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701 | Name: Dave Clinical Issues: Worry and anxiety Diagnostic Category: Anxiety Disorders;Substance Use Disorders Provisional Diagnosis: F41.9 Unspecified Anxiety Disorder; F10.99 Unspecified Alcohol-Related Disorder Age: 42 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: White Marital Status: Married Modality: Individual Therapy Location of Therapy : Agency | The client presents at the intake session biting his nails and cannot keep his legs from shaking. He feels anxious about his wife and work. He continually places his hands on his head and complains of headaches and nausea. He admits to drinking a bit more than he should. He denies thoughts of self-harm but sometimes wishes that he could "disappear." | First session You are a counseling intern at an agency that works with clients from various socioeconomic backgrounds. Your client is a 42-year-old married male massage therapist who owns two therapeutic massage practices. Over the past nine months, his business has been reduced by fifty percent. He is having great difficulty paying the bills for the business, and he has exhausted his personal savings. His wife is currently not working due to a back injury. He has difficulty concentrating during the day and is irritable around his employees, friends, and family. He states that he drinks "too much" in order to relax at night and admits that his hangover adds to his anxiety the next day. His wife has begun to complain, and their relationship has been strained over the past three months. The client is concerned about paying for the sessions due to financial issues. He offers to exchange massage sessions for therapy. The client is aware that anxiety and alcohol use are impacting his work and family life negatively, but he does not know how to get a handle on them. He reports feeling overwhelmed with worry about the future of his business and whether he will be able to continue providing for his family. The client has been avoiding people lately, including old friends, and only sees his mother occasionally due to her health problems. In terms of self-care, the client acknowledges that he tends to put everyone else's needs before his own, which leads to feelings of exhaustion and anxiety. Additionally, he finds it difficult to recognize or accept compliments from others and has difficulty expressing gratitude for their help. During the intake session, you identify anxiety as one of the primary issues the client is seeking help with. You also discuss the role that alcohol is playing in his anxiety and suggest strategies for reducing anxiety without relying on it as a coping mechanism. The conversation then turns to developing a plan with the client for addressing these issues, such as scheduling regular self-care activities, limiting or eliminating alcohol use, and exploring cognitive behavioral therapy techniques for managing anxiety levels. Fourth session The client presents for his fourth session. You were able to work out a payment plan with him which has relieved his immediate concerns about paying for therapy sessions. However, he reports ongoing tension about finances and says that his his wife packed a bag to leave after a "big fight" about money. She told him she needs some space to see if she wants a divorce. The client breaks down and begins to cry and shaking uncontrollably. While looking at the ground he laments, "I don't know what to do. It wasn't always like this. We used to be happy, but now I'm just stressed and worried about everything. I'm never going to be able to make enough money to support my family." He tells you that he works hard to provide for his family, but his wife does not appreciate or support him. He has been drinking more but knows that it is not helping. He has decided he needs to make some lifestyle adjustments; he is ready to make changes and work on his issues. In the session, you provide a supportive environment, helping your client to see his anxiety from a place of self-awareness and empowerment. You offer him concrete strategies for managing anxiety including relaxation techniques, cognitive restructuring, and grounding exercises. You also explore how he can work towards building better communication with his wife by expressing himself in an assertive yet respectful way. You both discuss how alcohol serves as a distraction but ultimately leads to additional anxiety. Together you come up with a plan that includes reducing the amount of alcohol he consumes, engaging in positive self-talk, and scheduling weekly activities such as going on walks to help him reduce stress levels. At the end of this session, you encourage your client to continue making strides towards his goals and remind him of the progress he has already made. You assure him that anxiety is something that can be managed with regular practice and together you will continue to work towards positive change. Eighth session The client has been seeing you once a week for the last two months. Today, he appears calm, and his thoughts are coherent. The client tells you that he has not completely abstained from alcohol, but his use has significantly decreased. He reports that he went to a virtual AA meeting but did not find it helpful, so he