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501 | 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 | The counselor is not familiar with East Indian culture. It is important for the counselor to approach this by? | Suppressing bias. | a and b | Acknowledging any bias he or she feels. | Learning more about the East Indian cultures. | (A): Suppressing bias.
(B): a and b
(C): Acknowledging any bias he or she feels.
(D): Learning more about the East Indian cultures. | a and b | B | Counselors must be culturally competent and be self-aware of any biases that he/she has. Biases occur naturally and can be addressed so they do not affect the therapeutic relationship. Learning about East Indian culture can be beneficial if the counselor also considers the individuality of the client/family as well. Suppressing bias would not be beneficial to the counselor or therapeutic progress. At times counselors may be surprised or embarrassed to acknowledge their biases. However, this is an important part of equity, diversity and inclusion in the counseling process. Therefore, the correct answer is (D) | professional practice and ethics |
502 | Initial Intake: Age: 29 Gender: Female Sexual Orientation: Heterosexual Ethnicity: Caucasian Relationship Status: In a relationship Counseling Setting: Private practice Type of Counseling: Individual | Taylor presents as well groomed, has good eye contact, and movements are within normal limits. Taylor appears anxious with tense affect and is occasionally tearful. Taylor has no history of suicidal thoughts or behaviors, no reported trauma history and has never been in counseling. | Diagnosis: Adjustment disorder with anxiety (F43.22)
You are a counseling intern working in a private practice with your supervisor and several other interns. Taylor is a 29-year-old college student who was referred to you by her university’s resource center for mental health counseling. Taylor went to them requesting someone to talk to about her family stress. Taylor’s 18-year-old brother has autism and is preparing to go to college in another state, and Taylor is feeling anxious about the transition since he will be leaving home for the first time and their family will not be around to help him. Taylor has been manifesting her anxiety in ways that are causing her difficulty in school and in her relationship, such as trouble concentrating, completing assignments, and lashing out with aggressive reactions towards her parents or her boyfriend whenever they bring up the topic of her brother’s college. She has even yelled at her brother once out of frustration. Taylor is hoping to find ways to cope with her stress and manage her emotions over her family’s decisions. | Family History:
Taylor lives at home with her parents and her brother, and commutes to University for her Bachelor studies. She stayed at home since graduating high school to help her parents with her brother with autism. Her parents had separated on and off for several years because of an affair her mother had, so the house has had tension and instability making Taylor feel responsible to keep her brother on a stable routine. Taylor comments that her brother’s challenges have always “taken up all her time” and that she used to complain about them, but now that he is going to be on his own, she is very upset she will not be able to be there for him. She complains her parents are “flaking out” on her and feels left out of their decision making but does not know what to do about it. | Which of the following should be included in treatment plan goals in addition to "emotional management"? | communication skills | autism family support group | academic advisement | family interventions | (A): communication skills
(B): autism family support group
(C): academic advisement
(D): family interventions | communication skills | A | It is apparent that Taylor is having difficulty communicating her concerns clearly to her family and within her relationship with her boyfriend since she has reported yelling at all of them and is seeking out a counselor to talk to instead. Teaching communication skills would be the most helpful intervention to help Taylor independently handle her own relationship issues. Conducting family interventions is not appropriate when Taylor, who is an adult, is the only one in the family who has requested help. Offering a support group as a resource is always an option to provide your clients but does not have to be a goal within itself; listing attendance to a relevant support group can fall under an objective within the greater goal of communication skills or emotional management. Academic advisement can be addressed by her school and is not necessarily a treatment provided by a mental health counselor. The subject of improvement in concentration relevant to her academic performance may be presented throughout counseling, however. Therefore, the correct answer is (A) | treatment planning |
503 | 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 | Sexual arousal from cross dressing is characteristic of? | Transvestic Disorder | Gender Dysphoria | Nonconformity to Gender roles | Depression | (A): Transvestic Disorder
(B): Gender Dysphoria
(C): Nonconformity to Gender roles
(D): Depression | Transvestic Disorder | A | Transvestic disorder is characterized by sexual arousal from cross dressing. Nonconformity to gender roles as an openness to atypical gender expressions. Gender dysphoria is a noncongruence with the gender someone is born with. Depression is characterized by sadness and hopelessness. Therefore, the correct answer is (B) | counseling skills and interventions |
504 | 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. Due to an increase in depressive symptoms, you explore major depressive disorder | Due to an increase in depressive symptoms, you explore major depressive disorder. All of the following are missing criteria for major depressive disorder EXCEPT: | Increased presence of risky behaviors | A 2-week period of depressive symptoms | A change of weight more than 5% in a month | Decreased interest in preferred activities | (A): Increased presence of risky behaviors
(B): A 2-week period of depressive symptoms
(C): A change of weight more than 5% in a month
(D): Decreased interest in preferred activities | Increased presence of risky behaviors | A | An increase in risky behaviors would align more with bipolar disorder, which does involve depressive episodes but is not required for major depressive disorder. The client needs at least five symptoms to meet the criteria for major depressive disorder that occur within a 2-week depressive episode, which include a change in weight of more than 5% in a month, and a decreased interest in preferred activities, among others. Therefore, the correct answer is (D) | intake, assessment, and diagnosis |
505 | Initial Intake: Age: 18 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Community Residence Type of Counseling: Individual | Nadia was initially resistant to the interview. She stated that she had been seeing counselors her whole life and none of them ever helped. Nadia had limited insight regarding her risk-taking behaviors. The counselor assessed that Nadia’s cognitive functioning appeared low. She stated that although she had contemplated suicide in the past, she currently had no intention or plan.
| Nadia is an 18-year-old in a community residence for children in foster care. She was referred for counseling because she has been running away from the group home, often for days at a time. Currently she is not getting along with her peers and gets into fights when they make comments about her activities, which is starting to affect everyone in the house.
History:
Nadia is one of 10 children by her birth parents. She has an extensive history of abuse and sexual exploitation by her parents until the age of 14 when she was removed from her parent’s care. Her and her siblings were sent to various foster homes as they could not all stay together. This is a subject that Nadia does not like to talk about since she was the oldest and had the responsibility to care for the younger ones. She feels as if she let them down. Nadia is frequently truant from school. For the past 4 years Nadia was in and out of foster homes due to her risk-taking behaviors and disrespect for others. She does have a good relationship with two staff members in the group home. | null | Nadia should be referred to? | A trauma support group | Social skills group | A group for sex addiction | Couples counseling | (A): A trauma support group
(B): Social skills group
(C): A group for sex addiction
(D): Couples counseling | A trauma support group | A | Nadia may benefit from attending a group of victims of trauma for support to help her process her past and help her to see that other have been through similar situations. There is no indication that Nadia has a sex addiction. Seeking sexual partners in this case has to do with the trauma she has experienced. Nadia is having difficulty with her peers, but an anger management group may be more beneficial than a social skills group. Although Nadia is having difficulties in her current relationship, couples counseling will only be effective if both people are willing. Therefore, the correct answer is (C) | treatment planning |
506 | Initial Intake: Age: 29 Gender: Female Sexual Orientation: Heterosexual Ethnicity: Caucasian Relationship Status: In a relationship Counseling Setting: Private practice Type of Counseling: Individual | Taylor presents as well groomed, has good eye contact, and movements are within normal limits. Taylor appears anxious with tense affect and is occasionally tearful. Taylor has no history of suicidal thoughts or behaviors, no reported trauma history and has never been in counseling. | Diagnosis: Adjustment disorder with anxiety (F43.22)
You are a counseling intern working in a private practice with your supervisor and several other interns. Taylor is a 29-year-old college student who was referred to you by her university’s resource center for mental health counseling. Taylor went to them requesting someone to talk to about her family stress. Taylor’s 18-year-old brother has autism and is preparing to go to college in another state, and Taylor is feeling anxious about the transition since he will be leaving home for the first time and their family will not be around to help him. Taylor has been manifesting her anxiety in ways that are causing her difficulty in school and in her relationship, such as trouble concentrating, completing assignments, and lashing out with aggressive reactions towards her parents or her boyfriend whenever they bring up the topic of her brother’s college. She has even yelled at her brother once out of frustration. Taylor is hoping to find ways to cope with her stress and manage her emotions over her family’s decisions. | Family History:
Taylor lives at home with her parents and her brother, and commutes to University for her Bachelor studies. She stayed at home since graduating high school to help her parents with her brother with autism. Her parents had separated on and off for several years because of an affair her mother had, so the house has had tension and instability making Taylor feel responsible to keep her brother on a stable routine. Taylor comments that her brother’s challenges have always “taken up all her time” and that she used to complain about them, but now that he is going to be on his own, she is very upset she will not be able to be there for him. She complains her parents are “flaking out” on her and feels left out of their decision making but does not know what to do about it. | Taylor realizes after several CBT exercises that she is not reacting to facts, but to her feelings. She doesn't understand where the feelings are coming from and asks what she can do to figure them out. Which of the following should be suggested based on her treatment plan? | Add a Trauma goal and conduct EMDR to get to the bottom of the feelings. | Include journaling, narrative therapy, and empty chair exercises under communication skills. | Explain that it's normal to not always understand your feelings and not to worry. | Teach thought stopping and refocusing techniques for emotional management. | (A): Add a Trauma goal and conduct EMDR to get to the bottom of the feelings.
(B): Include journaling, narrative therapy, and empty chair exercises under communication skills.
(C): Explain that it's normal to not always understand your feelings and not to worry.
(D): Teach thought stopping and refocusing techniques for emotional management. | Include journaling, narrative therapy, and empty chair exercises under communication skills. | B | The activities of journaling, narrative therapy or timeline therapy and Gestalt theory-based exercises such as the Empty Chair technique are all effective and evidence-based methods of improving communication skills and increasing self-discovery at a client-led pace. Answer b) does not validate the client's desire to better understand herself. Neglecting to offer interventions that lead her to change but instead placating with sentiments of comfort is unhelpful and irresponsible. Thought stopping and refocusing strategies are useful for clients who suffer intrusive thoughts, traumatic memories, or struggle with ruminations and are not the best match for a client who desires to intentionally think more about her feelings with the goal of modifying her thought processes. Adding a trauma goal when the client has expressed that she has no trauma is also not necessary unless cognitive behavioral strategies and other interventions have been exhausted, or if in the future a traumatic event is recalled because of these other interventions. Therefore, the correct answer is (A) | treatment planning |
507 | Initial Intake: Age: 37 Gender: Female Sexual Orientation: Heterosexual Race/Ethnicity: Caucasian/non-Hispanic Relationship Status: Married Counseling Setting: Mental health counseling agency Type of Counseling: Individual telemedicine | Leah is casually dressed, presenting with anxious mood and affect. Speech is of fast rate but with normal tone. Breathing is shallow from speaking fast, you note she stops to take deep breaths before continuing. Leah denies SI/HI, reports many protective factors, and admits that nothing in her life is “really that wrong.” Leah demonstrates good insight and judgment into the nature of her concerns. | Diagnosis: Generalized Anxiety Disorder (F41.1), Adjustment disorder with mixed anxiety and depressed mood (F43.23)
Leah is referred to your counseling agency by the U.S. Department of Veterans Affairs (VA) mental health program due to their inability to accommodate her because of their high caseloads. Leah is a 37-year-old married woman with a 2-year-old child and is a disabled combat veteran who served 8 years in active-duty Air Force service. Both you and Leah work full-time as mental health counseling interns in your respective practices. Leah struggles to manage her own anxiety which causes both interpersonal and professional problems for her. Leah reports experiencing trauma related to deployments, past divorce, death of a pet and birth trauma with her daughter. Leah tells you she needs someone to process everything with regularly as she does not want to exhaust members of her family with her stress. Leah’s biggest problem, she shares, is that she knows how to resolve her negative thoughts that lead her to act impulsively but cannot apply her skills when she feels overwhelmed. |
Education and Work History:
Prior to military life Leah worked several different jobs since the age of 13. Leah joined the Air Force at age 21, worked overseas as well as in the states, and had several deployments including one year in Kabul, Afghanistan as a Staff Sergeant during her fifth year of service. Leah obtained her bachelor’s degree right after separation, and then returned to Afghanistan as a contractor. Following this experience, she completed her master’s degree in counseling. She admits she is “skeptical” working with someone who has the same amount of experience as herself.
Family History:
Leah grew up with two younger siblings, and her parents divorced when she was 11. Due to joint custody, her and her siblings moved back and forth weekly every Friday until she originally left home for college at 18. Both of Leah’s parents remarried; her father having three more children with her stepmother, and Leah inheriting a stepsister when her mother married her stepfather. Leah was also previously married to an Army Sergeant while active duty, but her husband had an affair and left her prior to her military separation. | Leah makes a comment about how "only other veterans understand her" because of what she went through in the service. How can a counselor become more sensitive to veteran issues? | There is no limit to what strategies can be used | Join an auxiliary service or volunteer with their local American Legion | Ask their veteran clients to share and inform wherever possible | Read literature about military personnel transition to civilian stress | (A): There is no limit to what strategies can be used
(B): Join an auxiliary service or volunteer with their local American Legion
(C): Ask their veteran clients to share and inform wherever possible
(D): Read literature about military personnel transition to civilian stress | There is no limit to what strategies can be used | A | There is no wrong option for working to become more culturally knowledgeable of your clients by any means that are available. Cultural competency does not only refer to racial or ethnic identities, but also to cultures of varied work and life statuses that may experience challenges unique to others in mainstream society. Your willingness and ability to engage in any level of deepening your cultural sensitivity reflects this core counseling attribute of a culturally competent counselor. Therefore, the correct answer is (D) | counseling skills and interventions |
508 | Initial Intake: Age: 54 Gender: Male Sexual Orientation: Heterosexual Ethnicity: African American Relationship Status: Divorced, In a relationship Counseling Setting: Private Practice Type of Counseling: Individual | John presents as well-groomed with good hygiene and is dressed professionally. Motor movements are slightly fidgety, indicating nervousness or moderate anxiety. Eye contact is intermittent. Denies suicidal or homicidal ideation, no evidence of hallucinations or delusions. John tightens his fists when elaborating on situational issues between him and his ex-wife, with the same controlled expression and tense disposition when sharing about his girlfriend. John mentioned that his girlfriend is also unreasonable for complaining about how often John comes home smelling of alcohol, saying that meeting people for drinks is part of his job. He added the comment “I need to drink to deal with her attitude all the time.” | Diagnosis: Adjustment disorder with mixed disturbance of emotions and conduct (F43.25), provisional
John calls your practice asking to speak to a counselor to help him with his relationship. John tells you he’s never been to a counselor before and does not want anyone to know that he is seeing one, mentioning he will pay for sessions privately using cash. John admits to struggling with anger, specifically with his ex-wife of 15 years whom he divorced three years ago. John asks for availability in the evening hours and demonstrates hesitancy and reluctance to commit to more than a handful of sessions. In the initial assessment session, you notice he has difficulty making eye contact and is uncomfortable talking about his situation. After some rapport building, he begins to share that he is only seeing you because his girlfriend Sherry told him she would break up with him if he did not get his “anger issues under control.” John denied physically hitting Sherry, but alluded to several interactions that he stated, “got so heated I lost it on her, and she wouldn’t stop crying.” John complained of women he gets involved with being overly controlling of him and that he doesn’t understand why they are so “needy.” John works a demanding job in the sports marketing industry where he takes frequent trips out of state and spends long nights out, entertaining clients. He wishes he had the freedom to “do what he has to do” without “being treated like a child” by his romantic partners. | Family History:
John tells you he has two children, a 34-year-old son he had with a one-night stand in college and an 18-year-old daughter with his ex-wife the first year they were married. He has a decent relationship with his son and provides him and his family occasional financial support, visiting with his grandchild over social media video once a month. He reports once being close with his daughter but that their relationship became strained as she got older and that now they hardly speak, saying “she took her mother’s side during the divorce, so she doesn’t want anything to do with me right now.” While conducting further interviewing about John’s family health you learn that John’s father passed away at 56 after several heart attacks and his mother died of heart failure and diabetes complications at 49. John has no other living relatives besides an uncle in another state and his cousins who live near him. He tells you growing up he used to go to church with his mother every Sunday until she got sick and has not been to church since.
Work History:
John has a master’s degree in Business Marketing and made his connections with his current position through contacts he made while playing on collegiate basketball teams. John has always worked busy jobs with which he becomes heavily engaged in and puts in overtime hours. John prefers work that keeps him on the road and traveling often, as he does not like to engage in the same routine every day. He mentions when he was younger, he could not keep a 9-5 office job or at any place that did not encourage individuality, saying he “butted heads” with all his managers and bosses until he was older.
Legal History:
John has had two arrests made for domestic disturbances in his home that his wife called in after heated arguments that left his wife afraid for her life. He was always able to make bail and was never tried or sentenced as charges were usually dropped thereafter. John admits to one drinking and driving accident when he was 19 where he served community service and fines as punishment. | John notes that he is having difficulty at work as well. He feels he can make more money as an executive for a construction company and is considering selling his shares in the marketing industry. You do not agree this is the right time for a major career change. The best approach is to? | Cheer him on enthusiastically! He needs somebody on his side right now | Open a spreadsheet and help him compare the pros and cons of his financial choices. | Smile and nod, using motivational interviewing and Socratic questioning to learn more | Explain the risks associated with changing career fields and urge him to reconsider | (A): Cheer him on enthusiastically! He needs somebody on his side right now
(B): Open a spreadsheet and help him compare the pros and cons of his financial choices.
(C): Smile and nod, using motivational interviewing and Socratic questioning to learn more
(D): Explain the risks associated with changing career fields and urge him to reconsider | Smile and nod, using motivational interviewing and Socratic questioning to learn more | C | Your opinion is not helpful to John right now as he shares with you his career considerations from this vulnerable place in his life. The counselor's role is to support John's thinking process and provide clinical feedback and guidance to assist him in learning and practicing healthier, more adaptive strategies than what is being currently evidenced in his life. Learning more about his thoughts and feelings on the matter might steer the conversation in a therapeutic direction. Focusing on solely the content expressed in his concerns and not considering the whole picture dilutes the overall supportive counseling experience you are providing and takes away from what he could be learning for himself. Celebrating his every presented thought, especially thoughts you do not agree are in his best interest, is pandering to him as a friend and beyond the scope of your boundaries as his professional counselor. Helping him consider the pros and cons of his decision is not a bad option but getting involved in exploring the details of his financial situation is not the most appropriate use of this counseling moment. Therefore, the correct answer is (A) | counseling skills and interventions |
509 | Name: Dana Clinical Issues: Relationship distress with mother during divorce Diagnostic Category: Depressive Disorders;V-codes Provisional Diagnosis: F33.1 Major Depressive Disorder, Moderate, Recurrent Episodes; Z62.820 Parent-Child Relational Problem Age: 15 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: Multiracial Marital Status: Never married Modality: Individual Therapy Location of Therapy : Under Supervision | The client is dressed in black attire. She sits with her hands folded and slumped over in the chair. She makes little eye contact and seems to distrust you. Her mood seems flat. During the intake, the mother complains about how her daughter "does not listen," "acts out all the time," and "picks fights with her sister." The client is reticent and shrugs her shoulders. The client reported several other symptoms indicative of a depressive episode, including feelings of worthlessness, anhedonia, and lethargy. She also said having recurrent thoughts of self-harm that had become pervasive throughout her day-to-day life. On objective examination, the patient demonstrated psychomotor retardation, appearing to move and speak in a lethargic and sluggish manner. Cognitively, the patient's attention span was limited, and her concentration was impaired. She could not sustain her train of thought and had difficulty forming coherent sentences. Her mood was notably depressed, and her affect was constricted. This suggests a severe depressive episode, and these symptoms will likely require aggressive treatment. | First session You are a limited permit holder under direct supervision. The client is a 15-year-old multiracial female who presents to the first counseling session with her mother. The session begins with the client's mother monopolizing the conversation, and it is difficult for the client to get a word in edgewise. The client's mother continually brings up her husband as a source of her daughter's problems. The mother says, ""Our daughter is not doing well in school and has been talking back to her teacher. I think it comes from the relationship she's had with her father." The client interrupts and says, "It's not Dad's fault! You're the one who abuses me!" The mother is incredulous and begins to yell, saying that she would never hit her daughter and that the client is lying. The mother tells you that her daughter is a "liar, a thief, and creates problems." She reports that Child Protective Services (CPS) has been to their house several times, and she believes that these visits are her husband's fault. The client is visibly upset, and her mother continues to berate her. You intervene and explain that the client's disclosure is serious and should be taken seriously. You explain that you must speak to the client alone before deciding the best course of action. While speaking alone with the client, you notice that she is shaking and close to tears. You encourage her to take deep breaths and explain that she can take some time to regroup before continuing. After a few minutes, she appears calmer and begins to describe her home situation. It becomes clear that the client's home life is chaotic and that she is being subjected to verbal and emotional abuse from her mother. She tells you that she wants to live with her father. The client also states that she has been bullied in school, and this has been going on for some time. You explain to the client that she has a right to feel safe and that you will do everything in your power to ensure her safety. You continue asking question to assess her level of distress, and you note the client's self-reported symptoms consistent with depression, including insomnia, fatigue, and a significant decrease in her appetite. She is also alienating herself from her peers and family. After completing the initial session, you schedule an appointment to see the client and her mother next week to continue your assessment to determine the best course of action. Third session During last week's session, the client's mother accompanied her to the session. Throughout that session, the mother continued to talk about her own personal issues, and you could not gather information from her daughter's point of view. The client's mother presents with her daughter again to today's session. After a few minutes, you realize that the mother is monopolizing the counseling session by talking about her personal life and making snide comments aimed at her daughter. You suggest that it might be better for the client's mother to wait outside while you talk alone with the client. When the mother leaves, the client immediately relaxes and opens up about some of the struggles she has been going through. She shares that life at home has been difficult. She describes her mother as being "very mean" to her, and her grandmother makes fun of her. On the other hand, both adults are nice to her younger sister. The client states that she wishes she had never been adopted and that her life is "miserable." She expresses a desire to live with her father. Her behavior toward her parents has changed drastically since they started fighting in front of her, but she is not sure how to deal with their constant bickering. She has not told anyone at school about living in a "broken home" because she does not want any extra attention from her classmates. However, she has opened up more during therapy sessions, like today's meeting, telling you that music makes her feel better when upset. As homework, you ask the client to put together a playlist of music that is meaningful to her and bring it with her to the next session. Following today's session, the client's father calls you during off-hours to complain about his soon-to-be ex-wife. Sixth session You have seen the client every week since the initial intake. During today's session, the client tells you she has written a suicide note and left it in her room. Her mother is waiting in the lobby for the session to end. You tell the client you must bring her mother into the session and discuss the suicide note. You explain to the client that her mother's presence is necessary to explore and understand why the suicide note was written. The client expresses frustration and says, “You can’t bring my mom in here! She won’t understand why I wrote the note!” You empathize with her feelings, but also explain that it is important to discuss the reasons for writing the suicide note with her mother present. You reassure the client that you will guide the conversation to explore why she wrote the note and support her in addressing any underlying issues. You explain that understanding these reasons is an essential step toward moving forward and developing healthier coping strategies. The client reluctantly agrees, but insists on speaking with you alone first before bringing her mother into the session. You emphasize that it is important for her to be honest about her emotions and to talk about her experiences in order to identify the root cause of her distress. Throughout the conversation, you provide validation and affirmation in order to create a safe space for her to express her feelings. You remind her that she does not have to face the situation alone, and that you can work together to find a way forward. Once the client has had an opportunity to share her thoughts and feelings, you ask if she is ready for you to invite her mother in. She agrees, and the mother joins you in session. You explain to the mother that her daughter wrote a suicide note and that the two of you have been discussing the suicide note and why it was written. You emphasize that your goal is to better understand the circumstances leading up to this situation, so that you can work together to find a way forward. You state that your primary focus is on finding solutions, rather than assigning blame or judgment. The mother looks at you in disbelief and says, "What do you mean, she wrote a note saying she was going to kill herself? What are we doing here? I'm paying you to help my daughter, not make things worse!" She grabs her daughter's hand and storms out, after expressing her anger loudly the whole way to her car. You are unsure of how to proceed, so you discuss the case with your supervisor. Your supervisor listens and notes your concerns, offering advice and guidance on better handling the situation. He then suggests that you reach out to the client's primary care physician to discuss the possibility of hospitalization and other forms of support that might be available to the client. After further discussion, you call the client's physician and discuss the options. | The client has experienced a great deal of distress due to the chaotic environment of her home life. Her adoptive parents are in the middle of a "messy divorce," and it has been difficult for her to process, as she has had to witness her parents' arguments and the shifting dynamics of her family. This strain has been further compounded by her mother and grandmother's favoritism towards her younger sister, leading to the client feeling neglected and overlooked. In addition, her attempts to connect with her mother and sister have often been met with hostility, leading to frequent arguments and further exacerbating her feelings of alienation and loneliness. The client has also expressed feelings of anxiety and depression due to her current living situation. She has expressed a strong desire to live with her father and escape the hostile environment of her mother's home, yet her mother has continuously denied this request. This has resulted in the client feeling trapped and powerless to alter her current situation, leading to a sense of hopelessness. The client's relationship with her mother is strained, and she has difficulty trusting her. As a result, she is often guarded around her mother and expresses her distrust and resentment, resulting in further conflict and tension between them. The client's school environment has affected her mental health. She is constantly subjected to verbal and physical bullying from her peers, leading to feelings of worthlessness and insecurity. Her academic performance is suffering, and she cannot concentrate in class, leading to further isolation from her classmates. Previous Counseling: The client has been in and out of therapy with many different professionals. She has been diagnosed with Major Depressive Disorder. Her mother is also in therapy and believes her daughter needs "help." The client states that her mother has abused her before, and Child Protective Service (CPS) has been to the house numerous times but has not found any evidence of abuse. | Which best describes the reason why a safety plan is created with a client? | To give the client a sense of security. | To be able to contact the client's parents | To have professionals/agencies in place in case of a crisis | To stay in touch with your supervisor | (A): To give the client a sense of security.
(B): To be able to contact the client's parents
(C): To have professionals/agencies in place in case of a crisis
(D): To stay in touch with your supervisor | To have professionals/agencies in place in case of a crisis | C | This plan is for the client and therapist to use as a resource in a crisis. Therefore, the correct answer is (B) | treatment planning |
510 | Client Age: 32 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Counseling Setting: Community Mental Health Agency Type of Counseling: Individual Presenting Problem: Depressed Mood Diagnosis: Bipolar II 296.89 (F31.81), current episode depressed | Mental Status Exam: The client is dressed casually and is somewhat disheveled. She avoids eye contact and displays a flat affect. The client admits to having suicidal thoughts in the past but currently denies both suicidal and homicidal ideations. Her speech is soft in volume and tone. She tends to provide one-word responses but is cooperative when asked to elaborate. The client denies audio-visual hallucinations, and her thought content is coherent. The client’s mood is depressed, and her affect is flat. She appears tired and reports she has insomnia at night and is sleeping most of the day. The client has experienced depression off-and-on, beginning in late adolesc | You work at a community mental health agency providing outpatient services to adults. Today, you are meeting with a 32-year-old female who presents with her husband for an initial intake session. The client’s husband is concerned about his wife’s depressive symptoms. She is experiencing sadness, decreased appetite, and hypersomnolence. The client also expresses hopelessness and has lost interest in doing the things she once enjoyed. Until recently, the client worked at an art gallery. When employed, she reports that she, “just couldn’t get out of bed” and was eventually let go due to excessive absences. After her employment ended, her depressive symptoms worsened. The client was able to recall a time nearly one year ago when she felt “almost the opposite” of how she feels now. During this time, she experienced increased energy and felt more inspired and creative. The client explains that she and her husband used to travel selling their art at juried art exhibitions most weekends, but it has been awhile since she has joined him. | The client continues to benefit from counseling and presents today with a euthymic mood. She has met her treatment plan goals related to depressive symptoms and reports a better understanding of her illness. The client has begun painting again and accompanied her husband to an art show this past weekend. She expresses gratitude for your work together and is especially thankful that you have helped her get back into doing what she likes to do. At the end of the session, she gives you an original painting as a token of appreciation. She explains that the abstract painting conveys the emotional transformation she has experienced in counseling. You let the client know you would be joining a private practice in a few weeks. You explain you would be happy to see her again if needed and gave her your new business card with the address and contact information for the practice. The client’s husband calls and requests the client’s records. You are hesitant to comply because there are documented conversations concerning marital discord | The client’s husband calls and requests the client’s records. You are hesitant to comply because there are documented conversations concerning marital discord. According to the HIPAA Privacy Rule, how should you respond? | You cannot provide the record to the husband because there is a potential for harm to the client. | You cannot provide the record to the husband without first asserting counselor-client privilege. | You cannot provide the record to the husband unless requested by a third-party payor. | You cannot provide the record to the husband unless the client is aware of the request and does not object. | (A): You cannot provide the record to the husband because there is a potential for harm to the client.
(B): You cannot provide the record to the husband without first asserting counselor-client privilege.
(C): You cannot provide the record to the husband unless requested by a third-party payor.
(D): You cannot provide the record to the husband unless the client is aware of the request and does not object. | You cannot provide the record to the husband unless the client is aware of the request and does not object. | D | The HIPAA Privacy Rule contains provisions about confidential information disclosures to family members. According to the HIPAA Privacy Rule, “Specifically, a covered entity is permitted to share information with a family member or other person involved in an individual’s care or payment for care as long as the individual does not object” Specific state laws may differ. For answer A, the ACA Code of Ethics (2014) states, “Counselors limit the access of clients to their records or portions of their records, only when there is compelling evidence that such access would cause harm to the client” Since there is no indication that conversations about marital discord would create harm for the client, answer A is incorrect. However, some stipulations allow portions of a client’s record to be removed if there are multiple clients. The ACA Code of Ethics (2014) further states, “in situations involving multiple clients, counselors provide individual clients with only those parts of records that relate directly to them and do not include confidential information related to any other client” Since there is no information indicating that you provided couples counseling, this stipulation does not apply. Counselors must assert counselor-client privilege if records are subpoenaed. Privilege is a legal requirement rather than a HIPAA Privacy Rule. The release of records to third-party payers is prohibited without the client’s consent. Therefore, the correct answer is (C) | professional practice and ethics |
511 | 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. Third session You and the client have agreed to meet for biweekly therapy sessions as she feels she needs extra support right now. This is your third session with the client, and she presents looking exhausted and can barely speak. You consider alcohol use, but there is no smell of alcohol, and the client's eyes do not seem dilated. She is neither slurring her words nor stumbling. You can sense that she is exhausted, both mentally and physically. She shares that she has not slept in 48 hours and is struggling with nightmares about her deceased friend. She says, "Why did he have to die? I feel like it's my fault." Next, you ask her, "What do you think caused your friend's death?" but she looks away and shakes her head, unwilling to answer. You then try to explore the nightmares she has been experiencing, but she becomes irritable and angry. Finally, she breaks down and begins to cry. You allow her time to cry, knowing that it is a way for her to release some of the pain she is feeling. After a few minutes, you ask the client if she would like to talk about what is going on in her life. She agrees and starts talking about how overwhelmed she feels. She hates her job, her past, and her present. The client feels like everything is too much for her to handle. You listen patiently as she talks about her feelings. | 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. | Given the client's presentation during today's session, what would you prioritize as a short-term goal in her treatment plan? | Eliminate depression | Increase exercise | Extinguish anxiety | Decrease insomnia | (A): Eliminate depression
(B): Increase exercise
(C): Extinguish anxiety
(D): Decrease insomnia | Decrease insomnia | D | Increasing sleep is a short-term goal. She can be referred for medication such as Trazadone. You can create a sleep regime with her by using a tool such as a sleep diary to help with consistency. Therefore, the correct answer is (D) | treatment planning |
512 | Client Age: 42 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Divorced Counseling Setting: Agency Type of Counseling: Individual and Group Presenting Problem: Social Anxiety Diagnosis: Social Anxiety Disorder (Social Phobia), Provisional 300.23 (F 40.10) | Mental Status: The client is meticulously dressed and well groomed. She is cooperative and periodically exhibits a nervous smile. The client is fidgety and frequently repositions herself when seated. Her mood is anxious, and she becomes tearful when discussing feeling “stupid” during job interviews. She exhibits cohesive thinking, and her insight and judgment are intact. The client is oriented to person, place, situation, and time. Her affect is reserved. She denies suicidal and homicidal ideation as well as audio/visual hallucinations. | You are a certified mental health counselor working in a community mental health center. Your client is a 42-year-old white female who presents today with symptoms of social anxiety disorder. The client reports debilitating anxiety when interacting with others, particularly when meeting unfamiliar people or going somewhere for the first time. She states that she cannot sleep and has a poor appetite on the days leading up to social events. When encountering anxiety-provoking situations, she says that her hands shake, she sweats excessively, and her voice trembles. The client is recently divorced and, after more than 15 years of being out of the workforce, she is seeking employment. She explains that job interviews have been “humiliating” because of what she perceives as an “inherent lack of knowledge and a substantially impaired skill set.” | The client attends a process-oriented CBT group that is nearing the middle stage of group development. The client presents today with a bright affect and arrives early to converse with two other women in the group. During group activities, she is reticent to share and is sensitive to a conflict between two members that has started to emerge. One member becomes openly critical of the group tasks and their usefulness. Other members start to weigh in and take sides. The conflict quickly escalates between two members, with one shouting at another, “You have monopolized every session with your opinions. You are the most judgmental person I know! This group would be so much better without you.” Other members nod in agreement | After processing the conflict, what technique could you use to help group members recognize significant themes and patterns? | Genuineness | Summarization | Empathetic reflection | Unconditional positive regard | (A): Genuineness
(B): Summarization
(C): Empathetic reflection
(D): Unconditional positive regard | Summarization | B | Counselors use summarization to tie together certain concepts and themes. Summarization is particularly useful in the middle stages of group development, with special care being taken to emphasize positive growth or therapeutic progress. Genuineness, or congruence, occurs when the counselor’s responses are consistent with what the client is expressing. Counselors also use genuineness to show nonjudgmental acceptance, reflect empathetic attunement, and keep the focus on here-and-now interactions. Counselors express unconditional positive regard by showing nonjudgmental acceptance and care for clients. Counselors use empathetic reflection to respond to the client’s underlying feelings accurately. Empathetic reflections lead to empathetic responding, which consists of perceiving, understanding, and experiencing what the client is communicating. Therefore, the correct answer is (D) | counseling skills and interventions |
513 | Initial Intake: Age: 9 Gender: Female Sexual Orientation: Heterosexual Race/Ethnicity: Caucasian/Non-Hispanic Relationship Status: Single Counseling Setting: Private Practice Type of Counseling: Individual | Lottie presents as excited, over-stimulated and hyperactive, unable to sit still and does not take breaks from talking. Her appearance is highly disheveled with stained clothes and unbrushed hair. Lottie nervously walks around your office touching and commenting on everything. You ask her nicely to ask you before she touches your things, but she refuses and continues to do so. Lottie deflects from every question posed in your assessment. She denies SI/HI, hallucination, or delusion, which you were surprisingly able to find out from her. |
Diagnosis: Attention Deficit Hyperactivity Disorder, predominantly hyperactive type (F90.1), Oppositional defiant disorder (F91.3), Reaction to severe stress (F43.9)
Lottie is a 9-year-old girl in the fourth grade who has been referred to you by officials in her elementary school. You are a counseling intern of a private practice that specializes in adult personality disorders, but your supervisor accepted Lottie as a new client because Lottie’s mother is a former client of her agency, and she requested her daughter be seen by your practice as opposed to a school-based counselor. Lottie’s mother does not want Lottie’s peers to know she is in therapy. Lottie has been doing well in school academically but has not been able to behave appropriately for years, according to the referral report. Lottie bounces up and down in her chair constantly, makes impulsive noises throughout the day, and engages in inappropriate behaviors daily. Some of the behaviors listed include invading the personal space of her peers, licking and eating school supplies to garner reactions from fellow classmates, hiding on the playground and refusing to emerge, and many other behaviors. Lottie follows basic classroom directions but needs constant reminding or guiding that the teacher does not have time for. Lottie breaks down into hysterical emotional fits when she does not get her way and her behaviors have been spreading the school staff too thin to be capable of managing without intervention. This session is conducted with only Lottie in the room; her mother insists on waiting in the car outside so she can make some phone calls. She mentions her Medicaid has just been reactivated to pay for sessions. | Family History:
Lottie lives at home with her mother and mother’s boyfriend, as well as their 1-year-old son Davie who is her half-brother. You learned from speaking with her mother beforehand that Lottie’s biological father was a drug addict and homeless, and he was recently shot and killed, about four months ago. Lottie knows and understands what happened. During the intake session you ask her to draw a picture of something important to her. She likes this assignment and draws you a picture of her father’s homeless camp where she last saw him. She explains to you the details surrounding his murder and mature, intimate details of her mother’s broken relationship with him. “How do you know all of this, Lottie?” you ask her, concerned. “Oh, my mother told me. She tells me everything.” | Lottie continues to refuse the safety question and changes the subject. She then snorts and shows you her mucus, followed by spitting onto the floor. What should your response be? | Swift and immediate boundary setting with clearly stated consequences. | Reprimand her and make her understand inappropriate actions. | Go get her mother from the car and tell her what happened. | Ignore it out of empathy for her situation. | (A): Swift and immediate boundary setting with clearly stated consequences.
