's anxiety is likely due to the family's recent relocation and having to adjust to a new school. His fears are also likely rooted in his parents' profession, which may lead him to worry about their safety while they are away from home. You have personal experience in dealing with pediatric anxiety and consider briefly sharing your story with Michael and his parents as you believe it may help them to feel supported and less alone in their struggles, while also providing a practical example of how to work through difficult times. You suggest developing an intervention plan to address Michael's distress and recommend meeting with Michael and his parents for weekly sessions. Fourth session When you arrive at your office today, you realize that you inadvertently left therapy notes on your desk after work on Friday, which included information about Michael's case, and the notes are not where you left them. The weekend cleaning crew lets you know that the notes were discarded in the trash. You take the appropriate action in managing this breach of confidentiality, following your practice's guidelines and policies. You also take time to reflect on how this incident could have been prevented and use it as a learning opportunity for yourself. When you met with Michael and his parents during the previous two sessions, you gathered additional information about his symptoms, thoughts, and feelings. You provided psychoeducation about separation anxiety and recommended that Michael's parents make an appointment for him to see his pediatrician. You also began to formulate a treatment plan with the overall goal of tolerating separation from his parents without severe distress. Michael and his parents present for today's session on time. The parents begin by reporting that their son's symptoms continue to be a problem. School refusal is still an issue. His mother has had to come home from work three times this past week. His outbursts were so loud that the neighbors came by to check on him. The mother says, "My boss has been patient with me so far, but pretty soon, I'm going to be at risk of losing my job if we can't get a handle on our son's behavior. What are we doing wrong?" Your focus during this session is on helping the parents understand their role in the therapy process. You start by reviewing some of the psychoeducation you provided in prior sessions, focusing on the importance of consistency in parenting approaches and providing structure for Michael at home. You discuss different strategies they can use at home to help build their son's coping skills. You also provide some relaxation exercises that Michael can do when he feels anxious. At the end of the session, you thank Michael and his parents for coming in today and assure them that they are on the right track. You take time to summarize the key points of the session and emphasize the importance of follow-through with what was discussed in order for progress to be made. You provide them with resources to further support their efforts and suggest a follow-up appointment in one week. Tenth session You have been working with Michael to develop and practice effective coping skills appropriate to his age. You have been using behavioral modification techniques to decrease his anxiety about being away from his parents. During previous sessions, you suggested that his parents leave your office space for progressively more extended periods. Michael has complied with these requests, although he was initially anxious and agitated. After five weeks, he is now able to tolerate being away from his parents for up to an hour. In today's session, the parents reflect on their son's progress since he started therapy. They believe that he has made a significant improvement. To date, there have only been "little incidents." The parents report that two days ago, Michael was reluctant to go to bed without them and had a minor fit. Instead of escalating the situation, they calmly reminded him of the strategies he had learned in therapy such as taking deep breaths when feeling anxious. To their surprise, Michael began using his coping skills and went to bed peacefully. Michael's mother tells you, "It finally feels like we've turned a corner. I'm so proud of him!" The parents have also received positive updates from Michael's teachers who say that he is doing much better in school. They report that he has made a new friend and was invited to a sleepover. Michael seems excited about the idea. His parents are not sure how he will handle being away from home overnight, but they are willing to try. After providing you with an update, the parents leave the room to wait in the waiting room while you talk to Michael. He appears receptive and comfortable with this arrangement. He tells you, "I kind of feel dumb for being scared. I'm sorry for causing so much trouble." You respond affirmatively and validate his feelings. Next, you say, "I remember when you first came to my office with your mom and dad. You were having a lot of trouble being away from them. Do you think that's still a problem for you?" He shakes his head "No" and reports that he is now able to be away from his parents for longer periods of time without feeling scared or upset. You ask him what has been most helpful to him when he starts to feel anxious. He says, "The counting and breathing stuff you showed me how to do. Also, I think about something fun that I did with my mom and dad, like that time we went to the beach and built a giant sandcastle!" You tell him how proud you are of his progress and encourage him to keep using the coping strategies he has learned in therapy. Near the end of the session, you invite Michael's parents back into your office to check in with them about next steps. The parents agree that Michael has made significant progress in tolerating separation and they feel that the treatment has been successful. You offer additional resources for follow-up care and suggest a plan for transitioning out of therapy. Lastly, you thank Michael and his parents for their dedication throughout the course of therapy and let them know that you are available if they have any further questions or concerns. | Michael's parents have been married for nine years and both are dedicated to the well-being of their children. The father reports that he and his wife communicate openly with each other and make joint decisions about parenting issues. They also model healthy family dynamics, such as expressing affection and respect towards one another, being honest with one another, and sharing responsibilities. Michael has a five-year-old sister. His father characterizes the family as very close; they do everything together. The father says that he and his wife go to their children's sporting events and school meetings. Every weekend, the four of them are together doing family activities. Except when required to be away due to their work schedules as paramedics, the parents are home with the children at night. Prior to the family's move to a new state 6 months ago, Michael had been a successful student at school, typically performing at or above grade level. He was an active participant in the classroom, often volunteering to answer questions or participate in class discussions. Since the move, however, getting ready for school has been a struggle each day. He is struggling academically; while his grades haven't dropped drastically, he appears to be having trouble focusing and understanding the material. His parents have attended parent-teacher conferences and Michael's teachers have also reported that he seems distracted and uninterested in class. His parents also report that they are having difficulty getting him to stay on task when doing his homework at home. | Throughout the sessions with the client, his parents have accompanied him. You have asked one or both to leave the room for progressively longer periods of time as the sessions have progressed. What approach are you using? | Imaginal exposure therapy | Successive approximations | Flooding | Systematic desensitization | (A): Imaginal exposure therapy
(B): Successive approximations
(C): Flooding
(D): Systematic desensitization | Systematic desensitization | D | Systematic desensitization is a form of exposure therapy in which the client is gradually exposed to a situation/stimuli he fears. Over time and with repeated exposures, the anxiety about the situation/stimuli is reduced. Therefore, the correct answer is (C) | counseling skills and interventions |
460 | Initial Intake: Age: 70 Gender: Female Sexual Orientation: Heterosexual Race/Ethnicity: Caucasian/Non-Hispanic Relationship Status: Widowed Counseling Setting: Private Practice Telemedicine Type of Counseling: Virtual Individual | Mary presents with anxious mood and congruent affect. Speech is normal rate and tone, motor movements within normal limits. Denies hallucinations, delusions, suicidal or homicidal ideation. Mary is well-dressed, adorned with makeup, jewelry, and stylish hairstyle. Mary frequently resists the urge to cry as evidenced by smiling and deflecting when becoming tearful. She tells you she wants to work on herself but appears mildly offended whenever given feedback or asked a personal question and then changes the subject. | Diagnosis: Anxiety disorder, unspecified (F41.9), Adjustment disorder, unspecified (F43.20)
You are an associate counselor and receive a new referral for a virtual client through your company’s telehealth practice. Mary is a 70-year-old widow who lives alone with her dog in a 55+ active living community. Mary moved to her town to live closer to her daughter and son-in-law when she lost her husband suddenly to cancer four years ago. Mary is struggling with feeling comfortable leaving the house or engaging in any social gatherings outside of being with her children. She wants to make friends her age and take local activity classes, but her anxiety prevents her from committing to plans. Mary has been widowed for four years but has not yet committed to counseling or attendance in grief support groups. She has felt insecure socially since her husband died, but reports being a “social butterfly” before his passing. She admitted to only visiting her husband’s grave on his birthday but is unable to do so any other time. Also, since the COVID-19 outbreak, Mary’s fears and concerns have increased as she is immunocompromised. She asks you for counseling but cannot define what she wants to get out of it. |
Family History:
Mary was married to her children’s father for 25 years until he had an affair and left her for the other woman. After a few years, Mary met her late husband and was married another 20 years until he became diagnosed with lymphoma and died within three months of being diagnosed. Mary has three older sisters, all of whom live in different states but come to visit seasonally. She celebrates her late mother’s birthday annually, expressing symptoms of grief each year, and becomes inconsolable on the anniversaries of her late husband’s passing. She tells you only country music calms her down.
Work History:
Mary was a stay-at-home mother and wife for both of her marriages, working several jobs in-between marriages as a children’s dental receptionist and an antiques shopkeeper. She opened her own shoppe after meeting her late husband where she sold and displayed southern home décor. She had to close her store down when her husband moved for work. She spent much of her free time making greeting cards and crafts at home, until her hands developed arthritis and she lost enjoyment of her hobbies. She now lives off social security and her late husband’s estate that he left for her. | Unfortunately Mary is a no-show for your next virtual session and is unavailable for contact for over 30 days thereafter. You have three missed calls from Evelyn. What should you do? | Discharge Mary from care and ignore the missed call. | Call back and ask if Mary is okay because you are very worried. | Return the call without confirming any information and ask what it is regarding. | Do not return the phone call and continue to wait for Mary to re-contact. | (A): Discharge Mary from care and ignore the missed call.
(B): Call back and ask if Mary is okay because you are very worried.
(C): Return the call without confirming any information and ask what it is regarding.
(D): Do not return the phone call and continue to wait for Mary to re-contact. | Return the call without confirming any information and ask what it is regarding. | C | In this case, it is reasonable to assume Mary may be avoiding therapy as is consistent with her mental health diagnoses, but it is also a possibility that Mary is unwell or has befallen harm as she is a lonely senior with unresolved complex grief and has suddenly disappeared. Either way, the phone calls from Evelyn can be returned out of concern for Mary's safety, without breaking confidentiality. For instance, "Hello Ms Evelyn, I see you called me, and I was returning your call to ask what it was regarding". Evelyn may tell you directly if there is news involving Mary's status that may change the terms of confidentiality. If she does not, you are within your legal right to maintain your confidential position by replying "I'm sorry, Ms Evelyn, I am still unable to comment on the status of any clientele I may or may not have, I just wanted to follow up the reason for your call". Depending on your agency or practice's rules, you may be within your right to discharge Mary from care or wait for her to re-contact. However, the best practice decision would be to follow up if there is any doubt about her safety. Answer b) breaks confidentiality, even if you end up discovering that Mary is not okay. Therefore, the correct answer is (D) | professional practice and ethics |
461 | 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. Fourth session The client presents for his fourth session. You were able to work out a payment plan with him which has relieved his immediate concerns about paying for therapy sessions. However, he reports ongoing tension about finances and says that his his wife packed a bag to leave after a "big fight" about money. She told him she needs some space to see if she wants a divorce. The client breaks down and begins to cry and shaking uncontrollably. While looking at the ground he laments, "I don't know what to do. It wasn't always like this. We used to be happy, but now I'm just stressed and worried about everything. I'm never going to be able to make enough money to support my family." He tells you that he works hard to provide for his family, but his wife does not appreciate or support him. He has been drinking more but knows that it is not helping. He has decided he needs to make some lifestyle adjustments; he is ready to make changes and work on his issues. In the session, you provide a supportive environment, helping your client to see his anxiety from a place of self-awareness and empowerment. You offer him concrete strategies for managing anxiety including relaxation techniques, cognitive restructuring, and grounding exercises. You also explore how he can work towards building better communication with his wife by expressing himself in an assertive yet respectful way. You both discuss how alcohol serves as a distraction but ultimately leads to additional anxiety. Together you come up with a plan that includes reducing the amount of alcohol he consumes, engaging in positive self-talk, and scheduling weekly activities such as going on walks to help him reduce stress levels. At the end of this session, you encourage your client to continue making strides towards his goals and remind him of the progress he has already made. You assure him that anxiety is something that can be managed with regular practice and together you will continue to work towards positive change. | 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. | Given the client's comments, which treatment goal would you consider working on at this time? | Transitioning from individual to couples therapy | Determining whether or not he should divorce his wife | Creating a plan to file for bankruptcy for his business | Decreasing his drinking and learning to use relaxation techniques when feeling the urge to drink more | (A): Transitioning from individual to couples therapy
(B): Determining whether or not he should divorce his wife
(C): Creating a plan to file for bankruptcy for his business
(D): Decreasing his drinking and learning to use relaxation techniques when feeling the urge to drink more | Decreasing his drinking and learning to use relaxation techniques when feeling the urge to drink more | D | This is the correct answer because his drinking is affecting his relationship and his work performance. Therefore, the correct answer is (B) | treatment planning |
462 | 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 | At this point the counselor should? | Tell the mother that since she is the guardian, she can be told session details. | Introduce client confidentiality and privacy rights. | Encourage Shar to communicate what occurred in the session as they feel comfortable, with their mother. | Share minimal information with the mother. | (A): Tell the mother that since she is the guardian, she can be told session details.
(B): Introduce client confidentiality and privacy rights.
(C): Encourage Shar to communicate what occurred in the session as they feel comfortable, with their mother.