signed off. The client opens up and states, "I think one of the reasons I am anxious is because I am having an affair. Ever since my wife hurt her back, we have not been intimate." The client's speech becomes more rapid, and he begins to lose eye contact as he discloses the details of his affair to you. Your client tells you, "I'm not happy with my wife, either sexually or emotionally. The new woman I'm seeing understands me, and I don't want to drink when I'm around her. She helps me forget everything that causes me stress." In response to your client focusing on the positives of his affair, you engage the client in a discussion to explore the issue from other perspectives. You ask questions like, "What do you think would happen if your wife found out about your affair?" Your client pauses for a moment and looks down, and then says, "I'm not sure. I care about my wife, but I don't know if she will ever be able to understand me in the way that this other woman does. I feel like I'm trapped." You listen empathically as your client expresses his feelings of anxiety, despair and confusion. You provide clarification when necessary and strive to help your client gain insight into his thoughts and behaviors. In the session, you explore the client's anxiety and how it has been related to his affair. You address underlying issues that may be contributing to the anxiety such as unresolved feelings of guilt or fear of being discovered. You emphasize that anxiety is often a sign of trying to avoid uncomfortable emotions and situations, but acknowledging them can help him understand anxiety in a different way. You also talk about the role alcohol has played in his anxiety and suggest strategies for reducing anxiety without relying on it as a coping mechanism. The conversation then turns to incorporating strategies to address these issues in his treatment plan, such as scheduling regular self-care activities and exploring the relationship between his thoughts and behaviors. Toward the end of this session, the client appears calmer and confident in his ability to make positive changes. As you are wrapping up the session, the client confides to you that ever since he started having an affair, he has found himself sexually attracted to his daughter. He says, "It's just kind of exciting to peek in the bathroom and watch her in the bathtub. But I would never touch her! It's just a passing thought. I know that I need to stop. The thrill of my affair is satisfying enough." | The client has been married for ten years. He and his wife have two children together, a son, age 10, and a daughter, age 12. The client does not speak to his father, who divorced his mother when he was four years old. The client and his mother have a good relationship. The mother lives 15 minutes away from the client and helps his wife with the children. During the past nine months, his massage therapy practice revenue has decreased by fifty percent, and it has been difficult to pay the bills. The client has exhausted all personal savings. The client is the sole income provider for his family, as his wife is not working while recovering from a back injury. | Your client tells you, "I'm not happy with my wife, either sexually or emotionally. The new woman I'm seeing understands me, and I don't want to drink when I'm around her. She helps me forget everything that causes me stress." You respond, "I'm happy to hear that you seem less anxious and refrain from drinking with this partner, but how will this news be helpful for your wife?" What are you doing by responding in this way? | Reflecting feelings | Suggesting to the client that you believe he is not ready for termination | Exploring the problem | Providing constructive confrontation and redirection | (A): Reflecting feelings
(B): Suggesting to the client that you believe he is not ready for termination
(C): Exploring the problem
(D): Providing constructive confrontation and redirection | Providing constructive confrontation and redirection | D | Providing constructive confrontation and redirection is correct. You are letting the client know that although he seems happier in this other relationship as manifested by his lower anxiety and reduced alcohol consumption, he is forgetting about his finances and family. You are pointing out the discrepancies in his thought process and are redirecting his attention to the problems that have not gone away, even though he feels temporary relief from them. Therefore, the correct answer is (D) | counseling skills and interventions |
702 | Initial Intake: Age: 45 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Asian Relationship Status: Single Counseling Setting: Community outpatient clinic Type of Counseling: Individual | During the intake she looked visibly anxious. She appeared jumpy and kept looking at her watch. Although hesitated at times when she was asked a question. The counselor was concerned when Li paused for a long time when asked if she ever thought of hurting herself. Li eventually responded no. The counselor noticed that Li’s clothes looked disheveled and soiled. Li was not forthcoming with information about her past.
| Li is a self-referral. She walked into the clinic and stated that she had been experiencing feelings of anxiety.