(B): Reprimand her and make her understand inappropriate actions.
(C): Go get her mother from the car and tell her what happened.
(D): Ignore it out of empathy for her situation. | Swift and immediate boundary setting with clearly stated consequences. | A | With your knowledge of personality disorders at this practice, you should realize her defense mechanisms are attempts at pushing you away and waiting to see if you will remain with her despite her actions. She is intentionally trying to garner a response from you. Reprimanding will either cause shame or be ignored, and ignoring her behaviors is detrimental to your counseling while being neglectful to her growth. Getting her mother involved positions you as someone who cannot handle her on your own and shifts the dynamic into a disciplinary one as opposed to a healing one. Setting your boundaries with Lottie immediately, explaining consequences for each boundary infraction, will teach Lottie while also empowering her to make her own choices understanding their consequences. Therefore, the correct answer is (A) | counseling skills and interventions |
514 | 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 not a behavioral definition of ADHD? | Frequent disruptive, aggressive, or negative attention-seeking behaviors | Exhibiting a marked impairment or extreme variability in intellectual and cognitive functioning | Impulsivity as evidenced by frequent intrusions into other's personal business | Susceptibility to distraction by extraneous stimuli and internal thoughts | (A): Frequent disruptive, aggressive, or negative attention-seeking behaviors
(B): Exhibiting a marked impairment or extreme variability in intellectual and cognitive functioning
(C): Impulsivity as evidenced by frequent intrusions into other's personal business
(D): Susceptibility to distraction by extraneous stimuli and internal thoughts | Exhibiting a marked impairment or extreme variability in intellectual and cognitive functioning | B | This definition describes a facet of autism spectrum disorder; answers a) through c) all correctly fall underneath the symptoms of attention-deficit hyperactivity disorder. Therefore, the correct answer is (D) | intake, assessment, and diagnosis |
515 | Client Age: 30 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Pacific Islander Relationship Status: Single Counseling Setting: Private practice counseling clinic Type of Counseling: Individual counseling Presenting Problem: The client and her boyfriend recently broke up, and she is “tired of being with the wrong guys.” She admits that she will often stay in relationships even if she knows they are wrong for her. Diagnosis: Provisional diagnosis: Dependent personality disorder (F60.7), personal history (past history) of spouse or partner violence, physical (Z69.11), and personal history (past history) of spouse or partner psychological abuse (Z91.411) | Mental Status Exam: The client is oriented to person, place, time, and situation. No hallucinations, delusions, or paranoia are reported. The client was anxious at the start of the session, but she was able to calm herself down by easing into the counseling relation | You are a professional counselor working in a private practice clinic. The client comes in and sits quietly. The client appears nervous because she avoids eye contact and waits for you to initiate conversation. You ask why she is in counseling, and she responds that she is just tired. You ask more about this, and she says that she is not ready to talk about it yet. You decide to cover demographics and other less intimidating topics and then ask if she is comfortable talking yet. The client says that she feels a little more comfortable. She begins to state that she and her boyfriend broke up the previous week and that she was with him for 2 years. She explains that she has been “in this type of relationship before,” continually finds the “wrong guy,” and that she always goes “all in” with her relationships. Through processing, she identifies the following behaviors and beliefs: difficulty making daily decisions without the input of her partner, doing anything to gain support and affection even if she does not want to do the task or activity, quickly moving on to another relationship when a relationship ends, feeling that she cannot care for herself when she is not with someone else, and acknowledging that she needs others to take responsibility for major areas of her life. The client says that she has experienced physical and psychological abuse from partners, but that she is not ready to discuss this. The client identifies that her most important goal is to not end up in “the same relationship” again or rush into a relationship that is not right for her. Throughout the session, you provide empathetic and active listening. You suspect that the client has dependent personality disorder. | The client comes in, sits down, and immediately says that she has been thinking and decided that she is now ready to talk about the physical abuse that she has experienced. She recounts that from age 18 until age 20 she was with a boyfriend who would smack her if she said something he did not like. She believes this is why she is so preoccupied with pleasing others. The client’s second relationship was when she was 25 with a man who would get drunk nightly and punch her in the stomach or in the back when he was upset. You empathize with the client and reflect her emotions regarding these events. The client states, “I didn’t deserve it when the drunk guy hit me, but I do feel I wasn’t the best girlfriend with the first guy. I often didn’t do enough for him and often said the wrong thing.” Throughout the session, the client was tearful and started shaking slightly when speaking several times. The client paused for long periods before sharing more difficult parts of the story. You decide to assess for PTSD during this session, but she does not meet the criteria. When closing the session, the client states that she is not able to pay for today’s session until the end of the week. The client has no history of nonpayment with you thus far. At the end of this session, the client gives you a gift card to a restaurant because it is the last time you will see this client before Christmas | At the end of this session, the client gives you a gift card to a restaurant because it is the last time you will see this client before Christmas. Which one of the following is the most appropriate clinical response considering ethics and your client’s needs? | Based on the presenting problems, you decline the gift. | Accepting gifts with a value of greater than $50 is inappropriate, so you decline the gift. | Accepting gifts is never appropriate, and you decline the gift. | You accept the gift because it is not high in value and because the client’s culture would view this rejection as offensive. | (A): Based on the presenting problems, you decline the gift.
(B): Accepting gifts with a value of greater than $50 is inappropriate, so you decline the gift.
(C): Accepting gifts is never appropriate, and you decline the gift.
(D): You accept the gift because it is not high in value and because the client’s culture would view this rejection as offensive. | Based on the presenting problems, you decline the gift. | A | It would be inappropriate to accept the gift because the client’s diagnosis of dependent personality disorder makes boundaries more complicated and could possibly allow for manipulation. The ACA Code of Ethics does not specify a dollar amount or a clear point of view about when to accept gifts; rather, it focuses on the motivation of accepting the gift or the client’s intent for giving the gift. Cultural considerations for accepting or declining gifts are an important consideration; however, the client’s diagnosis takes priority in the consideration of accepting gifts. Therefore, the correct answer is (D) | professional practice and ethics |
516 | Name: Alex Clinical Issues: Hopelessness/depression Diagnostic Category: Depressive Disorders Provisional Diagnosis: F34.1 Persistent Depressive Disorder, Severe Age: 65 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: Multiracial Marital Status: Married Modality: Individual Therapy Location of Therapy : Private Practice | Appearance: The client is dressed in a manner that can be described as casual, suggesting that they might not have made any special effort to dress up for the session. Additionally, he is unshaven, which you note might indicate either personal preference, a decline in grooming habits, or possibly, decreased motivation and energy. Behavior: The client's overall behavior is withdrawn. Mood and Affect: His stated mood is depressed, implying feelings of sadness, hopelessness, or desolation. His affect, the observable manifestation of his feelings, is flat. Speech: His speech is both slowed and measured. Thought Process and Content: The client's thought process is tangential. He tends to veer off-topic and does not consistently answer questions directly or stay on point. The content of his thoughts is notably negative and self-defeating. Perceptual Disturbances: No delusions or hallucinations have been reported, indicating that the client has no gross misinterpretations of reality or perceptual disturbances. Orientation: The client is oriented to person, place, and time. Insight: It appears that the client has poor insight into his condition. Attitude: His attitude towards the evaluator is compliant and cooperative. | First session You are a licensed mental health therapist. Today you are seeing a 65-year-old male via distance counseling. You introduce yourself and ask him what prompted him to schedule an appointment to see you. He reports that he has felt "down in the dumps" for several years, and as he gets older, he feels more depressed and is in constant pain. As he is talking, he shifts around in his seat, appearing to have difficulty staying in a comfortable position. He continues by saying he feels depressed most of the time, has lost interest in activities that he once found enjoyable, feels hopeless, and is fatigued all the time. He also says he has lost his appetite and has difficulty sleeping. He states that "no one wants me around." Then he looks down and says, "I don't really blame them. I wouldn't want to be around me either." At work, he has difficulty concentrating and making decisions and is distressed that his co-workers see him negatively. When you ask him about his relationship with his wife, he says that while they live together, they have "not been close for a long time now." They both sleep in separate bedrooms and they lead separate lives. He explains, "We just kind of grew apart. We still love each other and would never get divorced, but now we're more like roommates. She's very social and involved in the community. I'm more of a homebody." After the client has shared why he is seeking counseling, you state, "I can hear that you are feeling very discouraged. It sounds like you have been going through a difficult time for quite some time now and it's taking a toll on your life. Let's explore what might be contributing to these feelings and how we can work together to help find solutions or ways to cope with the challenges you're facing." You use a solution-focused brief therapy technique and ask him visualize what successful treatment would look like. He contemplates it for some moments and says, "I'd feel better, I guess." You encourage the client to think more deeply about what successful treatment would look like and explain how this visualization process can help him gain clarity on his desired outcomes. He says, "Hmm, I'm not really sure. Can you give me some examples? This is my first time in therapy and I'm not really sure what to expect." You provide some examples of tangible goals that he might set for himself, such as improving sleep patterns, having better communication with family members and co-workers, and finding meaningful activities to engage in. The client is able to identify some areas that could be improved and formulates realistic, achievable goals. Together, you create an action plan for successful treatment, which includes specific steps he can take to reduce symptoms and increase positive outcomes. You schedule a follow-up appointment to meet with him next week. Fourth session It has been three weeks since your initial session with the client, and he has been keeping his weekly appointments. Last week you suggested he see a psychiatrist, and you begin today's session by discussing the results of his psychiatric referral. The client reports that he was prescribed antidepressant medication. He is not feeling much relief from his depressive symptoms now, but his psychiatrist told him that it could take a few months for the medication to reach maximum efficacy. Next, you discuss treatment options and the use of cognitive-behavioral therapy combined with his medication regimen. He is willing to try the combined approach, and together you create a treatment plan with both short-term and long-term goals. He mentions his job being a source of frustration. You spend some time discussing the client's job and his feelings about it. He expresses his desire to retire, but he worries about the financial burden it may place on his wife. He says, "My retirement benefits are not that great, and I lost a lot of money in the stock market last year. I just don't know how I can make this work. I'm not sure if retiring now is the right decision." You discuss other possibilities for him to consider for retirement, such as part-time work or freelancing in a field he enjoys. You also brainstorm with him about ways for him to transition out of his current job in a way that reduces conflict with his co-workers, such as taking scheduled breaks and speaking with his supervisor about his workload. You provide support and suggest that he speak with his wife about their financial situation before making any decisions about his retirement. He agrees and states he will bring it up with her this upcoming week. Toward the end of the session, the client reveals that he has been contemplating cutting back on his drinking, but he is worried that he will not have any friends if he stops drinking. He says, "I already feel like a failure at work and as a husband. If I lose the few friends that I still have, I'll be alone and will never be happy again." You utilize motivational interviewing strategies and suggest that if he stops drinking, it will not mean that he has to give up all of his friends, but rather that he may need to find new friends who do not drink alcohol or who can meet with him in an alcohol-free context. He nods his head and says, ""I hear what you're saying, but who is the world would want to be friends with someone like me? The only reason I've got any friends left is because I like to drink with them." You empathize with his feelings of self-doubt, but remind him that it is possible to find meaningful friendships without drinking. You give him a homework assignment to find at least one activity or group that seems interesting to him and create a plan to start building positive relationships with others. You reassure him that you will be there to support him through this process and set a date for his next appointment. | The client reports that his relationships with family members were strained growing up, with his father often away for work and his mother struggling with her own mental health. He reports that his mother drank a lot, which the client defends saying, "I guess I'd drink a lot if I had 5 kids by the time I was 22 years old. The client grew up feeling unsupported and unimportant, which led to a disconnect from the rest of his family. Of his four siblings, the client keeps in touch with one brother, but "my other two brothers and sister live in different states and have different lives. I think they've struggled with depression, too. We don't talk much." Despite this difficulty in connecting, the client has an adult daughter whom he "loves very much and tries to stay in contact with. He wishes he could have done better for her during his parenting years, and despite their rocky past, has a deep desire to maintain a healthy relationship. He says, "I don't want her to think the same way I do about family and relationships. I want her to have good ones." The client is currently employed as a corrections officer and feels his job has no potential for advancement. He has been working there for 20 years and is ready to retire in less than a year. He expresses that it has been challenging and physically and mentally exhausting. In addition, he is tired of "dealing with both the inmates and the administration." He tells you his co-workers consider him a "slacker" because he is always tired and takes as many breaks as he can get away with. He is also worried about "word getting back to his co-workers" that he is in therapy. The client expresses that he has some drinks, especially after work, to calm down. He reports that he will drink in social settings as well. He states that his preferred drink of choice is whiskey. | Which technique would you employ to provide the client with an immediate shift in perspective? | Decatastrophizing | Stress Inoculation | Self-Monitoring | Internal Dialogue Exercise | (A): Decatastrophizing
(B): Stress Inoculation
(C): Self-Monitoring
(D): Internal Dialogue Exercise | Decatastrophizing | A | Decatastrophizing ("What If" technique) is the most immediate and manageable technique that could be applied. First, the therapist has the client state his feared consequence of a situation and then identify strategies for coping. Therefore, the correct answer is (A) | counseling skills and interventions |
517 | Client Age: 32 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Counseling Setting: Community Mental Health Agency Type of Counseling: Individual Presenting Problem: Depressed Mood Diagnosis: Bipolar II 296.89 (F31.81), current episode depressed | Mental Status Exam: The client is dressed casually and is somewhat disheveled. She avoids eye contact and displays a flat affect. The client admits to having suicidal thoughts in the past but currently denies both suicidal and homicidal ideations. Her speech is soft in volume and tone. She tends to provide one-word responses but is cooperative when asked to elaborate. The client denies audio-visual hallucinations, and her thought content is coherent. The client’s mood is depressed, and her affect is flat. She appears tired and reports she has insomnia at night and is sleeping most of the day. The client has experienced depression off-and-on, beginning in late adolesc | You work at a community mental health agency providing outpatient services to adults. Today, you are meeting with a 32-year-old female who presents with her husband for an initial intake session. The client’s husband is concerned about his wife’s depressive symptoms. She is experiencing sadness, decreased appetite, and hypersomnolence. The client also expresses hopelessness and has lost interest in doing the things she once enjoyed. Until recently, the client worked at an art gallery. When employed, she reports that she, “just couldn’t get out of bed” and was eventually let go due to excessive absences. After her employment ended, her depressive symptoms worsened. The client was able to recall a time nearly one year ago when she felt “almost the opposite” of how she feels now. During this time, she experienced increased energy and felt more inspired and creative. The client explains that she and her husband used to travel selling their art at juried art exhibitions most weekends, but it has been awhile since she has joined him. | ence. Family History: The client is married and has a 10-year-old daughter from a previous marriage. The client explains that her father was “distant and quiet unless he was drinking.” She remembers hearing that her paternal grandfather declared bankruptcy “at least once” due to gambling losses. The client’s mother has been diagnosed with bipolar disorder, with acute episodes requiring hospitalization. The client indicates that a former therapist also diagnosed her with bipolar disorder, but she rejects the diagnosis stating her symptoms are “nothing like my mother’s | null | Bipolar II disorder is a more severe form of bipolar I disorder. | Bipolar II disorder requires at least one episode of mania; bipolar I requires more than one episode of mania. | Bipolar II disorder requires at least one episode of major depression; bipolar I does not. | Bipolar II disorder is a milder form of bipolar I disorder. | (A): Bipolar II disorder is a more severe form of bipolar I disorder.
(B): Bipolar II disorder requires at least one episode of mania; bipolar I requires more than one episode of mania.
(C): Bipolar II disorder requires at least one episode of major depression; bipolar I does not.
(D): Bipolar II disorder is a milder form of bipolar I disorder. | Bipolar II disorder requires at least one episode of major depression; bipolar I does not. | C | Bipolar II disorder requires a major depressive episode; bipolar I does not. Specifically, “Bipolar II disorder, requiring the lifetime experience of at least one episode of major depression and at least one hypomanic episode, is no longer thought to be a milder condition than bipolar I disorder, largely because of the amount of time individuals with this condition spend in depression and because the instability of mood experienced by individuals with bipolar II disorder is typically accompanied by serious impairment in work and social functioning” (American Psychological Association, 2013). Further, bipolar I disorder no longer requires “the lifetime experience of a major depressive episode” (APA, 2013). Lastly, bipolar II no longer requires an episode of mania, but individuals must have a history of at least one hypomanic episode as a requirement for diagnoses. Therefore, the correct answer is (C) | intake, assessment, and diagnosis |
518 | 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 | Which of the following would be the most appropriate clinical modality to treat depression? | Dialectical behavior therapy | Behavioral therapy | Exposure therapy | Cognitive behavioral therapy (CBT) | (A): Dialectical behavior therapy
(B): Behavioral therapy
(C): Exposure therapy
(D): Cognitive behavioral therapy (CBT) | Cognitive behavioral therapy (CBT) | D | CBT is a consistently accepted approach to treating depression because it focuses on addressing the unhelpful cognitive and behavioral processes that affect functioning. Behavioral therapy alone would not treat the cognitive needs of depression because depression is often affected by cognitive distortions and behavioral effects. Although dialectical behavior therapy is helpful with depression, it was created to treat borderline personality disorder, and CBT would be more generally accepted as helpful. Exposure therapy is primarily used to treat anxiety. Therefore, the correct answer is (B) | treatment planning |
519 | 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. | Since the start of counseling and services with the local government mental health agency, the client has maintained sobriety from fentanyl and has been moved into stable housing via assistance from the agency. The client reports that the management of his anxiety has been better, but that he often feels lonely and unengaged. The client states that he is not sleeping well and thinks it is because he does not do much during the day. He continues to participate in Narcotics Anonymous daily in order to have interactions with other people. The client says that he tried to reach out to his children but they would not answer his phone call. You empathize with the client regarding his difficulty reaching out to his children. You and the client use this session in order to review progress and identify new goals | Which of the following would be the most effective cognitive reframing of the statement “My kids hate me and don’t want anything to do with me”? | “I hurt my kids, and I need to learn to be okay without them.” | “My kids are done with me, and I should learn to move on.” | “My kids don’t like me right now, but eventually they will come around.” | “I hurt my kids, but I can take steps to rebuild my relationship with them.” | (A): “I hurt my kids, and I need to learn to be okay without them.”
(B): “My kids are done with me, and I should learn to move on.”
(C): “My kids don’t like me right now, but eventually they will come around.”
(D): “I hurt my kids, but I can take steps to rebuild my relationship with them.” | “I hurt my kids, but I can take steps to rebuild my relationship with them.” | D | “I hurt my kids, but I can take steps to rebuild my relationship with them” is the most effective cognitive reframing statement. This reframing addresses the reality that the client hurt his children, and it provides the motivation to make changes to improve his relationship with them, but it does not promise an outcome because its focus is on taking steps. It is important to instill hope that the future can be better because a common cognitive distortion is that past experiences will be the same in the future. Expecting the children to “come around” does not acknowledge the work that is required on the part of the client for positive change to occur. Expressing the need to “learn to move on” or to “learn to be okay without them” does not provide the client with motivation to change. Therefore, the correct answer is (C) | counseling skills and interventions |
520 | Name: Logan Clinical Issues: Bullying Diagnostic Category: V-codes Provisional Diagnosis: Z60.4 Social Exclusion or Rejection Age: 11 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Not Assessed Ethnicity: Asian American Marital Status: Not Applicable Modality: Individual Therapy Location of Therapy : School | The client is wearing clean clothes appropriate to his age. Initially hesitant and withdrawn, he becomes more relaxed and responsive as the interview progresses. He is soft-spoken but articulates clearly. Mood is depressed, anxious, and irritable. Affect is euthymic with occasional sadness. Thought process is logical, goal-directed, and organized. No evidence of any cognitive deficits. Good insight into the impact the bullying has on his emotional well-being and his ability to make appropriate decisions is intact. No suicidal ideation was reported. | First session You are a school counselor seeing an 11-year-old male named Logan. He presents to your office with his mother. His mother reports that her son has been struggling in school and has been the target of bullying. She tells you that he recently started at a new school after their neighborhood was re-zoned. The bullying started a few weeks ago when he was sitting alone in class during lunch. A group of boys, whom Logan had never seen before, sat beside him and began teasing him about his clothes, shoes, and hair. When Logan tried to ignore them, they started calling him names. He went home that day feeling embarrassed and alone. Since then, the boys have devised new ways to make fun of Logan. They sneak behind him in the hallways, push him around when the teacher is not looking, and push him into the bathroom. Logan has been refusing to go to school, saying he has stomach aches. His mother says, "He used to love school. He even loved doing his homework. How many parents are lucky enough to have a child who likes doing homework?" When questioned, Logan says that he now hates school and wants to be home-schooled. He says he is being bullied throughout the day, and it does not stop until he leaves the bus. Logan's mother has been worried about him and wants to know how to stop the bullying. At first, she thought it was just "kids being kids" when they tease each other, but she is now concerned that it has gone too far. She also asks if you can help him to make friends in his new school. During today's session, you notice that Logan appears anxious and withdrawn. As you gently probe further, Logan shares that he feels overwhelmed by the constant bullying, which has begun to affect his self-esteem. You observe that he appears hesitant to discuss the specifics of his experiences, suggesting that he may fear rejection by you or be embarrassed by what was done to him. This indicates that the situation has caused significant distress and has started to erode his resilience. As you explore Logan's support network, he hesitantly reveals that he has been unable to make new friends since starting at the new school. The fear of being targeted by bullies has made it challenging for him to approach other students or engage in extracurricular activities. Consequently, Logan feels increasingly isolated and struggles to see a way out of his current situation. This lack of social connection exacerbates his feelings of loneliness and despair. As part of his treatment plan, you include developing and maintaining positive relationships with peers to work on his tendency to isolate himself. Toward the end of the session, Logan's mother inquires about possible strategies to address the bullying. You acknowledge her concerns and emphasize the importance of a collaborative approach involving the school, family, and community. You suggest initiating communication with Logan's teachers and school administrators to create a safe and supportive environment for him. Additionally, you recommend Logan's mother encourage her son's interests and hobbies outside of school to help him build self-esteem and form new friendships. Meanwhile, you will continue to work with Logan on developing coping strategies and strengthening his emotional resilience in future sessions. | The client has a large supportive family. The extended family often gathers together for Sunday dinners. The client says that he has fun playing games with his cousins. The client's mother states that their family is very close, and she and her husband make a concerted effort to prioritize shared time with the extended family. | What additional resource will be most helpful to therapy and possibly contribute to a good prognosis for the client? | Referencing the client's history of school behaviors before this incident. | The child's previous academic performance. | Family therapy as a therapeutic resource, given reported extended family support. | The mother's support as a primary therapy resource. | (A): Referencing the client's history of school behaviors before this incident.
(B): The child's previous academic performance.
(C): Family therapy as a therapeutic resource, given reported extended family support.
(D): The mother's support as a primary therapy resource. | Family therapy as a therapeutic resource, given reported extended family support. | C | Given the presented history, providing family therapy as additional therapeutic support could become a very resourceful consideration in this case. Family therapy can help maneuver family members to take a more active role in supporting the client to deal with the impact of the bullying than individual counseling might provide. Therefore, the correct answer is (B) | treatment planning |
521 | Name: Denise Clinical Issues: Hopelessness/depression Diagnostic Category: Bipolar and Related Disorders Provisional Diagnosis: F34.0 Cyclothymic Disorder Age: 38 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: White Marital Status: Divorced Modality: Individual Therapy Location of Therapy : Private Practice | The client is appropriately dressed. She is overweight and appears edgy and irritable. Her attention wanders during the intake. She is articulate and able to communicate her thoughts logically. The client focuses on the negative aspects of life and appears to have a strong external locus of control. Insight is low, and judgment is strong. | First session You are a mental health counselor in a community agency. The client is a 38-year-old White female teacher referred to you by her principal. The client is experiencing difficulty with her school colleagues. She wants to keep her job and is motivated to improve her social skills. Since she was a young adult, she has had tumultuous relationships with co-workers, friends, and family. She tells you she has periods of highs and lows. During the high periods, she is overly talkative, impulsive, and insensitive to others. However, during the low periods, she withdraws from social contact, feels hopeless and helpless, and has trouble concentrating. She expresses a desire to be liked, but people see her as an "emotional roller coaster" and avoid her. She is very talkative throughout the session and changes the topic frequently. You raise your hand periodically to summarize what she is telling you. Early on during the session, the client says, "Please help me. I know something is wrong, but I don't know what to do. Can you fix me?" You discuss the scope of your practice and explore options for treatment with her. You explain that one of your responsibilities as a therapist is to provide a safe space where she can express her thoughts and feelings without fear of judgement or criticism. You explain that through understanding and integrating different aspects of herself, she has the potential to develop healthier relationships both in and outside of work. You emphasize the importance of building self-awareness and developing effective coping skills as part of her journey towards healing. Ultimately, you focus on empowering the client by providing support, guidance, and skills that will enable her to make positive changes in herself so she can function more effectively in life moving forward. You discuss the importance of the client taking an active role in her treatment process and explore methods she can use to become more mindful of her thoughts, feelings, and behavior. You suggest that this will help her gain better insight into the sources of her distress, which will enable her to take more control over how she copes with difficult situations in the future. The client appears relieved that there is something constructive she can do. You end the session by scheduling another appointment for next week and encourage the client to focus on self-care in between sessions. You also reassure her that you will be there as a supportive resource throughout the therapeutic journey ahead. The client leaves feeling empowered and energized to take the first steps towards change. Fourth session During the previous two sessions, you spent the majority of the time listening to the client describing her conflicted relationships. You asked her to start keeping a mood diary, and while you review it together today, you notice that entries involving her father always precipitate a depressive mood. While you try to bring her attention to this trigger, she says, "I bet my dad enjoys watching this from the grave," and laughs. She tells you that she never felt like her father really loved her, and she believes that he blamed her for her mother's death. You demonstrate empathy and unconditional positive regard in response to her feelings. You begin to explore the client's thoughts about her father's suicide. Her demeanor changes, and she begins to talk about finding his body and the pain he must have gone through. She has "an epiphany" as she describes how she feels and realizes that he must have suffered a lot. Following the client's disclosure, you take the time to normalize her feelings and process her experience. You acknowledge the immense amount of pain and suffering she has endured, both from her father's death, as well as his emotionally distant behavior during life. Through your therapeutic dialogue, you emphasize that it is natural for a person to feel overwhelmed and disconnected in such circumstances, and that these feelings are not a source of shame or weakness. You prompt her to think of new ways in which she can build healthier relationships with others, including developing more meaningful connections through open and honest communication. Finally, you ask her to brainstorm different activities and interests that she finds joy in doing so she can incorporate them into daily life as a way for her to find balance amidst the chaos. At the end of the session, the client mentions that she is going to be visiting a friend who lives on the other side of the country. They are planning to explore one of the national parks for a few days and spend the remainder of the time "just chilling" at her friend's house. She tells you that she is looking forward to spending some time in nature. The client does not want to miss her weekly appointment with you and asks if you can meet with her for a virtual session next week instead of your usual in-person counseling session. Sixth session The client has not been following through with her mood journal. She says that she "got bored and didn't feel like writing in it anymore." During this session, a month and a half into therapy, she relays an incident that happened with the friend she went to visit out-of-state. They argued due to political differences and are currently not talking to each other. The client now considers her friend "a drunk who doesn't know what she's talking about." You suggest that the client's anger and judgment may be a defense that she uses to avoid feeling rejected as she did with her father. You state, "It seems that in an attempt to avoid feeling hurt and rejected, you use anger and alcohol to push people away." The client responds with reflective silence and begins to tear up. You guide the client to examine her defensive behavior and understand why she relies on it when faced with difficult emotions. You emphasize that her feelings of hurt, rejection, and anger are valid, however, they can be managed in healthier ways. You suggest that part of processing these feelings is to recognize them and make attempts at reconnecting with her friend. Additionally, you recommend cultivating self-care practices. The client acknowledges the importance of looking after herself during this difficult time, understanding that if she is able to take care of herself first she will be in a better position to address her relationships. You remind the client that it is important to take steps to move forward, even if those steps are small. You highlight her willingness to talk through her emotions and gain insight into her reactions as an opportunity to grow in self-awareness. You explain that having knowledge of one’s own feelings helps them to make better decisions and boundaries, which can lead to healthier relationships with others and ultimately, more peace within oneself. With this understanding, you create a plan of action together for how she will move forward between now and your next session. You close the session by telling the client that she has made progress today by having gained insight into her feelings, and that will lead to exploration of how to respond to them more productively. You conclude by encouraging her to keep exploring new methods of self-care and to bring up any additional topics she wants to discuss in the next session. | The client's mother was diagnosed with Bipolar I Disorder. The client's mother passed away ten years ago in a car accident. The client reported constant criticism from her father when she was growing up. When the client's mother was not depressed, she acted as a buffer between the client and her father. The client reports getting married immediately after graduating high school to an abusive man who was similar to her father in many ways. The couple divorced two years ago after the client wound up in the emergency room after reporting that she "slipped on the last step of the staircase and fell into a door jam." She got full custody of their son and went to live with her father until he passed away a year ago from suicide. He was chronically ill with cancer. The client is currently a science teacher. For the past three years, every school she has worked at has declined to renew her contract. The client's father left his house and all of his financial assets to her, so she does not have to make a mortgage payment. She has savings, but she is burning through it quickly. Previous Counseling: The client sought grief counseling at the time of her mother's death. She felt the therapist was "not spiritual enough" to deal with the client's beliefs. The client knew she needed help, and her pastor recommended a group. She attended four group sessions before leaving the group due to interpersonal conflicts with some of the group members. She tells you that she is not interested in participating in any group therapy. | What suggestion would you refrain from making as an alternative to mood journaling? | Engage in a mindfulness exercise and write down what she is feeling in the moment | Participate in an activity that is distracting, such as watching a favorite TV show | Create a visual representation of her feelings like a collage or drawing | Utilize an interactive app to track emotions and symptoms | (A): Engage in a mindfulness exercise and write down what she is feeling in the moment
(B): Participate in an activity that is distracting, such as watching a favorite TV show
(C): Create a visual representation of her feelings like a collage or drawing
(D): Utilize an interactive app to track emotions and symptoms | Participate in an activity that is distracting, such as watching a favorite TV show | B | This suggestion should be avoided as a mood journaling alternative because it does not promote self-reflection or insight into the client's feelings and behavior. Additionally, engaging in activities that are passive or overly distracting can be used to avoid processing difficult emotions, which can lead to further avoidance of personal growth. Therefore, the correct answer is (B) | counseling skills and interventions |
522 | 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. | 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. | Given the dynamics and content of your interaction with the client during the session, what action have you taken that constitutes a breach of professional ethics? | Sharing former client information without consent. | Refusing to indicate that she attended therapy with her probation officer unless she actively participates. | Ignoring possible countertransference issues resulting from your attraction to the client. | Breaching the confidentiality of the client. | (A): Sharing former client information without consent.
(B): Refusing to indicate that she attended therapy with her probation officer unless she actively participates.
(C): Ignoring possible countertransference issues resulting from your attraction to the client.