(D): Share minimal information with the mother. | Encourage Shar to communicate what occurred in the session as they feel comfortable, with their mother. | C | Working with a minor often brings up issues of confidentiality. The best option out of the choices above is to help facilitate communication between Shar and Nadia. It is unethical to share with Nadia what is said in the counseling sessions unless there are safety concerns. Client confidentiality and privacy rights should be discussed at intake so this should not be the time to first introduce this. Regardless of the mother being the guardian, confidentiality and privacy rights still apply. Therefore, the correct answer is (D) | intake, assessment, and diagnosis |
463 | Name: Tabitha Clinical Issues: Family conflict and pregnancy Diagnostic Category: V-codes Provisional Diagnosis: Z71.9 Other Counseling or Consultation Age: 16 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: Latina Marital Status: Not Married Modality: Individual Therapy Location of Therapy : School | The client appears healthy but tired and distracted. She is dressed in loose-fitting clothing and sits with her hands between her knees. Eye contact is minimal. Speech volume is low. She is reluctant to talk at first and denies having a problem. Thought processes are logical, and her thoughts are appropriate to the discussion. The client's estimated level of intelligence is within average range. She appears to have difficulty maintaining concentration and occasionally asks you to repeat your questions. The client denies suicidal ideation but states that she has been considering abortion. She has not acted on anything but is feeling very overwhelmed and desperate. | First session You are a school counselor in an urban school setting. The client is a 16-year-old student who is reluctant to see you. The session begins with a discussion of the teacher's concerns and your role as a school therapist. After some gentle probing and reassurance, the client is able to open up more and discuss her difficult relationship with her father. She identifies feeling overwhelmed and frustrated by his expectations, which leads to frequent arguments between them. She appears tired and has trouble sleeping at home because her parents constantly argue. She suggests that her parents "are the ones who need therapy, not me." She briefly describes the arguments that she claims her parents get into regularly. "They are always going at it, unless thay are at church. Then they act like everything is perfect." When you ask about her friends and activities, she tells you she is involved in her church youth group and has an on-again/off-again boyfriend. You ask the client, "Can you tell me more about your relationship with your boyfriend? How long have you been together?" She says that they have been seeing each other for about a year, and she thought he was 'the one', but they had a "big fight" last week and have not talked since. You ask what she means by 'the one'. She looks down at the floor and starts to bite her fingernails. You see a tear fall down her cheek. She says, "I don't know what to do." You continue the session by providing a safe space for her to express and explore her feelings about her relationship with her boyfriend. She takes a deep breath and tells you that there is something she has not told anyone and she is scared that if she says it out loud that "it will make it too real." You tell her to take her time and that you are here to listen without judgment. She tells you that she missed her last menstrual period, and several "in-home" tests confirm that she is pregnant. She has not told her boyfriend and is scared to tell her parents because she is afraid they will disown her, so she has decided to keep the pregnancy a secret. While you are tempted to try to talk the client into telling her parents and boyfriend about her pregnancy, you recognize that it is important to respect her autonomy and allow her to make the best decision for herself. You provide her with accurate information about the options available to her and encourage her to explore the pros and cons of each option. You share that having a support system and someone to talk to during this time can be helpful. She nods her head and tells you that she knows that her parents will find out about the baby eventually, whether she tells them or not, but she is anxious about how they will react to the news. You listen and provide empathetic reflections to help her gain insight into her feelings. You then focus on helping the client develop effective coping strategies for managing her stress and anxiety about the situation. You let the client know that she can come back to see you at any time if she feels overwhelmed or needs additional support. The session concludes with an understanding of what to expect in future sessions, including exploring possible solutions for dealing with her parents and boyfriend, as well as developing healthy coping skills for managing her emotions. Second session A fews day after the intake session with your client, she stopped by your office and asked if she could talk to you for a few minutes. She told you that since your last session, she decided that she wanted to tell her parents and asked if you could be there when she told them. You set up an appointment to meet with the family. This is your second session with the client and she appears very nervous. When she sits down in the chair in your office, she tells you that she changed her mind about telling her parents. She keeps repeating, "I can't do this. You tell them." Your office phone rings, and the secretary tells you the client's parents have arrived. The client immediately bursts into tears and begs you not to let them in. You calmly explain that you are here to provide a safe space for her and will support her. You walk her through a grounding exercise and encourage her to take slow, deep breaths. After a few minutes, she relaxes and indicates she is ready to talk to her parents. You welcome the parents into your office and introduce yourself as a mental health professional who has been working their daughter. You explain that the client has something she would like to tell them and you will be here to help facilitate their conversation. Her father says, "We know that something is going on." He starts talking about his daughter's academic issues and recent argumentative behavior at home. The mother adds, "We pray daily that she will grow out of this hormonal phase. We miss our innocent little girl." You listen and reflect on the parents' feelings as they talk about their daughter. The client is quiet and looks down, not making eye contact with anyone. After a few moments, you gently encourage the client to share her thoughts and feelings. She tells you that she has something important to tell them but does not know where to start. You suggest that she take her time and start with whatever feels most comfortable for her. The client takes a deep breath and slowly begins to tell her story. She tells them about her pregnancy and how scared and overwhelmed she has been. At that moment, everything changed. The client's parents are no longer focused on her academic or behavioral issues. Instead, they are now focused on their daughter and her pregnancy. They are full of questions and concerns for their daughter's well-being. The mother looks shocked, and the father demands to know who the boy is that "did this to our daughter." The initial conversation is difficult, but you provide support as the family talks through their feelings. Fifth session You have been seeing the client weekly during her lunch break. After their initial shock, her parents have accepted the news and are now focused on helping their daughter. The client told you that they have been discussing the options available to them, such as adoption or parenting the baby. When you met with the client last week, she opened up about how she was feeling physically and emotionally. She told you that although her parents have been supportive, she was still feeling overwhelmed and uncertain about the future. She told her boyfriend about the baby, but he has been distant and unsupportive. Her parents met with the boyfriend's parents and tried to talk about options, but his parents said they did not want to be involved. They said they "already had too many mouths to feed" and could not help with the baby. Today, the client and her mother come to see you for a scheduled appointment. The mother smiles as she pulls out a picture of the baby's sonogram to show you. She says, "We met with our minister, and the three of us have been praying for guidance as we have been trying to cope with this situation." They decided that the best option for their daughter and the unborn baby was to find a loving family who would be willing to adopt. The mother explains, "We want our daughter to focus on her education and not worry about the responsibilities of raising a child right now. We are hoping that by finding a good home, we can provide this baby with a bright future." As the mother talks, you notice that the client is more relaxed and looks alert and focused. You ask her about how she feels about the decision. She admits that although she still feels overwhelmed, she is also starting to feel more at peace with the idea of adoption. You nod your head in understanding and offer some words of support. Finally, the mother states, "What we need at this point is for you to reschedule our daughter's classes so that she can continue with schoolwork virtually and also ensure that she gets the rest she needs during her pregnancy." You assure them that you will work with the school administration to facilitate the client's needs. You end the session with a plan for the client's continued care. You will continue to meet with her as needed and provide additional support. | The client has an older brother who is in college. The client lives at home with her parents. They are members of a Christian church and are all actively involved in their church group, and the client has a good relationship with her pastor. The client has never felt close with her father and says he has always had "high standards and expectations" for everyone in their family. The client says her parents "treat her like a child." She has not told her parents about her 16-year-old boyfriend as she knows they will disapprove. For the last year, she has been asserting her independence from her parents, which has caused conflict, friction, and discord within the family. The teacher who referred the client to you mentioned that the client has seemed distracted and anxious lately. She has not been completing homework assignments and failed a test last week. The client acknowledges these concerns and tells you she struggles to keep her grades up and has difficulty adjusting to hybrid learning. "One day, we're in school, and the next day we're virtual. It's just exhausting. I feel like giving up." | Through several professional development opportunities, you have been made aware that there have been changes in your state's legislation as to the types and character of the pregnancy-related resources that you can provide to the client, as an employee of the school system. Even though you have access to many possibly helpful programs, you are unsure what types of adolescent pregnancy resources you can provide. How do you proceed? | Since you have a grasp of the client's psychological frailty, your ethical choice is to provide any and all resources that will support the client. | Given your status as a school employee, you should seek supervision and consultation as your first ethical concern. | You should make a formal request to the school administration as to what materials you can share with the client that are consistent with any changes in legislation. | In light of the client's needs, you should consult with the client's parents and direct them toward resources that you cannot officially suggest. | (A): Since you have a grasp of the client's psychological frailty, your ethical choice is to provide any and all resources that will support the client.
(B): Given your status as a school employee, you should seek supervision and consultation as your first ethical concern.
(C): You should make a formal request to the school administration as to what materials you can share with the client that are consistent with any changes in legislation.
(D): In light of the client's needs, you should consult with the client's parents and direct them toward resources that you cannot officially suggest. | Given your status as a school employee, you should seek supervision and consultation as your first ethical concern. | B | If you are unsure of any regulations regarding resources to the client, first seek supervision and consultation. Therefore, the correct answer is (A) | professional practice and ethics |
464 | 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.” | After the second session, you now feel better equipped with information to reliably diagnose Davone with a Borderline or Antisocial Personality Disorder. All of the following factors would contribute to this decision, except? | Davone's persistent, inflexible pattern of maladaptive perceptions and interpretations | Davone's pervasive inability to change his behavior without insight | Davone's apparent fear of abandonment and extreme emotional mood swings | Davone's report of trying harder to do better with increased self-esteem | (A): Davone's persistent, inflexible pattern of maladaptive perceptions and interpretations
(B): Davone's pervasive inability to change his behavior without insight
(C): Davone's apparent fear of abandonment and extreme emotional mood swings
(D): Davone's report of trying harder to do better with increased self-esteem | Davone's report of trying harder to do better with increased self-esteem | D | Davone has clearly presented with a persistent, inflexible pattern of maladaptive perceptions and interpretations, a pervasive inability to change his behavior without insight, fear of abandonment and extreme emotional mood swings. He also demonstrates lack of remorse for his wrongful actions, abnormalities in his decision-making processes with criminal behavior and has an unclear or shifting self-image. These expressions can point towards further assessing for Borderline or Antisocial Personality Disorder. Davone expressing an increase in self-esteem or recent behavior changes that he has been making to improve upon himself are not factors in the determination of this diagnosis. Therefore, the correct answer is (D) | intake, assessment, and diagnosis |
465 | Name: Chad Clinical Issues: Maladaptive eating behaviors Diagnostic Category: Feeding and Eating Disorders Provisional Diagnosis: F50.2 Bulimia Nervosa, Moderate Age: 16 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: White Marital Status: Not Assessed Modality: Individual Therapy Location of Therapy : Agency | The client is appropriately dressed but disheveled. He is dressed in clothes associated with anime characters. Concentration is drifting. His speech is somewhat low, and he keeps his head low to avoid making eye contact with you. His mood is anxious. There is no suicidal ideation. Thought content shows no current homicidal ideation or plans. Thoughts are appropriate. The estimated level of intelligence is in the low average range with abstract thinking. | First session You are a mental health therapist who works for an agency specializing in helping teens with eating disorders. The client is 16 years old. He presents for therapy along with his mother. You start by welcoming both of them into your office. Then you introduce yourself, explain your role as a therapist, and briefly describe the experience you have in treating eating disorders. Next, you ask the client to explain and his mother to share with you why they came to see you today and what their expectations are for therapy. The mother begins by telling you, "My son is doing dangerous things to his body. He needs help, but he won't listen to me." The client rolls his eyes and replies, "She doesn't get it. Look at her. She's fat and is always overeating!" His mother's face turns red and she starts to yell at him. You remain neutral and ask them both take a few deep breaths and give each other some space. You explain that your goal is to create a trusting relationship with the client and his mother so that you can start working together towards understanding the issues that bring them to counseling and how to best help. You ask the mother to take a seat in the waiting room while you speak with her son for the first part of the session. She reluctantly agrees and leaves the room. Once the mother leaves, you start by letting the client know that you understand that this situation is difficult, and that you are here to help. You focus on building rapport with the client, emphasizing that you are here to help him. You ask him open-ended questions to get to know more about him, and to help him feel seen and understood. You acknowledge the client's feelings of being misunderstood and provide empathy by validating that it must feel difficult not having his mother understand what he is going through. You also recognize his mother’s concerns by saying, "It sounds like your mom is really worried about you." He tells you that his mother is constantly trying to control him and that he does not understand why she is always so angry all the time. You continue your assessment with structured questioning to understand the client’s current experiences with food, including what he likes to eat and how often he eats. At the end of your discussion with the client, you thank him for being open and honest with you. You acknowledge how brave it is to come in and start talking about his experiences. You invite him to bring his mother back in to the office so you can start working together and discuss the next steps. | The client does well in high school. He is concerned that he could quickly gain weight and no longer be in optimum shape for cheerleading and gymnastics. The client's self-esteem is closely related to his weight and body image, and he appears to lack insight into the dangers of his current eating behaviors. Stressors & Trauma: The client tells you throughout elementary school he was overweight. As a result, he was bullied by other boys and girls alike. They would leave notes on his desk saying "fatty" or "crispy crème." One student pushed him down in the schoolyard, and all the others stood in a circle around him and laughed as the client cried. Pre-existing Conditions: No significant medical issues were reported based on his last medical exam. He does, however, admit to eating four hamburgers and a large bag of French fries at a fast-food restaurant "as a treat" about four or five times a week. He shares that after these fast food "splurges," he goes home and purges to not gain weight. Feeling guilty after each episode, he does not eat anything the next day and doubles his workout routine. | What is your rationale for selecting a "moderate" specifier for the client's eating disorder? | The "moderate" specifier for the client's eating disorder is inaccurate and does not reflect the client's compensatory behaviors. | He engages in an average of 8-13 episodes of compensatory behavior per week to prevent weight gain. | He engages in an average of 4-7 episodes of compensatory behavior per week to prevent weight gain. | He engages in an average of 1-3 episodes of compensatory behavior per week to prevent weight gain. | (A): The "moderate" specifier for the client's eating disorder is inaccurate and does not reflect the client's compensatory behaviors.
(B): He engages in an average of 8-13 episodes of compensatory behavior per week to prevent weight gain.
(C): He engages in an average of 4-7 episodes of compensatory behavior per week to prevent weight gain.