History:
Li came into the community outpatient clinic asking to pay a sliding scale fee in cash. When asked for identifying information, Li asked if she had to give that information. She explained that she was undocumented and was weary of leaving any information that may lead government officials to her. Li did not want to give the counselor much of her history and cut the intake session short, stating that she had to get back to work. | null | An effective treatment for anxiety is? | Benzodiazepines | Corticosteroids | Cognitive Behavioral Therapy | Cardiovascular exercises | (A): Benzodiazepines
(B): Corticosteroids
(C): Cognitive Behavioral Therapy
(D): Cardiovascular exercises | Benzodiazepines | A | Benzodiazepines have been shown effective for anxiety. Corticosteroids treat conditions such as asthma, allergies, arthritis and bronchitis. They have also been shown to make people anxious. Cardiovascular exercises are not proven to help prevent panic attack. Cognitive behavioral therapy can be used to target irrational thought which may trigger anxiety. Therefore, the correct answer is (C) | intake, assessment, and diagnosis |
703 | Client Age: 15 Sex: Female Gender: Female Sexual Orientation: Heterosexual Ethnicity: African American Counseling Setting: Agency Type of Counseling: Individual and Group Presenting Problem: Anxiety Diagnosis: Generalized Anxiety Disorder (GAD) 300.02 (F41.1) | Mental Status Exam: The client is dressed in age-appropriate clothing and is neat in appearance. She is cooperative and, at times, overly compliant with the interview questions, which is exemplified by apologizing unnecessarily for “not answering questions in the right way.” Her eye contact is poor, but she is engaged in the interview process. The client is restless and fidgety, and her tone of voice is soft. She states that she gets between 5 and 6 hours of sleep each night, which makes her irritable at times. Her affect is anxious, and she reports poor concentration. Her excessive worry has resulted in exhaustion and feeling like she is “always playing catch-up” with sleep and schoolwork. She denies any suicidal or homicidal ideations. The client also denies drug or alcohol use. Family History and History of th | You are a counselor working in a child and family outpatient mental health center. Your client is a 15-year-old African American female enrolled in the 10th grade at a predominately white private high school. She presents today with her father, who says she “has not been herself lately.” The client reports that she is under an enormous amount of pressure to excel academically and athletically. She is the number-one ranked player on the varsity tennis team and is in the school’s honors program. The client states that she perseverates the night before a tennis match and worries that her performance will be subpar. She reports excessively practicing her serves and backhands in her spare time because she is constantly dissatisfied with her less-than-perfect performance. The client says that she feels like she doesn’t fit in with her peers, which she attributes to being the only person of color on her tennis team, and one of few in the student body. | The client is responding well to your therapeutic interventions. School has ended, and her summertime athletic and academic commitments have lessened. The client reports that she is happy to be out of school and spoke again about not fitting in with her peers. She states that there are limited opportunities for sustaining friendships and worries that she will never find a romantic interest. She reports that her mother has suspended her social media account because the client was overly consumed by the number of “likes” that she received for her online posts. You explain that you will be starting a 12-week group of diverse teens who also experience anxiety and would like her to join. She agrees and is eager to participate. Your responsibility as the group leader is to establish group rules, set limits, and develop a plan for group termination | Your responsibility as the group leader is to establish group rules, set limits, and develop a plan for group termination. In doing so, which leadership skill are you exhibiting? | Fostering autonomy | Emotional stimulation | Meaning attribution | Executive functioning | (A): Fostering autonomy
(B): Emotional stimulation
(C): Meaning attribution
(D): Executive functioning | Executive functioning | D | Group leaders demonstrate the skill of executive functioning when establishing rules, setting limits, and developing a group-specific termination (ie, discharge) plan. In other words, the group leader must remain vigilant of the group dynamics and set boundaries appropriately. Members are clear on the number of sessions held, and counselors establish the minimal discharge criteria. Lieberman et al. (1973) identified core group leadership functions as executive functioning, caring, emotional stimulation, and meaning attribution. Fostering autonomy and differentiation are therapeutic considerations for the middle stage of group development. Leaders execute meaning attribution when promoting insight and understanding among group members. Group leaders exhibit emotional stimulation at varying intervals by assessing emotional exchanges and stimulating or controlling levels of emotional expression. Therefore, the correct answer is (C) | professional practice and ethics |
704 | 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. | 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 most impacted by the client's pets' drawing her attention away from the therapy session? | The rapport between the client and therapist is impacted. | The client’s mood is affected. | The therapeutic process is impacted. | The client's ability to commit to therapy is impacted. | (A): The rapport between the client and therapist is impacted.