(D): Breaching the confidentiality of the client. | Sharing former client information without consent. | A | By sharing with her the name of two clients, you have violated the confidentiality of your former clients. Therefore, the correct answer is (A) | professional practice and ethics |
523 | 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. | What is your primary intention in summarizing what the client has expressed to you about her experience at school? | Establish therapeutic rapport | Integrate the client's thoughts, emotions, and behaviors | Help the client clarify therapy goals | Demonstrate a nonjudgmental stance | (A): Establish therapeutic rapport
(B): Integrate the client's thoughts, emotions, and behaviors
(C): Help the client clarify therapy goals
(D): Demonstrate a nonjudgmental stance | Integrate the client's thoughts, emotions, and behaviors | B | A client at this stage benefits from an integrative experience. Therefore, the correct answer is (D) | counseling skills and interventions |
524 | Name: Camron Clinical Issues: Worry and anxiety Diagnostic Category: Anxiety Disorders Provisional Diagnosis: F40.10 Social Anxiety Disorder Age: 20 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: White Marital Status: Never married Modality: Individual Therapy Location of Therapy : University Counseling Center | The client looks anxious and uneasy, presenting with a "nervous" laugh. He twirls his thumbs and shakes his legs while seated. Mood is anxious and frustrated. He feels isolated and misunderstood by his family and peers. Speech is soft and hesitant. Eye contact is sporadic. Thought process is concrete and linear. He has some difficulty with abstract concepts. Thought content reveals fear of social interactions, feeling judged by others, and feeling inadequate. He seems to recognize the negative consequences associated with his anxiety and behavior, but he has limited insight with regard to recognizing the source of his anxiety. He reports difficulty recalling past experiences or conversations due to anxiety levels. No suicidal or homicidal ideation noted. | First session Your client is a 20-year-old male who has been seeing your colleague at the university counseling center where you both work as mental health therapists. The client requested to be transferred to another therapist because his former therapist reminded him too much of his father and therapeutic progress could not be made. The client's former therapist contacted you as a referral, and you agreed to transfer the client to your caseload. When you meet with the client today, he seems very anxious and laughs nervously. You can see he is shaking his legs as he sits, twirling his thumbs, and making little eye contact with you. You explain the therapy process and that you need to go over some intake questions. You ask him who his ICE (in case of emergency) contact is, and he says it is his roommate. You continue with your assessment, gathering information about his presenting problem and what he would like to accomplish in counseling. He continues by telling you, "I thought that going to college would alleviate my social anxiety, but I'm not doing well here. I want to be social, but I can't." The client feels frustrated and overwhelmed by his fears of interacting with others. He tells you that when he is feeling anxious, he punches bathroom mirrors to try to distract himself from the anxiety. He notes that the anxiety is crippling, preventing him from doing the things he loves, and has resulted in him feeling isolated. He is afraid that others are judging him and is constantly worried that he will make a mistake and feel embarrassed. Fourth session It has been three weeks since the initial counseling session with your client. The client comes to your office for his weekly session and says, "I tripped on my way here when I got off the subway, and I felt so embarrassed. I'm going to take a cab back to campus. What if people who saw me fall are still in the subway by the time we finish?" You ask your client to explain this embarrassment and why he thinks people who saw him fall this morning would still be in the station an hour later. He tells you that when he was little, his father always told him, "Don't do this, don't do that. People are going to think you're stupid. I still hear his voice in my head, telling me what to do. I've spent my whole life trying to live up to his expectations, and I'm tired of it!" You explore this with your client and use guided imagery to ask him to return to that little boy in his memory. He tells you, "I can't concentrate right now. The anxiety of remembering my childhood is stressing me out." You switch to using behavioral techniques as a way to help him manage his anxiety. You explain that it is important for him not only to challenge his anxieties but also recognize his successes. To ensure that he feels successful and rewarded, you come up with a plan so he can realize progress and be able to measure it. In order for you and your client to monitor his progress, you create charts that will document any positive changes he experiences during the therapy sessions. As part of the plan, your client will commit to engaging in activities outside of the counseling session which are designed with the purpose of calming him down and helping him practice his newly-acquired skills to manage his anxiety. Eighth session It has been seven weeks since the client presented for the initial interview. Today, the client returns to your office for his weekly session. He admits that he has not been following through with any of the activities you have assigned as part of his systematic desensitization plan, and he continues to feels overwhelmed by anxiety. His facial expressions reveal a sense of defeat and disappointment as he shares his struggles with making progress. He says, "I just want to be a normal guy. What's wrong with me?" The client expresses feeling overwhelmed with fear and shame at being unable to make any changes. He asks if you know of anyone else who has experienced social anxiety before and if there is any hope for him to get better. You normalize his experience and briefly share a story about being afraid to wear glasses in high school out of fear that your classmates would make fun of you. You then explain to him that even though it may feel like he is alone in his experience and feels discouraged, recovery is possible. You emphasize the importance of being patient with himself and expressing self-compassion as he works through the process. During the session, the client also mentions that his parents are having a difficult time in their relationship which has been causing additional distress for him. You explain that this could cause extra feelings of worry and insecurity, even when he is away from them. He acknowledges the connection between his parents’ relationship dynamics and his own struggles with anxiety. In order to address the additional stressors created by the distress in the client's parents' relationship, you explore ways he can work on managing his own emotions and reactions. You explain that building self-awareness of his feelings and responses may help empower him to have greater control over his anxiety symptoms. You discuss mindful breathing and visualization techniques. Afterwards, you provide examples of cognitive reappraisal strategies that can be used to challenge any irrational beliefs related to fear of failure or embarrassment that might be driving his avoidance behaviors. You explain the importance of consistently doing the practice in order for it to be effective and positive changes can be expected with consistent effort. You also give the client a homework assignment to read about social anxiety. Toward the end of the session, you summarize what you have discussed during today's session, and you address his feelings of disappointment in his perceived lack of progress by saying, "I understand your frustration. It can seem like things are not changing but in reality, even small changes are a sign of progress. The most important thing for you to remember is that it takes time and effort to learn how to manage your anxiety and make meaningful change in your life. As you continue working on the strategies we have discussed, I want you to recognize any successes or moments of improvement as they occur; no matter how small they may be. This will help keep you motivated and encourage further growth." | The client grew up in an authoritarian house where all of his actions and behaviors were scrutinized by his father. His father demanded obedience from his son and would not accept anything but perfection from him. He graduated from high school at the top of his class and has been waiting to attend college to get out from "under the thumb" of his father. The client's parents are paying all of his college expenses. The client is experiencing difficulties adapting to college life. He states that he stays in his room because he believes he always says and does the wrong thing, and everyone can see what a "loser" he is. He further states that he rarely leaves his dorm room except to go to his work-study position. The client has experienced two panic attacks; one occurred when he was required to give a presentation in class, and the second happened when he was required to meet with a small group to discuss his input for their group project. The client has missed many classes in which he is expected to participate or present projects. He is currently failing three classes. The client is in danger of losing his work-study job on campus due to frequent absences. He is competent and conscientious when his job does not require customer interaction. Personal/Social Relationships: The client is interested in exploring social relationships but is anxious as his father never allowed him to interact with his peers. As a result, his level of social functioning is relatively low. He has talked with a few students in his dorm and classes when required, but he feels extremely uncomfortable and inept. The client has not developed any friendships because of his anxiety. | Which of the following is considered an open-ended question? | "What does it mean to you to be a 'normal' guy?" | "Is feeling 'normal' important to you?" | "Are there times that you feel like a 'normal' guy?" | "Do you think you are 'normal?'" | (A): "What does it mean to you to be a 'normal' guy?"
(B): "Is feeling 'normal' important to you?"
(C): "Are there times that you feel like a 'normal' guy?"
(D): "Do you think you are 'normal?'" | "What does it mean to you to be a 'normal' guy?" | A | This is a form of an open-ended question. It requires more than a one- or two-word answer. Therefore, the correct answer is (D) | counseling skills and interventions |
525 | 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 would be most effective for helping the client be successful in counseling? | Help the client set some new goals around his alcohol use so he can be more successful | Ask the client what he had hoped to achieve in counseling and whether that has changed | Share your concerns about the client's continued alcohol use and its impact on him | Review the client's original goals and ask him whether he thinks he's achieving these | (A): Help the client set some new goals around his alcohol use so he can be more successful
(B): Ask the client what he had hoped to achieve in counseling and whether that has changed
(C): Share your concerns about the client's continued alcohol use and its impact on him
(D): Review the client's original goals and ask him whether he thinks he's achieving these | Ask the client what he had hoped to achieve in counseling and whether that has changed | B | Asking the client what he had originally hoped to achieve and whether that has changed allows the client autonomy to determine if his original goals were accurate or if he wishes to make changes to how he can use counseling. Clients frequently come to counseling with one idea in mind and realize that they have other needs they had not realized. Reviewing the client's original goals and asking him if he is achieving these, highlights the power imbalance between counselor and client and may make the client feel defensive or accountable to the counselor for their actions. Sharing your concerns about his alcohol use and helping him set goals around his use reflect more of the counselor's needs and desires for the client than the client's autonomous rights to make their own choices. Therefore, the correct answer is (C) | treatment planning |
526 | Name: Dawn Clinical Issues: Maladaptive eating behaviors Diagnostic Category: Feeding and Eating Disorders Provisional Diagnosis: F50.01 Anorexia Nervosa, Restricting type Age: 17 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: White Marital Status: Single Modality: Individual Therapy Location of Therapy : University Counseling Center | The client presents as a female in her late teens who appears malnourished and underweight, dressed in loose, concealing clothing. She exhibits poor eye contact and a guarded, closed-off posture with arms protectively crossed. Her affect is tense and anxious. Speech is logical and goal-directed, with no evidence of hallucinations or delusions. She denies any suicidal or homicidal ideation. Cognition is grossly intact for person, place, and time. Her insight and judgment appear limited, as evidenced by unresolved conflict with her parents and changing college majors without considering long-term career goals. She reports a strained relationship with authoritarian parents who were often physically and emotionally absent, leaving her feelings of neglect. She exhibits low self-confidence and an inability to trust her thoughts and desires. She continues to seek parental approval but feels unable to assert her needs. Her mood is anxious and frustrated due to perceived external control and lack of autonomy. | First session You are a mental health counselor in a university counseling center. Dawn, a 17-year-old college student, is referred to you by her physician. The client's parents recently visited during their parents' weekend at the university campus and were very concerned when they saw their daughter, who appeared severely underweight. They had not seen her for several months and immediately contacted the family physician for guidance. After performing a complete physical exam, the physician could not determine any medical causes for the client's low weight. The physician noted, however, that the client expressed that she did not understand her parents' concern about her weight. During the physician's examination interview, she reported feeling intense anxiety about gaining weight and implied that she was unhappy with her appearance. Dawn reported feeling stressed and anxious about her schoolwork, friendships, and body image concerns. She explained that she often skips meals or severely restricts her food intake in an effort to maintain control. Dawn acknowledged that her eating habits have become more disordered over time and expressed openness to learning new coping strategies. While Dawn initially resisted her parents' efforts to intervene, their concern made an impression. She agreed to continue counseling to address the underlying issues driving her unhealthy behaviors. Dawn wants to improve her well-being despite lingering uncertainties. In today's initial counseling session, you focus on establishing trust and providing the client with a safe space to share her feelings without fear of judgment or reprisal. You begin by asking the client how she feels today and if there are any particular topics she would like to discuss. You also explore her feelings about her parents and brother and ask targeted questions to better understand the family dynamics and how they have impacted her self-esteem. You provide the client with psychoeducation regarding healthy eating habits, body image, and the consequences of not caring for oneself. Lastly, you discuss possible resources and referrals that may be helpful for the client during this time. Dawn seemed receptive to discussing her feelings and experiences in a judgment-free environment. She sometimes became emotional when describing her struggles but appeared relieved to openly share things she had kept private. Dawn stated the counseling session felt like a positive first step. After reviewing healthy coping tools and strategies, Dawn agreed to keep a daily food and feelings journal. She also committed to reaching out for support if feeling triggered or unable to care for herself. Dawn left the session with referrals for a nutritionist and an eating disorder support group. Fourth session You and the client have met twice weekly for therapy sessions on Monday and Thursday afternoons. This is your fourth session, and you begin to explore the client’s support network. She reports having a difficult time making friends at college and says that she feels very lonely. She shares a dorm room with two other female students who have been best friends since elementary school. The client says she feels like an “outsider” and struggles to share a living space with these two roommates. Dawn shared that she often spends time alone in her dorm room on weekends while her roommates go out together. She said this makes her feel even more isolated. Dawn explained that she has tried reaching out to her roommates to get to know them better, but they seem uninterested in including her in their plans. Dawn mentioned that her older brother is the only person she feels close with right now. However, since he lives so far away, they rarely see each other in person. Dawn said she misses having her brother around to talk to and confide in. One of her classmates invited her to have lunch on campus, but she was so anxious about eating in public that she declined the offer. Although she would like to have friends, she is worried that, eventually, she will end up in a social situation involving food; this idea creates intense anxiety for her. She believes that it is easier to avoid social situations altogether. The client begins to cry and says she often thinks about moving back home but does not feel like she belongs there anymore, especially since her parents repurposed her old bedroom. She continues crying and says, “I don’t have any friends at school, and I don’t even have a room at home. I feel like I don’t belong anywhere. I really miss my brother.” Dawn tearfully explained that she feels caught between missing her previous life and feeling unable to adjust to her new environment at college. She is longing for connection but finds it challenging to put herself out there socially. Crying, Dawn shared that she feels like she has no place where she truly belongs right now. She misses the security and familiarity of high school and being with her brother but also recognizes that things have changed there as well. Overall, Dawn conveyed profound feelings of loneliness and isolation. Eighth session You continue to work with the client in outpatient therapy. During a previous session, the client identified a few sources of support and was able to tell her parents that she switched her major. Today, the client arrives for her appointment 20 minutes early. She appears eager to see you and excited to talk with you. When she sits down, she pulls several cookbooks out of her backpack. She tells you that she plans to go home during spring break and has collected recipes for a large meal she wants to make for her family. During this session, while exploring the client's relationship with food, you discover that she spends many hours in the library reading through cookbooks and watching baking shows on her computer. She says that she has an apple for breakfast, picks up a small salad "to go" from the campus cafeteria every day at exactly 12:00 p.m., and bakes a sweet potato for dinner in the microwave in her room at 6:00 p.m. She looks forward to her meals and plans her day around them. She says she is envious of other people who "can eat anything whenever they want." She tells you she is worried that if she eats extra food, she will become obese overnight and never stop eating. You continue to explore the client's relationship with food by asking, "What do you think would happen if you ate whatever you wanted?" She replies, "I'm afraid that if I eat extra food, I'll gain weight and never be able to stop eating. I'll keep getting bigger and bigger and turn into a severely obese person." After taking a moment to think, the client shares, "I'm scared that if I gain weight, no one will love me or care about me. Then I'll be completely alone, and it will be all my fault because I couldn't control my eating!" You listen compassionately as the client shares her fear. You also emphasize that this is an extreme outcome and unlikely to occur. You encourage her to think realistically about the potential consequences of eating additional food and acknowledge that there may be some negative outcomes, but they are not guaranteed or irreversible. | The client has a 25-year-old brother who is a Navy Seal. The client's parents have government jobs and frequently travel to foreign countries for work. When the client moved away to live on campus, her parents immediately turned her old bedroom into a home gym, which the client found unsettling. The client says that while she knows her parents love her, they have never been very affectionate or spent much time with her. When she was younger, the client traveled with her family for a few weeks during the summer but was often left alone during their trips. She describes her relationship with her parents as "strained" but states that she does have a positive relationship with her brother. She plans to see him when he is on leave from the Navy. The client is a freshman at the university and has already changed her major from pre-med to music history. She is anxious about telling her parents that she switched majors and is worried they will be disappointed. She reports that she has always felt a lot of pressure from her parents to excel in school as her brother did. Since she was a child, her parents have expressed their desire to see her become a physician. Her parents have always set high expectations for her academic performance. Their authoritarian parenting style has left her doubting her confidence in her own capabilities. She is frustrated by this dynamic because she does not feel like she can think for herself or pursue her own goals without outside approval. | In consideration of the client's mood swings, what would be the most effective way to continue to maintain a supportive, positive therapeutic alliance with this client? | Allow the client to share her thoughts, feelings, and actions without critique | Provide bibliotherapy to the client regarding the course and progression of eating disorders | Guide the client to realizing how her anxiety regarding her parents is contributing to her unhealthy eating patterns | Assist the client in identifying past and present sources of support, discussing the qualities of these relationships | (A): Allow the client to share her thoughts, feelings, and actions without critique
(B): Provide bibliotherapy to the client regarding the course and progression of eating disorders
(C): Guide the client to realizing how her anxiety regarding her parents is contributing to her unhealthy eating patterns
(D): Assist the client in identifying past and present sources of support, discussing the qualities of these relationships | Allow the client to share her thoughts, feelings, and actions without critique | A | Unconditional positive regard, developed by Carl Rogers, is one of the tenets of client-centered therapy wherein the therapist maintains an accepting and caring attitude toward the client. The therapist provides acceptance and support to the client, regardless of what is said or done. Therefore, the correct answer is (C) | counseling skills and interventions |
527 | 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. | The client comes into the session and looks tired, as evidenced by the darkness under his eyes and he is walking slowly. The client starts talking immediately about 2 days prior when he went to his ex-wife’s house to pick up his kids for a visit and she told him that although she cannot stop this visit, due to recent inhalant use a few weeks ago, she talked with her lawyer about changing the status of his future visits to supervised visits, and she will be returning to court to do so. The client says that he spent time with his kids and that when he left, he stopped by a store to get acetone and that he used this substance that night. The client expresses guilt and shame surrounding using, which led to him using the acetone the next day. The day after he used inhalants, the client stated that he was thinking, “I already broke my sobriety; I may as well huff so that I can feel better.” You empathize with the client regarding the situation because you can see how this would be distressing for him. The client says that his children seem bored when they are with him, as if they want to go home, which induces feelings of shame and sadness | Which of the following cognitive distortions best defines the client’s statement of “I already broke my sobriety; I may as well huff so that I can feel better”? | Magnification | Mental filters | Jumping to conclusions | Emotional reasoning | (A): Magnification
(B): Mental filters
(C): Jumping to conclusions
(D): Emotional reasoning | Emotional reasoning | D | This is an example of emotional reasoning. The client felt guilt and shame for breaking his sobriety, and he used these emotions to justify the feeling that it would not matter if he used inhalants again. Jumping to conclusions involves either trying to predict the future or assuming others’ thoughts and feelings. Magnification involves focusing on shortcomings and exaggerating their importance or effect and minimizing positive qualities and behaviors. Mental filters involve focusing solely on a shortcoming and ignoring everything else. Therefore, the correct answer is (A) | counseling skills and interventions |
528 | Name: Amy Clinical Issues: Hopelessness/depression Diagnostic Category: Depressive Disorders Provisional Diagnosis: F34.1 Persistent Depressive Disorder (Dysthymia), Severe Age: 15 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: White Marital Status: Not Applicable Modality: Individual Therapy Location of Therapy : Private Practice | The client appears in your office with loose clothing and a thin physical frame. She has inconsistent eye contact and portrays a drowsy level of consciousness. Her speech rate is slow, her volume is soft yet monotone, and her fluency and rhythm are unclear and hesitant at times. She talks about how much she hates her life. Her mood is depressed and discouraged, while her affect is flat and sad. The client has been previously hospitalized for suicidal ideation. Her thoughts are slowed, and she is easily distracted. Her concentration is impaired with frequent lapses in attention. She is unable to follow a long line of thought or argument. She also reports difficulty making decisions. Her insight and judgment are limited. The client's emotional state is characterized by a pervasive sadness, irritability, and feelings of hopelessness. She exhibits difficulty in concentrating, making decisions, and expressing herself coherently. Additionally, she is experiencing disrupted sleep patterns, including insomnia and excessive daytime sleepiness, and has reported a diminished appetite with subsequent weight loss | First session You are licensed as a mental health therapist working on a post-doctoral thesis related to depression and have been working with several clients diagnosed with Persistent Depressive Disorder. One of your new research participants is a 15-year-old client who arrives at your office with her mother after being released from the hospital. Before beginning the session, you ask to talk with the mother and daughter separately. When interviewing the mother, she tells you about her daughter's ongoing behavioral difficulties, experimenting with drugs and alcohol, and getting involved with a "bad group of kids." The client's academic performance has also been affected, with teachers reporting a notable decline in grades and participation in class. This behavior has been ongoing for approximately six months and appears to be intensifying. The strained familial relationships that the client is experiencing are a constant irritation to the entire family. The father's instability may have contributed to the client's current emotional distress, exacerbating her depressive symptoms. The client's mother, while providing primary care, struggles to maintain any bond with her daughter due to the increasing social withdrawal and lack of communication Next, you interview the daughter. You ask her questions about school, friends, and activities she enjoys. She states that she is picked on daily at school, has no "real" friends, and hates her life. The client sighs heavily, saying, "Some nights I go to bed hoping that I won't wake up in the morning. There's nothing to look forward to. School is horrible. She explains that she feels like she is "stuck in a dark hole" and that she cannot get out. She reports feeling hopeless, helpless, and alone. You summarize what she has told you, and she confirms your understanding of her feelings. After completing your interview with the daughter, you invite the mother to join you in your office. You continue to gather information about the client's personal and family history, symptoms of depression, and risk factors contributing to her current state. You explore potential triggers for her suicidal ideation and any protective factors in place. The mother reports that her daughter has been struggling with a lack of self-confidence and low self-esteem. You also discuss her current support system and any potential areas for improvement. Through the assessment, you can comprehensively understand the client's challenges and strengths. At the end of the intake, you check to ensure that both mother and daughter clearly understand what you have discussed today. You plan to meet with the client on a weekly basis, and you schedule a session for the following week. Third session As the client enters your office, you notice she has been crying. She states that she does not want to be here and feels like she has "no say" in what happens to her. She says that she wants to start attending a virtual school, but her mother "forced" her back to a physical school. The client says, "I can't stand it anymore. My mom yells at me every day about how I'm doing something wrong. Yesterday she blew up at me about leaving my shoes and backpack in the living room. It's my house, too. She's such a control freak." You respond to her with empathy and understanding. You ask her to tell you more about how she has felt since the argument. She explains that in addition to feeling like she has no control over her life, she feels guilty and confused because she loves her mother but does not understand why she is so controlling and demanding. You let her know that it is natural to have complicated feelings in this situation and that you are here to help her work through them. You create a plan with her, outlining different goals and activities she can do on her own or with the support of her mother. Through further exploration, you discover that she has an interest in drawing and is used to create characters for stories. She admits she feels calm when creating these drawings but that it does not take away from her depressive symptoms. You explain that having a creative outlet and developing it further can give her a healthy outlet for her emotions. The client appears to be receptive to this idea, expressing that she is willing to try it. She leaves your office feeling hopeful and slightly less overwhelmed. You make an appointment for the following week and suggest she come with a piece of art or design to share. She nods in agreement before leaving. Seventh session It has been almost two months since you began therapy with the client. You suggested a session in which both she and her mother were present to discuss the client's progress. She presents to today's session with her mother. The client followed up with your referral from a previous session for her to see a psychiatrist and has provided you with a release of information to communicate with her psychiatrist. The client has been prescribed an antidepressant and says she does not feel any notable change yet but the psychiatrist told her it would take a few weeks to know if the medication was working. The mother states that since her daughter started taking the antidepressant, she is sleeping more than usual and struggles to get out of bed. She has been late to school several times. She is also having trouble with motivation. You reflect the client's current state and suggest she establish a daily routine to gain a sense of control in her life. You discuss the importance of making small achievable goals and explain that taking on too much can be overwhelming, so it is more beneficial to focus on one task at a time. The mother begins listing off potential activities that her daughter should take part in. The client closes her eyes and begins to sigh. When you ask her about her reaction, she says, "See, yet another example of my mom trying to control everything." The mother responds by saying, "I'm not trying to control you. Believe it or not, I just want what's best for you!" Understanding the tension between them, you suggest a compromise. You explain that if the client completes one activity each day, her mother will not pressure her to do more. The client appears hesitant but agrees to try it out. You then turn to the mother, thanking her for being willing to compromise and understanding. You encourage them to be patient with one another and remind them that progress takes time. You suggest they continue to have regular check-ins so that each party is aware of how the other is doing in following through on the agreement. You end the session by summarizing what was discussed, reinforcing the importance of communication between the client and her mother. | The client's mother reports that the client's father has a history of depression. The client's mother is her primary caregiver, as her father is in and out of psychiatric facilities. When the client was a child, she had a positive relationship with her mother, but as a teenager, she has been withdrawing from her mother and spending most of her time alone in her room. The client has missed many days of school in the past few months. She feels that no one at school likes her; she has tried to fit in by experimenting with alcohol and marijuana, controlling her weight, and staying out late at night. The client is struggling academically and lacks concentration in the classroom. At home, the client is withdrawn and spends most of her time in her room pretending she is doing homework but is actually scrolling through social media posts for several hours. In addition, she is having trouble sleeping and stays up late. | You suspect that the client's lack of motivation and energy may be due to too high a dosage of her medication. What should you do? | Based on your extensive work with depressive clients, suggest a lower dosage. | Relate your concerns to the client | Consult with your supervisor | Consult with her psychiatrist | (A): Based on your extensive work with depressive clients, suggest a lower dosage.
(B): Relate your concerns to the client
(C): Consult with your supervisor
(D): Consult with her psychiatrist | Consult with her psychiatrist | D | If the medication is not acting in the expected way, the prescriber should be notified. Therefore, the correct answer is (B) | treatment planning |
529 | Client Age: 26 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: African American Relationship Status: Single Counseling Setting: Community Mental Health Center Type of Counseling: Individual Presenting Problem: Depressive Symptoms Diagnosis: Persistent Depressive Disorder (PDD) (Dysthymia) Diagnostic Criteria 300.4 (F34.1) | Mental Status Exam: The client is dressed in age-appropriate clothing and is well groomed. His affect is blunted and anxious at times. The client denies anxiety but discloses that he is nervous about the counseling process and doesn’t know what to expect. He is cooperative but hesitant to offer more information than is asked. The client is tearful when discussing his breakup and states that there are days when it is a struggle to get out of bed and go to work. He denies suicidal ideation, and he says that he has had no previous attempts. The client is oriented to person, place, time, and situation, and his thought content is organized. Fam | You are a counselor working in a community mental health center. Your initial intake appointment is with a 26-year-old African American male who presents with symptoms of depression. The client states that he has felt depressed since his teens, with symptoms increasing within the last couple of months. He reports feelings of worthlessness, fatigue, and occasional bouts of insomnia. In addition, the client indicates that his symptoms worsened after his girlfriend of 2 years broke things off with him. He explained that she grew tired of his low energy and pessimistic outlook on life. As a result, he has been hesitant to seek help, believing that he just needed to “man up” and handle his problems privately. The client is unsure of his insurance benefits but thinks his policy allows for a limited number of counseling sessions. | ily and Work History: The client grew up in a home with his mother, father, and maternal grandmother. He has a 22-year-old sister who he believes also experiences depression, but he is unsure if she has received treatment. The client says that he attends church “most Sundays” with his family, primarily because he knows it is important to his grandmother. The client holds an associate degree in information technology and is a computer network support specialist. He has worked for the same company for the past 4 years | Which approach would you implement to help understand the influence of the client’s social and cultural factors, including systemic racism, gender, religion, and birth order? | Rogerian | Freudian | Gestalt | Adlerian | (A): Rogerian
(B): Freudian
(C): Gestalt
(D): Adlerian | Adlerian | D | Adlerian therapists emphasize the importance of social connection, asserting that all individuals strive for “superiority,” which is achieved through a purposeful, goal-oriented “lifestyle” Adlerian therapists contextualize each client’s social and cultural factors, initially shaped by family constellation, including birth order. Adlerians focus on each individual’s lifestyle as it is influenced by multiple factors, including systemic racism, gender, religion, and sexual orientation. Adlerian and Freudian therapists are categorized as psychoanalytic, and both emphasize early childhood influences; however, Freudians differ in that they also emphasize unconscious processes whereas Adlerians do not. Gestalt therapists are categorized as experiential or relational. Gestalt therapists stress the integration of mind and body through increased awareness of the present moment. For gestalt therapists, wholeness involves the integration of one’s cognitive, emotional, and behavioral factors. As their name suggests, person-centered, or Rogerian, therapists allow the client to become fully functioning in the context of the therapeutic experience. The goal of Rogerian therapy is to facilitate congruence between the client’s self-image and idealized self. Therefore, the correct answer is (A) | counseling skills and interventions |
530 | 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 is true about this client? | This client's most accurate diagnosis is Body Dysmorphic Disorder | Cognitive behavioral theory is likely to be helpful in addressing this client's concerns | A cancer support group will likely be unhelpful for the client due to her sexuality | This client's prognosis in this area is poor because cancer is a medical condition, not emotional | (A): This client's most accurate diagnosis is Body Dysmorphic Disorder
(B): Cognitive behavioral theory is likely to be helpful in addressing this client's concerns
(C): A cancer support group will likely be unhelpful for the client due to her sexuality
(D): This client's prognosis in this area is poor because cancer is a medical condition, not emotional | Cognitive behavioral theory is likely to be helpful in addressing this client's concerns | B | Negative self-esteem and body image are best addressed with cognitive behavioral theory and having the client identify cognitive distortions and negative core beliefs about herself and her post-cancer body. This process allows her to develop more positive core beliefs and view herself in a more healthy and loving way. The diagnosis of body dysmorphic disorder (BDD) does not apply to this client as her post-cancer scars and body changes would not be viewed as minor imperfections to others. Additionally, she does not engage in repetitive behaviors such as mirror checking, skin picking, or mental acts in response to her concerns. BDD is a disorder related to obsessive compulsive disorders and this is not evident in the client's behaviors. Cancer impacts people across all cultural spectrums and the client's sexuality is not likely to impact how a cancer support group could benefit her. The client's prognosis in the area of body image and self-esteem is quite good because she has been successful already in counseling and while cancer is a medical condition, the diagnosis leads to many emotional issues such as anger, sadness, worry, and loss. Therefore, the correct answer is (C) | counseling skills and interventions |
531 | Client Age: 38 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Married Counseling Setting: Private Practice Type of Counseling: Individual Presenting Problem: Marital Difficulties Diagnosis: Obsessive-Compulsive Personality Disorder 301.4 (F 60.5) | Mental Status Exam: The client is meticulously dressed and immaculately groomed. He frequently checks his watch and states he has owned his watch since adolescence and it “still works like new.” His speech is even, and his affect is blunted. At times, he is defensive and attempts to talk over you. He exhibits poor insight into his marital problems and is excessively preoccupied with perfectionism, structure, and order. Fam | You are a counselor working in private practice and meeting your client for the first time today. The client is here at his wife’s insistence, who has threatened divorce if he does not seek and comply with therapy. The client explains that he is swamped at work and has already lost an hour of productivity traveling to your office. He discloses that he has been married just over four years and has a daughter who is 3½. The couple dated briefly and married when the client’s wife discovered she was pregnant. The client believes that if he didn’t leave his wife a schedule and checklist, “things would never get done.” He states that they would be in “so much debt” if it weren’t for his detailed household budget. In his estimation, conflict occurs each time his wife tried to do things “her way” because “it is never the right way.” You paraphrase and clarify the client’s concerns. | ily and Work History: The client works as a web designer and developer. He allows you to obtain collateral information from his wife. You reach his wife by phone, who explains that the client has “an explosive temper when I don’t do things exactly how he asks.” The client’s wife states he can be controlling, overly critical, and irrational at times\. This is the client’s first marriage\. The client’s wife wants to participate in couples counseling but says the client is adamant about her not joining | What attitudes and behaviors would a client diagnosed with obsessive-compulsive personality disorder display (OCPD)? | Persistent, unwanted thoughts and repetitive rituals | Excessive drive to attain financial success | Inflexibility regarding morals and values | Frequent fears of being alone | (A): Persistent, unwanted thoughts and repetitive rituals
(B): Excessive drive to attain financial success
(C): Inflexibility regarding morals and values
(D): Frequent fears of being alone | Inflexibility regarding morals and values | C | According to the DSM-5-TR, obsessive-compulsive personality disorder is a persistent preoccupation with organization and mental or interpersonal control. They may force themselves and others to follow rigid moral principles and very strict standards of performance” Persistent, unwanted thoughts and repetitive rituals characterize obsessive-compulsive disorder (OCD) rather than OCPD. OCPD is a Cluster C personality disorder. Anxious and fearful conditions are included in Cluster C personality disorders. Frequent fears of being alone are a symptom of dependent personality disorder. There is an excessive devotion to work and productivity for individuals with OCPD that is not otherwise accounted for or driven by financial success or necessity. Therefore, the correct answer is (D) | intake, assessment, and diagnosis |