(D): He engages in an average of 1-3 episodes of compensatory behavior per week to prevent weight gain. | He engages in an average of 4-7 episodes of compensatory behavior per week to prevent weight gain. | C | The moderate specifier is used when the client engages in an average of 4-7 episodes of compensatory behavior per week to prevent weight gain. Therefore, the correct answer is (B) | intake, assessment, and diagnosis |
466 | Name: Ethan & Cindy Clinical Issues: Sexual functioning concerns Diagnostic Category: V-codes Provisional Diagnosis: Z63.0 Relationship Distress with Spouse Age: 69 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: White Marital Status: Married Modality: Couples Therapy Location of Therapy : Private Practice | The husband appears to be of average build. His dress is appropriate for the occasion, but his facial expression is blank and he keeps staring off into space. He has difficulty maintaining eye contact and speaks in an aimless monotone. His affect is blunted, and he appears to be emotionally detached from the situation. He reports feelings of worthlessness and emptiness that have been ongoing for many years. He has had recurrent suicidal ideations but is not currently making any plans to act on them. His thought process is disorganized, concrete and circumstantial in nature. The wife is slightly overweight and dressed in loose clothing. She appears agitated and tense but is able to maintain good eye contact throughout the conversation. She speaks in a clear, consistent manner and expresses her thoughts in an organized fashion. Her thought content is focused on her current difficulties with her husband, and she expresses feelings of disappointment, rejection, and anger. She acknowledges feeling a sense of hopelessness in the situation and shares concerns about her future. Her mood reflects her thoughts and is generally pessimistic. Insight is intact as she is able to recognize the impact of her own actions on the current state of affairs. Her judgment is also intact as she recognizes that her current behavior and attitude are not helping the situation. | First session You are a mental health therapist in a private practice setting. A couple, a 69-year-old male and a 65-year-old female, enters your office together. The couple has been married for over 40 years and have two grown children. Their second child age 31 is currently living at home. When you ask what brings them to therapy, the wife immediately states that her husband is not attracted to her anymore. She tells you that he never wants to be in a situation where they are romantic together. She is feeling unwanted, unattractive, and as if they are "roommates" who just cohabitate together. When you ask the husband how feels, he says that he has a sense of disgust toward his wife when he thinks of having an intimate encounter with her. The wife believes that her husband is repulsed by her physical appearance as she is overweight. The husband confesses to feeling guilty for his lack of interest in his wife, but he is unable to pinpoint why he feels this way or understand why it has become an issue now after 40 years of marriage. Exploring further, you ask the couple about their family of origin. The wife states that her parents were highly critical and demanding, while the husband's parents were more passive and removed when it came to expressing affection or showing disapproval. She also expresses concern over possible sexual abuse in the husband's past, though he is not sure if anything happened or simply cannot remember due to its traumatic nature. With these additional pieces of information, you begin to develop a comprehensive picture of their situation and focus on working with the couple towards a positive outcome. Fourth session You have seen the couple for three therapy sessions so far. Today is your fourth session with the couple. The wife tells you that she is "officially sleeping in the spare bedroom" and is considering a trial separation. Last week she bought lingerie to entice her husband, and he responded by ridiculing her, then turning away from her and going to sleep. The wife begins to cry as she says, "We don't talk anymore. He just berates me all the time, and that hurts a lot." As the wife tells you about the incident, the husband sighs audibly and shakes his head. He looks at you and states, "She's a mess. I don't know what to say." You empathize with the couple's emotional struggles, and you acknowledge their pain. You explain to them that it can be helpful for couples to explore personal issues in an individual therapy setting before coming together as a couple to make progress on their relationship challenges. You let them know that they may find it easier to express themselves when one partner is not present, and that individual counseling can give them each the space to address their own personal issues in a safe environment. You encourage them to take some time to reflect further on whether they believe individual therapy would be useful for them at this time, and you offer to provide further information about the process if needed. Finally, you let them know that you are here to support them as they make decisions about how best to move forward. You assure them that while their relationship may be in a difficult place right now, it is possible to heal and strengthen their connection with one another. You remind them that relationship issues are often complex and that it is important to be patient with each other as they work together to find solutions. You encourage them to stay committed to the process, even when things feel difficult, and you offer your ongoing support in helping them build a more fulfilling relationship. Seventh session You met previously with each partner separately. They shared their perspectives with you about their relationship. The husband told you that he was reluctant to stay with his wife. The wife described feelings of worthlessness and loneliness. Today, the husband arrives for their couples session ten minutes after the wife, as they are driving in separate cars. The husband states that he is bored at home and is tired of his wife "nagging" him. The wife rolls her eyes and expresses that she will never be a priority, and the husband blames her for everything that goes wrong. The wife is now staying at her friend's house, and the husband is relieved that she is gone. You talk to the couple about their perceived outcomes in therapy and what they hope to accomplish going forward. | 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. | You state to the husband, "You say you are bored at home and are tired of your wife's constant nagging. You're also relieved that she is not staying with you right now. Is that right?" What skill are you demonstrating with this response? | Reflecting meaning | Summarizing | Reflecting feelings | Encouraging | (A): Reflecting meaning
(B): Summarizing
(C): Reflecting feelings
(D): Encouraging | Summarizing | B | Summarization in therapy is the process of recapping and synthesizing a client's story or experiences. This involves actively listening to the client, reflecting on what has been said, and then providing a summary of those thoughts and feelings to ensure understanding between the therapist and client. Therefore, the correct answer is (A) | counseling skills and interventions |
467 | 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 you address first with this couple during the intake? | The wife's weight issues | The possibility of an extramarital affair | The husband's sexual issues | The couple's objectives for therapy | (A): The wife's weight issues
(B): The possibility of an extramarital affair
(C): The husband's sexual issues
(D): The couple's objectives for therapy | The couple's objectives for therapy | D | The couple is experiencing distress in their relationship, possibly due to sexual dysfunction. It is important that you understand what they want to gain from therapy. Therefore, the correct answer is (A) | intake, assessment, and diagnosis |
468 | 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 step is relevant when arranging a one-on-one aid for the client? | Review the client's family history of developmental delays | Obtain informed consent from the client's mother | Consult the client's past providers to determine eligibility | Begin "deconstructing the problem" with the client's mother | (A): Review the client's family history of developmental delays
(B): Obtain informed consent from the client's mother
(C): Consult the client's past providers to determine eligibility
(D): Begin "deconstructing the problem" with the client's mother | Obtain informed consent from the client's mother | B | This is the only relevant step in the actual process to arrange for this client's one-on-one aid. Therefore, the correct answer is (C) | professional practice and ethics |
469 | 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. Ninth session The client, his parents, and the math teacher present to your office. The teacher reports that the client seems to be achieving academic success with the addition of having a separate location for tests and extra time to complete assignments. The parents state they see improvement at home after deciding to put him on Ritalin. They are smiling as they report that their son seems to have entered a "new phase." His progress is evident in his increased engagement in the classroom and his improved academic performance. He is able to follow instructions and complete assignments in a timely manner, and is better able to interact with his peers. His attitude towards class participation has improved and he is able to self-regulate his emotions better. He has also expressed an increased level of self-esteem and self-efficacy in math class. Overall, the client has demonstrated improved functioning in the academic arena and the addition of Ritalin has helped him to become more alert and focused. The client appears content and keeps asking if it is time to go back to class yet. To further ensure successful progress and to provide additional support for the client, you suggest that the teacher and parents have consistent and frequent communication about the client’s academic progress. You recommend that the teacher provide regular feedback and encouragement to the client, and you suggest that the parents continue to provide a structured and supportive environment at home. Additionally, you discuss potential academic supports that the parents may consider to help the client maintain his academic progress. Finally, you suggest that the client continue to utilize his self-regulation strategies and other coping skills to manage any anxiety or other challenging emotions related to math class. | 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. | What additional educational resource would you suggest for the client in this new phase of his treatment? | Math Team | Youth group at church | Gym | Tutoring | (A): Math Team
(B): Youth group at church
(C): Gym
(D): Tutoring | Tutoring | D | Now that the client is more focused and has an IEP, this may be a good time for extra help in math to work on those areas where he is falling behind. Therefore, the correct answer is (C) | treatment planning |
470 | 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. | 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. | How would you use cognitive-behavioral therapy (CBT) to address the client’s feelings of not belonging? | Explore the client's need to belong | Use scaling questions to identify exceptions to feelings of not belonging | Identifying her self-talk that promotes social isolation | Help the client deal with her tendency to overgeneralization | (A): Explore the client's need to belong
(B): Use scaling questions to identify exceptions to feelings of not belonging
(C): Identifying her self-talk that promotes social isolation
(D): Help the client deal with her tendency to overgeneralization | Identifying her self-talk that promotes social isolation | C | CBT focuses on identifying and challenging the client’s negative self-talk and thought patterns in order to help them gain insight into how these thoughts are impacting their behavior. In this case, you would focus on helping the client identify her negative self-talk that is promoting social isolation and challenge those beliefs. By doing this, the client can gain insight into how these thought patterns are contributing to her feelings of not belonging and help her identify alternatives that will lead to healthier coping strategies. Therefore, the correct answer is (A) | counseling skills and interventions |
471 | 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. Fourth session Last week you misjudged the client, and she ended up in the hospital for mood stabilization. She was released after 7 days and arrives to today's session with an older gentleman who remains seated in the waiting room. You notice her mood is elevated, and she exhibits childlike behaviors in the session. The client is giggling and fidgeting in her chair. You ask her about her feelings and her goals for therapy. She describes feeling happy and having a "new chance at living." She further discloses that she recently met a "wonderful man." They have had dinner together every night since she was released from the hospital. The client continues to describe her newfound relationship with this man and explains that they met on a dating app. She shares that "he is the answer to all of my prayers to be in a healthy relationship with someone who truly loves and understands me." She also shares that her soon-to-be ex-husband never truly loved her and that this new relationship feels different. From her description, this new relationship appears to provide her with a sense of safety and security, but you remain cautious. You explore the client's thoughts and feelings about this newfound relationship in more detail. You ask the client to describe how the relationship has changed her outlook on life. The client explains that she now feels hopeful and optimistic about the future, as this new partner makes her feel loved and accepted for who she is. She also reports feeling more confident in herself and her decisions. You ask the client how she knows that this man cares about her. The client discloses that he has been very supportive and understanding, even when she was hospitalized for her mood stabilization. She explains that he has gone out of his way to make sure she feels safe and secure in their relationship. "He's always around when I need him," she explains, "And he listens to me and takes what I say seriously." The client acknowledges that the man is older, and they come from different cultural backgrounds. She shares that she does not know much about his past relationships, but he has been very honest with her about his intentions for their relationship. She tells you, "If I'm honest, I'm a little bit anxious about the future, but I'm more excited than scared." You recognize that the client is in an emotionally vulnerable state, and you want to ensure she is making healthy decisions. You proceed by exploring the potential risks of this relationship in more detail. You ask the client questions about her comfort level with entering into a relationship with someone from a different cultural background, and how she believes these differences may affect their relationship. You also explore the potential benefits and risks of entering into a new romantic relationship. You remind her that healthy relationships are built on trust, communication, and respect - all components that take time to develop. You further explain the importance of setting boundaries and expectations early in a relationship in order to ensure that both parties’ needs are met. Finally, you encourage the client to take any necessary steps to ensure her safety, such as getting to know her partner better and introducing him to friends or family members she trusts. | 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. | In what way would you best assess the client's progress and ongoing needs during the therapeutic process? | Ask the client to keep a comprehensive journal of actions and feelings. | Implement check-ins and review goals for therapy regularly. | Elicit information from the client's self-report during sessions. | Have the client take a survey or questionnaire. | (A): Ask the client to keep a comprehensive journal of actions and feelings.
(B): Implement check-ins and review goals for therapy regularly.
(C): Elicit information from the client's self-report during sessions.
(D): Have the client take a survey or questionnaire. | Implement check-ins and review goals for therapy regularly. | B | To assess the client's progress and ongoing needs during the therapeutic process, you can implement regular check-ins throughout sessions to explore any new thoughts or feelings that have arisen, as well as ask questions about how she is managing her relationship with her partner. Additionally, you can review goals for therapy regularly to ensure the client is on track for achieving her desired outcomes. Therefore, the correct answer is (D) | treatment planning |
472 | 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 help the client create self-affirmations to counter the anxiety that she experiences during job interviews | You help the client create self-affirmations to counter the anxiety that she experiences during job interviews. According to self-affirmation theory, what is the first step to developing these mental processes? | Replace a crossed transaction with a complementary transaction. | Identify a significant core value. | Identify the activating event. | Model unconditional positive regard. | (A): Replace a crossed transaction with a complementary transaction.
(B): Identify a significant core value.
(C): Identify the activating event.
(D): Model unconditional positive regard. | Identify a significant core value. | B | The first step in developing self-affirmations is to identify a significant core value. Core values are stable beliefs upon which a person acts or aspires to act. Self-affirmations are used to affirm a person’s self-worth. Core values create positive emotional states. Self-affirmation theory is based on the premise that a person’s core values provide a more global view of themselves. When self-affirmations are based on core values, the other parts of a person are reinforced and self-concept is better protected. Individuals engaging in self-affirmations are less likely to attribute negative feedback to the current experience and are less likely to distort information. Identifying the activating event is the first step in CBT. Providing the client with unconditional positive regard rather than modeling it is a person-centered technique. Crossed and complementary transactions are concepts associated with transactional analysis. Therefore, the correct answer is (B) | counseling skills and interventions |
473 | Initial Intake: Age: 16 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Biracial Relationship Status: Single Counseling Setting: High School Social Worker Type of Counseling: Individual | Autumn came to intake session, during her lunch period. She appeared younger than her stated age because she was so underweight. The counselor greeted Autumn and told her that she was welcome to eat during their session if she wanted to. Autumn looked down and responded, “It’s okay- I don’t like to eat in front of anyone- I can just eat later.” Erin seemed tired during the interview but was cooperative and friendly. | History:
Autumn is a junior in high school. Her parents divorced about a month ago. Recently, the teacher noticed a change in Autumn’s mood. Autumn’s teacher also noticed that she was taking her lunch and eating it outside by herself. Oftentimes, she didn’t seem to eat much of it at all. When asked about it, Autumn seemed embarrassed and stated that she was fine. | null | Autumn could be showing symptoms of all of the following except? | Social Anxiety Disorder (Social Phobia) | Anorexia Nervosa | Avoidant/Restrictive Food Intake Disorder | Binge Eating Disorder | (A): Social Anxiety Disorder (Social Phobia)
(B): Anorexia Nervosa
(C): Avoidant/Restrictive Food Intake Disorder
(D): Binge Eating Disorder | Binge Eating Disorder | D | Autumn is not showing signs of Binge Eating Disorder in where there is "eating, in a discrete period of time, an amount of food that is definitely larger than what most people would eat in a similar period of time under similar circumstances". Like Autumn, someone diagnosed with avoidant/restrictive food intake disorder shows significant weight loss. This is also a symptom with Anorexia Nervosa along with a restriction of caloric intake. The counselor may also consider social anxiety disorder (social phobia) because of the avoidance of eating in social situations. Therefore, the correct answer is (D) | treatment planning |
474 | Name: Sierra Clinical Issues: Adjustment related to physical loss/injury/medical condition Diagnostic Category: Trauma and Stressor Related Disorders Provisional Diagnosis: F43.23 Adjustment Disorder with Mixed Anxiety and Depressed Mood Age: 16 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: Native American (Cherokee) Marital Status: Not Applicable Modality: Individual Therapy Location of Therapy : Private Practice | The client's appearance is slightly disheveled. Her behavior is withdrawn. She has her arms crossed throughout the session. The client's affect is congruent. Her mood is depressed during the initial intake. She reports that she sometimes "doesn't feel like existing" when thinking about her injury. She shares that the thought of not being able to dance ever again is "too much to bear." Exploration of thought content reveals that she has considered how she might harm herself. She reports that her father has guns locked in a safe, but she knows the passcode. The client denies she would ever act on this impulse and identifies three friends she could contact for support. | First session You are a mental health therapist in a rural private practice setting. A 16-year-old female is referred to you by her pediatrician for concerns about her mood, behavior, and low appetite. She is accompanied by her mother and father. You begin by speaking with all three family members, reviewing the informed consent process and how confidentiality will be handled with the daughter. They all acknowledge and sign the appropriate paperwork. Next you meet one-on-one with the parents to understand their concerns. They are extremely concerned about their daughter's mental health and wellbeing. They share that their daughter has been crying more often lately and she has become incredibly sensitive to criticism. She is often irritable and "snaps" at them over minor issues. She withdraws from social interaction with friends, which is out of character for her. She appears increasingly withdrawn from activities she used to enjoy like drawing and playing the piano. She is also sleeping more and eating less than usual, resulting in weight loss. The parents confirm that they have limited insight into their daughter's actual feelings, as she often refuses to discuss them. The mother tells you, "She had a ballet injury a couple of months ago, and she seems to be struggling with it. We've been trying to stay positive and supportive, but she's just not getting better. Her physical therapist said that keeping up a positive attitude is really important in the recovery process, but our daughter doesn't seem to care." After you feel you have obtained a thorough understanding of the parents' concerns, you ask the parents to wait in your waiting room and invite the daughter back into your office. You begin by expressing your understanding of the situation that lead her parents to bring her in for therapy. You state, “From what your parents have told me, I understand you have been going through a difficult time lately with your physical injury and the changes that it has caused in your life.” After establishing this understanding, you ask her to tell you about her experience with the injury, how it has impacted her life, and how she has been feeling since it occurred. She tells you she has a hard time concentrating at school because she is unable to dance. She becomes tearful when you attempt to find out about how her ballet injury is affecting her. She says her "life is ruined now" and "I will likely never dance again. I'll never be able to fulfill my dream of being a ballet dancer. I hate it. All of my dreams are crushed." She begins sobbing uncontrollably. You take a moment to de-escalate her intense emotional reaction. You explain that it is common to feel overwhelmed in the aftermath of a major injury, and there are strategies she can use to cope with her feelings. You discuss the importance of staying connected to friends, family, and supportive people during this difficult time. After completing your mental status examination of the client, you note suicidal ideation as an issue to discuss with her parents. Second session The client presents to her second counseling session in a defensive state. She is upset that you reported her suicidal ideation to her parents because she thought that everything she told you would remain confidential. She says, "Why should I tell you anything else? You'll just tell my parents." You tell the client that you understand her frustrations and empathize with her. You explain to her why confidentiality is not always absolute and that as a clinician, it is your responsibility to keep clients safe, even when they don't want you to. You further explain that in this case, you felt it was important for her parents to know about the suicidal ideation she has been experiencing. You emphasize that her parents care deeply about her, and they need to know what is going on with her in order for them to help. She responds by saying, "Okay, I get what you're saying, but telling them about it has only made things worse." She reports that her parents now treat her "differently" and do not allow her access to any "dangerous items like kitchen knives" without supervision. She feels restricted and watched. You nod your head in understanding and reflect that it can be difficult to feel like your parents don't trust you and have put restrictions on things they normally wouldn't. You also encourage her to try and see the situation from their perspective and agree that although the restrictions can be inconvenient, her safety is their top priority. She takes a deep breath and says, "I guess I can understand why they did it, but it still doesn't feel fair." You acknowledge her feelings of unfairness and validate that feeling. After your discussion, the client appears to have a better understanding of her parents' motivation for the restrictions and feels less resentful towards them. You ask her to tell you more about how she has been feeling lately and invite her to share any other issues she is having trouble managing. She tells you that her ballet teacher has invited her to help teach the younger ballet classes, but she is ambivalent about pursuing this opportunity. Though she still loves ballet, she thinks it will be painful to watch other children fulfill the dreams that she can no longer pursue. She says, "I'm afraid that if I agree to teach, I'll never get over my injury. It will just keep reminding me of what I could have been." You explain to her that it is natural for her to have these feelings and that it is okay to take time to make a decision. You ask her if she can see any benefits to teaching. She pauses and says, "I don't know...I've never really thought of myself as a teacher. I've always been the student." You acknowledge the difficulty of this transition and understand that it can feel risky to try something new. You suggest that teaching could be an opportunity for her to gain a sense of purpose, as well as an activity to help her stay connected to something she loves. You encourage her to try and explore her capacity for teaching and imagine what impact she could have on her students. | The client reports that she is doing "okay" in school. Her parents report that she used to make straight A's but is now making C's and D's. She is failing history because she did not complete a project. They share that her teachers have tried to reach out to her, but she has not responded to any of them. The client reports that she smokes cigarettes. She used to smoke once every couple of months while out with friends. Her use has become more frequent, and she is now smoking several times a week. She has tried alcohol (three beers) and smoked a joint at a friend's party, but she reports that she did not like how they made her feel. Pre-existing Conditions: The client fell in dance class two months ago and broke her ankle. There were complications during surgery to repair the break. The client is currently in intense rehabilitation planned for at least one year, but it may take longer. Doctors are unsure if she will ever regain full mobility of her ankle. | Which of the following motivational interviewing techniques did you use during the session to encourage the client to consider pursuing the teaching opportunity? | Reframing | Emphasizing autonomy | Double-sided reflection | Affirmation | (A): Reframing
(B): Emphasizing autonomy
(C): Double-sided reflection
(D): Affirmation | Reframing | A | Reframing in the context of motivational interviewing is a technique used to help clients see a situation from a different perspective. During the session, the client told you that she still loves ballet but thinks it will be painful to watch other children fulfill the dreams she can no longer pursue. You responded with a different perspective by suggesting that teaching ballet 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. Therefore, the correct answer is (C) | counseling skills and interventions |
475 | Name: Alberto Clinical Issues: Sexual functioning concerns Diagnostic Category: Sexual Dysfunctions Provisional Diagnosis: F51.22 Erectile Disorder, Situational Age: 43 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: White Marital Status: Married Modality: Individual Therapy Location of Therapy : Agency | The client is dressed in casual clothing and appears to be clean and well-groomed. He is of average height and build, with short black hair. He is noticeably tense and avoids eye contact when describing his symptoms. His speech is audible and clear. He is able to express himself clearly and articulately. The client reports feeling frustrated, embarrassed, and confused concerning issues with his wife. He denies any suicidal or homicidal ideation. His mood is anxious and affect is flat. He is able to recall pertinent events and information. He has no difficulty understanding the session process or comprehending instructions. He appears to be alert and oriented to person, place, and time. The client displays average insight into his current situation and expresses willingness to explore relevant issues in more depth with the therapist. He displays average judgment when answering questions. | First session The client, a 43-year-old male, presents for his first Telehealth session through the agency where you are an intern, finishing your final hours for licensure under clinical supervision. You begin the session by striving to create a safe, comfortable, and non-judgmental environment. You provide the client with an introduction to yourself, your qualifications, and your approach to therapy. You also explain how Telehealth works and provide the client with an opportunity to ask questions about the process. Next, you review his informed consent and other paperwork that was filled out prior to the session. You explain the policies and procedures for confidentiality within your agency. He nods his head and verbally acknowledges understanding. You then begin to explore the client's presenting issues and goals for therapy. You ask what prompted him to schedule an appointment for counseling, and he responds saying, "I don't know what is wrong with me, but lately, I've been having trouble with my wife....on an intimate level. It's been very frustrating and embarrassing, and it's causing a lot of tension between us. My wife is getting frustrated and accusing me of cheating on her. We have two children. I never thought this would happen to me." The client has seen a urologist and has no sign of prostate cancer but is in poor health. The client appears anxious when describing his symptoms. He is fidgeting and has trouble maintaining eye contact as you explore the issue more deeply. This is your first client who presents with this particular issue, and you are not entirely sure of how to proceed. You take a few moments to pause and reflect on what he has said while also noting his body language. As you consider the best way forward, you remember the importance of validation in establishing rapport. You nod your head and say, "I can see how this has been difficult for you and your wife. It's understandable why it might be causing tension between the two of you." | The client is an only child. As he grew up, he reports that his father was often vocal about his dissatisfaction with his sex life. The client also reports that his mother often expressed resentment toward him from the day he was born. This has left him with a deep-seated dislike of his mother, as well as resentment of women in general. Currently, his parents are facing health issues, with his father drinking heavily and his mother having lung cancer. The client feels overwhelmed and stressed due to his job and family responsibilities. He is worried about his parents' health and is not happy about the potential of having to take care of his mother if his father passes away. After a decade of working as an illustrator designing greeting cards, the client has recently been promoted to creative director of his department. Because of his introverted nature, he is now feeling overwhelmed with the new responsibilities and having to communicate with other departments within the company. The client drinks weekly and occasionally smokes marijuana. The client drinks at least one beer every other night after work with dinner. He will finish two six-packs on some weekends if they have company over to watch football. He says he rarely drinks hard liquor. The client has reported that his alcohol use or smoking marijuana is not causing any impairments in his ability to carry out his daily responsibilities, but he is overweight because of his inactivity and indicates he would like to return to his normal weight. He also says that he has never experienced any adverse physical or psychological effects due to his substance use. | What is one of the three symptoms that must be experienced in order to diagnose Erectile Disorder? | Increase in premature ejaculation | Decrease in erectile rigidity | Duration of 3 months | Decrease in ability to climax | (A): Increase in premature ejaculation
(B): Decrease in erectile rigidity
(C): Duration of 3 months
(D): Decrease in ability to climax | Decrease in erectile rigidity | B | This is the correct answer because it is one of the symptoms in Criteria A that determines the diagnosis of Erectile Disorder. This symptom indicates the client may obtain an erection, but then the penis becomes flaccid. Therefore, the correct answer is (D) | intake, assessment, and diagnosis |
476 | Client Age: 13 Sex Assigned at Birth: Male Gender: Transgender; Gender Nonconforming (TGNC) Ethnicity: Caucasian Counseling Setting: Child and Family Agency, School-Based Services Type of Counseling: Individual and Family Presenting Problem: Truancy; Gender Dysphoria Diagnosis: Gender Dysphoria, Provisional (F64.1); Social Exclusion or Rejection V62.4 (Z60.4) | Mental Status Exam: The client is dressed in age-appropriate clothing. They wear eye makeup and chipped black fingernail polish, and they have bitten most fingernails down to the quick. The client’s mood is irritable, and they are quick to show anger toward their mother when misgendered. Their thoughts are coherent, and they deny audio/visual hallucinations. The client acknowledges feeling sad and hopeless but denies suicidal ideation. They attribute increased levels of anxiety at school to bullying, particularly with select peers. They explain that a select group of students threaten the client and call them offensive and derogatory names. Family History and History of th | You are a school-based mental health counselor in a public middle school. Your client is a 13-year-old Caucasian 7th grader who presents for the initial intake with their mother. The mother says that the client has had several unexcused absences from school because “he is confused about his gender.” The client adamantly denies being confused and explains that they self-identify as transgender. The client’s preferred pronouns are “they/them.” The client further states that they have had a strong desire to be a different gender since early childhood, and this desire and their distress have recently intensified. The mother reports that the client is chronically irritable, spends a lot of time alone, and has “basically shut everyone out.”The client reports experiencingbullying—both verbal and physical—in school “nearly every day.” In addition to the bullying, the client says that certain teachers refuse to allow them to use the bathroom aligned with their identified gender. To prevent this conflict, the client does not eat breakfast or lunch at school. | You work with the client and their parents to help the parents understand how the client conceptualizes their gender identity. You use the client’s self-identified, gender-affirming pronouns and praise the client for taking a brave first step. The client’s mother is fearful and anxious, particularly when thinking about the client’s safety. The client’s father expresses an overall lack of understanding and thinks it could be a phase. You recognize the father’s efforts to understand and help the client explain the distressing emotions associated with coming to terms with their gender identity, including an increase in severity since the onset of adolescence. The father states that he is unsure if he can accept the client’s transgender identity but says that he is committed to the counseling process. The client is discouraged by their father’s lack of acceptance | The client is discouraged by their father’s lack of acceptance. Which of the following can you use to reconceptualize the client’s perception by shifting their viewpoint? | Reframing | Joining | Linking | Restructuring | (A): Reframing
(B): Joining
(C): Linking
(D): Restructuring | Reframing | A | Reframing is used to help the client reconceptualize the problem and allow them to shift their perspective. In this situation, a reframe would emphasize the father’s commitment to counseling and his desire to understand as a possible indication of love and acceptance. Restructuring is used in family therapy when counselors intentionally unbalance the family’s homeostasis to facilitate transformation and improve interactions and functioning. Linking is a group therapy technique employed by group leaders to help members connect with one another. Joining is a family systems technique that refers to the counselor taking a leadership position within the family system. In structural family therapy, joining also involves blending, tracking, and mimesis. Therefore, the correct answer is (C) | counseling skills and interventions |
477 | 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.” | Regarding anger management, what exercises should Davone practice before next session to remain calm throughout the week? | physical expressive therapy using punching bags in the gym | journal writing to members of his family | release of negative energy through use of crystals | watch humorous videos and practice deep breathing in between laughter | (A): physical expressive therapy using punching bags in the gym
(B): journal writing to members of his family
(C): release of negative energy through use of crystals
(D): watch humorous videos and practice deep breathing in between laughter | watch humorous videos and practice deep breathing in between laughter | D | Using humor to release tension has been effective for men needing anger management, therefore combining deep breathing strategies with this activity can greatly calm anger and help Davone practice mindfulness. Exercise is a great solution to relieving stress, but it is not recommended to channel fueled emotions by engaging physical motions of aggression as it has been proven in scientific studies to heighten aggressiveness when angry. The use of holistic or crystal therapies are interventions to be delivered at the discretion of the therapist however are not evidence-based and should only be considered with clients who are already familiar with the practices or requesting to learn more about them. Although journaling is a healthy exercise in helping Davone reflect and relieve himself of things he wants to communicate, engaging in cognitive and emotional content through focusing on his reasons for anger may only serve to heighten his distress. Therefore, the correct answer is (C) | counseling skills and interventions |
478 | Name: Bianca Clinical Issues: Difficulty adjusting to life changes Diagnostic Category: V-codes Provisional Diagnosis: Z60.0 Phase of Life Problem Age: 62 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: Black Marital Status: Separated Modality: Individual Therapy Location of Therapy : Agency | The client is a 62-year-old female, wearing work attire. She appears to be in good hygiene and her dress is neat and appropriate for the situation. Her facial expression is sad and she has tear tracks on her cheeks. Her mood is noticeably depressed, anxious, and tearful. Her affect is constricted. She has coherent thought processes with appropriate content. She expresses feelings of sadness over her failed marriage and overwhelm about being alone. The client has intact memory and concentration. She has fair insight into her current situation and is able to verbalize her feelings in a coherent manner. | First session The client comes to the agency practice where you currently work as a licensed mental health therapist. She is a 62-year-old female who recently retired from an accounting firm employment. She is seeking treatment after her marriage recently failed. A few months ago, he husband filed for a legal separation and is currently romantically involved with another woman. The client looks at you tearfully and says, "I can't believe this is happening at my age. I am all alone. What am I going to do?" She continues to cry uncontrollably. You focus on providing a safe and secure environment. You assure her that she will not be judged or criticized in any way, and all of the conversations during the session will remain confidential. You gently let her know that it is okay to cry, and you are there to listen without judgement. You also tell the client that it is natural to feel lost and alone after a separation, especially since she and her husband have been together for such a long time. She says, "I just feel like such a fool. He cheated on me once before - that I know of - and now he's done it again. I stayed with him for over 30 years, and now I have nothing." She describes having mixed feelings of anger, sadness, fear, and confusion. She states, "There are moments where I'm so mad at him for leaving. Mad enough that I could break something! Our marriage wasn't perfect, but I thought he was committed to me. Well, obviously he wasn't. Then I start to question what's wrong with me that made him leave. And then I think about the future and how I'm going to live by myself. It's all so overwhelming." She further discloses that she is worried about having panic attacks again because "that's what happened the last time something of this magnitude happened to me." You reinforce the idea that it is important to focus on the fact that she is not alone and many people in similar situations feel overwhelmed and uncertain about their future. You let her know she is in a safe space to explore her feelings, work through her loss, and develop a plan for moving forward. You encourage her to reach out for support during this challenging time rather than isolate herself as she goes through this difficult change. Fifth session The client has been seeing you for individual therapy sessions every week. You have developed a strong rapport with her and collaborated on treatment goals, with her overall goal being to have a positive outlook on her life. During the last session, you gave her a homework assignment to begin keeping a journal, using the ABC model of rational emotive behavior therapy to identify self-defeating beliefs and understand how they are contributing to her emotional distress. You have also been working with her to process her feelings about her separation and develop coping skills. During today's session, she seems depressed, as she tells you her husband met with an attorney and officially filed for divorce. You explore her journal entries, noting one in particular in which she describes an experience in which she was driving and saw her husband sitting outside a café with "the other woman." She circled back a few times in her car, hoping he would see her. In her mind, she fantasized that he would leave his new girlfriend and drive away with her, and everything would return to normal. You ask her to tell you more about what "normal" means to her. She says, "I guess I just want things to go back to how it was before. When I mattered, when I felt loved, and when he was committed to our marriage." You acknowledge her feelings and explain that while it may not be possible to go back to exactly how things were, there is still hope for the future. You express compassion and understanding, emphasizing that there is no right or wrong way to feel. She states, "I just have mixed feelings about everything! I feel angry and betrayed by my husband, but sometimes I want him to come back. I start to feel lonely and realize the reality of my situation and that I have no purpose anymore and am alone. What's the point? My kids don't care; I have nothing in my life now. Things are so painful I'd be better off dead." You reassure her that you are here to support her as she works through all of her difficult emotions. | null | What is the most important action to take based on the client's statements during today's session? | Encourage the client to tell her husband she knows he is dating | Involuntary hospitalization | Develop a safety plan | Conduct a risk assessment | (A): Encourage the client to tell her husband she knows he is dating