532 | Client Age: 24 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: African American Relationship Status: Single Counseling Setting: Private practice counseling clinic Type of Counseling: Individual counseling Presenting Problem: The client comes to counseling for help in managing anxiety, workplace dissatisfaction, and a pornography addiction. Diagnosis: Generalized anxiety disorder (F41.1), other problem related to employment (Z56.9), religious or spiritual problems (Z65.8) | Mental Status Exam: The client is oriented to person, place, time, and situation. The client appeared hesitant when talking about pornography | You are a professional counselor, and the client comes to counseling to work on anxiety, work dissatisfaction, and a pornography addiction. You and the client discuss his anxiety, and he identifies that he experiences anxiety at work, regarding daily tasks, and in social settings. The anxiety is characterized by restlessness, difficulty concentrating, muscle tension, and insomnia. The client states that at work he is often treated poorly by his supervisors, who often point out what he does wrong and do not acknowledge what he does right. He does not feel that he does as much wrong as they claim, and he often finds that their accusations do not accurately reflect his actions, which is frustrating. The client states that he has had many meetings with his supervisors and that they do not appear to try to understand his point of view. The client appears uncomfortable and begins to speak but stops for about a minute before saying that he also has a pornography addiction. The client says that he is a Christian and that he does not feel he should view any pornography, but also that he uses pornography a lot and does not feel like he has control over himself or the frequency at which he uses it. The client asks if you are a Christian, and you decide to disclose with him that you are, knowing this is an important part of the client’s life and perspective. The client states that his work problems and pornography use are his most pressing issues. | The client comes into the session smiling and says that he is excited to share his log this week. The client shares that he masturbated an average of one to two times daily and that he even went a day without masturbating. You express your excitement for the client achieving his goals. Through processing, the client identifies that he refrained from masturbating most often by leaving his bedroom and finding something to structure his time late at night. The client says that he had difficulty refraining from masturbating mostly when he came home from a difficult day at work, or when he struggled to sleep. You and the client discuss calming techniques to use when he is stressed after work. You also recommend approaches to address difficulty sleeping. On days when the client masturbates, he explains that he often decides that since he already messed up, he can do it again. The client says that he is happy at his new place of employment and that it is just a hard job. You support the client in challenging his past cognitive distortion that his future employment experiences will be the same as his past experiences | All of the following can negatively affect sleep quality, EXCEPT: | Exercise | Melatonin | Drinking water around bedtime | Alcohol | (A): Exercise
(B): Melatonin
(C): Drinking water around bedtime
(D): Alcohol | Melatonin | B | Melatonin is a natural dietary supplement with proven efficacy in improving sleep onset, although it is not recommended as the primary treatment of insomnia. It is available in low doses over the counter and in higher prescription-level doses, and it has no proven negative influences on sleep. Alcohol, although it may help people fall asleep, often affects sleep maintenance because it is disruptive to the sleep cycle. Exercise, if done regularly, can help sleep, but if it is done within 3–4 hours before sleep, it can have a negative impact on sleep quality. The chemicals released during exercise increase the heart rate and body temperature, which can delay the onset of sleep. Drinking a large amount of water near bedtime can disrupt sleep by the need to urinate waking the individual in order to use the bathroom. Therefore, the correct answer is (B) | intake, assessment, and diagnosis |
533 | Client Age: 45 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Divorced, single Counseling Setting: Private practice Type of Counseling: Individual counseling Presenting Problem: The client is experiencing difficulty in functioning in all areas of his life due to inhalant use. Diagnosis: Inhalant use disorder, severe (F18.20) | Mental Status Exam: The client is oriented to person, place, time, and situation. The client does not appear to be under the influence of inhalants because he does not display any symptoms of use. The client is friendly and engaged in the ses | You are a licensed counselor working in a private practice. You specialize in substance use disorders. The client comes into the session, is very friendly, and states that although his sessions are court ordered, he wants to get help with his inhalant use. The client spent the first half of the session explaining what happened to lead to him getting his third charge of driving under the influence of inhalants. The client says that he had twin sons 13 years ago and they both were in the ICU; one of his sons died after about a month. The client began drinking alcohol to excess daily for about 6 months, which then transitioned to inhalant use. The client says that he uses contact cement, model glue, paint, and permanent markers to become intoxicated. The client identified the following symptoms of inhalant use disorder: increase in frequency and amount of use over the past 5 years, several failed attempts at cessation of inhalant use, craving inhalants throughout every day, losing several jobs because of his inability to get to work on time due to inhalant use, use that has affected his ability to have visits with his children and maintain employment, use that increases the risk of harm to himself and others such as driving under the influence, increased tolerance, and continued use even when he knows it is negatively affecting his life. The client wants to become sober, improve his relationship with his children, and maintain employment. | sion. Family History: The client has three sons that are 11, 13, and 16 years old. The client is divorced as of 3 years prior and reports a contentious relationship with his ex-wife due to his difficulty following through with visits with their children. The client and his ex-wife were married for 17 years and dated for about 5 years before they were married. The client states that he loves his ex-wife but that she has currently been dating another man for the past 2 years and he knows they likely will not reconcile. He says that he understands why she does not want to be with him, and he thinks that he is not good for her or his children at this time | When considering treatment goals, all of the following are indicated areas to explore, EXCEPT: | His relationship with his ex-wife | Depression symptoms that may lead to inhalant use | Grief or trauma regarding his son’s death | Barriers to maintaining employment | (A): His relationship with his ex-wife
(B): Depression symptoms that may lead to inhalant use
(C): Grief or trauma regarding his son’s death
(D): Barriers to maintaining employment | Depression symptoms that may lead to inhalant use | B | Depression is not indicated based on the presenting symptoms. Although depression may co-occur with inhalant use because the use of substances may alleviate depressive symptoms, the client did not report any depression symptoms. Grief and trauma related to the client’s son passing away are important areas to explore because these appear to be the triggering symptoms that led to his substance use. The client’s relationship with his ex-wife would be important to explore because the client is not able to see his children as much as he wants due to his substance use. The client also wants to maintain employment, so it would be helpful to focus on barriers to maintaining employment. Therefore, the correct answer is (B) | intake, assessment, and diagnosis |
534 | Name: Rick Clinical Issues: Referred for emotional and behavior issues Diagnostic Category: No Diagnosis Provisional Diagnosis: No Diagnosis Age: 18 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: Korean Marital Status: Single Modality: Group Therapy Location of Therapy : Community Center | The client is slouched over in his seat and appears withdrawn with a flat affect. He keeps his head down. The client plays with his shirt sleeve, twisting the material and pulling at it. You cannot see any cuts on his arms as reported by the mother. He does not appear to be angry at this time, which was also a symptom reported by his mother. He responds to your questions with one-word answers. He seems uninterested. The client denies any suicidal and homicidal ideation. The client mumbles, "I don't want to talk about anything here." | First session You work as both an individual and group therapist at a community center that primarily sees adolescents with emotional and behavioral issues. Rick is a senior in high school and lives with his mother and two sisters. Rick does not want to participate in individual or group therapy, but his mother insists that he get help. During the intake, you work to establish rapport with Rick. You also gather information to determine if he is an appropriate candidate for one of the groups you are preparing to start, along with a co-facilitator. You suspect he may have trouble trusting females as he expresses anger when talking about his mother, sister, and ex-girlfriend. Since his father left, Rick says that his mother has been "in his business" all the time, and he does not feel like he has any real privacy. You remain patient with Rick, listening to his story and validating his feelings. You empathize with him, letting him know it is understandable to feel frustrated about not having much privacy. You explain that you are here to help him, not to control him and that you are interested in learning more about him. You explain to Rick that you are planning to start a group therapy session with a co-facilitator and that you would like to see if it would be a good fit for him. You explain that the group will provide an opportunity for him to talk about his experiences in a safe space with others who may have gone through similar situations In addition, you share that it could be an excellent way for him to practice expressing himself and developing trust in others. You also explain to Rick that individual therapy sessions could be beneficial in addition to group therapy. You discuss the possibility of one-on-one sessions that would give him a chance to talk more deeply about his experiences in a safe, private setting You emphasize that this could be an excellent way for him to explore his feelings and learn how to cope with them in a healthy way. Sixth session Rick has been attending group therapy weekly. He continues to wear long sleeves to the session but appears engaged and involved in the group process. The group exhibits high cohesion, and all members participate in group activities. The focus is on continued productivity and problem-solving. You ask the members to reflect on the skills they have been practicing in the group and share an experience in which they have applied those skills outside the session. Rick's experience in the group has further helped him to identify and understand his feelings. He has been able to recognize his anger and express it in a healthier way. He has also been able to recognize his need for connection. He says he recently called his ex-girlfriend to apologize for being angry about his parents and "taking it out on her" by withdrawing from her. This has enabled him to develop a more constructive approach to conflict. The group members have provided Rick with a safe space to practice his new skills, giving him the confidence to try them in his real-life relationships. The other members have shown Rick support and encouraged him to take risks and to be open to opportunities for growth. Rick's active engagement in the group has been instrumental in his progress. He has become more aware of his emotions, and he can express himself in a way that is respectful and appropriate. His newfound ability to communicate effectively has been a significant step towards strengthening his relationships both inside and outside of the group. 11th session The group as a whole has made progress, and members have found healthy outlets for expressing their thoughts and feelings. Rick has become more open with the women in the group and seems more receptive to what they have to say. Rick says that his grades have improved, his mother is proud, and he is encouraged by other group members who nod their heads and smile. The group has met its goals. The members have learned strategies to take with them as they prepare for termination. You remind the group that there are only a few more weeks left to meet. You begin to discuss the group members' feelings regarding the end of therapy. Rick starts to cry and says, "Why does every woman in my life cause problems for me?" The other group members offer Rick reassurance and empathy, but he continues expressing his frustration and sadness. You encourage the group to reflect on each person's progress and to be mindful of the emotions that this ending brings out. You explain to the group that endings can be difficult and that giving them permission to feel the emotions that arise during this transition is important. Rick is still struggling with the idea of ending the therapy and expresses his fear of being left alone. He continues to express his feeling that every woman in his life has caused him pain and suffering, and this group's ending has triggered his worst fears. You recognize his fear and attempt to validate his experience by emphasizing his progress in the group and the positive changes he has seen in himself. You explain that the group can support him through the transition and the other members offer encouraging words of encouragement. Rick is still anxious and overwhelmed. He talks about the difficulty of coping with the loss of the group and how he worries that he won't be able to manage his feelings without the support of the group. You explain to the group that it is natural to feel sadness and loss as well as gratefulness and pride in the progress they have all made. You encourage the group to identify the strategies they have learned in the group that they can use to manage their emotions. Finally, you assure Rick that he can use the skills he has learned in the group to cope with the emotions associated with the end of therapy. | The client is a first-generation American whose parents immigrated from Korea. He has an old sister who, based on Korean culture, is his superior whom he must obey and be subservient to. His parents have high expectations for him and are very controlling, expecting him to study every night and attend tutoring sessions on the weekend. They have arranged for him to marry a daughter of a prestigious family in Korea after he completes medical school eight years from now, with the intention that he and his wife will live with them and provide financial support. However, this plan has drastically changed. Seven months ago, the client's father moved out after his mother had an affair. The client became sullen, angry, and withdrawn after this event. Four months ago, while doing laundry, the client's mother saw dried blood on his shirt sleeve. She also noticed that he was wearing long-sleeved shirts all the time. She waited until he was getting dressed, walked in on him, and found he had cuts up and down his arms. The client does not speak to his father much since his parents separated. The client expresses a lot of anger toward the women in his life, specifically his mother, sister and ex-girlfriend. The client is a senior in high school. His grades have been suffering lately, and he is currently failing his math and science classes. Personal/Social Relationships: The client had been concealing his romantic relationship with a girl from his Saturday tutoring class, but following his father's abrupt departure from the family, he chose to discontinue the relationship and cease attending the class. He has since refrained from any communication or contact with her. His mother's affair has caused him to feel overwhelmed with anger, leading him to develop a dislike of all women. | Although Rick has made significant progress in the group, you believe that he still has unresolved issues. What should you do to increase the likelihood of his success? | Reinforce progress that has been made in treatment | Offer to be available for individual therapy | Practice mindfulness skills during the next group session | Suggest that he join a new therapy group | (A): Reinforce progress that has been made in treatment
(B): Offer to be available for individual therapy
(C): Practice mindfulness skills during the next group session
(D): Suggest that he join a new therapy group | Offer to be available for individual therapy | B | At this time, the group has met its goals and is ready to enter the termination stage. The client has made progress in the group but still has unresolved issues. It would help if you made yourself available to him for individual counseling to address these issues. Therefore, the correct answer is (C) | intake, assessment, and diagnosis |
535 | Name: Aghama Clinical Issues: Cultural adjustments and sexual identity confusion Diagnostic Category: V-codes Provisional Diagnosis: Z60.3 Acculturation Difficulty Age: 18 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Bisexual Ethnicity: Nigerian Marital Status: Never married Modality: Individual Therapy Location of Therapy : University Counseling Center | The client comes to your office and sits rigidly and makes little eye contact. She is dressed neatly and appropriately for the weather with overall good hygiene. She appears cooperative and open to the therapeutic process. She expresses a willingness to discuss her experiences, thoughts, and feelings, but show some hesitation due to her unfamiliarity with therapy. The client's mood is depressed. Her affect is congruent with her mood, displaying a flat or subdued demeanor, but shows some variability when discussing her family or life in Nigeria. Her speech is clear, fluent, and coherent. She has no difficulty expressing herself in English and seems to have a good command of the language. Her speech is slightly slow. The client's thought process appears linear and goal-directed. She is able to articulate her concerns and goals; her thoughts seem to be dominated by her feelings of sadness, loneliness, and homesickness. The client demonstrates some insight into her situation and the impact of her homesickness on her overall well-being. She appears to be motivated to seek help and improve her situation. There is no evidence of suicidal ideation or intent. The client does not express any thoughts of self-harm or harm to others. However, her ongoing feelings of sadness and loneliness warrant close monitoring and support during the therapeutic process. | First session You are a licensed mental health counselor working at a university counseling center and take a humanistic approach in your work with clients. Today you are meeting with an 18-year-old student who recently moved to the United States from Nigeria. She tells you that she moved to the United States one month ago after missionaries in Nigeria granted her a scholarship. She feels lonely, misses her family, and is questioning her decision to come to the United States. She indicates she has never been to therapy before but was told by her academic advisor that it might be helpful to make an appointment with a counselor. You continue the intake session by exploring the client's current psychological functioning. She expresses that she is homesick and is struggling to find her place in a new environment. She describes having difficulty making friends at college and feels isolated. She does not feel comfortable talking about her personal life with people she does not know well, which makes it even more difficult for her. Additionally, she is struggling with the pressure of living up to the expectations of the members of her church that gave her the scholarship to attend the university. She is currently pursuing a nursing degree at the university. You ask her to share some details about her family and cultural background in order to gain a better understanding of the context of her situation. She tells you that her parents are both teachers and she has two siblings. The family is very close-knit and they typically speak in their native language at home. You also ask about how she is managing her academic obligations, any specific challenges or barriers she might be facing, and how she is spending her free time. She says that her courses are challenging, but she is managing them well. In between classes, she spends most of her time in the library studying. You discuss the therapeutic process and what she hopes to gain from counseling. She expresses that she would like to learn how to better cope with her homesickness and loneliness. She says, "I'm worried that I'll be a disappointment. It took a lot of money and effort to get me here, and I don't want to let them down. I was so excited when I first got the scholarship, but maybe it would have been better if it went to someone else." You validate her feelings and explain that it is natural to feel overwhelmed when faced with a new culture and environment. You further explain the importance of focusing on her strengths, as she has already accomplished so much by making the decision to attend college abroad. You describe therapy as an opportunity for her to explore her feelings, develop coping strategies, and adjust to her new environment. At the end of the session, she tells you she is on a "tight schedule" and needs to know when she can see you for therapy so she can plan accordingly. You provide her with your availability and suggest that an ideal therapy schedule would involve weekly sessions. You also explain the importance of consistency in order to allow her to make meaningful progress during therapy. You schedule an appointment for the following week. Fifth session This is your fifth weekly session with the client, and she states that she likes the "structure" of seeing you on Wednesday afternoons. The client appears to be doing better since she last saw you. She begins today's session by telling you that she still feels isolated and is having difficulty making friends. You ask her to elaborate on the challenges she has been facing in connecting with students at the university. She tells you that most of the other international students are from countries closer to America like the Caribbean islands, and it is difficult for her to relate to them. She pauses for a moment and asks if she can tell you about something that happened a few days ago that she is feeling nervous about. You respond affirmatively, and she tells you that her roommate invited her to a party and she ended up drinking which is not something she would normally do. When she and her roommate got back to their dorm room later that night, they kissed. She goes on to say that she thinks she has developed romantic feelings for her female roommate. This experience made her feel confused and anxious, and her family's expectations weigh heavily on her mind. You ask her to elaborate on her feelings in order to gain a better understanding of the situation. The client shares that she is unsure what this could mean for her future and worries if her family will be disappointed in her if they find out. She says, "I am actually engaged to a man in Nigeria. We decided to postpone the wedding until I finished my degree, but now I don't know what to do. My parents were so excited when we announced our engagement, and the thought of breaking it off feels like a betrayal." You explain that it is natural to feel confused when faced with new experiences and remind her that she is in control of the decisions she makes about her life. You suggest exploring what a relationship with her roommate might look like, as well as considering the consequences of breaking off her engagement. She says, "I know I need to stay true to myself. I just don't want anyone hurt in the process. I can't even imagine what it would mean if I told my parents or church family about my roommate. They are not as conservative as other people in the town where I grew up, but I don't think they know many, if any, people who are in same-sex relationships." You discuss with the client how her religious and cultural beliefs may affect her sexual identity and contribute to feelings of guilt and fear of disappointing her family. During the next few weeks following today's session, the client cancels twice without proper notice and later tells you that she "had other stuff going on." | null | What short-term goal would address the feelings of isolation? | Take classes to become a United States citizen | Improve social interactions | Increase study time to distract her from loneliness | Explore her sexuality | (A): Take classes to become a United States citizen
(B): Improve social interactions
(C): Increase study time to distract her from loneliness
(D): Explore her sexuality | Improve social interactions | B | This is relevant to the client's problem of feeling isolated and wishing she was more involved in college activities and the community. Therefore, the correct answer is (C) | treatment planning |
536 | Client Age: 32 Sex: Female Gender: Female Sexual Orientation: Heterosexual Ethnicity: Latina; Mexican American Relationship Status: Married Counseling Setting: Community Mental Health Type of Counseling: Individual and Psychoeducation Presenting Problem: Depression Diagnosis: Major Depressive Disorder (MDD) with Psychotic Features 296.24 (F32.3) | Mental Status Exam: The client is well groomed and appropriately dressed. Her voice is soft and low, and she avoids eye contact, mainly when talking about her family. She states, “I’ve put them through so much. And I feel so ashamed when I’m unable to care for them.” She endorses feelings of hopelessness but denies suicidal and homicidal ideations. The client says that she hears voices and believes that they are the voices of her deceased ancestors trying to communicate with her. She explains that the “spirits” whisper her name in the middle of the night and come to her when she is alone. The client denies command hallucinations. Her appetite is poor, and she has difficulty sleeping “most nights.” She has experienced depressive symptoms most of her life, but, outside of the recent hospitalization, she has not sought treatment due to believing that mental illness is a sign of weakness. History of Conditio | You work in a community mental health setting. Your client is a 32-year-old Latina presenting with symptoms of depression and psychosis. She reports that she was hospitalized more than 6 months ago and did not attend follow-up appointments due to losing her health insurance coverage. The client currently reports anhedonia, sadness, feelings of worthlessness, and poor concentration. She explains that there are many days when she cannot get out of bed and is unable to fulfill her role as a wife and mother. The client also reports audio hallucinations and says this began when her grandmother died more than a year ago. She explains that her grandmother lived in her home and that her loss was “devastating” to the client. The client is fluent in Spanish and English. | n and Family History: You obtain a signed release of information before the client’s session today, which has enabled you to receive the client’s hospital records. The client was admitted due to hallucinations and suicidal ideation. The hospital psychiatrist provided a diagnosis of brief psychotic disorder and bipolar II disorder. The client was prescribed antipsychotic medication and an antidepressant. She reports that she discontinued the antipsychotic medication shortly after discharge because it caused excessive sleepiness. Regarding the antidepressant, the client states, “I just take it on the days when I’m really having a hard time.” The client has two teenage sons and lives near her extended family. Although Latinos are multiracial and multicultural, there are some cultural differences between Latinos and Anglo Americans | Although Latinos are multiracial and multicultural, there are some cultural differences between Latinos and Anglo Americans. Which statement accurately depicts these differences? | Latinos are more likely to engage in direct communication than indirect communication (e.g., idioms, metaphors, and stories). | Latinos place higher importance on their nuclear family than on their extended family. | Latinos place greater significance on supernatural forces than on nonspiritual forces. | Latinos emphasize personal fulfillment over group (i.e., collective) harmony. | (A): Latinos are more likely to engage in direct communication than indirect communication (e.g., idioms, metaphors, and stories).
(B): Latinos place higher importance on their nuclear family than on their extended family.
(C): Latinos place greater significance on supernatural forces than on nonspiritual forces.
(D): Latinos emphasize personal fulfillment over group (i.e., collective) harmony. | Latinos place greater significance on supernatural forces than on nonspiritual forces. | C | Latinos place greater significance on supernatural forces than on nonspiritual forces. Latinos believe that spiritual influences include intermediary saints and other supernatural powers. In addition, Latinos place high importance on extended family, are more likely to use indirect communication, and emphasize collective harmony over personal fulfillment. Therefore, the correct answer is (D) | intake, assessment, and diagnosis |
537 | Initial Intake: Age: 20 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Married Counseling Setting: Community Mental Health Agency Type of Counseling: Individual | The client presents appropriately dressed with evidence of positive self-care related to hygiene and appearance. Her mood is stated as anxious about being labeled as “crazy” though you note her affect appears to be angry. Her movements and speech demonstrate no retardation; she is cooperative, engaged, and forthcoming. She reports past suicidal attempts using alcohol or pills when she was extremely angry at her boyfriend or her parents, but emphasizes she has no current suicidal ideations. She also states she has had past thoughts of hurting others but emphasizes she does not desire to or think about hurting others now. Her short- and long-term memory appear to be intact, but demonstrates poor insight and judgement in choices. | You are a counselor in a community mental health agency. The client presents for “an evaluation,” which she states is required by her parents before she is allowed to move back into their home. During the intake session, you learn that your client was married for 18 months and has been divorced for two years. The client states that her husband had an affair during their marriage, which led to the divorce. She states she has a daughter who is five years old and shares custody with her ex-husband, who is now remarried. She reports that she was living with her parents until recently and is now sleeping on a friend’s couch. The client acknowledges that she has had several traffic incidents related to driving while intoxicated in the past few months. She reports she “totaled” her new car last week but was not arrested, likely because her companion had a felony warrant and the police arrested him at the scene and not her. It was at this time that she says her parents insisted she move out of the house and cannot return until she has sought counseling. She states she wants to “move on from my past,” she misses how things used to be, and wishes that her parents understood her better. The client reports that she drinks at least 20 alcoholic drinks per week and uses marijuana intermittently. She states she takes Adderall to help her clean the house quickly, uses cocaine, and has used Klonopin in the past, but stopped due to a “back experience.” She states she does not have a problem with substance use but acknowledges it is a stressor in her relationship with her parents. She reports that using substances are the “only way to get to know people” and has found herself angry when attending parties where others were having fun but she was not drinking or high. | Family History:
Client reports that she is the youngest of two children and that her family relationships were terrific until she turned 14 years old and then her parents “went crazy” when her grades in school declined and she was often grounded. She tells you that her parents didn’t like her after that and were always angry at her. On further discussion, the client says that she began dating a 19-year-old male when she was 14 but her parents decided he was too old for her and would not allow her to see him. She admits being furious at him for not taking her out after that and she called him daily to try to change his mind for over two months. She says she can’t stand him now and that he is currently in prison for aggravated assault on a police officer. She also tells you that at 15 years old, she began a long-term relationship with another man, who is now in prison for attempting to shoot someone. She states that he got involved with another girl and your client ended up getting arrested after she started a fight with the girl. Her third relationship was with her husband and with whom she became pregnant. At that time, her parents “kicked me out of the house and I couldn’t even come back inside to get my things.” They divorced two years ago after he called the police after “he said I attacked him when I found out he was cheating on me.” | Based on the information gained in the intake interview and this session, which of the following would be the most appropriate diagnosis for this client? | Histrionic personality disorder (HPD) | Dependent personality disorder (DPD) | Borderline personality disorder (BPD) | Antisocial personality disorder (ASD) | (A): Histrionic personality disorder (HPD)
(B): Dependent personality disorder (DPD)
(C): Borderline personality disorder (BPD)
(D): Antisocial personality disorder (ASD) | Borderline personality disorder (BPD) | C | Clients like this one are appropriately diagnosed with BPD and present with patterns of instability in interpersonal relationships and self-image such that the individual frantically attempts to avoid abandonment, alternates between idealizing and devaluing persons, demonstrates impulsivity in potentially self-harming activities, recurrent suicidal threats or behaviors, and inappropriate intense anger or difficulty controlling one's temper. Clients with ASD show some similar traits related to disregard for safety of self or others but also demonstrate a lack of remorse for hurting others as well as lying or conning others to get what they want. People with DPD rely on others to tell them how they should feel and have difficulty making everyday decisions without someone telling them what they should do. Those with HPD tend to use sexually provocative behavior when interacting with others and are deeply uncomfortable when they are not the center of attention. Therefore, the correct answer is (B) | intake, assessment, and diagnosis |
538 | 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 should the counselor first seek to clarify during this session? | John's goals for counseling | Jane's goals for counseling | Helping Jane articulate how she feels about John's statement | Helping John build skills for demonstrating empathy | (A): John's goals for counseling
(B): Jane's goals for counseling
(C): Helping Jane articulate how she feels about John's statement
(D): Helping John build skills for demonstrating empathy | John's goals for counseling | A | The couple has presented for counseling sessions in distress and at the point of divorce. John appears to be disengaged from Jane and the marriage, so clarifying his goals for counseling is the most important task during this session. If John is not invested in counseling, movement toward resolution cannot be made. Jane's goals for counseling are also important, however, because she is the identified client, the one who both initiated counseling and the one who is seeking reconciliation with John, we can infer that her goal is to repair the relationship. Based on the information, Jane is engaged with her emotions and her affect is congruent with the sadness she feels at John's statement. John appears sad, which suggests that his affect is also congruent and that he is empathetic towards Jane. Therefore, the correct answer is (D) | intake, assessment, and diagnosis |
539 | Initial Intake: Age: 9 Gender: Female Sexual Orientation: Heterosexual Race/Ethnicity: Caucasian/Non-Hispanic Relationship Status: Single Counseling Setting: Private Practice Type of Counseling: Individual | Lottie presents as excited, over-stimulated and hyperactive, unable to sit still and does not take breaks from talking. Her appearance is highly disheveled with stained clothes and unbrushed hair. Lottie nervously walks around your office touching and commenting on everything. You ask her nicely to ask you before she touches your things, but she refuses and continues to do so. Lottie deflects from every question posed in your assessment. She denies SI/HI, hallucination, or delusion, which you were surprisingly able to find out from her. |
Diagnosis: Attention Deficit Hyperactivity Disorder, predominantly hyperactive type (F90.1), Oppositional defiant disorder (F91.3), Reaction to severe stress (F43.9)
Lottie is a 9-year-old girl in the fourth grade who has been referred to you by officials in her elementary school. You are a counseling intern of a private practice that specializes in adult personality disorders, but your supervisor accepted Lottie as a new client because Lottie’s mother is a former client of her agency, and she requested her daughter be seen by your practice as opposed to a school-based counselor. Lottie’s mother does not want Lottie’s peers to know she is in therapy. Lottie has been doing well in school academically but has not been able to behave appropriately for years, according to the referral report. Lottie bounces up and down in her chair constantly, makes impulsive noises throughout the day, and engages in inappropriate behaviors daily. Some of the behaviors listed include invading the personal space of her peers, licking and eating school supplies to garner reactions from fellow classmates, hiding on the playground and refusing to emerge, and many other behaviors. Lottie follows basic classroom directions but needs constant reminding or guiding that the teacher does not have time for. Lottie breaks down into hysterical emotional fits when she does not get her way and her behaviors have been spreading the school staff too thin to be capable of managing without intervention. This session is conducted with only Lottie in the room; her mother insists on waiting in the car outside so she can make some phone calls. She mentions her Medicaid has just been reactivated to pay for sessions. | Family History:
Lottie lives at home with her mother and mother’s boyfriend, as well as their 1-year-old son Davie who is her half-brother. You learned from speaking with her mother beforehand that Lottie’s biological father was a drug addict and homeless, and he was recently shot and killed, about four months ago. Lottie knows and understands what happened. During the intake session you ask her to draw a picture of something important to her. She likes this assignment and draws you a picture of her father’s homeless camp where she last saw him. She explains to you the details surrounding his murder and mature, intimate details of her mother’s broken relationship with him. “How do you know all of this, Lottie?” you ask her, concerned. “Oh, my mother told me. She tells me everything.” | Which goal best summarizes the intentions of a safety plan for Lottie? | Lottie will comply with crisis/safety plans while in counseling. | Therapist will assist Lottie in developing safety plan. | Lottie will sign crisis/safety plan with mother and review until discharge. | Lottie will review her safety plan monthly for duration of counseling. | (A): Lottie will comply with crisis/safety plans while in counseling.
(B): Therapist will assist Lottie in developing safety plan.
(C): Lottie will sign crisis/safety plan with mother and review until discharge.
(D): Lottie will review her safety plan monthly for duration of counseling. | Lottie will comply with crisis/safety plans while in counseling. | A | Developing, reviewing, and signing a safety plan are all objectives within an intended goal, of which in this case is Lottie's compliance with all items within the safety plan itself. Therefore, the correct answer is (A) | treatment planning |
540 | Initial Intake: Age: 38 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Married Counseling Setting: VA Type of Counseling: Individual | Carl came to the intake session alone and angrily stated, “I really don’t know why they are making me come to therapy - it doesn’t help anyway.” Carl appeared edgy throughout the interview and responded to questions with minimal effort.
| Carl is a 38-year-old Army Veteran who is attending counseling at the local VA. Carl was referred after he was arrested for a DUI last week.
History:
Carl has been on four deployments to the Middle East, he returned from the most recent tour 11 months ago, after he was injured during a military strike. Some of his team members were injured as well.
Since his return, Carl and his civilian wife, Lori, have discussed separation because of their frequent arguing and Carl’s drinking. Carl began drinking when he was deployed and since then has used it as a coping mechanism to combat the frequent flashbacks and nightmares that he gets. Carl and Lori mostly argue about money since Carl has not been able to sustain employment as a construction worker because of his drinking problems. Carl has been arrested several times for assault and disorderly conduct. Carl recently assaulted his last counselor after he had made a comment about Carl not being able to sustain work.
The counselor thanked Carl for his service and reviewed with him that he was referred as a part of his probation. He must attend individual therapy and an anger management group for veterans. The counselor then described to Carl the purpose of the meeting and what would be reviewed and discussed during their time together. This included the intake paperwork, including informed consent and several assessments. | null | At this time, it may be beneficial to refer? | Lori to have individual therapy with the same counselor | Carl and Lori to a financial advisor to manage their finances | Carl to a career specialist at the VA | Lori to attend Carl's group for anger management | (A): Lori to have individual therapy with the same counselor
(B): Carl and Lori to a financial advisor to manage their finances
(C): Carl to a career specialist at the VA
(D): Lori to attend Carl's group for anger management | Carl to a career specialist at the VA | C | Besides Carl's drinking, a primary source of stress is Carl's inability to retain employment. It is important for a counselor to be aware of available resources and refer to them when beneficial. Now that Carl is ready to make changes, a career specialist at the VA may be able to help Carl obtain and sustain employment. A financial advisor is not necessary currently. Although they are having financial difficulties, nothing indicates that they are not able to manage their finances once Carl has steady employment. The counselor is seeing Carl individually and brings Lori into some sessions to work on their communication. It is not advisable for the counselor to also see Lori individually as this may cause triangulation and confusion. It is also not advisable for Lori to attend Carl's group for anger management as it is a closed group for those who have been in combat. Therefore, the correct answer is (A) | treatment planning |
541 | 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. | You are evaluating interventions that will help the client better cope with the loss of her son. Which of the following will be most beneficial for the client at this time? | Client will engage in concurrent prolonged exposure (PE) therapy to process her grief. | Family members will attend therapy to provide support and gain understanding of client's needs. | Client will ask family members to encourage her not to carry out her grieving behaviors. | Client will attend a concurrent grief therapy group. | (A): Client will engage in concurrent prolonged exposure (PE) therapy to process her grief.
(B): Family members will attend therapy to provide support and gain understanding of client's needs.
(C): Client will ask family members to encourage her not to carry out her grieving behaviors.
(D): Client will attend a concurrent grief therapy group. | Client will attend a concurrent grief therapy group. | D | Attending a grief therapy group while pursuing individual counseling will provide a safe place for the client to express her feelings and where she can be challenged by other group members about the effectiveness and appropriateness of her grieving behaviors. PE is an effective intervention but has high drop-out rates due to imaginal exposure. At this time, the client is not likely to be suited for PE as she is at higher risk for drop-out due to her depression symptoms. Having family members engage in therapy when they do not wish to do so or acting as accountability partners for a distressed client may cause further ruptures in family relationships. Therefore, the correct answer is (B) | treatment planning |
542 | 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. | During the previous session, the client committed to controlled drinking and agreed on a limit of two drinks per night. She admits to having limited success with this goal and concedes to over-indulging when feeling “stressed out.” You learn she ran into a woman from her church who she discovered was a recovering alcoholic. She agreed to meet the woman at an AA meeting, and the client was surprised she could relate to other alcoholics. The client’s affect brightened as she reported that she has had seven days of continuous sobriety. She continues to have a strained relationship with her now ex-husband. Her youngest child is home on spring break, which has helped improve her mood and kept her accountable for staying sober. She is able to use relaxation and mindfulness techniques for insomnia, which have been effective at times at improving her sleep pattern. Your client states, “I can’t do anything right anymore; I’ve failed as a parent | Your client states, “I can’t do anything right anymore; I’ve failed as a parent.” Using Rational-Emotive Behavioral Therapy (REBT), you respond with the following: | “You told me you were a stay-at-home mother. Would a failed parent make that sacrifice?” | “All parents feel like that every so often. It’s just part of the human condition.” | “What evidence is there that indicates you haven’t failed but instead succeeded as a parent?” | “You felt criticized by your ex-husband and your automatic thought was that you can’t do anything right, including parenting.” | (A): “You told me you were a stay-at-home mother. Would a failed parent make that sacrifice?”
(B): “All parents feel like that every so often. It’s just part of the human condition.”
(C): “What evidence is there that indicates you haven’t failed but instead succeeded as a parent?”