(B): Involuntary hospitalization
(C): Develop a safety plan
(D): Conduct a risk assessment | Conduct a risk assessment | D | The client alludes to death and other feelings which could be problematic. Conducting a risk assessment will give you a better idea of where the client is, especially regarding whether she is thinking about suicide or if she intends to harm herself. Therefore, the correct answer is (C) | intake, assessment, and diagnosis |
479 | 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. | 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. | Which treatments have been shown to be effective in treating clients with NCDs? | Electro-Convulsive Therapy (ECT) | Dynamic Supportive Therapy (DST) | Exposure and Response Prevention (ERP) | Mindfulness-Based Stress Reduction (MBSR) | (A): Electro-Convulsive Therapy (ECT)
(B): Dynamic Supportive Therapy (DST)
(C): Exposure and Response Prevention (ERP)
(D): Mindfulness-Based Stress Reduction (MBSR) | Mindfulness-Based Stress Reduction (MBSR) | D | MBSR is inexpensive, easy to teach, and relatively simple to practice. Therefore, the correct answer is (C) | counseling skills and interventions |
480 | 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 Gregory's behavior in the session and his mother's disclosure, what topic may need further exploration in the next session? | Bullying at school | Unprocessed grief | Sibling rivalry | Nicotine withdrawal | (A): Bullying at school
(B): Unprocessed grief
(C): Sibling rivalry
(D): Nicotine withdrawal | Unprocessed grief | B | Gregory's emotional response was incongruent with improved functioning in school performance. Given what his mother told you, his angry response could be a secondary emotion tied to unprocessed grief related to his father's death. Therefore, the correct answer is (B) | intake, assessment, and diagnosis |
481 | Name: Amy Clinical Issues: Hopelessness/depression Diagnostic Category: Depressive Disorders Provisional Diagnosis: F34.1 Persistent Depressive Disorder (Dysthymia), Severe Age: 15 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: White Marital Status: Not Applicable Modality: Individual Therapy Location of Therapy : Private Practice | The client appears in your office with loose clothing and a thin physical frame. She has inconsistent eye contact and portrays a drowsy level of consciousness. Her speech rate is slow, her volume is soft yet monotone, and her fluency and rhythm are unclear and hesitant at times. She talks about how much she hates her life. Her mood is depressed and discouraged, while her affect is flat and sad. The client has been previously hospitalized for suicidal ideation. Her thoughts are slowed, and she is easily distracted. Her concentration is impaired with frequent lapses in attention. She is unable to follow a long line of thought or argument. She also reports difficulty making decisions. Her insight and judgment are limited. The client's emotional state is characterized by a pervasive sadness, irritability, and feelings of hopelessness. She exhibits difficulty in concentrating, making decisions, and expressing herself coherently. Additionally, she is experiencing disrupted sleep patterns, including insomnia and excessive daytime sleepiness, and has reported a diminished appetite with subsequent weight loss | First session You are licensed as a mental health therapist working on a post-doctoral thesis related to depression and have been working with several clients diagnosed with Persistent Depressive Disorder. One of your new research participants is a 15-year-old client who arrives at your office with her mother after being released from the hospital. Before beginning the session, you ask to talk with the mother and daughter separately. When interviewing the mother, she tells you about her daughter's ongoing behavioral difficulties, experimenting with drugs and alcohol, and getting involved with a "bad group of kids." The client's academic performance has also been affected, with teachers reporting a notable decline in grades and participation in class. This behavior has been ongoing for approximately six months and appears to be intensifying. The strained familial relationships that the client is experiencing are a constant irritation to the entire family. The father's instability may have contributed to the client's current emotional distress, exacerbating her depressive symptoms. The client's mother, while providing primary care, struggles to maintain any bond with her daughter due to the increasing social withdrawal and lack of communication Next, you interview the daughter. You ask her questions about school, friends, and activities she enjoys. She states that she is picked on daily at school, has no "real" friends, and hates her life. The client sighs heavily, saying, "Some nights I go to bed hoping that I won't wake up in the morning. There's nothing to look forward to. School is horrible. She explains that she feels like she is "stuck in a dark hole" and that she cannot get out. She reports feeling hopeless, helpless, and alone. You summarize what she has told you, and she confirms your understanding of her feelings. After completing your interview with the daughter, you invite the mother to join you in your office. You continue to gather information about the client's personal and family history, symptoms of depression, and risk factors contributing to her current state. You explore potential triggers for her suicidal ideation and any protective factors in place. The mother reports that her daughter has been struggling with a lack of self-confidence and low self-esteem. You also discuss her current support system and any potential areas for improvement. Through the assessment, you can comprehensively understand the client's challenges and strengths. At the end of the intake, you check to ensure that both mother and daughter clearly understand what you have discussed today. You plan to meet with the client on a weekly basis, and you schedule a session for the following week. | The client's mother reports that the client's father has a history of depression. The client's mother is her primary caregiver, as her father is in and out of psychiatric facilities. When the client was a child, she had a positive relationship with her mother, but as a teenager, she has been withdrawing from her mother and spending most of her time alone in her room. The client has missed many days of school in the past few months. She feels that no one at school likes her; she has tried to fit in by experimenting with alcohol and marijuana, controlling her weight, and staying out late at night. The client is struggling academically and lacks concentration in the classroom. At home, the client is withdrawn and spends most of her time in her room pretending she is doing homework but is actually scrolling through social media posts for several hours. In addition, she is having trouble sleeping and stays up late. | If you are going to bill a third party insurance company, what information do you need to share with the parents regarding their daughter’s therapy records? | The insurance company will have access to records that the parents have released. | The insurance company will have full access to the client's therapy records without any restrictions. | The insurance company will have limited access to her records to conduct a utilization review. | The insurance company will have access to a separate, redacted narrative produced by the therapist and the client. | (A): The insurance company will have access to records that the parents have released.
(B): The insurance company will have full access to the client's therapy records without any restrictions.
(C): The insurance company will have limited access to her records to conduct a utilization review.
(D): The insurance company will have access to a separate, redacted narrative produced by the therapist and the client. | The insurance company will have limited access to her records to conduct a utilization review. | C | While therapy records may be shared with third party insurers, there are still professional and legal limitations on how much information can be released and what it can be used for. Therefore, the correct answer is (B) | professional practice and ethics |
482 | Initial Intake: Age: 12 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: School Counselor Type of Counseling: Individual | Michael came to the office and looked upset as he sat down. When asked about how he felt about what happened, Michael respectfully stated that he was sorry but that he did not want to talk about it.
| Michael came to the counselor’s office after he was suspended for fighting with one of the other students.
History:
Michael, who was a new student this year, did not typically get in trouble. Michael has excelled academically since his arrival and joined several school clubs. When the teacher was questioned regarding what happened, she stated that the other student made a gesture to Michael that could not see. Suddenly, she stated that they were both throwing punches. Michael’s teacher stated that now that she thought about it, she recently noticed Michael exhibiting some repetitive movements that she never witnessed before. | null | Which of the following interventions would NOT help Michael recognize a situation and an urge before a tic arises? | Cognitive behavioral therapy | Psychoeducation | Insight-oriented therapy | Neuroleptics | (A): Cognitive behavioral therapy
(B): Psychoeducation
(C): Insight-oriented therapy
(D): Neuroleptics | Insight-oriented therapy | C | Insight-oriented therapy would not be an appropriate modality. This modality helps to identify unconscious motivation in behavior. Neuroleptics, also known as antipsychotic medication, has been shown to reduce tics. CBT can help the individual recognize the urge before the tic and identify situations prior. Psychoeducation can be used to help the person learn things that may alleviate or worsen symptoms. Therefore, the correct answer is (D) | intake, assessment, and diagnosis |
483 | Initial Intake: Age: 26 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Married Counseling Setting: Private Practice Type of Counseling: Individual | Molly was initially guarded, but pleasant, during the intake session. After some time, she became tearful. Molly stated to the counselor that although she always had a level of anxiety, she never came to counseling before because she thought that only unsuccessful people with serious issues get counseling.
| Molly came into individual counseling due to increased feelings of anxiety.
History:
Molly began showing symptoms of anxiety when she was in high school. Molly was star of the track team and on the honor roll. During her senior year she was writing for the yearbook and preparing to attend college at an Ivy League university. She successfully finished college and law school. Despite the symptoms she experienced throughout her educational career, she was able to ride it out and has been extremely successful in her law career. | null | Which of the following statements about panic and anxiety is not accurate? | Panic attacks usually subside within 20 to 30 minutes. | Anxiety does not have an abrupt onset. | In a panic attack the symptoms develop abruptly. | Anxiety symptoms are always intense. | (A): Panic attacks usually subside within 20 to 30 minutes.
(B): Anxiety does not have an abrupt onset.
(C): In a panic attack the symptoms develop abruptly.
(D): Anxiety symptoms are always intense. | Anxiety symptoms are always intense. | D | Anxiety symptoms are not always intense; they can have a range in severity and are typically mild. In addition, the onset is usually not abrupt. Panic attacks have an abrupt onset and usually subside within 20 to 30 minutes. To distinguish between the two, it is important to look at brevity and intensity. Therefore, the correct answer is (C) | intake, assessment, and diagnosis |
484 | Age: 27 Sex: Female Gender: Female Sexuality: Declined Ethnicity: Hispanic/African American Relationship Status: Single Counseling Setting: Community Agency Type of Counseling: Individual | The client presents as her stated age with positive signs of self-care related to hygiene and dress. She appears overweight for height as noted in her intake. Her mood and affect are congruent and she appears to be cooperative and forthcoming in her responses. She demonstrates no retardation, spasticity, or hyperactivity of motor activity. She is oriented and demonstrates no unusual thought processes or patterns. Her insight is intact and she identifies goals for therapy. She reports no suicidal ideations, thoughts of harm to self or others, or difficulties with memory, judgement, or concentration. | You are a counselor in a community agency that provides counseling. Your client presents with a history of convictions for felony criminal offenses in her early 20s, of weight loss and gains since college, and currently rates herself as approximately 50 pounds overweight. She describes herself in years past as “fat,” “ugly,” and “grotesque.” She reports one long term relationship during high school and college, with a male she tells you was “manipulative, controlling, and emotionally abusive. She reports not “dating-dating” since their break up six years ago. She does report that recently she has engaged in self-destructive behaviors with different people in the context of online relationships. She states that in several cases, she has met men and women online and used elaborate methods, including using multiple telephone numbers and creating false names and life events to establish relationships with these individuals. Several relationships ended abruptly when the individuals, both male and female, made concerted efforts to meet the client, at which time she disclosed the truth to them. She tells you that she feels very badly about what she did, particularly because she had been helping each of the people with different problems in their lives, including one of the women with an abusive spouse, and she believes now these people will have no help. She attended counseling for several months three years ago but reports she did not tell the counselor everything. Today she tells you that she is now in a professional graduate program for counseling and wants to be open about everything so she can “finally get her life in order.” | Family History:
The client reports her support system as several male and female friends. She feels close to these people though she says they sometimes irritate her. She describes her father as distant and her mother as strict and controlling. She states she and her siblings were punished frequently for not following their mother’s strict expectations for “how young women and young men should act.” She states she and her siblings were required to engage in daily exercise; always dress in “their Sunday best” during childhood; and focus on dieting, food intake, and weight ideals. She tells you she daily engaged in binging and purging from age 13 to age 20, but never told anyone or saw a doctor for this. She tells you that she has not binge/purged for the past five years. She states that her sister did the same and still struggles with it, and two other siblings are in treatment for alcohol and methamphetamine addiction. Additionally, the client tells you that both of her maternal and paternal grandparents have histories of alcoholism, and she smiles when telling you that one of her grandparents was imprisoned for criminal behavior and “is connected.” She says that several other maternal and paternal relatives have criminal convictions. | Which of the following counseling interventions will be least helpful in helping her connect to her story? | Using a Feeling Wheel or Feeling List to review the categories and levels of emotions | Provide psychoeducation about the connection between emotions, thoughts, and behaviors | Use a therapeutic game to help client explore her feelings | Record the client telling her story and pause so she can add thought and emotion details | (A): Using a Feeling Wheel or Feeling List to review the categories and levels of emotions
(B): Provide psychoeducation about the connection between emotions, thoughts, and behaviors
(C): Use a therapeutic game to help client explore her feelings
(D): Record the client telling her story and pause so she can add thought and emotion details | Using a Feeling Wheel or Feeling List to review the categories and levels of emotions | A | Therapeutic games, such as the Ungame are often used to help clients begin talking about their feelings. These are usually used with children and adolescents, and it would be unusual to do this with an adult with normal intellectual abilities. As the client has demonstrated willingness to talk with the counselor about her life history, it would be most beneficial to follow a sequential process of introducing the connections between emotions, thoughts, and behaviors, followed by helping the client identify feelings she has experienced. Counselors, with clients' permission, may record or have the client record their narrative so that the recording can be used in session to process thoughts and emotions that underlie or result from the client's actions. Therefore, the correct answer is (C) | counseling skills and interventions |
485 | Name: Gordon Clinical Issues: Mood instability and substance use leading to occupational impairment Diagnostic Category: Bipolar and Related Disorders;Substance Use Disorders Provisional Diagnosis: F31.0 Bipolar I Disorder with Rapid Cycling; F10.20 Alcohol Use Disorder, Severe Age: 33 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: White Marital Status: Never married Modality: Individual Therapy Location of Therapy : Agency | The client appears to the intake session disheveled and displaying a strong presence of body odor. He is inconsistently cooperative within the session. His mood and affect are anxious and labile. His attention and concentration are impaired, and he is easily distracted in the session. He admits to his recent suicidal ideations and hospitalization but minimizes the impact stating, "Everyone overreacts these days." He mentions that when he was in his 20s, he was prescribed Lithium. He denies any homicidal ideations and displays no acts of delusion or hallucination. The client's ability to abstract and generalize is slightly lower than average. The client grapples with his impulse control regarding alcohol. He has insight into the level of the illness with which he is struggling but lacks judgment when making healthy choices. | First session You are a mental health therapist in an agency. The client, a 33-year-old former cab driver, comes to see you per his hospitalization discharge. The client's speech is characterized by an increased rate of speech, tangentially, and circumstantiality. He reports feeling overwhelmed and out of control, often losing his temper and having difficulty regulating his emotions. He reports a history of alcohol abuse, as well as self-medicating to cope with his emotional distress. He states that he has lost his job due to his difficulty controlling his emotions, and he is hopeful that therapy can help him regain his job. He also reports a history of legal trouble and has been incarcerated multiple times in the past. His legal record shows a history of violent offenses and domestic abuse. After the initial interview, you review the paperwork from the client. You recognize his last name and realize he is a distant cousin by marriage, although this is your first time meeting him. You consider the ethical implications of continuing to see him for therapy along with the possibility of transferring him to one of your colleagues. | The client had a history of alcohol abuse and had been warned multiple times by his employer to stop drinking while on the job. The client's boss tried to counsel him, but he refused to accept help or advice. Instead, he continued driving while under the influence, and his reckless behavior eventually led to an accident. As a result, the client was dismissed from his job and has struggled ever since. The client has been unsuccessful in finding other employment due to his record of drinking on the job. He has been trying to seek help with his drinking but without any success. He believes that therapy may be his last hope for getting his job back, and he is desperate to change his life. The client tells you, "I started drinking years ago. I've tried to quit, but I can't do it." He further states, "It used to be a couple of beers, but that doesn't do it for me anymore. So now, I drink almost half a bottle of whiskey a day. I usually start in the morning because if I don't, I feel terrible; my hands shake, I feel clammy, and I get an upset stomach. For years, I used just to let the mood pass, but in the last year or so, the alcohol has helped." | After you have reviewed the paperwork from the client, you recognize his last name and realize he is your wife's cousin, although this is your first time meeting him. What would be the most appropriate response in this situation? | Notify the client that you are transferring his case as mandated due to ethical concerns. | Ask the client if he is comfortable continuing with therapy | Consider your ability to remain objective | Discuss the situation with the client and collaboratively come to a decision regarding therapy | (A): Notify the client that you are transferring his case as mandated due to ethical concerns.