(D): “You felt criticized by your ex-husband and your automatic thought was that you can’t do anything right, including parenting.” | “What evidence is there that indicates you haven’t failed but instead succeeded as a parent?” | C | Rational-Emotive Behavioral Therapy (REBT) takes the ABC model used in CBT and adds two more elements—D and E—with D representing disputing irrational thoughts and E representing the newly formed alternative thoughts. Counselors using the technique of forceful disputing ask the client to review evidence that supports or does not support the client’s irrational thought. Answer A is an example of cognitive behavioral therapy rather than REBT. The activating event would be the ex-husbands criticism. The dysfunctional automatic thought is the statement about her inability to do anything right, including parenting. The potential consequences are frustration, hopelessness, depression. If you state that every parent feels like a failure every so often (Answer B), you might leave the client thinking their feelings are invalid. Answer C uses a closed-ended question and does not enable the client to engage in the forceful disputing of an irrational belief. Therefore, the correct answer is (D) | counseling skills and interventions |
543 | Name: Alex Clinical Issues: Hopelessness/depression Diagnostic Category: Depressive Disorders Provisional Diagnosis: F34.1 Persistent Depressive Disorder, Severe Age: 65 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: Multiracial Marital Status: Married Modality: Individual Therapy Location of Therapy : Private Practice | Appearance: The client is dressed in a manner that can be described as casual, suggesting that they might not have made any special effort to dress up for the session. Additionally, he is unshaven, which you note might indicate either personal preference, a decline in grooming habits, or possibly, decreased motivation and energy. Behavior: The client's overall behavior is withdrawn. Mood and Affect: His stated mood is depressed, implying feelings of sadness, hopelessness, or desolation. His affect, the observable manifestation of his feelings, is flat. Speech: His speech is both slowed and measured. Thought Process and Content: The client's thought process is tangential. He tends to veer off-topic and does not consistently answer questions directly or stay on point. The content of his thoughts is notably negative and self-defeating. Perceptual Disturbances: No delusions or hallucinations have been reported, indicating that the client has no gross misinterpretations of reality or perceptual disturbances. Orientation: The client is oriented to person, place, and time. Insight: It appears that the client has poor insight into his condition. Attitude: His attitude towards the evaluator is compliant and cooperative. | First session You are a licensed mental health therapist. Today you are seeing a 65-year-old male via distance counseling. You introduce yourself and ask him what prompted him to schedule an appointment to see you. He reports that he has felt "down in the dumps" for several years, and as he gets older, he feels more depressed and is in constant pain. As he is talking, he shifts around in his seat, appearing to have difficulty staying in a comfortable position. He continues by saying he feels depressed most of the time, has lost interest in activities that he once found enjoyable, feels hopeless, and is fatigued all the time. He also says he has lost his appetite and has difficulty sleeping. He states that "no one wants me around." Then he looks down and says, "I don't really blame them. I wouldn't want to be around me either." At work, he has difficulty concentrating and making decisions and is distressed that his co-workers see him negatively. When you ask him about his relationship with his wife, he says that while they live together, they have "not been close for a long time now." They both sleep in separate bedrooms and they lead separate lives. He explains, "We just kind of grew apart. We still love each other and would never get divorced, but now we're more like roommates. She's very social and involved in the community. I'm more of a homebody." After the client has shared why he is seeking counseling, you state, "I can hear that you are feeling very discouraged. It sounds like you have been going through a difficult time for quite some time now and it's taking a toll on your life. Let's explore what might be contributing to these feelings and how we can work together to help find solutions or ways to cope with the challenges you're facing." You use a solution-focused brief therapy technique and ask him visualize what successful treatment would look like. He contemplates it for some moments and says, "I'd feel better, I guess." You encourage the client to think more deeply about what successful treatment would look like and explain how this visualization process can help him gain clarity on his desired outcomes. He says, "Hmm, I'm not really sure. Can you give me some examples? This is my first time in therapy and I'm not really sure what to expect." You provide some examples of tangible goals that he might set for himself, such as improving sleep patterns, having better communication with family members and co-workers, and finding meaningful activities to engage in. The client is able to identify some areas that could be improved and formulates realistic, achievable goals. Together, you create an action plan for successful treatment, which includes specific steps he can take to reduce symptoms and increase positive outcomes. You schedule a follow-up appointment to meet with him next week. Fourth session It has been three weeks since your initial session with the client, and he has been keeping his weekly appointments. Last week you suggested he see a psychiatrist, and you begin today's session by discussing the results of his psychiatric referral. The client reports that he was prescribed antidepressant medication. He is not feeling much relief from his depressive symptoms now, but his psychiatrist told him that it could take a few months for the medication to reach maximum efficacy. Next, you discuss treatment options and the use of cognitive-behavioral therapy combined with his medication regimen. He is willing to try the combined approach, and together you create a treatment plan with both short-term and long-term goals. He mentions his job being a source of frustration. You spend some time discussing the client's job and his feelings about it. He expresses his desire to retire, but he worries about the financial burden it may place on his wife. He says, "My retirement benefits are not that great, and I lost a lot of money in the stock market last year. I just don't know how I can make this work. I'm not sure if retiring now is the right decision." You discuss other possibilities for him to consider for retirement, such as part-time work or freelancing in a field he enjoys. You also brainstorm with him about ways for him to transition out of his current job in a way that reduces conflict with his co-workers, such as taking scheduled breaks and speaking with his supervisor about his workload. You provide support and suggest that he speak with his wife about their financial situation before making any decisions about his retirement. He agrees and states he will bring it up with her this upcoming week. Toward the end of the session, the client reveals that he has been contemplating cutting back on his drinking, but he is worried that he will not have any friends if he stops drinking. He says, "I already feel like a failure at work and as a husband. If I lose the few friends that I still have, I'll be alone and will never be happy again." You utilize motivational interviewing strategies and suggest that if he stops drinking, it will not mean that he has to give up all of his friends, but rather that he may need to find new friends who do not drink alcohol or who can meet with him in an alcohol-free context. He nods his head and says, ""I hear what you're saying, but who is the world would want to be friends with someone like me? The only reason I've got any friends left is because I like to drink with them." You empathize with his feelings of self-doubt, but remind him that it is possible to find meaningful friendships without drinking. You give him a homework assignment to find at least one activity or group that seems interesting to him and create a plan to start building positive relationships with others. You reassure him that you will be there to support him through this process and set a date for his next appointment. 15th session You have been seeing the client regularly for the past four months. He states that he is feeling "better" these days, and he is doing better at work. He has been taking his antidepressant medication as prescribed and feels therapy has been helpful. You review the treatment plan and discuss the progress he has made and the termination process. Near the end of the session, he tells you, "Well, there is one more thing. I'm worried that my wife might be having an affair. I know it's probably crazy, but I can't help but think that she's seeing someone else. And you know what, I wouldn't blame her. I haven't been the best husband with my constant depression. I just think about her leaving me, and it makes me feel afraid." You express understanding and validate his feelings, noting that it's not uncommon for people to have affair-related thoughts when feeling insecure in their relationship. You inquire whether he has been spending time with his wife and how he and his wife have been communicating. He reports that they have been talking more and that he has been trying to be more present when he is with her. You remind him of his progress in therapy and how much better he has been feeling overall, which has likely contributed to him being able to engage more in his marriage. You suggest that as he continues to work on himself and generally feels better, his worries about his wife cheating on him will likely lessen. In the meantime, you caution against drinking to cope with his anxiety, as it can lead to further problems down the road. | The client reports that his relationships with family members were strained growing up, with his father often away for work and his mother struggling with her own mental health. He reports that his mother drank a lot, which the client defends saying, "I guess I'd drink a lot if I had 5 kids by the time I was 22 years old. The client grew up feeling unsupported and unimportant, which led to a disconnect from the rest of his family. Of his four siblings, the client keeps in touch with one brother, but "my other two brothers and sister live in different states and have different lives. I think they've struggled with depression, too. We don't talk much." Despite this difficulty in connecting, the client has an adult daughter whom he "loves very much and tries to stay in contact with. He wishes he could have done better for her during his parenting years, and despite their rocky past, has a deep desire to maintain a healthy relationship. He says, "I don't want her to think the same way I do about family and relationships. I want her to have good ones." The client is currently employed as a corrections officer and feels his job has no potential for advancement. He has been working there for 20 years and is ready to retire in less than a year. He expresses that it has been challenging and physically and mentally exhausting. In addition, he is tired of "dealing with both the inmates and the administration." He tells you his co-workers consider him a "slacker" because he is always tired and takes as many breaks as he can get away with. He is also worried about "word getting back to his co-workers" that he is in therapy. The client expresses that he has some drinks, especially after work, to calm down. He reports that he will drink in social settings as well. He states that his preferred drink of choice is whiskey. | You respond to the client's disclosures in the session by stating, “What I hear you saying is that you're feeling as though you haven't been there for your wife, yet I'm struck by how you're able to do all that is required at your job, and you still have the resolve to work on yourself and your relationship. How do you do that?” What technique are you using? | Structural Analysis | Paradoxical Intervention | Reframing | Coping Question | (A): Structural Analysis
(B): Paradoxical Intervention
(C): Reframing
(D): Coping Question | Coping Question | D | The coping question technique underscores his personal resources that he is not acknowledging. This is tailored to help him recognize coping skills he already uses with his relationship issues. Therefore, the correct answer is (D) | counseling skills and interventions |
544 | Name: Marta Clinical Issues: Caregiving concerns Diagnostic Category: Trauma and Stressor Related Disorders Provisional Diagnosis: F43.23 Adjustment Disorder, with Mixed Anxiety and Depressed Mood Age: 55 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: Colombian American Marital Status: Married Modality: Individual Therapy Location of Therapy : Agency | The client appears older than her stated age. She is disheveled, poorly groomed, and has a strong body odor. She is cooperative but demonstrates a high level of distress manifested as restlessness, being easily distracted, and consistently rubbing her hands. Her speech is initially slow and halted but later becomes elevated and loud. She is oriented X3. Her affect is characterized by anxiety and depression, as she is having difficulty answering your questions. The client indicates that she has thoughts about putting a pillow over her mother's face or taking an overdose of sleeping pills so that she does not have to deal with her family or her mother's demands anymore. | First session You are a counseling intern for a mental health agency. A 55-year-old Colombian American female presents to therapy with tears in her eyes. She appears distraught, anxious, and despondent. She describes feeling guilty about wanting to put her mother in an assisted living facility. Although the client knows that putting her mother in an assisted living facility is probably the best decision, she feels guilty because it goes against the values of her culture. She explains that in traditional Colombian culture, elders are revered, and it is the responsibility of the oldest child to take care of them. The client's siblings have been "critical of me even talking about moving her into an assisted living facility" and are pressuring her to keep their mother at home. The client starts to cry and covers her face. Finally, she looks up and says, "I feel torn. There are these cultural expectations that I look after my mother, but she never even liked me and made my life miserable when I was growing up." The client does not have any nearby family who can help support her or assist in the care of her elderly mother. Her brothers live in different states, and her husband is an only child whose parents both passed away a few years ago. The client has expressed feeling overwhelmed by the responsibility of taking care of her mother and running her own household. She says, "I feel like I just can't keep up with everything. My kids need me, my husband needs me, and now I have to take care of my mother, too. And as for having any time to myself, that's a dream that's never going to happen." She further explains that her current circumstances remind her of what it felt like growing up in a chaotic household and feeling the pressure of having to take care of her younger siblings. She states, "It's like history is just repeating itself." She reports feeling "like a failure at being a wife, mother, sister, and daughter." As you listen to the client's story, you sense her feelings of guilt, frustration, and overwhelm about not being able to meet all the demands placed on her. You empathize with the client and validate her feelings. You compliment her on the strength it took for her to take on an additional responsibility despite the hardships that come with it. When asked what she hopes to gain from therapy, the client tells you that she wants to figure out how to balance her responsibilities. She expresses wanting to find a way to care for her family members without "losing myself and my sanity in the process." You suggest meeting with the client for weekly sessions as a place to begin, and you walk the client through what she can expect from therapy. | The client is the oldest child in her family. She has 3 younger brothers, all of whom are separated in age by one year. She was born and raised in Colombia. When she was in middle school, her family immigrated to the United States in search of better opportunities. Her father worked long hours as a taxi driver while her mother worked as a nanny taking care of other people's children. The client stated that she often felt like she had no parents because they were always working. The client stated that when they moved, her mother asked her to help out more at home with the cooking, cleaning, and taking care of her siblings. She often felt overwhelmed and guilty because she wanted to spend time with friends or focus on her studies rather than watching her brothers. The client revealed that she often feel a deep sense of resentment knowing that while other girls were able to go outside and play, she had responsibilities to take care of. Personal/Social Relationships: The client's father passed away four months ago and her 76-year-old mother has been living with the client since then. The mother does not speak English and requires assistance with medical appointments, financial dealings, and daily care. She constantly "nags" the client about how she is raising her children and often complains about her cooking. The client's husband, who is second-generation Irish American and grew up in Boston, is becoming increasingly irritated with his mother-in-law. He complains to his wife about her mother, which puts a "massive strain" on the couple's relationship. | Which of the following assessment instruments would provide you with the most comprehensive evaluation of the client's distress? | Beck Anxiety Inventory (BAI) | DSM-5-TR Level 1 Cross-Cutting Symptom Measure | Beck Depression Inventory (BDI-II) | Minnesota Multiphasic Personality Inventory (MMPI-3) | (A): Beck Anxiety Inventory (BAI)
(B): DSM-5-TR Level 1 Cross-Cutting Symptom Measure
(C): Beck Depression Inventory (BDI-II)
(D): Minnesota Multiphasic Personality Inventory (MMPI-3) | DSM-5-TR Level 1 Cross-Cutting Symptom Measure | B | The DSM-5-TR Level 1 Cross-Cutting Symptom Measure would provide the most comprehensive evaluation of the client's distress as it explores symptoms of depression and anxiety in addition to several other mental health domains. It also determines the severity of those symptoms. Therefore, the correct answer is (D) | intake, assessment, and diagnosis |
545 | 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 is not relevant to a comprehensive assessment of Michael? | Michael's medical history | Any recent significant events in Michael's life | Michael's current support system | If the suspension goes on Michael's permanent record | (A): Michael's medical history
(B): Any recent significant events in Michael's life
(C): Michael's current support system
(D): If the suspension goes on Michael's permanent record | If the suspension goes on Michael's permanent record | D | Whether the suspension goes on Michael's permanent record is not relevant information for a comprehensive assessment. Relevant information would include assessing Michael's current support system. Also, since this recent event seems uncharacteristic for Michael, it is important to understand any recent events that could have triggered this behavior. Finally, a person's medical history can provide a holistic framework and thorough assessment. Therefore, the correct answer is (D) | counseling skills and interventions |
546 | 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 one of the following is a possible symptom or criterion of a manic episode? | Hallucinations | Symptoms are present but do not impair social or occupational functioning | Symptoms last at least 4 days | An inflated sense of self or grandiosity | (A): Hallucinations
(B): Symptoms are present but do not impair social or occupational functioning
(C): Symptoms last at least 4 days
(D): An inflated sense of self or grandiosity | An inflated sense of self or grandiosity | D | An inflated sense of self and/or grandiose thinking are symptoms that often occur with manic episodes. Manic episodes have a criterion of 1 week of symptoms, whereas at least 4 days of symptoms is a criterion for a hypomanic episode. A hypomanic episode is not as severe as a manic episode and does not affect functioning in social or occupational settings. Hallucinations are not a symptom of a manic episode. Therefore, the correct answer is (A) | intake, assessment, and diagnosis |
547 | 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.” | Davone agrees to work on communication skills. Which of the following would best support Davone's situation? | Help Davone write an apology letter to his ex-wife. | Teach Davone assertiveness for verbalizing desires and clarifying boundaries. | Conduct mock interviews for Davone to practice gaining employment. | Use Empty Chair technique for Davone to talk to his father. | (A): Help Davone write an apology letter to his ex-wife.
(B): Teach Davone assertiveness for verbalizing desires and clarifying boundaries.
(C): Conduct mock interviews for Davone to practice gaining employment.
(D): Use Empty Chair technique for Davone to talk to his father. | Teach Davone assertiveness for verbalizing desires and clarifying boundaries. | B | Supporting Davone's direct interaction with specific people or agencies is secondary to teaching Davone how to assert his wants and needs and be capable of defining and differentiating between them. Answers a), c) and d) are also therapist-led suggestions and do not necessarily reflect the objectives desired by Davone in the first place. By prioritizing answer b), Davone can develop the skills necessary to further clarify what he wants to use his communication skills for and that could lead to collaborating on new, specific objectives. Therefore, the correct answer is (B) | counseling skills and interventions |
548 | Initial Intake: Age: 32 Gender: Female Sexual Orientation: Bisexual Ethnicity: Caucasian Relationship Status: In a relationship Counseling Setting: Community mental health agency Type of Counseling: Individual via Telehealth | Melanie is unkempt, looks tired and is casually dressed. Motor movements are within normal limits, eye contact is appropriate. Melanie reported passive suicidal ideation intermittently throughout her depressive episode as a means for escaping her feelings but has no plan or intent. Melanie reluctantly admits to several instances of past trauma which include losing her son’s father to a tragic car accident four years ago where her son witnessed him die, as well as having three other older children, all with separate fathers, with whom she has no contact. Her only support system is her boyfriend who takes great care of her and her son’s school, which provides help with his Individualized Education Plan. | Diagnosis: Dysthymic disorder (F34.1), provisional, Anxiety disorder, unspecified (F41.9), Post-traumatic stress disorder (PTSD) (F43.1)
Melanie has been in mental health counseling for several years through your agency and was referred to you by her last counselor who obtained a position with a local University and was leaving your company. Melanie is a 32-year-old Caucasian female who lives in a house with her boyfriend and her 9-year-old son, Gus, who suffers from ADHD, anxiety, and PTSD. Melanie is receiving psychiatric medication from your agency’s Psychiatrist, another Psychiatric practice by a Nurse Practitioner in a different city and is being treated medically by a Gastroenterologist who has also prescribed medications. Melanie is complaining of ongoing depression caused by her chronic nausea and a cyclic vomiting syndrome and does not want to leave her bed out of helplessness and hopelessness that nothing will ever change. She also reports experiencing anxiety and panic-like attacks when she is around others which causes her to socially isolate for sometimes days at a time. She is upset she cannot care for her son the way she desires and wants to continue counseling to help her feel better. | Family History:
Melanie has what she states is a “complicated” relationship with her family, including her mother, whom she believes wants no involvement with her or her son, and has no contact with anyone else. Melanie states her falling out with her mother began when she was just a child. She comments that her father and her were “very close”, but his new wife makes it “challenging to communicate with him.” Melanie has lived on her own for much of her life and has not engaged in or sustained any relationship with her first three children. She adds that in each instance they were either unfairly taken away by the father or the state and that she has tried to initiate contact, but it has not been successful. Melanie continues to deflect from discussing family dynamics, causing gaps in your initial interviewing process.
Work History:
Melanie reports never having an “official” job but always being able to make money “somehow.” She has been on Medicaid for most of her life and continues to survive off government support and the charity of others. She tells you she has dreams of writing a book or even owning her own bakery but does not demonstrate willingness to take the steps at achieving those goals.
Legal History:
Melanie has incurred a criminal record for failing to pay child support several times over the past nine years and continues to receive notices and warnings to ensure she is making her payments on time. | What information should you gather about Melanie's current level of functioning? | How she manages her daily routine including eating and sleeping | Whether she is up to date on her child support payments | Her interest level in activities that bring her joy | The quality of a relationship between her and her son | (A): How she manages her daily routine including eating and sleeping
(B): Whether she is up to date on her child support payments
(C): Her interest level in activities that bring her joy
(D): The quality of a relationship between her and her son | How she manages her daily routine including eating and sleeping | A | How Melanie functions daily is vital to understanding her level of current functioning both cognitively and physically. Relationship dynamics, depression, as evidenced by lack of interest in activities, and her ability to cope with external stressors such as financial obligations can all be better understood considering this first set of baseline data in answer c). Therefore, the correct answer is (C) | intake, assessment, and diagnosis |
549 | 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. | The client received a score of t=55 on the total Antisocial scale, with a significant elevation on the Antisocial-Acts subscale (t=76), but no elevations on the Antisocial Egocentricity (t=39) or Antisocial-Stimulation Seeking (t=40) subscales t=55 on the total Antisocial scale, with a significant elevation on the Antisocial-Acts subscale (t=76), but no elevations on the Antisocial Egocentricity (t=39) or Antisocial-Stimulation Seeking (t=40) subscales. Which of the following is the most accurate diagnostic choice after reviewing the scores on the assessment of the client's current needs? | Antisocial Personality Disorder | Bulimia Nervosa, In Full Remission | Conduct Disorder | Narcissistic Personality Disorder | (A): Antisocial Personality Disorder
(B): Bulimia Nervosa, In Full Remission
(C): Conduct Disorder
(D): Narcissistic Personality Disorder | Bulimia Nervosa, In Full Remission | B | Based on the client's self-report, she previously met criteria for a diagnosis of Bulimia Nervosa from the ages of 13 to 20. These include the acts of binging and purging, at least once a week for 3 months. Based on her descriptive comments about her weight and self-image, she meets criterion C as her self-evaluation was unduly influenced by her body weight and shape. Because she has not engaged in the binge-purge cycle for 5 years, she merits the specifier, In Full Remission. The assessment shows a significant elevation in antisocial acts, which is expected due to her past criminal history, but no elevations in egocentricity or stimulation-seeking. A diagnosis of antisocial personality disorder would require elevations in all three areas. Additionally, her score on the total Antisocial scale is within 10 points of the Mean, which is not clinically significant. The client may have demonstrated some traits in the past of a narcissistic personality disorder such as a grandiose sense of self-importance, desiring excessive admiration, and is interpersonally exploitative as indicated by her criminal history and the people she interacted with using false personas. However, she does not meet the required five criteria for diagnosis as she shows remorse and insight of her past actions, which is not characteristic of someone with this personality disorder. Conduct disorder is a child and adolescent disorder. Therefore, the correct answer is (C) | intake, assessment, and diagnosis |
550 | 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 | The counselor states, "Let's take a step back and take deep breaths. The good thing is that you are both here. Now let's try to talk to each other, using I statements and focus on your feelings." This is an example of? | Paraphrasing | Capping | Reflection of feeling | Regrouping | (A): Paraphrasing
(B): Capping
(C): Reflection of feeling
(D): Regrouping | Capping | B | Capping is an intervention that counselors use when they observe the escalation of emotions. By giving the couple a task, it switches their thinking from an emotional level to a cognitive one. Regrouping means to be regrouped or reassembled. It is not a clinical intervention. Paraphrasing is a skill that lets the client know that they are heard by the counselor repeating the client's words. Reflection of feeling is when the counselor focuses on the feeling regarding what was just expressed to also show understanding. Therefore, the correct answer is (D) | counseling skills and interventions |
551 | Client Age: 51 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Divorced and single Counseling Setting: Local government mental health agency Type of Counseling: Individual counseling Presenting Problem: The client is experiencing a recent separation from her last partner who was verbally and physically abusive, and she is currently living in a domestic violence home. Diagnosis: Major depressive disorder, recurrent episode, moderate (F33.1) and post-traumatic stress disorder (PTSD) (F43.10) | Mental Status Exam: The client’s affect is flat, and she is hunched over in the chair. The client is oriented to person, place, time, and situation. She reports no hallucinations, paranoia, or depersonalization/dissocia | You are a licensed counselor working for a local government mental health agency in the counseling clinic. The client was referred to receive case management and counseling after experiencing homelessness due to leaving a physically and verbally abusive relationship with her last partner. The client is experiencing the following depressive symptoms: sadness more often than not, mental fogginess, suicidal ideation, insomnia, significant weight loss, feelings of worthlessness, and fatigue. The client experiences PTSD symptoms due to having experienced several abusive relationships, including recurrent distressing intrusive thoughts regarding the physical abuse, distressing dreams related to abuse, and physiological reactions (difficulty breathing, heart racing) when she goes near certain places that remind her of the abuse. She also explains that she has been avoiding triggers, believes that no one can be trusted, has an exaggerated startle response, and has had difficulty experiencing positive emotions. The client says that she does not know if therapy can help because she feels like these events have changed her and that she cannot get back to “normal,” but that she would like to make friends so she doesn’t feel so alone. | tion. Family History: The client has three adult children: a daughter(age 32), son (age 30), and a second daughter (age 28). The client reports on and off relationships with her children historically because they did not want to be around these men, but that they have rekindled their relationships recently. The client has been married twice, and, in addition to her most recent partner (unmarried), all three men have been physically and verbally abusive toward her | What information would be the most important to guide the development of a treatment plan for this client within the scope of the counselor? | The client stating that she wants to make friends | Reported frequency of trauma responses | The client stating that she wants to find housing | Reported amount of sleep per night | (A): The client stating that she wants to make friends
(B): Reported frequency of trauma responses
(C): The client stating that she wants to find housing
(D): Reported amount of sleep per night | The client stating that she wants to make friends | A | The most important thing when treatment planning is to support the client’s goals and objectives. Although insomnia and trauma responses are important observations as presenting symptoms, the client expressed the desire to make friends, which would be an appropriate focus in therapy because it likely would include treating most of the client’s symptoms in order to reach this goal. The client’s housing needs are also important to therapy and an indicated desire by the client, but this would be outside the scope of the counselor and would require either a referral for support or support from elsewhere within the government agency. Therefore, the correct answer is (C) | treatment planning |
552 | 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. | The client comes to the counseling center during walk-in hours. The client is continuing to experience a manic episode. She reports that she went out to dance with friends the previous evening and ended up buying a gram of cocaine for $100 and reported doing several lines throughout the night. The client says that she has never used any drugs before and that it scared her that she would spend that much money on drugs and that she used drugs at all. You empathize with the client’s frustration with her behavior and provide psychoeducation on impulse control to support her. The client appears tired as evidenced by her affect and slow movements, and she also appears to have poor hygiene because her clothes have visible stains and she has a slight body odor | Based on the information presented, all of the following are behavioral triggers for impulsive behavior EXCEPT: | The client’s routine is not maintained. | The client is out of the home late at night. | The client uses drugs. | The client is awake late at night. | (A): The client’s routine is not maintained.
(B): The client is out of the home late at night.
(C): The client uses drugs.
(D): The client is awake late at night. | The client uses drugs. | C | Managing behavioral triggers is a way to become more aware of when impulsive behavior may occur during a manic episode and provides activities that should be avoided or coped with in order to prevent impulsivity. Drug use is not a behavioral trigger for this client because the drug use was a result of impulsive behavior and did not lead to more impulsive behavior. For this client, being up late, going out with friends, and poor adherence to her usual routine increase the likelihood of impulsivity. Therefore, the correct answer is (D) | intake, assessment, and diagnosis |
553 | 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. | Given the situation that occurred during this session, what would you prioritize working on with this client? | The client's resentment of women and his mother | The client's expressed need to fantasize about his ex-girlfriend to get an erection | The client's need to separate from his verbally abusive wife | The client's issues with his father that may be contributing to his erectile dysfunction | (A): The client's resentment of women and his mother
(B): The client's expressed need to fantasize about his ex-girlfriend to get an erection
(C): The client's need to separate from his verbally abusive wife
(D): The client's issues with his father that may be contributing to his erectile dysfunction | The client's resentment of women and his mother | A | His issues with his mother and his resentment of women need to be addressed as his conflict continues with his wife. He recognizes that his wife triggers him with her comments, and working with his beliefs about women and mother issues is paramount. Therefore, the correct answer is (B) | treatment planning |
554 | 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. Third session You and the client have agreed to meet for biweekly therapy sessions as she feels she needs extra support right now. This is your third session with the client, and she presents looking exhausted and can barely speak. You consider alcohol use, but there is no smell of alcohol, and the client's eyes do not seem dilated. She is neither slurring her words nor stumbling. You can sense that she is exhausted, both mentally and physically. She shares that she has not slept in 48 hours and is struggling with nightmares about her deceased friend. She says, "Why did he have to die? I feel like it's my fault." Next, you ask her, "What do you think caused your friend's death?" but she looks away and shakes her head, unwilling to answer. You then try to explore the nightmares she has been experiencing, but she becomes irritable and angry. Finally, she breaks down and begins to cry. You allow her time to cry, knowing that it is a way for her to release some of the pain she is feeling. After a few minutes, you ask the client if she would like to talk about what is going on in her life. She agrees and starts talking about how overwhelmed she feels. She hates her job, her past, and her present. The client feels like everything is too much for her to handle. You listen patiently as she talks about her feelings. Eighth session You have been seeing the client for a few months now, and she has consistently come to therapy and has made some progress, but some areas still need work. Regarding the death of her friend, she remains in the denial stage of his passing. She had been prescribed medication to help with her insomnia and depression, which seemed to be helping somewhat. In addition, she is limiting her alcohol intake, but she has not stopped drinking altogether. She had also been working on identifying her triggers for anxious distress, and you discussed several of them during previous sessions. Today, you focus on the stress the client reports in relationship to her job. You ask, "What has been going on at work that has been making you feel stressed out?" She starts to talk about her boss and seems to be caught up in the details, getting lost in her story. You notice her becoming agitated. You ask her to explain what she is feeling and she says, "overwhelmed, frustrated, and like I can't keep up." She tells you that just talking about it makes her feel physically uncomfortable. You offer the client some grounding techniques to help her stay in the present moment. You suggest she take a few deep breaths and focus on her breathing. You then ask her to focus on her physical sensations, including any tension or tightness in her body and gently encourage her to release that tension. You suggest she identify something in the room that can help her stay grounded and focus on it if her mind starts to wander. When she appears to be calm again, you ask her to describe the situation at work that is causing her the most distress in simple terms, without getting caught up in details. The client goes on to explain that her supervisor is often critical of her and she feels as though he does not appreciate the hard work she puts in. You listen to her and empathize, then encourage her to think about specific ways she can address the situation at work. You suggest that she start by making a list of her skills and competencies, so that she can remind herself of her worth when feeling attacked. Throughout the session, you mirror the client's body language by following her lead. When she leans forward, you lean forward. When she furrows her brows or crosses her arms, you do the same. You also make eye contact with the client, giving her your undivided attention. | 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 intervention would best enable you to accomplish the treatment objective of increasing the client's support network? | Encourage the client to reconnect with her friends | Suggest that the client reconnect with her siblings | Recommend grief group for the client | Explore the client's relationship with her father | (A): Encourage the client to reconnect with her friends
(B): Suggest that the client reconnect with her siblings
(C): Recommend grief group for the client
(D): Explore the client's relationship with her father | Recommend grief group for the client | C | A group would provide good social support for the client to help her through her grief. Her best friend died, and she does not have a healthy family dynamic. Therefore, the correct answer is (C) | treatment planning |
555 | 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. | Using the information provided, which of the following represents the client's current struggle? | Lack of support | Lack of boundaries | Desire for control | Desire for approval | (A): Lack of support
(B): Lack of boundaries
(C): Desire for control
(D): Desire for approval | Desire for control | C | The client's narrative focuses on her desire to control herself by controlling others. She required her parents to buy and eat the way she is eating. She became angry at her brother for not acquiescing to her demands and at her father when he ignored them and ate a doughnut. She tells you she is aware of her mother's attempts to control her but shows no recognition of her own attempts to control others. The client demonstrates rigid boundaries for how others should act around her so while they are not appropriate, she is not lacking boundaries. Her family's actions, as narrated, do not show a lack of support for the client but instead show some resistance to her desires to control them. The client likely does desire her mother's approval but is currently engaged in a power struggle with her mother to determine who ultimately will control the client. Therefore, the correct answer is (C) | intake, assessment, and diagnosis |
556 | Name: Ella Clinical Issues: Seeking help after experiencing a trauma Diagnostic Category: Trauma and Stressor Related Disorders Provisional Diagnosis: F43.0 Acute Stress Disorder Age: 35 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: White Marital Status: Married Modality: Individual Therapy Location of Therapy : Private Practice | The client is a 35-year-old white female with a slender build. She is wearing jeans and a t-shirt and appears to be clean and well groomed. Her posture is slumped, her facial expression is flat, her eyes are downcast, and she has been displaying signs of crying. She speaks softly in a monotone voice. The client appears depressed and anxious, with tearfulness and trembling. She seems overwhelmed by her current situation and is unable to control her emotions. She reports difficulty concentrating on day-to-day activities. Her thoughts are logical and organized with tangential moments. She reports feeling as if she is living in a dream-like state since the trauma occurred. She experiences frequent nightmares about people she loves being killed. She is able to recall her personal history accurately. She is able to understand and follow your instructions and questions. She recognizes that she needs help. She denies suicidal ideation or intent. | First session You are a mental health counselor working in a private practice setting while under supervision. The client is a 35-year-old white female who presents for therapy following a trauma. When you ask the client why she made an appointment to see you, she begins to cry and shake uncontrollably. She tells you that her friend was shot two weeks ago and the client saw it happen. Her friend is in the intensive care unit at the hospital. She cannot consciously recall the actual shooting. Since the assault, she cannot concentrate and feels anxious all the time. She does not want to talk to her friends, and she has been withdrawing from her family. The client tearfully tells you that "life has no meaning." She is seeking your help to find some relief. You validate the client's emotions and begin processing her subjective experience. You help her to understand that witnessing such a traumatic event can lead to the physical and emotional symptoms that she is experiencing. She appears receptive to what you are saying and nods her head. You emphasize that she has taken a courageous step by seeking professional help. As you continue with the initial session, you focus on providing an empathetic space where she can explore her feelings without fear of being judged. You provide her with information about resources she can access for further help. You also discuss the principles of cognitive-behavioral therapy as a method to begin to process her traumatic experience. Before the session ends, you present relaxation exercises that she can practice at home in order to reduce distress and tell her that learning healthy coping skills will be an important part of her recovery. Following the session with your client, your supervisor tells you that she has worked extensively with the client’s parents in the past and offers to give you their files so that you can understand more of the client's family history. Second session After meeting with the client for the initial session, you thought it would be beneficial to meet with her again in a few days. She scheduled an appointment to meet with you via telehealth three days after her initial visit. You begin today's session by discussing potential avenues of treatment. The client reports not sleeping well because of vivid nightmares. She excessively worries about losing her parents but does not want to concern them. Since the assault, she has withdrawn from her family. She reports becoming angry when they suggest that she go for a walk outside to "get some fresh air". She now believes they do not care that she feels unsafe. The client denies suicidal ideation but sometimes feels she would be better off not waking up in the morning. During the first 10 minutes of the session, the client's two pet dogs continually draw her attention away from the session. You notice the distraction and acknowledge it. You ask the client if she would like to take a break and play with her dogs for a few minutes. The client agrees and takes a few minutes to interact with her animals. When she is finished, she escorts the dogs out into the hallway and returns to her room, closing the door behind her. You sit with the client and share a compassionate space together, allowing her to share her vulnerable feelings. You notice that, as you talk, her two pet dogs are still being disruptive, barking in the hallway, and distracting her from the conversation. You bring her attention back to the session by reiterating your understanding of how she has been feeling since the assault. You then explain that these feelings may be compounded by the disruption caused by her pets during their sessions. You offer suggestions on ways to create a better environment for therapy such as having another family member manage the pets while they work together, or setting up a comfortable area in another room where she can work with you away from distractions. The client is appreciative of your suggestion and agrees to put some of these ideas into practice for their next session. From here, you move onto discussing potential treatment options for her recovery. You explain the benefits of cognitive behavioral therapy and how it can help her in managing her feelings more effectively. Additionally, you share relaxation techniques with the client to help reduce her physical symptoms of distress. Finally, you work collaboratively with your client on developing coping skills and increasing self-care practices in an effort to improve her overall well-being. You end the session feeling that progress has been made, both in terms of providing an understanding environment and suggesting ways to further address the trauma she experienced. Eighth session It has been one month since your initial counseling session with the client. You have been meeting with her twice a week. Today, you take time to review the progress she has made in therapy. She has utilized several calming techniques while demonstrating a willingness to discuss the traumatic event with you. She is experiencing fewer nightmares, and her mood has improved. She is once again finding some meaning and value in life. You have established excellent rapport with the client, and she has been reestablishing supportive relationships with her family. She still experiences high anxiety, however, when worrying, particularly when passing the store where her friend was shot. Your client reveals that the shooter she witnessed during the robbery was Irish American. She now has a feeling of genuine fear toward all Irish Americans. She uses several derogatory slurs during the session and reveals she hates all Irish men due to her experience. You empathize with the client's feelings and explain how post-trauma symptoms can lead to increased levels of fear and distress in certain situations. You discuss with her the importance of understanding that trauma can cause us to make generalizations about people or groups who we associate with the traumatic event, but these are not necessarily accurate or fair assessments. You encourage your client to practice self-reflection when feeling overwhelmed by similar thoughts in order to gain perspective. Additionally, you introduce exercises which promote relaxation and offer a safe space for her to pause and consider her thoughts before reacting emotionally. | The client's family has a long history of living in the Bronx, New York, as her great-great-grandparents immigrated from Italy. She currently lives with her parents in a house that has been in her family for generations. Her entire life she has always felt safe and secure living in her Italian neighborhood. The client has one older brother who is married and works as a paramedic. She is close to her parents and describes them as supportive, hardworking, and loving. Her father was diagnosed with cancer several years ago and she has tried to be there for him in every way possible. Stressors & Trauma: The client witnessed her friend being shot during a robbery. Since then, she cannot stop thinking about the event. As a result, she has insomnia and frequent nightmares about people she loves being killed. She is unable to stop shaking and crying when discussing the nightmares. In addition, the event has left the client feeling angry, confused, ashamed, depressed, and highly anxious in her day-to-day activities. | Which of the following is not a developmental domain of Multicultural Counseling and Social Justice Competencies (MSJCC)? | Culturally sensitive unconditional positive regard | Counseling relationship | Counseling and advocacy interventions | Client worldview | (A): Culturally sensitive unconditional positive regard
(B): Counseling relationship
(C): Counseling and advocacy interventions
(D): Client worldview | Culturally sensitive unconditional positive regard | A | Although it is appropriate to use unconditional positive regard with culturally diverse populations, this is not one of the developmental domains that help lead to multicultural and social justice competence. Therefore, the correct answer is (A) | core counseling attributes |
557 | Client Age: 8 Sex: Female Gender: Female Grade: 3rd Ethnicity: African American Counseling Setting: School-based Type of Counseling: Individual and Family Presenting Problem: Defiance Diagnosis: Oppositional Defiant Disorder 313.81 (F91.3) | Mental Status Exam: The client displays an angry affect and sits with her arms crossed. She is well dressed and well groomed. The client’s PGM repeatedly prompts her to say, “yes ma’am” and “no ma’am” when answering questions. The client sits slumped in her chair. She agrees to color in a feelings thermometer that reflects increased anger, sadness, and fear. Her insight is poor. The client often refuses to eat school lunch, and the PGM reports that the client is a picky ea | You are a school-based mental health counselor conducting an initial intake with an 8-year-old African American female in the 3rd grade. The client presents today with her paternal grandmother (PGM), the client’s legal guardian. The PGM states that the client is argumentative, refuses to take responsibility for her actions, and has a tantrum when she receives a consequence for her behavior. She reports that the client is restricted from “every single privilege indefinitely.” The client has been told she can regain privileges once she “learns to act her age.” The client states she is treated unfairly and “blamed for everything” at home and school. The client’s teacher reports that she has difficulty following directions, is easily annoyed by her classmates, and frequently loses her temper. The client’s grades are poor, and she is below grade level in reading. However, she enjoys art and proudly reports that one of her pictures came in 1st place and is hanging in the library. | You are meeting with the client individually and providing parenting training with the client’s PGM. The client’s teacher has implemented a behavioral chart for the classroom, and you ensure the client is receiving appropriate reinforcement for targeted behaviors. The teacher believes the client’s behavior indicates ADHD, and you have agreed to conduct classroom observations. During the observation, you note that the client gets out of her seat multiple times to sharpen her pencil. While doing so, she glares at other students and is observed balling up her fists and threatening others. The teacher yells at the client to sit down and stop disrupting the classroom, which has little effect on the client’s behavior. You are working collaboratively with the client’s teacher and PGM to establish treatment plan goals | null | SMART goal setting | Goal Attainment Scaling (GAS) | Functional Behavioral Assessment (FBA) | Behavior Intervention Plan (BIP) | (A): SMART goal setting
(B): Goal Attainment Scaling (GAS)
(C): Functional Behavioral Assessment (FBA)
(D): Behavior Intervention Plan (BIP) | Goal Attainment Scaling (GAS) | B | Goal Attainment Scaling (GAS) is a criterion-referenced, collaborative goal setting method that allows participants to measure three targeted behaviors. The targeted behaviors can be transferred to the client’s treatment plan, with goals and objectives designed to measure incremental changes. For each targeted behavior, minimum, moderate, and significant improvement measures are used to determine the client’s progress. SMART goal setting uses the SMART acronym to guide goal setting. SMART goals are specific, measurable, achievable, relevant, and time sensitive. A Behavior Intervention Plan (BIP). is generally implemented as part of a student’s Individualized Education Plan (IEP). or 504 plan. The function of the BIP. is to identify problematic behaviors, determine their cause, and implement strategies that reward appropriate behavior. A Functional Behavioral Assessment (FBA). entails identifying problematic behavior, measuring the behavior, and determining the function of the behavior. Therefore, the correct answer is (C) | intake, assessment, and diagnosis |
558 | Client Age: 9 Sex: Male Gender: Male Sexuality: Unknown Ethnicity: Caucasian Relationship Status: Not Applicable Counseling Setting: School Type of Counseling: Individual Presenting Problem: Severe Temper Outbursts Diagnosis: Disruptive Mood Dysregulation Disorder (DMDD), Provisional (F34.81) | Mental Status Exam: The client’s affect is irritable and angry. He sits with his arms crossed and exhibits poor eye contact. His appearance is somewhat disheveled. Mother reprimands the client multiple times, requesting that he “sit up straight” and “answer the lady’s questions.” The client mumbles responses at his mother’s prompting and is otherwise minimally engaged. The client reports that he “gets mad” daily and feels unjustly “blamed for everything.” His motor activity is somewhat fidgety. Speech and language skills are developmentally appropriate. The client states he “sometimes” feels sad and denies feeling worried or scared. His appetite is good and his sleep is poor. The mother attributes his sleep difficulties to the client staying up late playing video games. | You are a school-based mental health clinical counselor conducting an initial intake evaluation. A 9-year-old 3rd-grade male is accompanied by his mother, who reports that the client has been in several school and neighborhood altercations. She states she is at her “wit’s end” with him and is about to lose her job due to constant calls from his school. The client’s teacher reports that the client has daily temper outbursts, and his mother says that his mood is irritable for most of the day, every day. The client was recently suspended from school for flipping over his desk when his teacher told him he lost recess privileges. The mother first noticed these behaviors when her son was in kindergarten. The client recently kicked a hole in his wall after losing a video game. His grades are poor, and the school is currently evaluating him for special education services. The client was reluctant to take part in the intake. He shrugged his shoulders when asked if he would agree to participate in counseling. | History of Condition: The client’s milestones were all developmentally appropriate; he was walking at ten months, toilet trained by 24 months, and speaking in complete sentences at almost 30 months. The mother describes the client as “moody” beginning in kindergarten. His temper outbursts began to escalate in intensity and duration within the last few years. During this time, there were no known associated stressors. The mother reports that the client has always had a hard time following directions and difficulty complying with authority figures. Family History: The client has two maternal half-brothers, ages 18 and 20, and has positive relationships with both of them. His parents divorced when the client was three years old, and the mother has physical custody of the child\. Before the divorce, the client witnessed verbal and physical altercations between his parents. The client’s father visits periodically, and he has been in and out of substance abuse treatment centers for most of the client’s life. When angry with his mother, the client tells her he wishes he could live with his father. The client’s maternal grandmother is diagnosed with bipolar disorder, and the client’s mother states she struggles “off and on” with depression. Aside from the father’s substance use disorder, a paternal history of mental illness is unknown | What information would best guide the initial development of the client’s treatment plan? | Consultation with an interdisciplinary team | The client’s motivation to change | Classroom observation | Collateral information from the client’s teacher | (A): Consultation with an interdisciplinary team
(B): The client’s motivation to change
(C): Classroom observation
(D): Collateral information from the client’s teacher | Collateral information from the client’s teacher | D | Remember, you are looking for the best option for creating an initial plan of care. Since you are school-based, collateral information obtained from the client’s teacher would best guide this process. Collateral information from the teacher allows you to obtain measurable information about the client’s presenting problem. In doing so, you can determine the frequency, duration, and severity of the client’s angry outbursts. Classroom observations are useful, but only provide information for a moment in time and are subject to the Hawthorne effect. The Hawthorne effect occurs when a subject changes their behavior simply due to knowing they are being observed. An interdisciplinary approach is used when seeking to improve or enhance treatment outcomes but is not the best option for information gathering. Lastly, the client’s motivation to change is an important consideration for adults but less so for children. For children, the therapeutic alliance and the family’s treatment compliance greatly influence the client’s motivation to change. Therefore, the correct answer is (A) | treatment planning |
559 | Initial Intake: Age: 15 Gender: Female Sexual Orientation: Unknown Ethnicity: Hispanic Relationship Status: Unknown Counseling Setting: School-based through a counseling agency Type of Counseling: Individual | Maria is slightly unkempt with a flat expression and normal rate and tone of voice. Maria is highly tense, hypervigilant, and anxious, flinching in response to loud noises and intermittently darting eye contact. She appears to “veer off” mentally while you are speaking with her, then realizes she is doing so and returns her attention to you by nodding her head and reconnecting with her gaze. She denies history of trauma, prior to this event, has no prior experience in counseling, and denies SI/HI. Maria maintains the position that she does not need counseling for herself but is willing to talk to someone about how she can better help her siblings. | Diagnosis: Acute Stress Reaction (F43.0), Provisional
You are a mental health counseling intern providing sessions for students inside of a high school. Maria enters the conference room that you use to meet with students and sits down to tell you that she needs help for her siblings. You have no referral for Maria and were not scheduled to meet with anyone during this hour of the day. Maria shares that two days ago, her and her two younger elementary school siblings witnessed their father take a gun to their mother, shoot and kill her, and then use the gun on himself. She tells you she is fine and does not need counseling, but she wants her brother, age 7, and sister, age 4, to receive counseling because it was likely “very traumatic for them.” Identifying that Maria is clearly in shock, you offer your sincere condolences, followed by recommending Maria have counseling as well. She declines at first, insisting she is doing okay and has nothing to talk about. After inviting the school counselor and assistant principal to the discussion, with Maria’s permission, they help convince her that it would be healthy for her and her siblings if she was also being seen by a counselor. The principal adds that some of the school staff, including herself, responded to the incident the following day by going to the neighbor’s house to assess for the children’s safety and let them know they had permission to take a leave of absence from school. Maria insisted on coming to school the next day, saying she was “fine” and “needed the distraction.” Maria consents to meeting with you, but only because she believes it will help her family stick together. Due to the nature of the trauma and obvious client need, you receive permission from your supervisor to provide services pro bono until insurance or payment can be established. | Family History:
Maria is the oldest child of three children, and to her knowledge her siblings were born of the same two parents as herself; but she was unable to confirm this with absolute certainty during the initial assessment. She has difficulty providing historical information on her parents but can tell you in her own words she knows her dad was “sick” with “mental problems” and that her parents fought often. She tells you after the incident occurred her neighbors rushed to their aid and were able to take them in until they can establish a more permanent living situation with their grandmother, who lives across town and is preparing to have them move in soon. You ask if she can have her grandmother sign your company’s consent paperwork, but she replies that she has no transportation and does not speak English. She adds that her mother always told her she would want her to “go to her grandmother” if something ever happened to her and her father. | What is the difference between "Acute Stress Disorder" and "Acute Stress Reaction" in the DSM-5? | reaction symptoms usually appear within hours to days of the traumatic event | reaction symptoms include intrusion, negative mood, dissociation, avoidance, and arousal | the duration of symptoms in acute stress disorder extends beyond 1 month | disorder symptoms usually appear within hours to days of the traumatic event | (A): reaction symptoms usually appear within hours to days of the traumatic event
(B): reaction symptoms include intrusion, negative mood, dissociation, avoidance, and arousal
(C): the duration of symptoms in acute stress disorder extends beyond 1 month
(D): disorder symptoms usually appear within hours to days of the traumatic event | reaction symptoms usually appear within hours to days of the traumatic event | A | Symptoms of Acute Stress Reaction are within the normal range of reactions given the extreme severity of the stressor, and usually appear within hours to days of the impact of the trauma. This applies to Maria as she experienced her trauma two days prior to this initial assessment. The duration of the disturbance of symptoms for criteria to be met for Acute Stress Disorder is persistence of at least three days to one month after trauma exposure and include nine or more specific symptoms from any of the five categories of intrusion, negative mood, dissociation, avoidance, and arousal. Symptoms present beyond one month begin criteria development for post-traumatic stress disorder. Therefore, the correct answer is (A) | intake, assessment, and diagnosis |
560 | Client Age: 32 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Counseling Setting: Community Mental Health Agency Type of Counseling: Individual Presenting Problem: Depressed Mood Diagnosis: Bipolar II 296.89 (F31.81), current episode depressed | Mental Status Exam: The client is dressed casually and is somewhat disheveled. She avoids eye contact and displays a flat affect. The client admits to having suicidal thoughts in the past but currently denies both suicidal and homicidal ideations. Her speech is soft in volume and tone. She tends to provide one-word responses but is cooperative when asked to elaborate. The client denies audio-visual hallucinations, and her thought content is coherent. The client’s mood is depressed, and her affect is flat. She appears tired and reports she has insomnia at night and is sleeping most of the day. The client has experienced depression off-and-on, beginning in late adolesc | You work at a community mental health agency providing outpatient services to adults. Today, you are meeting with a 32-year-old female who presents with her husband for an initial intake session. The client’s husband is concerned about his wife’s depressive symptoms. She is experiencing sadness, decreased appetite, and hypersomnolence. The client also expresses hopelessness and has lost interest in doing the things she once enjoyed. Until recently, the client worked at an art gallery. When employed, she reports that she, “just couldn’t get out of bed” and was eventually let go due to excessive absences. After her employment ended, her depressive symptoms worsened. The client was able to recall a time nearly one year ago when she felt “almost the opposite” of how she feels now. During this time, she experienced increased energy and felt more inspired and creative. The client explains that she and her husband used to travel selling their art at juried art exhibitions most weekends, but it has been awhile since she has joined him. | The client continues to benefit from counseling and presents today with a euthymic mood. She has met her treatment plan goals related to depressive symptoms and reports a better understanding of her illness. The client has begun painting again and accompanied her husband to an art show this past weekend. She expresses gratitude for your work together and is especially thankful that you have helped her get back into doing what she likes to do. At the end of the session, she gives you an original painting as a token of appreciation. She explains that the abstract painting conveys the emotional transformation she has experienced in counseling. You let the client know you would be joining a private practice in a few weeks. You explain you would be happy to see her again if needed and gave her your new business card with the address and contact information for the practice. You smile and tell the client, “You’ve done a lot of hard work to get to this place. I’m so pleased with how far you’ve come | You smile and tell the client, “You’ve done a lot of hard work to get to this place. I’m so pleased with how far you’ve come.” This is an example of which one of the following? | Congruence | An encourager | Summarization | Empathy | (A): Congruence
(B): An encourager
(C): Summarization
(D): Empathy | Congruence | A | This is an example of congruence. Counselors demonstrate congruence through genuine and authentic feedback. Congruence is a person-centered technique communicated by counselors when their verbal and nonverbal messages are aligned. Along with congruence, empathy is a person-centered facilitative condition. Counselors display empathy when reflecting a client’s feelings, thoughts, and perceptions from the client’s point of view. An encourager is a verbal or nonverbal signal for the client to continue talking (eg, saying “Please, go on”). Summarization ties together multiple concepts, feelings, or ideas. Therefore, the correct answer is (B) | counseling skills and interventions |
561 | 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 learn from Jonny's university mentor that he has dropped out of his classes and moved out of his dorm. Both the university Dean and Jonny's mother have called requesting to discuss what has happened. You are feeling incredibly overwhelmed and fearful. How do you handle this? | Immediately call them apologizing how your actions caused these choices. | Immediately call them and explain why it was not your fault. | Take a short vacation from work prior to returning everyone's calls. | Address your self-care as needed, then proceed to engage in honest discussions as soon as reasonably possible. | (A): Immediately call them apologizing how your actions caused these choices.