(B): Ask the client if he is comfortable continuing with therapy
(C): Consider your ability to remain objective
(D): Discuss the situation with the client and collaboratively come to a decision regarding therapy | Consider your ability to remain objective | C | According to the ACA Code of Ethics, "Counselors are prohibited from engaging in counseling relationships with friends or family members with whom they cannot remain objective". Therefore, the correct answer is (C) | professional practice and ethics |
486 | 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. | Diagnosis: Premature Ejaculation, Acquired, Generalized, Mild (F52.4) ions. Family History: The client reports that he has been in a relationship with his girlfriend for 3 years. The client says that he is close with his parents and his younger brother | According to the American Psychological Association (APA)’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR), which of the following would be a differential diagnosis for premature ejaculation? | Substance-induced sexual dysfunction | A specific phobia | Generalized anxiety disorder | Bipolar disorder | (A): Substance-induced sexual dysfunction
(B): A specific phobia
(C): Generalized anxiety disorder
(D): Bipolar disorder | Substance-induced sexual dysfunction | A | Substance-induced sexual dysfunction is a DSM-5-TR differential diagnosis because substance use can affect sexual functioning. Generalized anxiety disorder covers general anxiety about many topics, but it does not necessarily lead to sexual functioning impairment. Social phobia is about a very specific situation or trigger for anxiety, and, although the client does have anxiety about sex and work, this would not meet the criteria. Bipolar disorder does not have known causes of sexual dysfunction. Therefore, the correct answer is (C) | intake, assessment, and diagnosis |
487 | Client Age: Husband, 38; wife, 37 Sex: Husband,male; wife, female Gender: Husband,male; wife, female Sexuality: Husband,heterosexual; wife, bisexual Ethnicity: Caucasian Relationship Status: Married Counseling Setting: Counseling clinic Type of Counseling: Couples counseling Presenting Problem: The couple is experiencing distress because the wife has had a sexual affair with a woman. Diagnosis: Adjustment disorder, unspecified (F43.20) and relationship distress with spouse or intimate partner (Z63.0) | Mental Status Exam: The couple presents as withdrawn at the start of the session, but they open up as they talk about lighter subjects. Both individuals are oriented to person, place, time, and situa | You are a licensed counselor meeting with a couple in your private practice clinic. The couple comes in, and they both sit down at far ends of the couch and do not look at each other. After explaining informed consent and other intake policies, you begin to ask the couple what brought them to counseling, and they both sit silently. You ask the couple if it is hard to start this conversation because of why they came, and they both nod. You ask the couple if it might be easier to start with how they met and why they fell in love with each other, and they both nod in agreement that they can talk about that. The couple appears more comfortable after this and even say a few statements to each other about shared experiences during the conversation. You circle back to the reason why they came to therapy, and the wife says that she assumes that she should talk first. She states that about a week prior she told her husband that she had an affair with a woman a few months before. She continues that, at the time, she was curious and it occurred while she was drunk and insists that it meant nothing. The husband states that he still loves her, but he is not sure how he is going to move past this. He emphasizes that not only did she have an affair, but her action exposed an aspect of her that he did not know about, making him question whether she even finds him attractive. | The couple comes into the session and sits down. Their body language does not appear as uncomfortable as it has in previous sessions because they are sitting a little closer together. You ask both individuals what they need to work on. The wife says that she knows that she needs to rebuild trust, and the husband says that he wants to know more about what happened in the affair before they move forward. The couple report that they tried to engage in sex, but that the husband stopped during intercourse. The husband states that he could not get the idea out of his mind that his wife does not find him attractive because she was with a woman. You ask the husband what it means for their marriage if his wife does not find him attractive, and he states that it means he will not be able to please her. You then ask him what it means for the relationship if he cannot please her, and he responds that it means he cannot be a good husband. You follow up asking what it means if he cannot be a good husband, and he says that they will have a miserable marriage. You support effective communication strategies and empathize with the couple. After the session, the wife comes back to get her coffee that she left and says that she knows that she hurt her husband and is in the wrong, so she will do whatever her husband needs to rebuild trust. The Gottman Method focuses on having five positive interactions to every one negative interaction | The Gottman Method focuses on having five positive interactions to every one negative interaction. Which of the following statements uses the Gottman Method approach of the positive-to-negative ratio? | Focus on small acts of love often | Take breaks in an argument to ensure that you mean what you say. | Communicate early and often to manage conflicts before they grow. | Focus on your friendship with each other. | (A): Focus on small acts of love often
(B): Take breaks in an argument to ensure that you mean what you say.
(C): Communicate early and often to manage conflicts before they grow.
(D): Focus on your friendship with each other. | Focus on small acts of love often | A | The Gottman Method encourages maintaining more positive than negative interactions by focusing on engaging in small acts of love often to counterbalance negative interactions. Taking breaks during conflict and regulating what you say is important, but these actions do not reflect the Gottman Method of improving positive interactions. Focusing on friendship is helpful, but this comes from engaging in positive interactions often. Communicating and dealing with conflict as it happens prevent the exacerbation of conflicts but are not the focus of the Gottman Method. Therefore, the correct answer is (B) | counseling skills and interventions |
488 | Client Age: 12 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Private Practice Type of Counseling: Individual Counseling Presenting Problem: Withdrawn and Avoidant Behavior Diagnosis: Undetermined | Mental Status Exam: The client appears oriented to person, place, time, and situation. The client is dressed appropriately for the weather and appears to be maintaining appropriate hygiene. The client was withdrawn for most of the session but was able to open up slightly about what was going on with | You are a licensed therapist working in private practice. A 12-year-old female client comes into your office for the intake session and is accompanied by her parents. The client’s parents report that their daughter has been withdrawn and has refused to return to school for the past 6 school days. The client is avoiding eye contact with anyone and is slouching with her arms crossed. You try to engage the client in open questions to initiate the intake session with her, and she does not answer you or look at you. You ask her if privacy would make her more comfortable, and she nods, so you ask her parents if they would mind waiting in the lobby, and they agree. The client continues to refuse to talk about school, but she does engage in conversation with you about other topics. | You and the client meet 4 days after the initial intake session due to truancy because she has missed several days of school. For about half of the session, the client seems to be withdrawn. She asks you what you are required to report, and you remind her of the limits of confidentiality. The client says that she understands, and then says she is going to talk about what happened anyway. She says that her volleyball coach asked to meet with her after practice about 7 months ago and when she entered his office, he asked to look at her right thigh following a fall during practice. She continues to state that when she showed him, he started to touch her genital area from the outside of her pants. She states that she ran out of the room and went home. She explains that after this event she quit the team and told her parents that she did not want to play anymore, but recently she has started to experience distressing memories of the sexual abuse; she refuses to go to school because she would see the man daily; she has difficulty feeling happiness; and she is experiencing feelings of shame, insomnia, and difficulty concentrating. You praise the client for disclosing this information and empathize with her about how hard it must have been to share this experience | All of the following are appropriate short-term treatment goals following the new information presented during the session EXCEPT: | Identify situations that could trigger a trauma response in order to reduce the impact of the sexual assault. | Identify and reduce the symptoms and effects of the sexual assault. | The client will process her feelings of shame associated with the sexual assault. | Process thoughts and feelings regarding the investigation process into the sexual assault. | (A): Identify situations that could trigger a trauma response in order to reduce the impact of the sexual assault.
(B): Identify and reduce the symptoms and effects of the sexual assault.
(C): The client will process her feelings of shame associated with the sexual assault.
(D): Process thoughts and feelings regarding the investigation process into the sexual assault. | Identify situations that could trigger a trauma response in order to reduce the impact of the sexual assault. | A | Identifying situations that may trigger a trauma response would likely come later in treatment from processing because the effects of the sexual assault are not fully understood at this point. It is important to begin processing the feeling of shame because this is a feeling the client is experiencing presently. One of the first steps in working through trauma is to process how it affects present functioning; therefore, it would be helpful to assist the client in reducing the sexual assault’s effects on herself. It is also helpful to prepare the client for the investigation because this may be further triggering and occur quickly, and the client would be otherwise unprepared to emotionally manage the situation. Therefore, the correct answer is (D) | treatment planning |
489 | Initial Intake: Age: 16 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Private Practice Type of Counseling: Individual | Molly muttered one-word answers during the intake session, made little eye contact and frequently rolled her eyes. She started to warm up towards the middle of the intake session, with some prompting from her mother. She reluctantly agreed to continue counseling sessions- only due to the fact her mother stated that she could not use the family car unless she went to counseling. | Molly is a 16-year-old female who was referred to an outpatient mental health clinic after a two-week admission at a local psychiatric hospital. Molly was brought to the hospital by ambulance after she disclosed to the school psychologist that she wanted to kill herself.