(B): Immediately call them and explain why it was not your fault.
(C): Take a short vacation from work prior to returning everyone's calls.
(D): Address your self-care as needed, then proceed to engage in honest discussions as soon as reasonably possible. | Address your self-care as needed, then proceed to engage in honest discussions as soon as reasonably possible. | D | Whether or not Jonny's actions were a direct response to his anger towards your comments, you must first take care of yourself mentally and emotionally prior to engaging in discussions about what occurred. Processing the events, your assessment of Jonny's emotional state and behavior, your own personal feelings towards his reported choices; all of these must be filtered through a lens that has been well-fed and after a good night's sleep. You will be more confident and clinically capable of utilizing your professional counseling skills in your conversations with others after you have taken the time to prepare. Escaping or avoiding these conversations is neglectful considering Jonny's risk factors, but jumping into explanations without feeling prepared can also be harmful to both you as a counselor and your confidential agreements with Jonny. Therefore, the correct answer is (D) | counseling skills and interventions |
562 | Initial Intake: Age: 65 Gender: Male Sexual Orientation: Heterosexual Race/Ethnicity: Caucasian Relationship Status: Married Counseling Setting: Inpatient detox facility Type of Counseling: Individual | William presents as irritable and quite anxious with congruent strained affect. William is casually dressed and with good hygiene. William’s rate and tone of speech are normal with motor movements appearing tense and agitated as evidenced by shifting of position and frequent crossing of arms. William avoids eye contact the entire visit. William denies any depression however his chart indicates that he reported having a history of depression with suicidal thoughts. He says, “Only God can judge me, and I know where I’m goin’ so I don’t have any worries about whether I go now or later.” You then notice in his intake he identified as Christian with active faith-based beliefs. He repeats several times that he plans to leave as soon as he meets with the doctor later today and receives “medical clearance” saying “I can’t stay the whole three weeks it’s just not possible, not going to happen.” | Diagnosis: Alcohol dependence (F10.20), Major depressive disorder, single episode, unspecified (F32.9)
You are a mental health counseling intern providing brief crisis intervention and counseling support for patients admitted to a substance use rehabilitation facility at the detox-level of care. Your clinical director schedules William to meet with you on his first Monday morning after being admitted the Friday night before for alcohol dependency. William tells you he had a “medical issue” last week that “freaked his wife out” and she said she would “kick him out of the house” if he did not come to your program. He notes that he has been drinking their entire marriage and does not understand why it is suddenly such an issue for her, but that he would have “nowhere to go” otherwise so he conceded to coming in. You learn from the overnight staff nurse that William had several bouts of delirium and vomiting with tremors over the weekend, and one instance of a seizure which required emergency interventions to have him stabilized. You ask what “medical issue” he was referring to and she tells you that his chart indicates he had a heart attack. William interjects, saying “She thought I had a stroke, but it wasn’t that big a deal I just had some bad indigestion.” He is now on a benzodiazepine regimen to help regulate his symptoms and stabilize his mood throughout his detox process until he can report a reduction in anxiety and be seen by the weekday psychiatrist. | Work History:
William has worked has a construction company manager for almost 30 years until just before reaching retirement he was let go due to COVID-related company downsizing. He attempted to file a legal case against his company for wrongful actions that would in William’s words “rob him of his hard-earned retirement” however they cited his daily alcohol use on the job as an additional reason he was fired. He was informed due to his longevity with the company that they would offer him a generous severance package and not pursue administrative actions against him for breaking company policies. He adds that he was not planning on stopping working when retiring from his company, saying “I’m too young to just stop. I was going to start my own business.” He also retorts that no one calls him William but his wife and insists that you call him “Bob.” | You must assign Bob a category for the group therapy schedule. Which is the most appropriate? | seniors 65 and up because he would benefit from a same-age peer group | working professionals because he strongly identifies with his occupation | adults 18-65 so he can view a wide range of perspectives | faith-based 12-step track due to his identified spirituality | (A): seniors 65 and up because he would benefit from a same-age peer group
(B): working professionals because he strongly identifies with his occupation
(C): adults 18-65 so he can view a wide range of perspectives
(D): faith-based 12-step track due to his identified spirituality | faith-based 12-step track due to his identified spirituality | D | In this case, a faith-based 12-step track would be the most appropriate to address his addiction due to Bob's spiritual belief that "only God can judge him". This group would focus on faith-based interventions helping Bob view his addiction through the perspective of originating from his Higher Power. The Big Book in Alcoholics Anonymous teaches that if you admit to being powerless over your addiction, then you need a higher power that is greater than you or your addiction to help you get clean. This attitude would be supportive of Bob's mental state as he seems to be rejecting clinical evidence of his need for recovery. Answer a) would likely trigger Bob since he was just relieved of his occupation and these groups focus around how to balance substance use recovery and an active professional career. A group where Bob would be the oldest adult as in answer b) might also not be helpful based on his presentation and attitude of disinterest in rehabilitation, which could be negatively influential on the others in the group. Answer c) would put Bob in a category where he would be the youngest in a group of seniors, which might deter him considering he presents as in denial over retiring in disgrace and reported feeling "too young to stop working". Therefore, the correct answer is (D) | treatment planning |
563 | 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 | Regarding her relationship and the allegations that her boyfriend is hitting her, the counselor should immediately? | Encourage Elaina to leave him | Provide Elaina trauma focused CBT to help her understand her relationship patterns | Encourage Elaina to invite her boyfriend to a session | Complete a crisis plan that Elaina can use if she feels that she is in danger | (A): Encourage Elaina to leave him
(B): Provide Elaina trauma focused CBT to help her understand her relationship patterns
(C): Encourage Elaina to invite her boyfriend to a session
(D): Complete a crisis plan that Elaina can use if she feels that she is in danger | Complete a crisis plan that Elaina can use if she feels that she is in danger | D | A crisis plan is important to have if a client is in frequent crises or a possibly dangerous situation. It should include practical steps with accessible resources for the client. Considering the allegation that Elaina's boyfriend is hitting her, a crisis plan should be made if Elaina feels that things are beginning to escalate. It is not up to the therapist to tell Elaina to leave her boyfriend, this may damage the therapeutic relationship or Elaina may not return to therapy. Trauma focused CBT would be a good intervention for Elaina, after the crisis plan is constructed. Inviting Elaina's boyfriend to a session may or may not be a good idea, depending on how open he would be to this suggestion. Knowing that Elaina told the counselor may anger the boyfriend. Therefore, the correct answer is (C) | counseling skills and interventions |
564 | Initial Intake: Age: 35 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Employee Assistance Program Type of Counseling: Individual | Harold comes into the office, visibly upset, stating, “I really don’t know why I am here, but I am sure you will see that too after some time together. And I am sure that anything I say here- you can’t report it to anyone anyway, right?” Harold did not display any self-awareness of his actions when speaking to the counselor. At times he showed defensiveness and irritability and other times he was making jokes and complimenting the counselor. | Harold, an accounting executive, was referred for counseling by his supervisor after Human Resources received several complaints about Harold’s attitude towards others.
History:
Harold has been successful in his career and is knowledgeable in his field. However, he stated that he is often not well liked. Harold attributes this to people being envious of him. Harold told the counselor that recently he was called to human resources because of complaints from his peers. Complaints included allegations of rude remarks, bullying, and Harold taking credit for work that others did. One coworker stated that Harold took frequent breaks and suspected he may be using drugs. | null | When reviewing confidentiality, the counselor should not include? | Limits of confidentiality | Confidentiality of electronic communication | What information will be provided to Harold's supervisor | What information Harold should share with his supervisor | (A): Limits of confidentiality
(B): Confidentiality of electronic communication
(C): What information will be provided to Harold's supervisor
(D): What information Harold should share with his supervisor | What information Harold should share with his supervisor | D | Confidentiality does not apply to what the client chooses to share with others about themselves. In accordance to the code of ethics, a counselor should review the limits of confidentiality which includes duty to warn. Confidentiality of electronic communication including the use to text messages, email and social media should be reviewed as well. Since the counseling was suggested as the result of coworker's grievances, what will or will not be reported to Harold's supervisor should also be reviewed. Therefore, the correct answer is (D) | professional practice and ethics |
565 | 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 emotional state, which therapeutic technique would be beneficial? | Creating a structural family map | Using empathic listening | Utilizing circular questioning | Applying positive and negative reinforcement | (A): Creating a structural family map
(B): Using empathic listening
(C): Utilizing circular questioning
(D): Applying positive and negative reinforcement | Using empathic listening | B | The client is anxious, has issues with his wife, and drinks to cope with his stress. Being able to listen and empathize with the client's difficulties will be most beneficial. Therefore, the correct answer is (B) | counseling skills and interventions |
566 | Name: Gary Clinical Issues: Behavioral problems Diagnostic Category: Disruptive/Impulse-Control/Conduct Disorders Provisional Diagnosis: F91.3 Oppositional Defiant Disorder Age: 10 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Not Assessed Ethnicity: White Marital Status: Not Assessed Modality: Individual Therapy Location of Therapy : Agency | The client reluctantly enters the session accompanied by his mother. He is slightly overweight for his age and is wearing clothes that appear too small for his physique. He is sitting in the chair with his arms crossed, refusing to make eye contact with you. His mood is angry, and his affect is irritable. His attitude during the initial part of the examination is defiant. Speech characterized by short responses and refusal to engage in conversation. Client refuses to discuss feelings or issues. He appears to have difficulty focusing. He lacks insight into his behavior and impact on others. Judgment and impulse control are poor. He denies suicidal or homicidal ideation. | First session You are a mental health therapist in an agency, and a 10-year-old male is referred to you due to behavioral issues. The client and his mother arrive at your office, and you note that he has an irritable look on his face. The two are arguing with each other. His mother threatens him with punishment if he does not cooperate with you and says that this is his "last chance". He glares at her and then stares at the floor. You introduce yourself and explain what you do as a therapist. The client barely says a word and keeps his head down with his arms crossed over his chest. You ask the mother to describe the issues that prompted her to seek help and she begins to tell you the story. She explains that her son has difficulty listening to adults and gets into verbal altercations with his peers. She informs you that he got suspended again from school because he lost his temper in the cafeteria when the student in front of him in the lunch line "wasn't moving fast enough". When you ask about how often his temper outbursts occur, the mother pauses for a moment to think and says, "It seems like he's always losing it, but I guess maybe a few times a month? The rest of the time, he's just angry, mostly at me and other adults. No matter what I do, he seems like he hates me." As she tells you this, you notice that the client is not paying attention and continues to look down at the floor, appearing disinterested in the conversation. His mother goes on to say that the school is threatening expulsion if her son's behavior does not improve. After thanking the mother for sharing this information with you, you look toward the client who has been sitting quietly the entire time. You explain that you understand it must be hard for him to be here and that you are not here to judge or criticize him. He looks up at you with a surprised expression on his face. He slowly nods and mumbles something under his breath. You let him know that you want to help him find ways to better manage his emotions so he can get along better with the people in his life. He looks away again, but this time there is a hint of curiosity in his eyes. You sit in silence for a moment. The client finally looks up at you and says, "It's just...everyone's always telling me what to do and they never listen to me. They think they know everything, but they don't. I can't help it if I get angry, but then everyone looks at me like I'm a monster. It's not fair." His mother looks away, tears in her eyes. You thank the client for expressing his feelings and explain that it is normal to feel upset when things are unfair. You further emphasize that you are here to help him find positive ways to handle his anger and other emotions. You then address the mother, "Parenting can be challenging, especially when it feels like your child is angry or upset with you. I'd like to work with both of you to improve your communication and relationship. It might be helpful to schedule separate sessions for you and your son, as well as joint sessions, so we can address individual concerns and work on improving your relationship together." The mother agrees, and you proceed to discuss a plan of action, including setting up regular weekly therapy appointments and providing resources to help support the family. Fifth session It has been over one month since you first began working with the client. You've been meeting with him for individual therapy and have implemented parent training with his mother. During previous counseling sessions, you focused on building rapport with the client and talked about different triggers for his outbursts. He said that he often gets angry when people do not listen to him or when they try to tell him what to do. You also discussed strategies for managing these triggers and the importance of communicating his needs in a respectful way. Last week, as part of your parent management training approach, you assigned the mother homework to read from a parent training handbook. When the client arrives for today's session, he is clearly upset, saying that he does not want to be here. His facial expression is one of anger and frustration. His mother is exasperated and apologetic. You calmly remind her that it is all right, that this is a normal part of the process. You ask if she would like to accompany them into your office, but she declines, saying that she needs some time to herself and she would like to wait in the waiting room for the first half of her son's session. Once inside your office, you start by asking the client why he does not want to be here. He says that he is tired of talking about his problems and he does not think it will make any difference. When you ask him to tell you more, he glares at you and says, "Why do you care? You're only asking because you want to get paid." You acknowledge how difficult it can be to keep coming back, but emphasize that whatever feelings he is having in this moment are valid and important. The client then looks away and sighs. He slowly says, "I don't know why I have to keep coming here...it feels like no matter what I do, nothing changes. I still get mad, my mom and teachers still get mad at me, and the school still threatens to kick me out." After a few moments of silence, you ask the client if he remembers what goals were set for the session today. He looks away and mumbles something under his breath. You gently remind him that you want to help him learn how to manage his emotions in a healthier way so he can get along better with the people in his life. He gradually relaxes and you ask him what strategies he has been using in the past week to work toward this goal. He thinks for a few moments before recounting an incident at school where instead of getting angry, he took a deep breath and walked away from the situation. You use behavioral modification techniques to encourage this positive behavior. You then move into today's activity, which is a role-play exercise. Once you have completed your planned tasks with the client, you invite his mother in to your office to provide her with feedback on her son's progress and discuss next steps with parent training. | The client's father left the family two years ago. The mother, still married to him, retains sole legal custody of the client. Since his father left, the client will not help out around the house, seems angry, and sometimes loses his temper when he does not get his way. The client receives frequent but inconsistent corporal punishment from his mother. His mother made the appointment with you but did not tell him where they were going. The relationship between the client and his mother has been strained as the mother does not know how to handle the abandonment of the father. The client is in fifth grade and has been skipping school for the last six months and refuses to do any homework. His school records were released to you and show A's and B's through third grade, but C's and D's during the past two years. His decline in grades coincides with his truancy. He is also known as a "bully" at school and has been suspended and given detention a few times due to his behavior. He has a history of walking out of classrooms, running down the hallways, refusing to sit in his chair, and running away from the school counselor or anyone in an authoritative position. Personal/Social Relationships: The client does not have friends his age in the neighborhood, and parents do not want their children playing with him because they believe he is a "troublemaker". In addition, children in school avoid him because they are afraid of upsetting him. He does not seem interested in making friends and does not care to engage in any play time with the neighborhood children. Instead, he spends most of his time alone playing video games. | What short-term objective are you trying to achieve with your homework assignment for the client's mother? | Teach her how to effectively discipline her son when he exhibits temper outbursts | Provide her with greater understanding of why her son feels angry and frustrated | Educate her on effective parenting strategies and techniques for managing her son's behavioral issues | Encourage her to become more involved in her son's activities and strengthen their bond with each other | (A): Teach her how to effectively discipline her son when he exhibits temper outbursts
(B): Provide her with greater understanding of why her son feels angry and frustrated
(C): Educate her on effective parenting strategies and techniques for managing her son's behavioral issues
(D): Encourage her to become more involved in her son's activities and strengthen their bond with each other | Educate her on effective parenting strategies and techniques for managing her son's behavioral issues | C | The short-term objective of assigning homework to the client's mother is to educate her on effective parenting strategies and techniques for managing her son's behavioral issues. By providing her with a parent training handbook and specific tasks to complete, you aim to empower her with knowledge and practical tools that she can use to manage his disruptive behavior. Therefore, the correct answer is (B) | treatment planning |
567 | Client Age: 30 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Pacific Islander Relationship Status: Single Counseling Setting: Private practice counseling clinic Type of Counseling: Individual counseling Presenting Problem: The client and her boyfriend recently broke up, and she is “tired of being with the wrong guys.” She admits that she will often stay in relationships even if she knows they are wrong for her. Diagnosis: Provisional diagnosis: Dependent personality disorder (F60.7), personal history (past history) of spouse or partner violence, physical (Z69.11), and personal history (past history) of spouse or partner psychological abuse (Z91.411) | Mental Status Exam: The client is oriented to person, place, time, and situation. No hallucinations, delusions, or paranoia are reported. The client was anxious at the start of the session, but she was able to calm herself down by easing into the counseling relation | You are a professional counselor working in a private practice clinic. The client comes in and sits quietly. The client appears nervous because she avoids eye contact and waits for you to initiate conversation. You ask why she is in counseling, and she responds that she is just tired. You ask more about this, and she says that she is not ready to talk about it yet. You decide to cover demographics and other less intimidating topics and then ask if she is comfortable talking yet. The client says that she feels a little more comfortable. She begins to state that she and her boyfriend broke up the previous week and that she was with him for 2 years. She explains that she has been “in this type of relationship before,” continually finds the “wrong guy,” and that she always goes “all in” with her relationships. Through processing, she identifies the following behaviors and beliefs: difficulty making daily decisions without the input of her partner, doing anything to gain support and affection even if she does not want to do the task or activity, quickly moving on to another relationship when a relationship ends, feeling that she cannot care for herself when she is not with someone else, and acknowledging that she needs others to take responsibility for major areas of her life. The client says that she has experienced physical and psychological abuse from partners, but that she is not ready to discuss this. The client identifies that her most important goal is to not end up in “the same relationship” again or rush into a relationship that is not right for her. Throughout the session, you provide empathetic and active listening. You suspect that the client has dependent personality disorder. | The client comes in, sits down, and immediately says that she has been thinking and decided that she is now ready to talk about the physical abuse that she has experienced. She recounts that from age 18 until age 20 she was with a boyfriend who would smack her if she said something he did not like. She believes this is why she is so preoccupied with pleasing others. The client’s second relationship was when she was 25 with a man who would get drunk nightly and punch her in the stomach or in the back when he was upset. You empathize with the client and reflect her emotions regarding these events. The client states, “I didn’t deserve it when the drunk guy hit me, but I do feel I wasn’t the best girlfriend with the first guy. I often didn’t do enough for him and often said the wrong thing.” Throughout the session, the client was tearful and started shaking slightly when speaking several times. The client paused for long periods before sharing more difficult parts of the story. You decide to assess for PTSD during this session, but she does not meet the criteria. When closing the session, the client states that she is not able to pay for today’s session until the end of the week. The client has no history of nonpayment with you thus far | All of the following are considerations that influence the reporting of abuse, EXCEPT: | The client asking you not to report the abuse | Having insufficient information about the abuse | The age of the client | The cognitive ability of the client | (A): The client asking you not to report the abuse
(B): Having insufficient information about the abuse
(C): The age of the client
(D): The cognitive ability of the client | The client asking you not to report the abuse | A | The client signed an informed consent at the start of services, and in doing so she has already agreed that you can report abuse or neglect. Additionally, even if she does not want you to report the abuse, as a mandatory reporter, you are legally required to do so. The age of the client and their cognitive ability are factors that influence the reporting of abuse because adult abuse and neglect includes elderly and intellectually disabled individuals. Having sufficient information also influences the reporting of abuse, because certain elements are necessary to include, such as the name of the abuser. Therefore, the correct answer is (D) | professional practice and ethics |
568 | Initial Intake: Age: 12 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Hispanic Relationship Status: Single Counseling Setting: Outpatient Clinic Type of Counseling: Individual | Carlos came to the intake with his mother, Claudia. Claudia did most of the talking during the intake while Carlos sat in his chair, slumped down low and avoiding eye contact. | Carlos is a 12-year-old male referred to an outpatient community clinic by the court after he was caught breaking into several cars on his block.
History:
Claudia reported that she and Carlos’ father separated two years ago. Since then, Carlos has had frequent suspensions in school for bullying others and fighting. Carlos often threatens students on social media prior to the altercations. Claudia reported that she no longer knows what to do anymore and she hoped that the counselor can fix him or at least report to her what he is thinking when he does these things. | null | The counselor responds to Carlos by stating, "It's okay to be angry or hopeless. I can see your strengths. You came today which is a start." The counselor is expressing? | Denial | Positive regard | Congruence | Empathy | (A): Denial
(B): Positive regard
(C): Congruence
(D): Empathy | Positive regard | B | Positive regard is the display of warmth and acceptance by the counselor. This also includes the counselor's belief that the client is capable of positive changes. Denial is a Freudian defense mechanism in which a person refuses to see the truth because it brings up feelings of discomfort or pain. Empathy is the ability for the counselor to "walk in the shoes" of the other person. Congruence is when the counselor gives honest feedback regarding the client and his progress. Therefore, the correct answer is (C) | intake, assessment, and diagnosis |
569 | Initial Intake: Age: 82 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Widowed Counseling Setting: Community Clinic Type of Counseling: Individual | Theodore is tearful most days and has dropped a significant amount of weight. He has not been sleeping and stays up watching videos of his deceased wife. | Theodore is an 82-year-old who was referred for grief counseling by his son, Nate. Theodore’s wife, Nancy died one month ago after a 4-year battle with cancer.
History:
Theodore was the primary caretaker for Nancy and has not paid attention to his own health in years. Nate would like his father to move in with him and his family and sell the house his parents lived in to pay off their debt. However, Theodore refuses to sell the house and stated that he will not give away or sell anything that they owned. Nate drove Theodore to the initial session and sat in for the intake, with Theodore’s consent.
Once everyone sat down, Theodore looked at the counselor and stated, “I am only here so my son stops bugging me about selling the house. I am not getting rid of anything in that house- and especially not the house itself!” Nate explained that his father cannot maintain the house on his own and is worried about him being lonely. Theodore insists that he has other options and thinks that living with Nate would put a burden on him. | null | At this point Theodore would not need a referral to a? | Cognitive assessment to make sure he can live on his own | A physician for a physical exam | Care manager for housing | Group for bereaved spouses | (A): Cognitive assessment to make sure he can live on his own
(B): A physician for a physical exam
(C): Care manager for housing
(D): Group for bereaved spouses | Cognitive assessment to make sure he can live on his own | A | There is no indication that Theodore's cognitive functioning is in question. It would also be unethical to refer him to an assessment that is not necessary. A care manager may be able to help Theodore during this stressful time and find appropriate housing for him. A bereavement group may also be a support for Theodore, so that he can be around others who have suffered the same type of loss. Theodore's physical health is just as important as his mental health. Since he has been neglecting himself and dropped a significant amount of weight, a physical exam would be beneficial. Therefore, the correct answer is (B) | intake, assessment, and diagnosis |
570 | 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. The client’s food log has the following statement: “I’m not worth anything if I get fat, and I’m going to die | The client’s food log has the following statement: “I’m not worth anything if I get fat, and I’m going to die.” All of the following are more rational ways of reframing this thought, EXCEPT: | “Although being overweight isn’t healthy, my worth isn’t defined by weight.” | “My body isn’t letting me down, and my husband loves me.” | “The reality is that I could get fat, which may result in my husband’s unhappiness and my own death, but I can be healthy and keep this from happening.” | “My worth isn’t defined by my weight, and there are ways that I can be healthy to reduce my chances of dying younger than I want to.” | (A): “Although being overweight isn’t healthy, my worth isn’t defined by weight.”
(B): “My body isn’t letting me down, and my husband loves me.”
(C): “The reality is that I could get fat, which may result in my husband’s unhappiness and my own death, but I can be healthy and keep this from happening.”
(D): “My worth isn’t defined by my weight, and there are ways that I can be healthy to reduce my chances of dying younger than I want to.” | “The reality is that I could get fat, which may result in my husband’s unhappiness and my own death, but I can be healthy and keep this from happening.” | C | While identifying the reality of becoming overweight and its possible consequences may carry elements of truth, there is a balance that needs to be found when reframing this client’s cognition. The thought that she could become overweight and suffer the consequences (her husband’s unhappiness and her own death), but that she can do something to keep that from happening may accept a reality, but it also encourages the unhealthy behavior that the client already engages in. In this situation, identifying that her body is not letting her down and that her worth is not defined by weight is a healthier balance in thinking. Therefore, the correct answer is (A) | counseling skills and interventions |
571 | 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. | The client resides with his mother and three older brothers. He describes his brothers and mother as "annoying" and tells you that none of them listens to him. 18 months ago, his father passed away after a long illness. The client says that his dad was the only family member who understood him. The client feels he has no one to talk to and does not get along with his family members. He reports difficulty trusting others and is guarded in his relationships. He has become more irritable and vindictive since his father's death. The client denies drug or alcohol use and responds to your question, saying, "What? Are you an idiot? Do I look like someone that would be stupid enough to do drugs?" The client scoffed and continued, "Why would I waste my time and energy risking my future for something so pointless." He then crossed his arms and stared defiantly, clearly not interested in discussing the matter further. | What characteristics would be most important for you, as Gregory's therapist, to exhibit for the therapeutic process to be successful? | You must be able to work with adolescents and set firm limits when needed. | You must be able to motivate Gregory to change and teach warmth and acceptance. | You must be able to take a nonjudgmental stance and reinforce confidentiality. | You must be accommodating, genuine, supportive, and action-oriented. | (A): You must be able to work with adolescents and set firm limits when needed.
(B): You must be able to motivate Gregory to change and teach warmth and acceptance.
(C): You must be able to take a nonjudgmental stance and reinforce confidentiality.
(D): You must be accommodating, genuine, supportive, and action-oriented. | You must be able to work with adolescents and set firm limits when needed. | A | The client has been diagnosed with ODD. These are the ideal characteristics needed to treat a client with ODD. Therefore, the correct answer is (A) | counseling skills and interventions |
572 | Client Age: 51 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Divorced and single Counseling Setting: Local government mental health agency Type of Counseling: Individual counseling Presenting Problem: The client is experiencing a recent separation from her last partner who was verbally and physically abusive, and she is currently living in a domestic violence home. Diagnosis: Major depressive disorder, recurrent episode, moderate (F33.1) and post-traumatic stress disorder (PTSD) (F43.10) | Mental Status Exam: The client’s affect is flat, and she is hunched over in the chair. The client is oriented to person, place, time, and situation. She reports no hallucinations, paranoia, or depersonalization/dissocia | You are a licensed counselor working for a local government mental health agency in the counseling clinic. The client was referred to receive case management and counseling after experiencing homelessness due to leaving a physically and verbally abusive relationship with her last partner. The client is experiencing the following depressive symptoms: sadness more often than not, mental fogginess, suicidal ideation, insomnia, significant weight loss, feelings of worthlessness, and fatigue. The client experiences PTSD symptoms due to having experienced several abusive relationships, including recurrent distressing intrusive thoughts regarding the physical abuse, distressing dreams related to abuse, and physiological reactions (difficulty breathing, heart racing) when she goes near certain places that remind her of the abuse. She also explains that she has been avoiding triggers, believes that no one can be trusted, has an exaggerated startle response, and has had difficulty experiencing positive emotions. The client says that she does not know if therapy can help because she feels like these events have changed her and that she cannot get back to “normal,” but that she would like to make friends so she doesn’t feel so alone. | The client comes into the session, sits down, and immediately begins to talk about one of her roommates in the domestic violence home that has been making her angry because the roommate comes into her room when the client is gone and borrows her personal hygiene items. The client continues to explain that she worries that the roommate might come in while she is sleeping, but that she has not done this yet. You process these feelings with the client and identify that when she was a child, her uncle would come into her room without her permission and sexually abuse her. The client also reported that one of her ex-husbands would enter their bedroom drunk at night and would often hit her while she was asleep. You and the client discuss how to make her environment feel safe and how to engage in cognitive reframing. You empathize with the client and validate her emotions. The client brings up how she often avoids certain restaurants and stores because they remind her of arguments she has had with her past partners that led to her experiencing physical abuse | The client brings up how she often avoids certain restaurants and stores because they remind her of arguments she has had with her past partners that led to her experiencing physical abuse. Which one of the following treatments would be most helpful in managing this avoidance? | DBT | Integrative therapy | Exposure therapy | CBT | (A): DBT
(B): Integrative therapy
(C): Exposure therapy
(D): CBT | Exposure therapy | C | Exposure therapy, when completed over an appropriate period of time with gradually more difficult exposures, can be effective in treating the avoidance-related symptoms of PTSD. Although it makes sense that an individual would want to avoid stimuli that trigger strong emotions, restaurants and stores are not actual threats to the client, and her avoidance of these settings is inhibiting her ability to live her life. Through gradual exposure, the client can see that she is safe in those environments and does not need to avoid them. DBT and CBT are each therapy modalities that have cognitive and behavioral aspects that might benefit treatment of PTSD, but they do not address the avoidance behavior adequately on their own. Integrative therapy is the blending of different therapy techniques for a holistic approach to treatment; however, this would not be as effective in treating avoidance behaviors. Therefore, the correct answer is (A) | treatment planning |
573 | Initial Intake: Age: 15 Gender: Female Sexual Orientation: Unknown Ethnicity: Hispanic Relationship Status: Unknown Counseling Setting: School-based through a counseling agency Type of Counseling: Individual | Maria is slightly unkempt with a flat expression and normal rate and tone of voice. Maria is highly tense, hypervigilant, and anxious, flinching in response to loud noises and intermittently darting eye contact. She appears to “veer off” mentally while you are speaking with her, then realizes she is doing so and returns her attention to you by nodding her head and reconnecting with her gaze. She denies history of trauma, prior to this event, has no prior experience in counseling, and denies SI/HI. Maria maintains the position that she does not need counseling for herself but is willing to talk to someone about how she can better help her siblings. | Diagnosis: Acute Stress Reaction (F43.0), Provisional
You are a mental health counseling intern providing sessions for students inside of a high school. Maria enters the conference room that you use to meet with students and sits down to tell you that she needs help for her siblings. You have no referral for Maria and were not scheduled to meet with anyone during this hour of the day. Maria shares that two days ago, her and her two younger elementary school siblings witnessed their father take a gun to their mother, shoot and kill her, and then use the gun on himself. She tells you she is fine and does not need counseling, but she wants her brother, age 7, and sister, age 4, to receive counseling because it was likely “very traumatic for them.” Identifying that Maria is clearly in shock, you offer your sincere condolences, followed by recommending Maria have counseling as well. She declines at first, insisting she is doing okay and has nothing to talk about. After inviting the school counselor and assistant principal to the discussion, with Maria’s permission, they help convince her that it would be healthy for her and her siblings if she was also being seen by a counselor. The principal adds that some of the school staff, including herself, responded to the incident the following day by going to the neighbor’s house to assess for the children’s safety and let them know they had permission to take a leave of absence from school. Maria insisted on coming to school the next day, saying she was “fine” and “needed the distraction.” Maria consents to meeting with you, but only because she believes it will help her family stick together. Due to the nature of the trauma and obvious client need, you receive permission from your supervisor to provide services pro bono until insurance or payment can be established. | Family History:
Maria is the oldest child of three children, and to her knowledge her siblings were born of the same two parents as herself; but she was unable to confirm this with absolute certainty during the initial assessment. She has difficulty providing historical information on her parents but can tell you in her own words she knows her dad was “sick” with “mental problems” and that her parents fought often. She tells you after the incident occurred her neighbors rushed to their aid and were able to take them in until they can establish a more permanent living situation with their grandmother, who lives across town and is preparing to have them move in soon. You ask if she can have her grandmother sign your company’s consent paperwork, but she replies that she has no transportation and does not speak English. She adds that her mother always told her she would want her to “go to her grandmother” if something ever happened to her and her father. | Considering Maria no longer has parents to sign consent for counseling and Maria is a minor, what should you do regarding legal and ethical boundaries in providing services? | You cannot legally or ethically provide counseling for a child without parental consent. | Have the school officials sign in lieu of parents. | Make every attempt to communicate with and obtain consent from her grandmother. | Have Maria sign her own consent and proceed with counseling. | (A): You cannot legally or ethically provide counseling for a child without parental consent.
(B): Have the school officials sign in lieu of parents.
(C): Make every attempt to communicate with and obtain consent from her grandmother.
(D): Have Maria sign her own consent and proceed with counseling. | Make every attempt to communicate with and obtain consent from her grandmother. | C | With the knowledge that Maria and her siblings have a next of kin who will likely become their official guardian, it is of legal and ethical best practice to attempt coordination with their grandmother. You may need to obtain a translator, or have Maria provide translation in signing consent documentation provided she is capable; but it is the safest option for both you and Maria. You still may be able to provide Maria counseling without her grandmother's knowledge. If Maria insisted on privately counseling, or if there were no familial options available, it may be possible for Maria to sign her own consent forms provided she is able to demonstrate understanding of her confidentiality rights. You must first check with your state's laws concerning minors seeking therapy without parental consent, as some states allow for a counselor to provide a limited number of sessions or for specific circumstances for children as young as 12 years old. Another option would be for Maria's school counselor to provide Maria counseling within the school, but school officials would not be able to take the place of Maria's guardians on your agency's consent paperwork. Additional options would be to offer lay counseling or other local resources for Maria and her siblings should you not be able to work out an appropriate counseling situation. Therefore, the correct answer is (B) | professional practice and ethics |
574 | 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. | When considering the client's desire to address his alcohol use in counseling, which of the following interventions would be used first? | Identify irrational core beliefs | Implement an abstinence contract | Implement motivational interviewing | Use the Prochaska-DiClemente's Stages of Change assessment | (A): Identify irrational core beliefs
(B): Implement an abstinence contract
(C): Implement motivational interviewing
(D): Use the Prochaska-DiClemente's Stages of Change assessment | Identify irrational core beliefs | A | Identifying irrational or negative core beliefs is a proven CBT intervention that is part of the process when addressing substance abuse issues. Clinicians use different methods to identify these, however, identifying and modifying unhelpful core beliefs is the most important part of the process. Both the Stages of Change model and motivational interviewing are used when a client is resistant to making changes or when the counselor is unsure whether the client is interested in making changes. As the client has presented with a stated desire to address his alcohol use, the counselor can move directly into helping him work in this area. Abstinence contracts have shown positive and negative outcomes depending on the client and their values and willingness to embrace abstinence. Substance abuse treatment counselors vary in supporting an abstinence model or a harmful reduction model of treatment. Implementing an abstinence contract may not coincide with the client's values and desires. Therefore, the correct answer is (C) | counseling skills and interventions |
575 | Name: Robin Clinical Issues: Substance use/addiction issues Diagnostic Category: Substance Use Disorders Provisional Diagnosis: F10.20 Alcohol Use Disorder, Moderate Age: 28 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: Black Marital Status: Not Married Modality: Individual Therapy Location of Therapy : Private Practice | The client is well-groomed. She reports her mood as depressed due to her relationship breakup and feeling that she is unable to talk to family members about her life. Her affect is characterized by anxiousness and difficulties in answering questions. Her overall speech is slow and soft, with little eye contact as she speaks. The client's insight is fair. She recognizes that alcohol has been a major factor in her life, and she is aware of the negative effects it has had on her relationships and work performance. She states that she is at a point where she feels like she needs help to make changes in her life. Though she presents as sober at the time of the interview, her judgment appears impaired due to her continued heavy drinking despite the negative consequences. | First session You are a clinical mental health counselor at a community mental health center. You see many clients who struggle with substance use issues. A 28-year-old female presents for outpatient services today. She is an attorney who works long hours, specializing in family law. She and her boyfriend of ten years recently ended their relationship due to the client's excessive drinking. She says, "I can't live with the pain of our separation much longer, and I don't know how to cope with it." She tells you she is devastated and does not know what to do next. The breakup has triggered her to drink even more lately, and she is currently facing a DUI charge. Her attorney recommended that she seek an assessment for substance use disorder treatment in an effort to avoid a criminal conviction. You administer an assessment to determine the severity of the client's alcohol use and further evaluate her statement about being unable to live with the pain of her breakup. She reports an urge to drink daily, and acknowledges she has lost control of her drinking on many occasions. She also states that she has increased her alcohol intake because "it helps numb the pain and I can forget about everything for a little while." The client discusses her father's death when she was 17 and how this affected her life. She states that his death hit her hard, and only made matters worse because of her family's lack of emotional support in the wake of his passing. Even though she was still in High School, she began drinking heavily to cope with the grief, a pattern which has been present ever since. She drinks alone, typically at home or in bars after work. When asked about the effects of alcohol on other areas of her life like her finances, she says, "One of the perks of my job is that I get paid pretty well, so at least I'm not in debt like my brother." She pauses for a moment, then says, "Well, not yet anyway. I've got some court costs coming up." You explain to the client that substance use disorder is treatable and that it is important to take an honest look at her relationship with alcohol, in order to make positive changes to her lifestyle. You discuss the effects of excessive drinking on physical health, mental health, and personal relationships. You review the various options for treatment available and encourage her to be proactive in seeking help. The client acknowledges your advice but expresses hesitancy about beginning treatment due to fear of the stigma associated with addiction. You empathize with her feelings while emphasizing the importance of taking action now rather than waiting until her issues become worse. You present evidence-based treatment modalities that have been shown effective in managing substance use disorders. You let the client know you are here for her to help develop healthy coping skills, explore the underlying causes of her drinking, and create a plan to avoid future drinking and driving offenses. Then, you both discuss a treatment plan with the goal of helping the client resolve her current crisis and developing a strategy to maintain sobriety and avoid future legal issues. She provides you with releases to speak with her mother and her attorney. You set up a follow-up appointment one week from now. Second session The client had an appointment to meet with you two weeks ago, but she called to reschedule twice, citing a busy work schedule. The client shows up 10 minutes late for her second counseling session today, looking slightly disheveled. She starts off by telling you that "this morning has been a mess." She overslept and missed two appointments with clients. She contacted her secretary to reschedule the appointments, but she is still feeling stressed and overwhelmed. She tells you she was up late last night talking to her ex-boyfriend. You ask what motivated her to talk with her ex-boyfriend and she tells you, "It felt like the only way I could make sense of what had happened between us." She is not forthcoming with any additional details about their conversation. You then ask if anything else has been on her mind lately. She reports that her mother told her that she should be focusing more on finding someone new to date instead of worrying about getting back together with her ex. The client becomes distant and quiet during the session. She makes minimal eye contact and her responses are brief, often giving a one-word response to your questions. You can tell that something has shifted in her since last week's session as she presented to the intake as more talkative and open. You decide to address her change in behavior directly, saying "I notice that you seem more closed off today compared to the last session we had. Is there something specific that is causing you to feel this way?" The client responds, "I don't know, I'm just so tired of it all." When you ask her to elaborate, she closes her eyes and takes a deep breath before responding. She says that she feels emotionally drained. She is overwhelmed with the weight of all that has been happening and feels like she is a "total failure" for allowing things with her ex-boyfriend to come this far. She describes feelings of guilt for "treating him like dirt" the entire time they were together and sad that "I messed things up so badly." She also shares that she is feeling ashamed about being charged with a DUI. She says, "I'm an attorney, not a criminal. People like me don't get DUIs, yet here I am. What's wrong with me?" The client expresses both a desire and a fear of change. She often talks about wanting to make changes in her life, but is also uncertain about how to go about it, feeling overwhelmed by the idea of taking action. Her tone reveals a sense of hopelessness as she talks about where her life is headed. You empathize with her, acknowledging the difficulty of changing deeply-rooted patterns. You provide her with psychoeducation about the nature of addictions and the biological and environmental factors that can contribute to substance abuse. | The client has a younger brother. Her father died when she was 17, and her mother never remarried. The client's family has a history of problematic alcohol use, with family members utilizing alcohol to mask underlying emotions and distress. This pattern can be seen in her mother and brother, as well as extended family. Her mother is particularly reliant on alcohol and uses it as a way to cope with negative feelings. This has been an ongoing issue for many years. The client was raised in an environment where emotions were not discussed openly. The client expresses she learned early that it was best not to bring attention to any discomfort or upset she may have felt because it would only be met with more criticism and judgments. She states, "My mother and brother 'don't believe in depression.' When I told my mom that my boyfriend broke up with me and I was feeling depressed, she told me to that I needed to 'get over it and move on.' It's like I'm talking to a wall when I try to tell her anything about how I'm feeling." Although the client does not feel that her family understands her problems, she does communicate with her mother weekly. The client has been using alcohol as a way to cope with stress for many years. She expresses she has "been through a lot" in her life and that going to bars after work is an escape. Alcohol has maintained a significant presence during various phases of her life. | Even though the client is sharing about her life within the context of a depressed mood, she is able to elaborate on her feelings about her breakup with her boyfriend, and her role in it. What cognitive error, or distortion, did you detect as she spoke? | Jumping to Conclusions | Disqualifying the positive | Black-and-white thinking | Catastrophizing | (A): Jumping to Conclusions
(B): Disqualifying the positive
(C): Black-and-white thinking
(D): Catastrophizing | Black-and-white thinking | C | In this situation, the cognitive error that you would bring to the client's attention is black-and-white thinking; she views her situation as either all or nothing (ex. calling herself a "total failure" and describing her actions as "treating him like dirt" the entire time they were together). You could point out the tendency to think of her situation in extremes and how this is likely making it difficult for her to find a healthy resolution. Therefore, the correct answer is (C) | intake, assessment, and diagnosis |
576 | 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 | You assess for disturbances in social cognition, which is indicated by several symptoms or observations EXCEPT which of the following? | Difficulty remembering names of acquaintances | Diminished motivation in pursuing hobbies | Difficulty remembering social cues | Increased introversion | (A): Difficulty remembering names of acquaintances
(B): Diminished motivation in pursuing hobbies
(C): Difficulty remembering social cues
(D): Increased introversion | Difficulty remembering names of acquaintances | A | Difficulty remembering names of acquaintances is not a symptom or observation included in the social cognition domain. In the DSM-5-TR, Criteria A, the diagnosis of mild neurocognitive disorder (MND) is marked by a modest decline in cognitive functioning. Individuals with mild neurocognitive disorder exhibit moderate difficulty with memory, planning, organization, attention, learning, or processing social cues. Symptoms or observations of individuals who avoid use of specific names of acquaintances is included in the language domain. Further, the DSM-5-TR defines the cognitive domains associated with neurocognitive disorders which also includes symptoms or impairments impacting everyday activities. Therefore, the correct answer is (D) | intake, assessment, and diagnosis |
577 | Client Age: 60 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Married Counseling Setting: Private Practice Clinic Type of Counseling: Individual Counseling Presenting Problem: Unemployment; Anxiety; Depressed Mood Diagnosis: Adjustment Disorder with Mixed Anxiety and Depressed Mood (F43.23) | Mental Status Exam: The client appears to have a depressed mood as evidenced by his affect, slow speech pattern, and body posture. The client is dressed appropriately for the season and is in clean clothing. The client is oriented to person, place, time, and situa | You are a private practice therapist working in an outpatient clinic. Your 60-year-old male client comes into the intake session, sits down, and sighs deeply. You verbally acknowledge that the client looks as though he is carrying a big mental weight, and he nods. The client begins to talk about how he was let go from his job at an assembly plant a month prior due to budget cuts. The client says that he worked there for about 30 years and that he was most recently a plant manager for the past 10 years. The client states that the plant shut down because the automotive company moved their manufacturing to another country. The client expresses anxiety surrounding what he is going to do for work next. The client states that he worries that he does not have much to offer other employers due to the extent of time he spent at his last job and also that his age will make him unemployable. The client says that he has been isolating himself, feels down more often than not, and often worries about making ends meet. The client states that his wife is currently receiving cancer treatment and, because of this, they have significant, regular medical bills. | The client comes into the session with a similar presentation as last week as he sits down and sighs deeply. You ask the client what he is thinking about, and he recounts an argument earlier in the day that he had with his wife when they were discussing finances. The client expresses frustration that they have had several arguments over the past week regarding finances. You empathize with the client and support him with further processing his anxiety about finances. The client expresses an immediate need to start working soon for financial reasons and because he is having a hard time “doing nothing” every day | Which of the following would be an example of reflection skills when the client is talking about the need to start working soon because he feels like he is doing nothing every day? | “In addition to being frustrated and anxious about finances, it sounds like you might also feel bored and unengaged.” | “It sounds like we need to focus very intently on figuring out what you are going to do for work because this is causing you a lot of distress.” | “It sounds like most days have been hard because you feel you are not doing much.” | “I can see how hard it must be feeling the pressure of finding a new job and dealing with conflict at home.” | (A): “In addition to being frustrated and anxious about finances, it sounds like you might also feel bored and unengaged.”
(B): “It sounds like we need to focus very intently on figuring out what you are going to do for work because this is causing you a lot of distress.”
(C): “It sounds like most days have been hard because you feel you are not doing much.”
(D): “I can see how hard it must be feeling the pressure of finding a new job and dealing with conflict at home.” | “In addition to being frustrated and anxious about finances, it sounds like you might also feel bored and unengaged.” | A | Reflection is about identifying the underlying feelings that the client is experiencing based on what he says. Identifying that the client’s statement about “doing nothing” every day might mean that he feels bored and unengaged identifies an unspoken feeling behind the statement and would be considered reflection. Stating that the client’s days are hard because he is not doing much is a paraphrase because it restates the client’s words in a different manner. Stating the difficulty of the pressure that the client is facing is an empathetic statement. Although it is important to focus on the client finding meaningful employment, this is not reflection. Paraphrasing, reflecting, empathizing, and defining goals all show the client that you are listening and are attuned with him. Therefore, the correct answer is (A) | counseling skills and interventions |
578 | 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 | Following the intake session, you determine that you have the experience and education to provide counseling, but because this is not your specialty, what would be an appropriate next step? | Refer to a psychiatrist for medication management and continued observation by another professional. | Seek continuing education regarding treatment of bipolar disorder. | Refer to a therapist that specializes in bipolar disorder. | Continue to provide counseling, but seek peer supervision/consultation to ensure your interventions are clinically appropriate, and refer to a psychiatrist for medication management. | (A): Refer to a psychiatrist for medication management and continued observation by another professional.
(B): Seek continuing education regarding treatment of bipolar disorder.
(C): Refer to a therapist that specializes in bipolar disorder.
(D): Continue to provide counseling, but seek peer supervision/consultation to ensure your interventions are clinically appropriate, and refer to a psychiatrist for medication management. | Continue to provide counseling, but seek peer supervision/consultation to ensure your interventions are clinically appropriate, and refer to a psychiatrist for medication management. | D | You have the experience and education for treatment of bipolar disorder; therefore, clinical supervision or consultation would be beneficial in ensuring that you are providing appropriate treatment. Therapists should seek supervision in areas of new specializations per the ACA Code of Ethics in order to ensure that the service provision is appropriate (2014, p 8). That said, because evidence-based practice in the treatment of bipolar disorder supports the combination of counseling and medication management, a referral to psychiatry to oversee the medication management is also required because this is outside the scope of the counselor. A referral to another therapist would not be necessary because your education and experience are appropriate for effective treatment. It is always beneficial to seek ongoing education as a therapist, but if the client came to counseling and you did not already have the education in the area required to appropriately support her, you would refer her to another therapist. Therefore, the correct answer is (C) | treatment planning |
579 | 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 would be the most appropriate response to the client's question? | I'm so sorry that you feel this way. | You feel torn between caring for your parents and caring for yourself at the same time. | You are not terrible. Culture is important but so is what you need and want. | Have you tried talking to your parents and explaining what you are trying to do? | (A): I'm so sorry that you feel this way.
(B): You feel torn between caring for your parents and caring for yourself at the same time.
(C): You are not terrible. Culture is important but so is what you need and want.
(D): Have you tried talking to your parents and explaining what you are trying to do? | You feel torn between caring for your parents and caring for yourself at the same time. | B | The most appropriate response is paraphrasing the client's problem, giving her the opportunity to hear her dilemma restated. This provides an opening for the client to talk about how her collectivist culture and individualism are struggling within her and gives her the opportunity to begin processing this. Telling the client "I am so sorry" puts the focus on the counselor rather than the client and is likely to make the client regret sharing her distress, especially if she believes it is negatively impacting the counselor. Telling the client she is not terrible can provide some normalization, however, minimizing the importance of culture to the client suggests the counselor is not aware of its importance to the client. Asking if the client has tried talking to her parents suggests the counselor lacks cultural awareness and may be bringing her own cultural biases into the session by suggesting the client tell her parents what she wants to do. Therefore, the correct answer is (D) | intake, assessment, and diagnosis |
580 | Name: Camron Clinical Issues: Worry and anxiety Diagnostic Category: Anxiety Disorders Provisional Diagnosis: F40.10 Social Anxiety Disorder Age: 20 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: White Marital Status: Never married Modality: Individual Therapy Location of Therapy : University Counseling Center | The client looks anxious and uneasy, presenting with a "nervous" laugh. He twirls his thumbs and shakes his legs while seated. Mood is anxious and frustrated. He feels isolated and misunderstood by his family and peers. Speech is soft and hesitant. Eye contact is sporadic. Thought process is concrete and linear. He has some difficulty with abstract concepts. Thought content reveals fear of social interactions, feeling judged by others, and feeling inadequate. He seems to recognize the negative consequences associated with his anxiety and behavior, but he has limited insight with regard to recognizing the source of his anxiety. He reports difficulty recalling past experiences or conversations due to anxiety levels. No suicidal or homicidal ideation noted. | First session Your client is a 20-year-old male who has been seeing your colleague at the university counseling center where you both work as mental health therapists. The client requested to be transferred to another therapist because his former therapist reminded him too much of his father and therapeutic progress could not be made. The client's former therapist contacted you as a referral, and you agreed to transfer the client to your caseload. When you meet with the client today, he seems very anxious and laughs nervously. You can see he is shaking his legs as he sits, twirling his thumbs, and making little eye contact with you. You explain the therapy process and that you need to go over some intake questions. You ask him who his ICE (in case of emergency) contact is, and he says it is his roommate. You continue with your assessment, gathering information about his presenting problem and what he would like to accomplish in counseling. He continues by telling you, "I thought that going to college would alleviate my social anxiety, but I'm not doing well here. I want to be social, but I can't." The client feels frustrated and overwhelmed by his fears of interacting with others. He tells you that when he is feeling anxious, he punches bathroom mirrors to try to distract himself from the anxiety. He notes that the anxiety is crippling, preventing him from doing the things he loves, and has resulted in him feeling isolated. He is afraid that others are judging him and is constantly worried that he will make a mistake and feel embarrassed. Fourth session It has been three weeks since the initial counseling session with your client. The client comes to your office for his weekly session and says, "I tripped on my way here when I got off the subway, and I felt so embarrassed. I'm going to take a cab back to campus. What if people who saw me fall are still in the subway by the time we finish?" You ask your client to explain this embarrassment and why he thinks people who saw him fall this morning would still be in the station an hour later. He tells you that when he was little, his father always told him, "Don't do this, don't do that. People are going to think you're stupid. I still hear his voice in my head, telling me what to do. I've spent my whole life trying to live up to his expectations, and I'm tired of it!" You explore this with your client and use guided imagery to ask him to return to that little boy in his memory. He tells you, "I can't concentrate right now. The anxiety of remembering my childhood is stressing me out." You switch to using behavioral techniques as a way to help him manage his anxiety. You explain that it is important for him not only to challenge his anxieties but also recognize his successes. To ensure that he feels successful and rewarded, you come up with a plan so he can realize progress and be able to measure it. In order for you and your client to monitor his progress, you create charts that will document any positive changes he experiences during the therapy sessions. As part of the plan, your client will commit to engaging in activities outside of the counseling session which are designed with the purpose of calming him down and helping him practice his newly-acquired skills to manage his anxiety. | 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. | Using a behavioral approach, which of the following techniques would be appropriate to use to decrease the client's phobic avoidance? | Looking for exceptions | Systematic desensitization | Looking for previous solutions | Reframing the problem | (A): Looking for exceptions
(B): Systematic desensitization
(C): Looking for previous solutions
(D): Reframing the problem | Systematic desensitization | B | Systematic desensitization is a behavioral technique which is commonly used to address phobias and anxiety-related issues. To create a systematic desensitization plan, it is important to first identify the individual's specific fears and anxieties related to social situations. Once these have been identified, the therapist and client can work together to create a list of hierarchy of fears that they can systematically work through. For example, if a person is afraid of speaking in front of an audience, their list might start with smaller goals such as introducing oneself to a stranger, then gradually increase in difficulty such as leading a group discussion. Therefore, the correct answer is (C) | counseling skills and interventions |
581 | 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. | 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. | What do you identify as a potential treatment barrier for the client? | Language barrier | Lack of social support | Inability to commit to treatment | Lack of insight | (A): Language barrier
(B): Lack of social support
(C): Inability to commit to treatment
(D): Lack of insight | Lack of insight | D | The client displays an unwillingness to take responsibility for his actions with substance use, makes excuses for why he is late or misses work, and denies any current thoughts of homicidal ideations. These all suggest that the client has a lack of insight into his behaviors and that addressing this barrier will be essential in his treatment. Therefore, the correct answer is (A) | counseling skills and interventions |
582 | 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 | A referral that can be made prior to the next session would be? | A medical referral for Molly's stomach aches | A support group for teens who have lost a parent | Extra help for Molly's decline in grades | A psychiatrist for medication | (A): A medical referral for Molly's stomach aches
(B): A support group for teens who have lost a parent
(C): Extra help for Molly's decline in grades
(D): A psychiatrist for medication | A medical referral for Molly's stomach aches | A | It is important to first rule out medical issues. Molly's stomachaches have had a significant impact in her school functioning, and it should be determined if the cause is medical or psychological. Although a support group may be beneficial later, it does not seem that Molly is ready for that yet. It is important to first address the areas of functioning that have significantly declined such as her schoolwork and her relationship with her mother. This can be a possible long-term goal. Part of the reason that Molly's grades have declined was due to missing a lot of school. Prior to her father's death Molly was in advanced placement classes and achieved high scores. Molly was not discharged from the hospital with medication. If it is determined that her hearing her father's voice is a hallucination, or if suicidal ideation worsens, medication may be warranted later. At this point it would benefit Molly to try therapy first. Therefore, the correct answer is (A) | treatment planning |
583 | Initial Intake: Age: 31 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Widowed Counseling Setting: Private Practice Type of Counseling: Individual | The client appears her stated age, dressed appropriately for the circumstances. Her mood is identified as sad and frustrated and her affect is restricted and flat. Her primary emotion in the session is anger, though it is expressed in a tempered manner. She demonstrates limited insight, and appropriate judgment, memory, and orientation. She reports having considered suicide when she was in high school but made no attempt and would now never consider harming herself or anyone else. | You are a counselor in a private practice setting. Your client is a 31 year-old female who reports that she is very impatient and feels angry all the time, and is taking it out on her children and others with angry outbursts. She says that her children are good but they don’t pick up when she tells them to and often, they put their toys away in the wrong places. The client states that her husband died while the family was on a vacation. She tells you that they had stopped for a break and her husband was hit by a car. She says that it happened in front of her and the children, who are now 6 and 7 years old. She endorses feeling angry, restless, and having trouble making decisions. She tells you that she is having trouble falling asleep, is anxious and overwhelmed. The client tells you that her husband was a good man and “very much my opposite.” She has high expectations for neatness and being on time, he was often messy and ran late. She tells you that sometimes she felt like the whole activity they were doing was “ruined” because he made them late or the kids didn’t follow the rules. She states that she was the “controller” in their relationship, which worked well for both of them, except when she got angry with him for not doing what she wanted, when she wanted, or how she wanted it. She acknowledges that she was often angry and frustrated with his casual way of going through life but now regrets it because he’s gone. She states that her goals for counseling are to be more patient and decrease her anger. | Family History:
The client reports a significant family history with her mother diagnosed with schizophrenia, with catatonia and was not medicated. She describes her mother as a “zombie” who loved her children but never told them because she was “absent.” The client describes her father as verbally abusive and involved with drugs and alcohol, often yelling, screaming, and throwing things. She states he often told the client that any mistakes she made were the reason that their life was so bad. She has no siblings but her husband has two sisters, with whom the client does not engage. She states one of his sisters is living with her boyfriend and the other asked to borrow money from her and her husband, which made the client angry. She identifies her support system as her church and a group of couples whom she and her husband were friends with prior to his death, most of whom attended the client and her husband’s high school and college. The client says she tends to be drawn to overly controlling people and her church, though fundamentalist and legalistic, became like family to her in high school. She tells you that the couple’s closest friends are her husband’s best friend, whom the client dated in high school, and his wife. She says that while dating, her then boyfriend was very attentive, “almost smothering,” but also very demanding by leaving her notes with things or work he wanted her to do for him. She states they dated for several years and then she met and married his best friend, who was her husband. She tells you that their best friend’s wife is her best friend, although “she irritates me all the time, and I don’t really like her that much.” She says her friend has a strong personality, is controlling, and wants to make all the decisions and plans in their relationship. | Which of the following will be most helpful for the client in reducing her negative emotions related to being late? | Reassure the client that being late at times is a normal occurrence | Create a plan that gradually acclimates the client to arriving late to some events | Ask the client to choose two events in the next week and arrive at least 10 minutes late | Help the client identify ways that she can be proactive in being on time to events | (A): Reassure the client that being late at times is a normal occurrence
(B): Create a plan that gradually acclimates the client to arriving late to some events
(C): Ask the client to choose two events in the next week and arrive at least 10 minutes late
(D): Help the client identify ways that she can be proactive in being on time to events | Create a plan that gradually acclimates the client to arriving late to some events | B | Prolonged exposure helps an individual to gradually become more comfortable with situations that cause high emotions or anxiety. The client's rigidity that causes her distress when she is late can be modified by helping her create a plan that gradually exposes her to not meeting her own time constraints and allows her to become more comfortable without her perfectionistic tendencies related to time. Asking the client to choose two events and arrive late without preparation may increase the client's embarrassment and self-anger because she has not yet experienced positive situations when she has been late. Helping the client increase her need for perfectionism in not being late through proactive planning will not help her manage unforeseen circumstances or help her manage her negative emotions when she cannot control the situation. Therefore, the correct answer is (B) | counseling skills and interventions |
584 | Initial Intake: Age: 38 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Married Counseling Setting: VA Type of Counseling: Individual | Carl came to the intake session alone and angrily stated, “I really don’t know why they are making me come to therapy - it doesn’t help anyway.” Carl appeared edgy throughout the interview and responded to questions with minimal effort.
| Carl is a 38-year-old Army Veteran who is attending counseling at the local VA. Carl was referred after he was arrested for a DUI last week.
History:
Carl has been on four deployments to the Middle East, he returned from the most recent tour 11 months ago, after he was injured during a military strike. Some of his team members were injured as well.
Since his return, Carl and his civilian wife, Lori, have discussed separation because of their frequent arguing and Carl’s drinking. Carl began drinking when he was deployed and since then has used it as a coping mechanism to combat the frequent flashbacks and nightmares that he gets. Carl and Lori mostly argue about money since Carl has not been able to sustain employment as a construction worker because of his drinking problems. Carl has been arrested several times for assault and disorderly conduct. Carl recently assaulted his last counselor after he had made a comment about Carl not being able to sustain work.
The counselor thanked Carl for his service and reviewed with him that he was referred as a part of his probation. He must attend individual therapy and an anger management group for veterans. The counselor then described to Carl the purpose of the meeting and what would be reviewed and discussed during their time together. This included the intake paperwork, including informed consent and several assessments. | null | Which of the following steps should be taken in the intake stage? | Convince Carl to include his wife in counseling sessions | Tell Carl that he if he does not attend individual or group therapy, he is violating his probation | Assess the severity of Carl's alcohol use | Ensure Carl goes to group therapy | (A): Convince Carl to include his wife in counseling sessions
(B): Tell Carl that he if he does not attend individual or group therapy, he is violating his probation
(C): Assess the severity of Carl's alcohol use
(D): Ensure Carl goes to group therapy | Assess the severity of Carl's alcohol use | C | Alcohol use seems to be a contributing factor in Carl's current issues. A comprehensive assessment would include assessing the severity of Carl's alcohol use to gain an accurate clinical picture and to help determine goals. Although it may be beneficial to have Carl's wife in therapy sessions, that may come later, after the intake and assessment. Group therapy would benefit Carl, but the question is, what needs to be completed as part of the intake session. Finally, the counselor is trying to build rapport and trust with Carl. If the counselor comes across as confrontational to Carl about violating his probation, this may hinder the alliance building process. Therefore, the correct answer is (B) | intake, assessment, and diagnosis |
585 | Initial Intake: Age: 48 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Divorced Counseling Setting: Acute Inpatient Psychiatric Hospital Type of Counseling: Individual | Sandy wandered into the ER waiting room asking for a police officer. After further conversation, it was clear that Sandy thought she was in a police station and repeatedly called once of the nurses Officer McKinney, as if she knew him.
During the intake, the nurse practitioner mentioned that she was running a temperature, had a rapid heartbeat and breath smelled foul. In addition, her hands were trembling as well as her tongue and lips. Sandy’s behavior was somewhat irritable and erratic. At one point she was seemed to be hallucinating and stated that that she saw rats.
| Sandy was sent to the inpatient psychiatric from the emergency department for symptoms of hallucinations, memory loss, and disorientation.