History:
When asked what brought the family to the session, Molly’s mother was tearful as she disclosed that her husband died in a car accident 11 months ago. Molly and her father had been close, spending time together as Molly played recreational softball and her father was the coach. Since her father’s death, she has been distant with her mother, and often picks fights with her. Additionally, Molly frequently complains of stomach aches, stating that the pain is so severe, she cannot go to school. Before her father’s death, Molly was in Advanced Placement classes and maintained a high average. Recently, Molly’s grades have been declining and she is no longer interested in softball. She states that when she goes to the softball field, she can almost hear her father speaking to her. | null | All of the following areas must be reviewed during the initial interview, except? | Support system | Paperwork from the hospital | Mental status | Family mental health history | (A): Support system
(B): Paperwork from the hospital
(C): Mental status
(D): Family mental health history | Paperwork from the hospital | B | Paperwork from past evaluations and hospital stays can be collected later and can be also obtained during the clinical interview and used as confirmation after the interview. Family mental health history can show depression in first degree family members, a risk factor for depression in the patient. Without knowing details of her father's car accident, some car related deaths are intentional. Molly's support system should be assessed and built upon as it is a protective factor when experiencing grief; a mental status exam can discover key areas of risk for suicide or self-harm and help the clinician understand thought processes, assess for auditory or visual hallucinations and gain insight into behaviors and judgment. Therefore, the correct answer is (B) | intake, assessment, and diagnosis |
490 | 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. | 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. | What is the best way to build rapport with the client? | Assess the client's current level of support | Express empathy and validate the client's feelings | Ask the client to tell you more about his family and their conflicts | Use humor to lighten the mood | (A): Assess the client's current level of support
(B): Express empathy and validate the client's feelings
(C): Ask the client to tell you more about his family and their conflicts
(D): Use humor to lighten the mood | Express empathy and validate the client's feelings | B | Building rapport with a client is an important aspect of counseling and therapy. Expressing empathy and validating the client's feelings helps to create a trusting relationship and provides a safe space for the client to open up. Therefore, the correct answer is (C) | counseling skills and interventions |
491 | Initial Intake: Age: 26 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Private Practice Type of Counseling: Individual | The client appears his stated age and is dressed appropriately for the circumstances in clean jeans and a t-shirt. He identifies his mood as “anxious but a little excited” because he “is hopeful that he can finally let his anger go.” He tells you he is tired because he has difficulty falling asleep and staying asleep most nights. His affect is pleasant with emotional lability evident. He demonstrates appropriate insight and judgment, memory, and orientation. He reports never “seriously” having considered suicide but acknowledges that there were times when he wondered “if dying would make this pain go away.” He has never attempted suicide and states he would never consider harming himself or anyone else. | You are a counselor in a private practice setting. Your client is a 26-year-old male who presents for counseling at the request of his family and his employer, with whom he is close and who knows his history. The client tells you that he has been angry for the past 15 years, beginning a year after the death of his father from a heart attack. He says that his anger is triggered very quickly when frustrated by people or situations and that his “fuse is very short these days.” He states that he has been in some “loud arguments” with his mother, and later his stepfather. He admits that there have been times in the past when he and his stepfather have “almost come to blows” but his mother stepped in and made them stop. He admits to having hit or kicked walls at times in his anger, but has never hit a person. He tells you that he doesn’t want to feel this way because it interferes with his relationships and his former girlfriends have never understood that when the anniversary of his dad’s death comes around, he just wants to be alone for a couple days and not have to talk to anyone. He tells you that he has never had a long-term relationship with a woman because either he gets “depressed” for a few days during certain times of the year (i.e., father’s birthdate and death date) or because he is too quick to get angry and then says things he doesn’t mean. He says that he has been in a relationship with a woman now for eight months and really wants to get himself together because he feels “she’s the one.” | Family History:
The client reports a family history of being the youngest of three siblings born to his mother and father. He reports a “great life” with his family and that they regularly spent time together playing, camping, traveling, and “just being a family.” He tells you that he is sure there were occasional arguments but that he doesn’t remember anything significant, except that he had been mad at his dad the night he died because his dad wouldn’t let him stay up late, but that before the client went to bed, he had come down, apologized to his dad, and they had both said “I love you.” He states his parents had been married for 15 years prior to his father’s death, which occurred when the client was 11 years old. He states his dad died of a heart attack while sleeping, so while he did not see it, he knew something had happened because his mother woke him and his siblings and rushed them over to the next door neighbors’ house. He said that his mother went to the hospital with his father in the ambulance and came home that night to tell him and his siblings that their father had died. He tells you that he and his siblings are still very close and that they now have three much younger siblings born after his mother married his stepfather. He says that he is very close to his mother and stepfather, although he lives three hours away from them. He tells you that he tries to get home for big family events, like birthdays. He states that his stepfather adopted him and his siblings after the wedding and the client loves him very much. He tells you that he and his stepfather have gotten in what the client thinks are “typical teenager/parent” conflicts but that they have often been made worse by the client’s anger that seems to always be inside and erupts quickly. | Based on the information provided, which of the following diagnoses should the counselor suspect? | Post-Traumatic Stress Disorder (PTSD) | Major Depressive Disorder (MDD) | Adjustment Disorder (AD) | General Anxiety Disorder (GAD) | (A): Post-Traumatic Stress Disorder (PTSD)
(B): Major Depressive Disorder (MDD)
(C): Adjustment Disorder (AD)
(D): General Anxiety Disorder (GAD) | Post-Traumatic Stress Disorder (PTSD) | A | The client has met the first criterion for PTSD in that he was exposed to an actual death, by witnessing the event which happened to a close family member (Criterion A). Additionally, his angry outbursts with little provocation and his difficulty falling asleep meet Criterion E, which requires marked alterations in arousal and reactivity. An adjustment disorder could be expected with significant life changes, but the disturbance of an adjustment disorder cannot encapsulate normal bereavement (Criterion D), nor can the client meet criteria for another mental health disorder (Criterion C). Given the time period of 15 years since the event and the client's positive experiences with family since the event, it would not be appropriate to diagnose an adjustment disorder. The client uses the word "depression" to describe periods of "a couple days" during the year in which he feels sad and isolates himself. MDD requires that the individual have either a depressed mood, most of the day, nearly every day during a two-week period (Criterion A1); or a loss of interest in almost all activities, most of the day, nearly every day during a two-week period (Criterion A2). The client does not demonstrate these conditions for more than "a couple days" so he does not meet criteria for MDD. Finally, the client does not demonstrate evidence of a general anxiety disorder as he describes no excessive worries or fears related to events or activities (Criterion A). Therefore, the correct answer is (C) | intake, assessment, and diagnosis |
492 | 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. | 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 type of therapy are you employing with your homework assignment for the client? | Gestalt therapy | Play therapy | Bibliotherapy | Behavioral therapy | (A): Gestalt therapy
(B): Play therapy
(C): Bibliotherapy
(D): Behavioral therapy | Play therapy | B | Music may be used in play therapy wherein the individual brings meaningful music and discusses it with the therapist. Therefore, the correct answer is (C) | counseling skills and interventions |
493 | Client Age: 22 Sex: Male Gender: Male Sexuality: Homosexual Ethnicity: Latino American Relationship Status: Single Counseling Setting: Community Mental Health Center Type of Counseling: Individual Presenting Problem: Depression Diagnosis: Major Depressive Disorder, Moderate | Mental Status Exam: The client is pleasant and dressed in age-appropriate attire. He is tearful when discussing his family and states this has been difficult for him. The client has had no previous suicide attempts. He is observed biting his nails. He describes feeling sad daily and states he sleeps during the day because he cannot sleep at night. He is slightly underweight but denied any difficulties with appetite. The client’s speech is coherent and clear. He denies suicidal ideation but often questions his worth and purpose. Fam | You are providing counseling services at a Community Mental Health Center. A 22-year-old Latino male, accompanied by his aunt, presents with symptoms of depression. The aunt is concerned about the client’s social isolation, feelings of hopelessness, and excessive daytime sleeping. Four months ago, the client’s parents kicked him out of their home after discovering a suggestive social media post of him with another male. He is close with his aunt and uncle, who have allowed him to stay in their basement. The client’s father refuses to speak to him and has told him he is “less than a man” and an embarrassment to the family. The client’s symptoms worsened last month when he was laid off from his job as a server. | The client reports fewer symptoms of hopelessness and depression. He discloses that he has been seeing a guy he met at his previous job. He is happy with this new relationship but says he’s still “fighting against” feelings of guilt and shame surrounding his sexual orientation and his parents continued rejection of him. The client says he has attended Metropolitan Community Church (MCC) with his boyfriend and was surprised to hear their messages of acceptance and inclusion. He has stopped going to bars and nightclubs since dating and reports less substance and alcohol misuse. The client states it has been quite some time since he felt like he had no purpose in life | How should the client’s disclosures about dating and attending church affect the direction of therapy? | It allows you to explore if the client has the ego-strength required for dating and finding a new church. | It determines the need for you to help the client establish his own LGBTQIA+ identity. | It causes you to re-evaluate potential risks associated with the client being “out” in the community. | It helps connect these events to the client’s management of his hopelessness, depression, and social isolation. | (A): It allows you to explore if the client has the ego-strength required for dating and finding a new church.
(B): It determines the need for you to help the client establish his own LGBTQIA+ identity.
(C): It causes you to re-evaluate potential risks associated with the client being “out” in the community.
(D): It helps connect these events to the client’s management of his hopelessness, depression, and social isolation. | It helps connect these events to the client’s management of his hopelessness, depression, and social isolation. | D | By connecting dating and attending church with the client’s treatment plan goals, you and the client can best determine the direction of therapy. The client is in the mid to late stages of treatment. Evaluating these events in the context of his treatment plan goals will help clarify the client’s readiness for termination. The client already has established his identity as a gay male, making answer A incorrect. Determining the client’s ego-strength could undermine the client’s confidence and self-efficacy, making this option incorrect. Re-evaluating the potential risks associated with being out in the community is also incorrect because the client is already well aware of the risks. Therefore, the correct answer is (B) | counseling skills and interventions |
494 | 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. | It has been 1 month since you last saw the client because he has canceled many sessions in a row without explanation. You process attendance with him and then ask him for updates regarding how symptoms have been over the last month. The client says that there were many reasons for cancellations, such as going to dinner with friends, being too tired, and forgetting about the session and making other plans. The client says that he got a new job and states that he is doing much better managing his ADHD symptoms in the new position. You and the client process what was difficult about his last position and then identify that these tasks are not present in the current position. A majority of this session was spent assessing the level of symptomatology experienced over the past month and the client reporting on events that occurred since the last session. During several sessions, you have noted in your mental status exam that the client demonstrated psychomotor activity | During several sessions, you have noted in your mental status exam that the client demonstrated psychomotor activity. Which of the following might be a common psychomotor activity for someone who has ADHD? | Pacing | Posturing | Fidgeting | Scanning/excessive eye movement | (A): Pacing
(B): Posturing
(C): Fidgeting
(D): Scanning/excessive eye movement | Fidgeting | C | Fidgeting is a common psychomotor activity for individuals who have ADHD and many other mental health disorders. This may be hard to assess because sessions are conducted via telehealth. Scanning and excessive eye movement are likely more related to anxiety, paranoia, and other mental health disorders, not ADHD. Posturing is not a typical symptom associated with ADHD. Pacing is typically associated with anxiety disorders, panic attacks, and at times autism spectrum disorders with repetitive behaviors. Therefore, the correct answer is (A) | intake, assessment, and diagnosis |
495 | Client Age: 35 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Hispanic Relationship Status: Divorced Counseling Setting: Private Practice Clinic Type of Counseling: Individual Counseling Presenting Problem: Anxiety; Depressed Mood, Difficulty with Changing Relationship Roles Diagnosis: Adjustment Disorder with Mixed Anxiety and Depressed Mood (F43.23) | Mental Status Exam: The client presents as oriented to person, place, time, and situation. The client appears anxious because he avoids eye contact often and expresses that he has never been in counseling and is ner | You are a licensed counselor in Texas in a private practice. A 35-year-old male client comes to counseling for support during a recent divorce. The client says that he and his wife separated a year ago and had to wait a year for divorce per state law; therefore, they finalized the divorce recently. The client says that his wife decided she married him because she was lonely and that, after 8 years of being married, she wanted to find someone she loved. The client states that he still loves his ex-wife and that he has a hard time with his new relationship with her because he shares custody of his children and still has to communicate with her regularly. He continues saying that his wife often calls him for emotional support and he does not know how to respond when this happens because he loves her and wants to support her, but this is confusing for him. The client says that he knows he “shouldn’t be with someone who doesn’t want to be with him and that things won’t go back to how they were.” The client identifies that anxious and depressive symptoms are present and that they affect his ability to engage socially, engage with his children, and perform at work. The client wants to work on navigating his new relationship with his ex-wife, his relationship with his children, and being single again. | The client comes into your office and says hello in a quiet voice and then sits down, slumps his shoulders, and does not make eye contact. You inquire about what you see, and the client says that he has been feeling more depressed over the past week. The client says that he is experiencing low appetite, a down mood, fatigue, and irritability. You empathize with the client and discuss coping skills for depressive symptoms. The client expresses frustration with his church because he worked part-time in the church office until recently when they encouraged him to resign because he is divorced and he is now unable to work in the church because of this. You empathize with the client regarding his situation at church. The client states, “I don’t understand how a loving God would approve of disqualifying me from working at church because of a decision my wife made.” The client then begins to cry | The client states, “I don’t understand how a loving God would approve of disqualifying me from working at church because of a decision my wife made.” The client then begins to cry. Which of the following responses would be considered an expression of validation? | “If I am understanding you correctly, it sounds like you’re feeling depressed and frustrated following the finalization of the divorce and the church encouraging you to resign.” | “It does sound frustrating to be encouraged to resign when the choice to divorce was not yours. I think it is perfectly understandable to be sad and frustrated about this.” | “It sounds like you are frustrated that the church encouraged you to resign because of a situation that you do not have control over.” | “I can see how that would be frustrating for you because it might feel incongruent with your beliefs.” | (A): “If I am understanding you correctly, it sounds like you’re feeling depressed and frustrated following the finalization of the divorce and the church encouraging you to resign.”
(B): “It does sound frustrating to be encouraged to resign when the choice to divorce was not yours. I think it is perfectly understandable to be sad and frustrated about this.”
(C): “It sounds like you are frustrated that the church encouraged you to resign because of a situation that you do not have control over.”
(D): “I can see how that would be frustrating for you because it might feel incongruent with your beliefs.” | “It does sound frustrating to be encouraged to resign when the choice to divorce was not yours. I think it is perfectly understandable to be sad and frustrated about this.” | B | Reflecting the emotion of being frustrated about the resignation and then moving to agreeing that the client’s feelings are understandable is validation because it goes a step past reflection to normalizing his emotions. Understanding that a situation is frustrating aligns more with empathy. Simply acknowledging frustration regarding the situation would just be reflection because you are reflecting his emotion. Expressing understanding about frustration regarding the church situation and depressive symptoms is simply a summarization of what the client has said. Therefore, the correct answer is (B) | counseling skills and interventions |
496 | Client Age: 13 Sex Assigned at Birth: Male Gender: Transgender; Gender Nonconforming (TGNC) Ethnicity: Caucasian Counseling Setting: Child and Family Agency, School-Based Services Type of Counseling: Individual and Family Presenting Problem: Truancy; Gender Dysphoria Diagnosis: Gender Dysphoria, Provisional (F64.1); Social Exclusion or Rejection V62.4 (Z60.4) | Mental Status Exam: The client is dressed in age-appropriate clothing. They wear eye makeup and chipped black fingernail polish, and they have bitten most fingernails down to the quick. The client’s mood is irritable, and they are quick to show anger toward their mother when misgendered. Their thoughts are coherent, and they deny audio/visual hallucinations. The client acknowledges feeling sad and hopeless but denies suicidal ideation. They attribute increased levels of anxiety at school to bullying, particularly with select peers. They explain that a select group of students threaten the client and call them offensive and derogatory names. Family History and History of th | You are a school-based mental health counselor in a public middle school. Your client is a 13-year-old Caucasian 7th grader who presents for the initial intake with their mother. The mother says that the client has had several unexcused absences from school because “he is confused about his gender.” The client adamantly denies being confused and explains that they self-identify as transgender. The client’s preferred pronouns are “they/them.” The client further states that they have had a strong desire to be a different gender since early childhood, and this desire and their distress have recently intensified. The mother reports that the client is chronically irritable, spends a lot of time alone, and has “basically shut everyone out.”The client reports experiencingbullying—both verbal and physical—in school “nearly every day.” In addition to the bullying, the client says that certain teachers refuse to allow them to use the bathroom aligned with their identified gender. To prevent this conflict, the client does not eat breakfast or lunch at school. | e The client’s mother and father are both realtors. The mother states that she used to see a therapist for anxiety, which she now manages with medication. The father works long hours, and the mother returns home early to attend to the client’s needs. The mother states that she realized that the client wished to be another gender when they were younger, but she believed it was just a phase. She explains that the father is not supportive and refuses to discuss the issue. The mother is concerned about the client’s truancy and desires to be supportive but has mixed feelings about it. She says that she is fearful every day and believes that if she accepts the client’s truth, it will set the child up for “a lifetime of prejudice and discrimination.” Your religious beliefs prohibit you from affirming the gender identity of a 13-year-old | Your religious beliefs prohibit you from affirming the gender identity of a 13-year-old. Which of the following is your best first response? | Conduct a trauma-informed assessment to determine the etiology of the client’s gender identity to help refine the treatment focus. | Use self-reflection and self-assessment to examine the personal biases and stereotypes you may have about transgender individuals. | Self-disclose your misgivings with the mother to help establish a therapeutic alliance. | Refer the client to a counselor who specializes in counseling transgender youths to prevent imposing your personally held values and beliefs. | (A): Conduct a trauma-informed assessment to determine the etiology of the client’s gender identity to help refine the treatment focus.
(B): Use self-reflection and self-assessment to examine the personal biases and stereotypes you may have about transgender individuals.
(C): Self-disclose your misgivings with the mother to help establish a therapeutic alliance.