History:
Sandy currently lives alone and is unemployed. She has a history of alcohol abuse and has been admitted to the hospital before because of this. Sandy has gotten into trouble with the law and has alienated most of her family and friends because of her alcohol use. She currently attends alcoholics anonymous. | null | A psychosocial cause of drug addiction is? | Drugs stimulate the brain producing immediate pleasure | Exposure to substances in utero | Genetics | Failures in parental guidance | (A): Drugs stimulate the brain producing immediate pleasure
(B): Exposure to substances in utero
(C): Genetics
(D): Failures in parental guidance | Failures in parental guidance | D | Children with parents who abuse drugs or alcohol may not have the proper guidance to avoid drugs/alcohol themselves. Other psychosocial causes include using drugs/alcohol to relieve tension and an expectation or social norm which portrays alcohol to "loosen up" or increase their popularity in social settings. Genetics, exposure to substances in utero, and the positive feeling drugs may give are the physical causes of addiction. Therefore, the correct answer is (A) | intake, assessment, and diagnosis |
586 | Client Age: Husband, 38; wife, 37 Sex: Husband,male; wife, female Gender: Husband,male; wife, female Sexuality: Husband,heterosexual; wife, bisexual Ethnicity: Caucasian Relationship Status: Married Counseling Setting: Counseling clinic Type of Counseling: Couples counseling Presenting Problem: The couple is experiencing distress because the wife has had a sexual affair with a woman. Diagnosis: Adjustment disorder, unspecified (F43.20) and relationship distress with spouse or intimate partner (Z63.0) | Mental Status Exam: The couple presents as withdrawn at the start of the session, but they open up as they talk about lighter subjects. Both individuals are oriented to person, place, time, and situa | You are a licensed counselor meeting with a couple in your private practice clinic. The couple comes in, and they both sit down at far ends of the couch and do not look at each other. After explaining informed consent and other intake policies, you begin to ask the couple what brought them to counseling, and they both sit silently. You ask the couple if it is hard to start this conversation because of why they came, and they both nod. You ask the couple if it might be easier to start with how they met and why they fell in love with each other, and they both nod in agreement that they can talk about that. The couple appears more comfortable after this and even say a few statements to each other about shared experiences during the conversation. You circle back to the reason why they came to therapy, and the wife says that she assumes that she should talk first. She states that about a week prior she told her husband that she had an affair with a woman a few months before. She continues that, at the time, she was curious and it occurred while she was drunk and insists that it meant nothing. The husband states that he still loves her, but he is not sure how he is going to move past this. He emphasizes that not only did she have an affair, but her action exposed an aspect of her that he did not know about, making him question whether she even finds him attractive. | tion. Family History: The husband and wife have been married for 13 years. They report that they met when friends introduced them and that they dated for about 2 years before getting married. The couple have two children: two daughters (ages 7 and 10). The couple reports that they have been in “parent mode” for the past few years and have not been emotionally connected to each other because their attention has been predominantly focused on their children | Which of the following assessments would be the most helpful in treatment planning for this couple? | Gottman Relationship Checkup | Family APGAR assessment | Relationship Assessment Tool | Love Language Quiz | (A): Gottman Relationship Checkup
(B): Family APGAR assessment
(C): Relationship Assessment Tool
(D): Love Language Quiz | Gottman Relationship Checkup | A | The Gottman Relationship Checkup assesses several areas in a relationship including conflict resolution, finances, housework, parenting, and more. This would be helpful in identifying areas that led to the affair because the relationship was likely experiencing difficulties prior to this culminating point. The Relationship Assessment Tool assesses intimate partner violence, which is not indicated for assessment at this time. The Family APGAR assessment reviews family relational aspects and would not be appropriate for the issues that this couple is experiencing. The Love Language Quiz identifies how each partner most feels and expresses love, but it is not an evidence-based theory to use during the assessment process. Therefore, the correct answer is (B) | intake, assessment, and diagnosis |
587 | 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. | What further information would be most helpful in determining the client's diagnosis? | Whether the client has been exposed to a traumatic death or serious injury | Whether the client fears her anxiety symptoms will lead to rejection from others | Whether the client experiences anorexia or binge eating | Whether the client has experienced difficulties being in line or in a crowd | (A): Whether the client has been exposed to a traumatic death or serious injury
(B): Whether the client fears her anxiety symptoms will lead to rejection from others
(C): Whether the client experiences anorexia or binge eating
(D): Whether the client has experienced difficulties being in line or in a crowd | Whether the client experiences anorexia or binge eating | C | Clients who are preoccupied with their appearance may be diagnosed with body dysmorphic disorder as long as symptoms do not meet criteria for an eating disorder. The client's symptoms do not suggest a traumatic stress disorder as she does not experience flashbacks, nightmares, or avoidance of stimuli associated with a traumatic experience. Her expressed symptoms do not represent criteria for agoraphobia, such as fear of large or small places, and/or crowds. While the client worries that others will negatively evaluate her body related to her perceived flaws, she is not concerned that they will evaluate her anxiety, which is seen in social anxiety disorder. Therefore, the correct answer is (B) | intake, assessment, and diagnosis |
588 | Name: Gregory Clinical Issues: Behavioral problems Diagnostic Category: Disruptive/Impulse-Control/Conduct Disorders Provisional Diagnosis: F91.3 Oppositional Defiant Disorder Age: 14 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Not Assessed Ethnicity: Black Marital Status: Not Assessed Modality: Individual Therapy Location of Therapy : Private Practice | The client appears obese and his clothing is unkempt. His behavior is uncooperative. He finds people "annoying" and can at times be vindictive toward people he finds "annoying." His mood is angry and affect is irritable. His flow of thought is coherent and goal-directed. His overall responses at times show themes of low self-esteem. He denies any current thoughts of suicide or homicide. He does not display any signs of hallucinations or delusions. His vocabulary is age-appropriate, but his speech is at times sarcastic. He answers questions coherently. Thought process is linear and coherent. He is oriented X3. Memory is intact for recent, remote, and immediate. Insight and judgement are poor. | First session You are a mental health counselor working in private practice. Gregory, a 14-year-old male, presents to the initial session with his mother. She reports that her son has been skipping school, hanging out with a negative peer group, and his grades are starting to slip. He refuses to listen to his mother, saying she is "strict and unfair." Gregory, who up to this point has been sitting quietly with his arms crossed, rolls his eyes and says, "She should be in therapy, not me." Gregory's mother continues on to express concern over his decline in school performance, noting that "he is having problems with some teachers and staff." Last week, he got up in the middle of class and when told to sit down, he said, "I have to go to the bathroom." He walked out and slammed the door behind him. He was sent to the principal's office as a consequence. He has also become vindictive toward certain classmates. When asked why, he states, "because they think they're better than me." His mother reports that at home, Gregory has become increasingly isolated, spending most of his free time alone in his room or out with a group of teenagers she does not recognize. He has has become increasingly hostile and verbally abusive toward his mother and brothers, resulting in frequent arguments. He routinely ignores his curfew and refuses to participate in family activities. You thank the mother for sharing her concerns and ask to speak with Gregory alone to give him a chance to express himself freely. You want to obtain his assent to join in therapy and understand what is causing him to act out. | The client resides with his mother and three older brothers. He describes his brothers and mother as "annoying" and tells you that none of them listens to him. 18 months ago, his father passed away after a long illness. The client says that his dad was the only family member who understood him. The client feels he has no one to talk to and does not get along with his family members. He reports difficulty trusting others and is guarded in his relationships. He has become more irritable and vindictive since his father's death. The client denies drug or alcohol use and responds to your question, saying, "What? Are you an idiot? Do I look like someone that would be stupid enough to do drugs?" The client scoffed and continued, "Why would I waste my time and energy risking my future for something so pointless." He then crossed his arms and stared defiantly, clearly not interested in discussing the matter further. | What is most important when gathering information regarding Gregory's presenting problem? | Gregory's eating habits and sleep schedule | Gregory's frequency, intensity, and duration of symptoms | Gregory's frequency of symptoms and correlating sleep schedule | Gregory's ability to complete homework despite frequent symptoms | (A): Gregory's eating habits and sleep schedule
(B): Gregory's frequency, intensity, and duration of symptoms
(C): Gregory's frequency of symptoms and correlating sleep schedule
(D): Gregory's ability to complete homework despite frequent symptoms | Gregory's frequency, intensity, and duration of symptoms | B | The client's frequency, intensity, and duration of symptoms are the essential interview questions when gathering information on the client's presenting problem. Therefore, the correct answer is (C) | intake, assessment, and diagnosis |
589 | 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. | The client resides with his mother and three older brothers. He describes his brothers and mother as "annoying" and tells you that none of them listens to him. 18 months ago, his father passed away after a long illness. The client says that his dad was the only family member who understood him. The client feels he has no one to talk to and does not get along with his family members. He reports difficulty trusting others and is guarded in his relationships. He has become more irritable and vindictive since his father's death. The client denies drug or alcohol use and responds to your question, saying, "What? Are you an idiot? Do I look like someone that would be stupid enough to do drugs?" The client scoffed and continued, "Why would I waste my time and energy risking my future for something so pointless." He then crossed his arms and stared defiantly, clearly not interested in discussing the matter further. | What short-term goal would you include in your treatment plan? | Explore ambivalence and determine where he is in the stages of change | Uncover the underlying factors contributing to the client's behavior and resolve this conflict | Modify oppositional behaviors at school to more positive interactions | Decrease the occurrence and intensity of confrontational behaviors towards adults | (A): Explore ambivalence and determine where he is in the stages of change
(B): Uncover the underlying factors contributing to the client's behavior and resolve this conflict
(C): Modify oppositional behaviors at school to more positive interactions
(D): Decrease the occurrence and intensity of confrontational behaviors towards adults | Explore ambivalence and determine where he is in the stages of change | A | At this point, the client and his mother are in a destructive cycle. In order to move forward, you need to explore the client's ambivalence; he does not seem interested in the therapy process. Therefore, the correct answer is (C) | treatment planning |
590 | Client Age: 18 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: University Counseling Center Type of Counseling: Individual and Group Presenting Problem: Interpersonal relationships Diagnosis: Autism Spectrum Disorder. 299.00 (F84.0) | Mental Status Exam: The client is sloppily dressed and appears his stated age. He exhibits pressured speech at times; otherwise, he speaks in a monotonous tone. The client becomes irritable when discussing the incident with campus police, and brightens when expressing his passion for snakes. He displays poor eye contact and there is difficulty with normal back-and-forth conversation. The client denies suicidal or homicidal ideation. He lives on campus in sober student housing and denies drug or alcohol use. History of th | You are a counselor a university counseling center. The university has a program providing limited assistance to students diagnosed with Autism Spectrum Disorder (ASD). The ASD program director has referred an 18-year-old white male enrolled in the program. She is concerned over his recent run-in with campus police. The client arrives to his scheduled counseling session today and explained that he has a girlfriend who “now apparently wants nothing to do with me.” Campus security has been involved due to the client showing up at his girlfriend’s dorm, yelling and creating a disturbance. The client explains that his peers told him he would have sex in college once he got a girlfriend. When his girlfriend refused to have sex, he said he didn’t understand and only wanted to talk. The client continues to express a desire to have sex now that he is in college by stating matter-of-factly, “I haven’t had much luck, but I’m going to keep trying.” When asked about interests, the client spoke at length about his love for snakes and knowledge of all 300 worldwide species. | The client arrives twenty minutes late for his appointment today. He explains that Mondays are the days he does laundry, and he cannot come again on a Monday. You review the required components of informed consent with the client. He expresses an understanding of the counseling process and provides written consent. The client states he has re-considered counseling because he believes you can help him find another girlfriend who will have sex with him. You tell him about a small group you run with other neurodiverse men, most of whom are on the autism spectrum. He expresses an interest in joining after hearing that sexual intimacy would be part of the curriculum. He provides a more solid commitment when you tell him the group is not held on Mondays | Because of his history with the campus police, you focus on helping the client regulate angry emotional outbursts using which one of the following techniques? | Systematic desensitization | Mapping | Cognitive reappraisal | Rolling with resistance | (A): Systematic desensitization
(B): Mapping
(C): Cognitive reappraisal
(D): Rolling with resistance | Cognitive reappraisal | C | Cognitive appraisal is a technique used to help with emotional regulation. The client’s difficulties with emotional regulation led to the run-in with campus police. Cognitive reappraisal is a staged process beginning with the client examining his initial perception of the associated stressor, discerning if he has the skills and resources to cope with the stressor, and understanding if the solution lies in changing the situation or in his reaction to the situation. Systematic desensitization is used with anxiety and involves replacing a fear response with a relaxation response in counterconditioning. Reciprocal inhibition uses the new relaxation response to replace the fear response. MI uses “roll with resistance” as a nonconfrontational means for lessening opposition to change. The counselor is attempting to regulate outburst, rather than committing to a change. Mapping is a structural family technique used to creating a visual representation of family patterns of interaction, including family rules and family structures. Therefore, the correct answer is (B) | counseling skills and interventions |
591 | 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. | 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. | Which assessment instrument would provide the most comprehensive information about the client's level of suicidality? | Mental Status Examination (MSE) | Hamilton Depression Rating Scale (HDRS) | Mclean Screening Instrument for Borderline Personality Disorder (MSI-BPD) | Beck Anxiety Inventory (BAI) | (A): Mental Status Examination (MSE)
(B): Hamilton Depression Rating Scale (HDRS)
(C): Mclean Screening Instrument for Borderline Personality Disorder (MSI-BPD)
(D): Beck Anxiety Inventory (BAI) | Mental Status Examination (MSE) | A | The MSE will provide the most comprehensive information about the client's level of suicidality. The MSE provides a snapshot of the client's current mental health functioning and behaviors within the clinical setting. This examination explores the client's overall impulse control and the likelihood of committing suicide or homicide. Because the MSE relies on your observations of the client while in session, you can gain valuable non-verbal cues within these crisis states. This allows for a far more comprehensive examination than the other answer options. Therefore, the correct answer is (A) | intake, assessment, and diagnosis |
592 | Client Age: 27 Sex: Female Gender: Female Sexual Orientation: Heterosexual Ethnicity: Caucasian Relationship Status: Married Counseling Setting: Career Counseling Center Type of Counseling: Individual Presenting Problem: Employment-related Stress; Anxiety Diagnosis: Adjustment Disorder with Anxiety 309.24 (F43.22) | Mental Status: The client was well-groomed and dressed appropriately. She appears nervous and jittery and quickly places her hands under the table when she notices them shaking. The client states that she is not sleeping well and says it is difficult making it to work each day knowing that “things rarely go as planned.” She explains that she has irritable bowel syndrome, which is exacerbated by stress. The client reports that there are no known medical conditions that would cause her chronic headaches. The client denies homicidal or suicidal ideations but remarks that she has felt like this in the past. Wor | You work in a career counseling center, and your intake is a 27-year-old white female employed as a fourth-grade elementary schoolteacher. The client has been a teacher for 3.5 years and has become increasingly dissatisfied with her job. The client explains that she is “at her breaking point” and relays that her stress level has increased sharply within the past 3 months. This is her first school year with a newly hired principal who has been “unreasonably demanding and unsupportive.” The client states that she was already second-guessing her career choice and explains that disruptive students and a lack of parental involvement have made teaching incredibly challenging. She reports “stress-induced physical symptoms,” which include acute stomach distress and chronic headaches. She worries that her skill set is nontransferable. | The client reports that her husband’s patience continues to wear thin, so she has explored the possibility of alternate employment. She states that she applied for a position as a curriculum sales representative but did not get an interview. The client reports that the company used a personality inventory to prescreen job applicants. She says that someone in human resources told her she was not selected for an interview because the company was looking for someone who was more extraverted and a “thinker” rather than a “feeler.” The client explains that she was under the impression that they were looking for a male. She expresses an interest in using personality inventories to help identify employment that would be a good fit for her | Which of the following personality inventories is based on Carl Jung’s theory of psychological types? | Strong Interest Inventory | Career Orientations Inventory | Myers-Briggs Type Indicator | Ashland Interest Inventory | (A): Strong Interest Inventory
(B): Career Orientations Inventory
(C): Myers-Briggs Type Indicator
(D): Ashland Interest Inventory | Myers-Briggs Type Indicator | C | The Myers-Briggs Type Indicator is based on Carl Jung’s theory of psychological type. The Strong Interest Inventory helps individuals identify careers based on interests. The Career Orientations Inventory is based on Edgar Schein’s career anchors or career identities. The Ashland Interest Inventory is available to individuals with employment barriers, including certain educational, mental, cognitive, or physical conditions. Therefore, the correct answer is (A) | intake, assessment, and diagnosis |
593 | 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 continue to have trouble assisting the client with becoming more comfortable by talking about topics that may interest her | You continue to have trouble assisting the client with becoming more comfortable by talking about topics that may interest her. What else can you do in order to build a level of comfort with the client? | Explain the nature of therapy and how it can be helpful to her. | Use the immediacy skill to address the client’s feelings about the session and the therapist. | Use the silence skill to encourage the client to talk about what is happening. | Play a board game with the client. | (A): Explain the nature of therapy and how it can be helpful to her.
(B): Use the immediacy skill to address the client’s feelings about the session and the therapist.
(C): Use the silence skill to encourage the client to talk about what is happening.
(D): Play a board game with the client. | Play a board game with the client. | D | Because talking has not been beneficial, playing a game may help develop comfort because play is a nonthreatening activity that does not require disclosure. Play also helps some children lower their guard, and they may begin talking or be more willing to talk while you play. You have tried talking with her, and she is resistant to talking about what is happening; therefore, explaining the nature of therapy would not provide further benefit because you did this as part of informed consent. Immediacy has been attempted because you identified the client was not comfortable and tried to support her in this feeling. Silence may make the client feel pressured and even more uncomfortable, although it may be valuable later on in therapy because it does encourage reflection and communication. Therefore, the correct answer is (B) | counseling skills and interventions |
594 | 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 | Informed Consent should? | Explain the risks, benefits, and limitations of the counseling process | Be regularly revisited and reassessed | All of the above | Allow the client to decide about which provider they should use for treatment | (A): Explain the risks, benefits, and limitations of the counseling process
(B): Be regularly revisited and reassessed
(C): All of the above
(D): Allow the client to decide about which provider they should use for treatment | All of the above | C | The counselor should always act in the best interest of the client. If the client is a minor, it is necessary to discuss confidentiality and the limitations with the legal guardian. Collaboration is necessary to have a therapeutic alliance with all parties. Informed consent should include information such as client background, credentials, methods of payment, etc. so that the client can have the information needed to choose the provider who would best meet their needs. Clients must be informed of procedures that may be utilized in counseling. Risks, benefits, and limitations of the counseling process should be discussed, as well as any risk or benefits in using different modalities of treatment such as telemental health. Informed Consent is fluid and should be revisited throughout the life of the counseling relationship. Therefore, the correct answer is (D) | intake, assessment, and diagnosis |
595 | 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. | Following the 10th session, the client has not responded to your attempts to contact him and the only communication from the client has been the cancellation of the 11th session | Which of the following would be the most ethical response to the client’s lack of communication regarding cancellations? | You attempt to reach out several times to provide contact information and referral information. | You continue to attempt to make contact with the client until a response is provided. | You terminate services because the client is participating voluntarily and if he does not want to attend, then he does not have to. | You reach out after the first no-show, and then you wait for the client to make contact to initiate services again. | (A): You attempt to reach out several times to provide contact information and referral information.
(B): You continue to attempt to make contact with the client until a response is provided.
(C): You terminate services because the client is participating voluntarily and if he does not want to attend, then he does not have to.
(D): You reach out after the first no-show, and then you wait for the client to make contact to initiate services again. | You attempt to reach out several times to provide contact information and referral information. | A | If you determine that the client is not going to initiate contact regarding services, then reaching out several times to ensure that he knows how to reconnect with you or another therapist is an appropriate next step. This demonstrates that you have attempted to follow up with the client and that you are not abandoning him. Termination based only on whether the client is voluntary or involuntary does not matter because you want to ensure that the client has the information that he needs and that you make every effort to continue services. Continuing to attempt contact without a cutoff point does not make the best use of your time, and it does not put the responsibility on the client to decide if therapy is important enough for him to participate in. Reaching out once and waiting for a response might be missed by the client and does not demonstrate genuine attempts to support the client. Therefore, the correct answer is (B) | professional practice and ethics |
596 | 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. | What would be the most effective strategy for reducing her social anxiety symptoms? | in-vivo exposure | group therapy | behavioral therapy | behavioral activation | (A): in-vivo exposure
(B): group therapy
(C): behavioral therapy
(D): behavioral activation | behavioral therapy | C | Evidence-based practices within Dialectical Behavior Therapy, Cognitive Behavioral Therapy, and Acceptance and Commitment Therapy are all better choices than answers b through d because they will help support Mary's thinking process, using her own values to make different choices, and help her prepare for eventual exposure on her own timeline. In-vivo exposure mandating Mary to slowly attempt social engagements until she becomes comfortable may be harmful since Mary has concerns about Covid-19. Behavioral activation is a tool used for clients with depression who have poor motivation to take charge of their behaviors but may become more inclined once they engage in their desired behaviors regardless of how they feel. Mary has expressed desire to do the things she used to; she is just inhibited from doing so. Group therapy might be a great asset for Mary in time, but there should be a foundation of cognitive restructuring and learned coping skills for Mary to thrive in a group setting. Therefore, the correct answer is (A) | counseling skills and interventions |
597 | 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. | ily and Work History: The client was recently laid off from his job as a server at an upscale restaurant in the downtown area. He misses the sense of family he had with his previous co-workers and feels “stuck” and “unable to move forward.” The client is a third-generation Cuban American whose paternal grandparents immigrated to the United States during Castro’s regime. His parents worked hard to put him and his siblings through Catholic school and instilled in him traditional heteronormative religious values and “familism” (i\. e., the belief that the family unit is more important than individual needs). The client also has a strong work ethic but states he is poorly motivated to seek another job because he doesn’t want to be “shot down.” History of Condition: The client reports that he has struggled with bouts of depression from a very early age. He explains that he never felt like he fit in. In middle school, he was bullied and harassed. He remembers locking himself in his room, crying, and asking God for help during this time. He continued to ask for forgiveness and bargain with God as he grew older. In his mid- to late-teens, he began drinking and vaping, “because I couldn’t keep my end of the bargain,” he explains. Despite finding acceptance in the community, he still feels guilty for disappointing his parents. The client reports feeling “defective” and carries a significant amount of shame related to his sexual orientation. Your client is unmotivated to seek employment because he doesn’t want to be “shot down | Your client is unmotivated to seek employment because he doesn’t want to be “shot down.” According to person-centered theory, what is the root of your client’s maladaptive behavior? | The client has an underlying irrational belief that he must be capable in all areas of life or else he is worthless. | The client has developed a failure identity as the result of not taking responsibility for change. | The client has adopted the unhealthy life position of “I’m not okay. You’re not okay.” | The client has developed incongruence between the value of being employed and the behavior of not seeking employment. | (A): The client has an underlying irrational belief that he must be capable in all areas of life or else he is worthless.
(B): The client has developed a failure identity as the result of not taking responsibility for change.
(C): The client has adopted the unhealthy life position of “I’m not okay. You’re not okay.”
(D): The client has developed incongruence between the value of being employed and the behavior of not seeking employment. | The client has developed incongruence between the value of being employed and the behavior of not seeking employment. | D | Person-centered therapy is a non-directive approach designed to help clients recognize incongruence between their personal values (ie, the value of being employed) and behavior (not seeking employment). Core facilitative conditions used to help the client obtain this goal are empathy, genuineness, and unconditional positive regard. Glasser’s reality therapy helps clients transform failure identities into success identities by encouraging personal responsibility. Rational-emotive behavioral therapy (REBT) would attribute the client’s maladaptive behavior to the irrational belief that he must be capable in all areas of life or else he is worthless, leading to remaining stuck. Healthy and unhealthy life positions are characteristics of transactional analysis. Therefore, the correct answer is (C) | counseling skills and interventions |
598 | Name: Gary Clinical Issues: Behavioral problems Diagnostic Category: Disruptive/Impulse-Control/Conduct Disorders Provisional Diagnosis: F91.3 Oppositional Defiant Disorder Age: 10 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Not Assessed Ethnicity: White Marital Status: Not Assessed Modality: Individual Therapy Location of Therapy : Agency | The client reluctantly enters the session accompanied by his mother. He is slightly overweight for his age and is wearing clothes that appear too small for his physique. He is sitting in the chair with his arms crossed, refusing to make eye contact with you. His mood is angry, and his affect is irritable. His attitude during the initial part of the examination is defiant. Speech characterized by short responses and refusal to engage in conversation. Client refuses to discuss feelings or issues. He appears to have difficulty focusing. He lacks insight into his behavior and impact on others. Judgment and impulse control are poor. He denies suicidal or homicidal ideation. | First session You are a mental health therapist in an agency, and a 10-year-old male is referred to you due to behavioral issues. The client and his mother arrive at your office, and you note that he has an irritable look on his face. The two are arguing with each other. His mother threatens him with punishment if he does not cooperate with you and says that this is his "last chance". He glares at her and then stares at the floor. You introduce yourself and explain what you do as a therapist. The client barely says a word and keeps his head down with his arms crossed over his chest. You ask the mother to describe the issues that prompted her to seek help and she begins to tell you the story. She explains that her son has difficulty listening to adults and gets into verbal altercations with his peers. She informs you that he got suspended again from school because he lost his temper in the cafeteria when the student in front of him in the lunch line "wasn't moving fast enough". When you ask about how often his temper outbursts occur, the mother pauses for a moment to think and says, "It seems like he's always losing it, but I guess maybe a few times a month? The rest of the time, he's just angry, mostly at me and other adults. No matter what I do, he seems like he hates me." As she tells you this, you notice that the client is not paying attention and continues to look down at the floor, appearing disinterested in the conversation. His mother goes on to say that the school is threatening expulsion if her son's behavior does not improve. After thanking the mother for sharing this information with you, you look toward the client who has been sitting quietly the entire time. You explain that you understand it must be hard for him to be here and that you are not here to judge or criticize him. He looks up at you with a surprised expression on his face. He slowly nods and mumbles something under his breath. You let him know that you want to help him find ways to better manage his emotions so he can get along better with the people in his life. He looks away again, but this time there is a hint of curiosity in his eyes. You sit in silence for a moment. The client finally looks up at you and says, "It's just...everyone's always telling me what to do and they never listen to me. They think they know everything, but they don't. I can't help it if I get angry, but then everyone looks at me like I'm a monster. It's not fair." His mother looks away, tears in her eyes. You thank the client for expressing his feelings and explain that it is normal to feel upset when things are unfair. You further emphasize that you are here to help him find positive ways to handle his anger and other emotions. You then address the mother, "Parenting can be challenging, especially when it feels like your child is angry or upset with you. I'd like to work with both of you to improve your communication and relationship. It might be helpful to schedule separate sessions for you and your son, as well as joint sessions, so we can address individual concerns and work on improving your relationship together." The mother agrees, and you proceed to discuss a plan of action, including setting up regular weekly therapy appointments and providing resources to help support the family. Fifth session It has been over one month since you first began working with the client. You've been meeting with him for individual therapy and have implemented parent training with his mother. During previous counseling sessions, you focused on building rapport with the client and talked about different triggers for his outbursts. He said that he often gets angry when people do not listen to him or when they try to tell him what to do. You also discussed strategies for managing these triggers and the importance of communicating his needs in a respectful way. Last week, as part of your parent management training approach, you assigned the mother homework to read from a parent training handbook. When the client arrives for today's session, he is clearly upset, saying that he does not want to be here. His facial expression is one of anger and frustration. His mother is exasperated and apologetic. You calmly remind her that it is all right, that this is a normal part of the process. You ask if she would like to accompany them into your office, but she declines, saying that she needs some time to herself and she would like to wait in the waiting room for the first half of her son's session. Once inside your office, you start by asking the client why he does not want to be here. He says that he is tired of talking about his problems and he does not think it will make any difference. When you ask him to tell you more, he glares at you and says, "Why do you care? You're only asking because you want to get paid." You acknowledge how difficult it can be to keep coming back, but emphasize that whatever feelings he is having in this moment are valid and important. The client then looks away and sighs. He slowly says, "I don't know why I have to keep coming here...it feels like no matter what I do, nothing changes. I still get mad, my mom and teachers still get mad at me, and the school still threatens to kick me out." After a few moments of silence, you ask the client if he remembers what goals were set for the session today. He looks away and mumbles something under his breath. You gently remind him that you want to help him learn how to manage his emotions in a healthier way so he can get along better with the people in his life. He gradually relaxes and you ask him what strategies he has been using in the past week to work toward this goal. He thinks for a few moments before recounting an incident at school where instead of getting angry, he took a deep breath and walked away from the situation. You use behavioral modification techniques to encourage this positive behavior. You then move into today's activity, which is a role-play exercise. Once you have completed your planned tasks with the client, you invite his mother in to your office to provide her with feedback on her son's progress and discuss next steps with parent training. Eighth session The client and his mother arrive for today's session. You begin by meeting with the client alone and plan to speak with his mother afterwards. You ask the client how he has been doing since last week. He is quiet and shrugs his shoulders. You take a moment to notice his non-verbal cues and then gently ask him, "It looks like something is on your mind. Do you want to tell me about it?" He hesitates for a moment and then says, "I don't know. My mom told me that I have to stop playing video games so much. She said it's getting in the way of my homework. But I don't have any friends and video games are the only thing that makes me feel better. It's not fair. My mom gets to do whatever she wants." You listen attentively and validate his feelings. You explain to him that it is important to have a balance between recreational activities and taking care of responsibilities, like doing your homework. You say, "Your mom has a job, right? Sometimes she has to take care of things like going to work or paying bills, and it's the same when we have responsibilities at school. It takes time and effort, but if we do it, then it can free up some time for fun activities like playing video games." He shrugs and says, "Yeah, I guess." You continue the session by discussing his behavior in school and ask him if he can think of any positive experiences he has had since the last session. He thinks for a moment, then starts to shout excitedly, "Yes! There was something!" You intervene by giving him a choice of writing down his feelings or starting over with a quieter tone. He stops, takes two breaths, then proceeds to tell you about his experience in the school playground, where he managed to stay calm when he was provoked by a classmate. He said that his teacher was watching and praised him for staying calm. She gave him a sticker and told him that he could choose the game they would play at recess. You congratulate him on his success and praise him for his efforts. After you conclude the session with him, you invite his mother to your office and direct the client to wait in your waiting room. You talk to his mother to determine how her home parent training is going and review the client's treatment plan with her. His mother states that when she tried to set boundaries on gaming time, he had a "melt down". You suggest that she could consider increasing the amount of time he can play his video games in increments if he meets certain goals, such as completing all of his homework or cleaning up his room. She agrees to try this during the upcoming week. She also mentions that her son continues to struggle socially. When she told him that he could invite a friend over for pizza, he said, "What friend? Making friends is dumb. Who needs them anyway?" Following the session, you receive a phone call from the client's father who states that he has recently reconnected with his family. He says, "My wife told me that you've been working with my son. I know he's got some issues. I'm trying to get back in his life and make things right. What should I do?" | The client's father left the family two years ago. The mother, still married to him, retains sole legal custody of the client. Since his father left, the client will not help out around the house, seems angry, and sometimes loses his temper when he does not get his way. The client receives frequent but inconsistent corporal punishment from his mother. His mother made the appointment with you but did not tell him where they were going. The relationship between the client and his mother has been strained as the mother does not know how to handle the abandonment of the father. The client is in fifth grade and has been skipping school for the last six months and refuses to do any homework. His school records were released to you and show A's and B's through third grade, but C's and D's during the past two years. His decline in grades coincides with his truancy. He is also known as a "bully" at school and has been suspended and given detention a few times due to his behavior. He has a history of walking out of classrooms, running down the hallways, refusing to sit in his chair, and running away from the school counselor or anyone in an authoritative position. Personal/Social Relationships: The client does not have friends his age in the neighborhood, and parents do not want their children playing with him because they believe he is a "troublemaker". In addition, children in school avoid him because they are afraid of upsetting him. He does not seem interested in making friends and does not care to engage in any play time with the neighborhood children. Instead, he spends most of his time alone playing video games. | The client's father calls and tells you that he has recently reconnected with his family. He knows you are working with his son and asks what he can do to help. How would you respond? | "I'm so glad that you called. I believe that your son can benefit from a positive male role model if your wife agrees." | "Thank you for your willingness to help. Can you join us in the next session?" | "Is there a time when I can meet with you and your wife to get her consent and bring you up to date on parent management training?" | "I cannot confirm or deny any information regarding my clients. I suggest that you contact your son's mother and discuss the issue with her directly." | (A): "I'm so glad that you called. I believe that your son can benefit from a positive male role model if your wife agrees."
(B): "Thank you for your willingness to help. Can you join us in the next session?"
(C): "Is there a time when I can meet with you and your wife to get her consent and bring you up to date on parent management training?"
(D): "I cannot confirm or deny any information regarding my clients. I suggest that you contact your son's mother and discuss the issue with her directly." | "I cannot confirm or deny any information regarding my clients. I suggest that you contact your son's mother and discuss the issue with her directly." | D | The client's mother has full legal custody of son. She has not given you permission to speak with the father concerning her son's treatment. This response protects the client's confidentiality while also acknowledging the father's desire to reconnect. Therefore, the correct answer is (D) | professional practice and ethics |
599 | Name: Timmy Clinical Issues: Developmental processes/tasks/issues Diagnostic Category: Neurodevelopmental Disorders Provisional Diagnosis: F84.0 Autism Spectrum Disorder, Level 2 Age: 13 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: Black Marital Status: Not Applicable Modality: Family Therapy Location of Therapy : School | The client speaks using only a few words. There is no report of echolalia or other repetitive or overly formal use of language. You ask him to say "hi," and he opens his mouth wide, smiles, and laughs. He sustains direct eye contact with you for about two seconds. When you ask him to show you where his mother is, he points to her, looks back at you, and begins to laugh again. There are no reported or observed preoccupations and no reported or observed sensory symptoms to date. | First session You are a mental health therapist in a school setting. The client is referred to you by your school district to complete an evaluation. The client and his mother enter the session. The mother is prompting the client in a "toddler-like" voice to sit in the seat. The mother tells you that the client is becoming increasingly "violent" in the home setting, and she and her husband are not equipped to teach their son the skills he needs to regulate his emotions. In addition, she states that he needs some social exposure to others. He is nonresponsive to subtle social cues and has difficulty when others cannot understand his needs. She states that they need professional help and requests assistance in getting him "the education he deserves". You listen carefully to the mother's concerns and ask additional questions about her son's behavior, both at home and in school, as well as any history of mental health treatment or diagnoses. You explain to the client’s mother that you will provide an assessment of her son’s social and emotional needs and use evidence-based interventions to help him develop effective strategies for regulating his emotions and interacting with others. You review your therapy procedures in detail, including your expectations regarding how often the client and family should come for sessions and what to expect in terms of treatment outcomes. You also discuss any potential risks associated with therapy and the importance of open communication between family members, the client, and yourself during treatment. The mother expresses her understanding of your expectations and agrees to follow through with treatment. You encourage her to ask questions if she has any concerns or needs clarification about any part of the therapy process. | The client has a close-knit family, and his parents strive to support their son in any way they can. They have little outside support, however, and have been overwhelmed by their child's needs. The client has been home-schooled and lacks social skill development. Parents report that lately he refuses to do school work; as he gets older they will not have the skills to teach him what he needs to know academically. They feel it is now best for him to learn how to thrive socially and emotionally in a public school setting. | What question would you ask the mother to gather more information about the client's needs? | "Does he prefer playing alone or with others?" | "What strategies have been most effective in addressing his behaviors thus far?" | "What has been the most challenging aspect of parenting your son so far?" | "How would you describe your parenting style?" | (A): "Does he prefer playing alone or with others?"
(B): "What strategies have been most effective in addressing his behaviors thus far?"
(C): "What has been the most challenging aspect of parenting your son so far?"
(D): "How would you describe your parenting style?" | "What strategies have been most effective in addressing his behaviors thus far?" | B | By asking this question, the therapist is able to gain more insight into the client's needs and behavior patterns, as well as what strategies have been successful in helping him regulate his emotions and interact with others. Additionally, this question can help inform the therapist about any potential risk factors associated with therapy for the client. This will enable them to tailor their plan of care based on the needs and history of the client. Therefore, the correct answer is (B) | intake, assessment, and diagnosis |
600 | 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 implemented during this session? | Provide psychoeducation on systems and the impact of change | Process the client's desire to continue in his marriage relationship | Remind the client that change is difficult and his spouse needs additional kindness | Help the client set strong boundaries to protect the success he has made | (A): Provide psychoeducation on systems and the impact of change
(B): Process the client's desire to continue in his marriage relationship
(C): Remind the client that change is difficult and his spouse needs additional kindness
(D): Help the client set strong boundaries to protect the success he has made | Provide psychoeducation on systems and the impact of change | A | Individuals exist in systems and systems theory states that when one member of the system changes, this causes distress for the other members of the system as they respond to the change. The client's changes are helpful for him but create dissonance for his husband when the client is not responding as he usually does. Providing education on change and its impact on the family system allows the client to understand current circumstances and may help him respond with empathy to his partner as they navigate the changes. It would be inappropriate for the counselor to suggest the client might not want to stay in the relationship or suggest that the client should either strengthen or lower his boundaries to appease his spouse. Therefore, the correct answer is (C) | intake, assessment, and diagnosis |
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