(D): Refer the client to a counselor who specializes in counseling transgender youths to prevent imposing your personally held values and beliefs. | Use self-reflection and self-assessment to examine the personal biases and stereotypes you may have about transgender individuals. | B | Your best first response is to use self-reflection and self-assessment to examine the personal biases and stereotypes you may have about transgender individuals. Per the ACA Code of Ethics, disclosing your misgivings is unethical because it is not aligned with transaffirmative care and can be detrimental to the client. Conducting a trauma-informed assessment is appropriate, particularly for clients who are at risk for or may have experienced victimization or assault. However, providing this assessment to determine the etiology of the client’s gender identity suggests that there is an underlying cause that should be addressed to “fix” or change the “damaged” client. Assessments can be helpful appraisals for gender dysphoria rather than gender identity. Lastly, the ACA Code of Ethics states that counselors must “refrain from referring prospective and current clients based solely on the counselor’s personally held values, attitudes, beliefs, and behaviors” It is important to note that, although making values-based referrals is unethical, counselors are ethically responsible for practicing within the boundaries of their professional competence. Therefore, the correct answer is (C) | professional practice and ethics |
497 | Initial Intake: Age: 23 Gender: Male Sexual Orientation: Heterosexual Ethnicity: Indian American Relationship Status: Single Counseling Setting: Private Practice Type of Counseling: Individual | Shawn is slightly unkempt, completes ADLs and has good hygiene. His motor movements are fidgety and tense, and he consistently averts eye contact and darts his eyes around the room and towards the door every time he hears a noise. He appears to be sensitive to the lighting in the office as evidenced by fluttering his eyes when he looks up and commenting about its brightness. Shawn speaks within normal rate and tone, however low volume and often mutters under his breath. He denies any past suicidal or homicidal ideation and denies hallucinations or delusions. Shawn also denies history of trauma. | Diagnosis: Social Phobia, unspecified (F40.10) provisional; Alcohol Use Disorder, moderate, in early remission (F10.10)
Rishaan is a 23-year-old heterosexual male of Indian origin and is being referred to you by his parents for counseling in your private practice who are telling you Rishaan is at risk for going back to his drinking because he “never does anything constructive.” Further complaints by Rishaan’s parents include that “all he does is play video games and watch TV,” that he “never has money to pay for anything himself” and is constantly asking them for money. His parents offer to self-pay for Rishaan’s sessions. You welcome Rishaan to your office for an initial assessment. He respectfully requests that you refer to him as “Shawn,” which he explains is his preferred American name, and remarks that his parents really want him to talk to you. Shawn has agreed to counseling because he shares with you that he “has stuff to talk about anyway” and does not think he can go to his parents. | Substance Use History:
Shawn entered treatment and rehabilitation five months ago after his ex-girlfriend’s family had an intervention with him about his abusive drinking and he has now been through all phases of treatment for Alcohol use disorder. Shawn tells you he is ashamed that his parents found out about his problem through his ex-girlfriend’s parents, because he had been lying to his own parents about his well-being for several years since he left home for college at 18 years old. Shawn is currently five months sober but is not engaged in any post-treatment recovery program nor has he continued counseling.
Family History:
Shawn has two older siblings, both of whom he shares are “successful and have families.” Shawn says, “my parents always want me to be like them and are constantly comparing me to them, it’s so annoying.” Shawn’s father is a dermatologist, and his mother is his father’s secretary in their medical practice. Both parents observe traditional Indian cultural practices in their social lives and with respect to Hinduism.
Work History:
Shawn has attempted part-time work following his graduation from his alcohol rehabilitation treatment program but was unable to make his shifts on time and was let go from his job. He tried another job selling products by cold calls but could not keep up with the volume required to make a viable salary. When asked what Shawn would like to do for a living, he says “I’d like to be a gaming coder or tester, something like that.” | Shawn asks for help with overcoming interviewing anxiety. You offer to run a mock interview with him and coach him through his presenting fears. He then mentions he saw your agency's job posting for clinical assistant and would like to be considered. What is the most appropriate response? | "Our counseling strategies must have been effective, so proud of you for asking! I'll tell my clinical director of your interest!" | "Do you really think that is a good idea considering how anxious you already are?" | "Unfortunately, there is a conflict of interest seeing as you are a current client, I'm so sorry!" | "Maybe in a few months when you're better we can see where you would best fit." | (A): "Our counseling strategies must have been effective, so proud of you for asking! I'll tell my clinical director of your interest!"
(B): "Do you really think that is a good idea considering how anxious you already are?"
(C): "Unfortunately, there is a conflict of interest seeing as you are a current client, I'm so sorry!"
(D): "Maybe in a few months when you're better we can see where you would best fit." | "Unfortunately, there is a conflict of interest seeing as you are a current client, I'm so sorry!" | C | Clearly presenting a boundary line without offering any hope of future opportunity is the most ethical and appropriate response currently for this client. All other responses are either too presumptuous of his future progress (answer c), unethical due to the dual relationship he would have with the agency or irresponsible considering the level of care he currently needs (answer b) and unnecessarily shaming (answer a). Therefore, the correct answer is (D) | professional practice and ethics |
498 | 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 | Darrel is showing symptoms of? | Persistent Depressive Disorder | Other specified depressive disorder | Adjustment Disorder with mixed anxiety and depressed mood | Major depressive disorder | (A): Persistent Depressive Disorder
(B): Other specified depressive disorder
(C): Adjustment Disorder with mixed anxiety and depressed mood
(D): Major depressive disorder | Major depressive disorder | D | Darrel's symptoms are consistent with Major Depressive Disorder marked by a depressed mood and loss of interest in any activity, weight loss, difficulty sleeping, feelings of worthlessness and inability to concentrate, all causing severe impairment in functioning. Although Daniel's symptoms occurred within three months of a stressful event, his symptoms are beyond those of an adjustment disorder. Additionally, to meet the criteria for persistent depressive disorder, symptoms must have lasted for two years, which they have not. Other specified depressive disorder also cannot be used since Darrel meets the criteria for Major Depressive Disorder. Therefore, the correct answer is (B) | core counseling attributes |
499 | 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. | ily and Work History: The client divorced nearly 15 years ago and has lived alone since. She has two adult children and four grandchildren who all live locally. She reports experiencing depression and anxiety for most of her life. She currently takes an antidepressant and has done so for years. The client’s career was in school administration, where she dedicated nearly 30 years of service until retiring 6 years ago. She reports that retirement caused an increase in depression as she grieved the “loss of (her) identity.” The client’s mother had Alzheimer’s disease, which placed significant stress on the client and her father. The client’s sister is diagnosed with bipolar disorder, and there are no other noted mental health or substance use disorders in the family | Which screening and assessment instrument includes the question, “What are the three objects that I asked you to remember a few moments ago?” | Vineland-II | Mini-Mental State Examination (MMSE) | Cornell Scale for Depression in Dementia (CSDD) | Daily Living Activities 20 (DLA-20) | (A): Vineland-II
(B): Mini-Mental State Examination (MMSE)
(C): Cornell Scale for Depression in Dementia (CSDD)
(D): Daily Living Activities 20 (DLA-20) | Mini-Mental State Examination (MMSE) | B | The MMSE includes the question “What are the three objects that I asked you to remember a few moments ago?” The MMSE is one method used to quantify an individual’s cognitive functioning. In addition to recall, the MMSE assesses orientation, language, mathematical calculation, attention, and motor skills. The CSDD is a screening tool used to help detect symptoms of depression in individuals experiencing dementia. The CSDD measures a broad range of symptoms, including mood, behavioral disturbances, eating, sleeping, and suicidality. The Vineland-II is an assessment tool rather than a screening instrument. The Vineland-II measures several factors, including daily functioning, adaptive functioning, emotional disturbance, and other behavioral health conditions. Finally, the DLA-20 is an assessment instrument measuring multiple domains, including time management, safety, and communication. The DLA-20 is useful for establishing baseline measures and can be used again at various treatment intervals to measure outcomes. Therefore, the correct answer is (D) | intake, assessment, and diagnosis |
500 | Name: Marta Clinical Issues: Caregiving concerns Diagnostic Category: Trauma and Stressor Related Disorders Provisional Diagnosis: F43.23 Adjustment Disorder, with Mixed Anxiety and Depressed Mood Age: 55 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: Colombian American Marital Status: Married Modality: Individual Therapy Location of Therapy : Agency | The client appears older than her stated age. She is disheveled, poorly groomed, and has a strong body odor. She is cooperative but demonstrates a high level of distress manifested as restlessness, being easily distracted, and consistently rubbing her hands. Her speech is initially slow and halted but later becomes elevated and loud. She is oriented X3. Her affect is characterized by anxiety and depression, as she is having difficulty answering your questions. The client indicates that she has thoughts about putting a pillow over her mother's face or taking an overdose of sleeping pills so that she does not have to deal with her family or her mother's demands anymore. | First session You are a counseling intern for a mental health agency. A 55-year-old Colombian American female presents to therapy with tears in her eyes. She appears distraught, anxious, and despondent. She describes feeling guilty about wanting to put her mother in an assisted living facility. Although the client knows that putting her mother in an assisted living facility is probably the best decision, she feels guilty because it goes against the values of her culture. She explains that in traditional Colombian culture, elders are revered, and it is the responsibility of the oldest child to take care of them. The client's siblings have been "critical of me even talking about moving her into an assisted living facility" and are pressuring her to keep their mother at home. The client starts to cry and covers her face. Finally, she looks up and says, "I feel torn. There are these cultural expectations that I look after my mother, but she never even liked me and made my life miserable when I was growing up." The client does not have any nearby family who can help support her or assist in the care of her elderly mother. Her brothers live in different states, and her husband is an only child whose parents both passed away a few years ago. The client has expressed feeling overwhelmed by the responsibility of taking care of her mother and running her own household. She says, "I feel like I just can't keep up with everything. My kids need me, my husband needs me, and now I have to take care of my mother, too. And as for having any time to myself, that's a dream that's never going to happen." She further explains that her current circumstances remind her of what it felt like growing up in a chaotic household and feeling the pressure of having to take care of her younger siblings. She states, "It's like history is just repeating itself." She reports feeling "like a failure at being a wife, mother, sister, and daughter." As you listen to the client's story, you sense her feelings of guilt, frustration, and overwhelm about not being able to meet all the demands placed on her. You empathize with the client and validate her feelings. You compliment her on the strength it took for her to take on an additional responsibility despite the hardships that come with it. When asked what she hopes to gain from therapy, the client tells you that she wants to figure out how to balance her responsibilities. She expresses wanting to find a way to care for her family members without "losing myself and my sanity in the process." You suggest meeting with the client for weekly sessions as a place to begin, and you walk the client through what she can expect from therapy. Fourth session During a previous session, the client expressed an interest in bringing her husband to a therapy session to discuss her feelings and how to best manage their respective responsibilities. The client arrives to today's session with her husband, but he appears disengaged as you begin the session. You notice that the client is on edge, and she avoids looking at her husband. You start out by addressing both of them and asking how they are doing. The client responds first, saying that things have been difficult for her lately due to all the pressure she has been under from taking care of her mother in addition to managing her own household. She expresses feeling overwhelmed and anxious about not being able to meet everyone's needs perfectly. The husband remains silent, so you ask him specifically what he thinks about his wife's concerns. He replies that he feels frustrated because he believes that she is being "too sensitive" and should focus on fulfilling her obligations as a wife and mother instead of worrying about how others think she should do things. Feeling defensive, the client interjects and tells her husband that he does not understand what it feels like to be in her position. He replies, "You're right. I don't get it. Look, I don't want to be the 'bad guy' here, but you're obsessed with what your brothers think. They don't have to live with your mother. We do. We should be thinking about what's best for our family, not your siblings." The client says, "I'm trying my best, but I feel like I'm alone in this. When you get home from work, instead of helping around the house, you just binge watch cartoons and ignore everything. It's like I don't have a husband - I have an extra child!" The husband appears angry and tenses up, and you notice that the client is equally upset. You acknowledge their feelings of frustration, disappointment, and overwhelm and reiterate that it is understandable to feel this way given the amount of pressure they are both under. You take this moment to help both the client and her husband understand each other's perspectives in a supportive way. As you discuss their different points of view, it becomes clear that both the client and her husband are feeling overwhelmed by having to balance the demands of caring for an elderly family member. You explain the importance of being able to express their feelings and work together when making decisions about how to manage the family's needs. Next, you suggest that the client and her husband take some time to reflect on their feelings and experiences. You educate them about strategies they can use at home to express their feelings in a supportive way. 10th session During the last few counseling sessions, you and the client explored ways that she and her husband could better collaborate and communicate in order to manage their respective responsibilities. You worked with the client to develop coping skills to manage her anxiety, including deep breathing exercises and visualization techniques. You also engaged the client in a discussion about how her beliefs and values were influencing her reactions to her family's needs and strategized how to set boundaries and make decisions that honor her values without feeling guilty or overwhelmed. She has been actively using these coping strategies to better manage her emotions and has been more successful in communicating her needs to her husband. When you meet for today's session, the client appears to be in a positive mood. After a long discussion with her husband and her brothers, everyone finally agreed it would be best to move her mother into an assisted living facility. She says, "I had the most trouble convincing my youngest brother that assisted living was the best option. I think my sister-in-law was the one who finally helped him to understand why making the switch would give my mother the best chance for a better quality of life." She goes on to describe it as "one of the most difficult decisions I've ever made." You ask her how she is feeling now that the decision has been made, and she tells you, "a little bit guilty, but mostly relieved." You affirm her courage and ability to handle such a challenging situation. She tells you that she "can finally breathe again." She also believes that she might be able to have a better relationship with her mother with her being in an assisted living facility. The client does not want to resent her mother every day and expresses a desire to try to make the most of the time they have left together. She tells you that she has been going through some old family photo albums and came across a picture of her mother when she was newly married. She says, "She and my dad looked so happy together. There was a time when she wasn't so critical and demanding." The client tells you that she has been reflecting on her own experiences as a mother lately and thinking about "the courage my mother must have had to leave everything that was familiar to her and move to a new country with four kids in tow." She remarks that this newfound awareness has helped her understand why her mother was so demanding and strong-willed; she now sees that all of these qualities stem from a desire to provide for their family and give them the best possible life. Toward the end of the session, the client says, “I’m so grateful for everything you have done. You have been a great listener and given me the tools to cope with everything in a healthier way." You acknowledge her progress and remind her that she has come a long way since the beginning of your counseling sessions. | The client is the oldest child in her family. She has 3 younger brothers, all of whom are separated in age by one year. She was born and raised in Colombia. When she was in middle school, her family immigrated to the United States in search of better opportunities. Her father worked long hours as a taxi driver while her mother worked as a nanny taking care of other people's children. The client stated that she often felt like she had no parents because they were always working. The client stated that when they moved, her mother asked her to help out more at home with the cooking, cleaning, and taking care of her siblings. She often felt overwhelmed and guilty because she wanted to spend time with friends or focus on her studies rather than watching her brothers. The client revealed that she often feel a deep sense of resentment knowing that while other girls were able to go outside and play, she had responsibilities to take care of. Personal/Social Relationships: The client's father passed away four months ago and her 76-year-old mother has been living with the client since then. The mother does not speak English and requires assistance with medical appointments, financial dealings, and daily care. She constantly "nags" the client about how she is raising her children and often complains about her cooking. The client's husband, who is second-generation Irish American and grew up in Boston, is becoming increasingly irritated with his mother-in-law. He complains to his wife about her mother, which puts a "massive strain" on the couple's relationship. | What intervention would be most appropriate for the client to sustain her progress with her family? | Mindfulness exercises/stress management | Peer support group consisting of people with similar situations | Psychoeducation regarding helping aging parents | Couples Therapy | (A): Mindfulness exercises/stress management
(B): Peer support group consisting of people with similar situations
(C): Psychoeducation regarding helping aging parents
(D): Couples Therapy | Peer support group consisting of people with similar situations | B | Recommending a peer support group would be most appropriate. Peer support groups provide clients with another layer of support beyond what is offered in individual therapy. The client can benefit from and learn from a peer group and use it to augment her individual therapy. Therefore, the correct answer is (B) | treatment planning |
Subsets and Splits