(B): The client’s mood is affected.
(C): The therapeutic process is impacted.
(D): The client's ability to commit to therapy is impacted. | The therapeutic process is impacted. | C | The therapeutic process is impacted when the client's pets draw her attention away from the therapy session. The setting is the most challenging part to control in online therapy and can hinder progress with the client. Therefore, the correct answer is (B) | counseling skills and interventions |
705 | Age: 27 Sex: Female Gender: Female Sexuality: Declined Ethnicity: Hispanic/African American Relationship Status: Single Counseling Setting: Community Agency Type of Counseling: Individual | The client presents as her stated age with positive signs of self-care related to hygiene and dress. She appears overweight for height as noted in her intake. Her mood and affect are congruent and she appears to be cooperative and forthcoming in her responses. She demonstrates no retardation, spasticity, or hyperactivity of motor activity. She is oriented and demonstrates no unusual thought processes or patterns. Her insight is intact and she identifies goals for therapy. She reports no suicidal ideations, thoughts of harm to self or others, or difficulties with memory, judgement, or concentration. | You are a counselor in a community agency that provides counseling. Your client presents with a history of convictions for felony criminal offenses in her early 20s, of weight loss and gains since college, and currently rates herself as approximately 50 pounds overweight. She describes herself in years past as “fat,” “ugly,” and “grotesque.” She reports one long term relationship during high school and college, with a male she tells you was “manipulative, controlling, and emotionally abusive. She reports not “dating-dating” since their break up six years ago. She does report that recently she has engaged in self-destructive behaviors with different people in the context of online relationships. She states that in several cases, she has met men and women online and used elaborate methods, including using multiple telephone numbers and creating false names and life events to establish relationships with these individuals. Several relationships ended abruptly when the individuals, both male and female, made concerted efforts to meet the client, at which time she disclosed the truth to them. She tells you that she feels very badly about what she did, particularly because she had been helping each of the people with different problems in their lives, including one of the women with an abusive spouse, and she believes now these people will have no help. She attended counseling for several months three years ago but reports she did not tell the counselor everything. Today she tells you that she is now in a professional graduate program for counseling and wants to be open about everything so she can “finally get her life in order.” | Family History:
The client reports her support system as several male and female friends. She feels close to these people though she says they sometimes irritate her. She describes her father as distant and her mother as strict and controlling. She states she and her siblings were punished frequently for not following their mother’s strict expectations for “how young women and young men should act.” She states she and her siblings were required to engage in daily exercise; always dress in “their Sunday best” during childhood; and focus on dieting, food intake, and weight ideals. She tells you she daily engaged in binging and purging from age 13 to age 20, but never told anyone or saw a doctor for this. She tells you that she has not binge/purged for the past five years. She states that her sister did the same and still struggles with it, and two other siblings are in treatment for alcohol and methamphetamine addiction. Additionally, the client tells you that both of her maternal and paternal grandparents have histories of alcoholism, and she smiles when telling you that one of her grandparents was imprisoned for criminal behavior and “is connected.” She says that several other maternal and paternal relatives have criminal convictions. | Which of the following statements will be the most appropriate response to the client's statements "I did just what you suggested"? | "I'm really glad that things worked out for you." | "Hmm...I don't remember saying that. Let's talk about it?" | "It sounds like you are trying to control me by saying that I said to do that." | "Counselors try not to give advice, but I'm glad that you were able to use that." | (A): "I'm really glad that things worked out for you."
(B): "Hmm...I don't remember saying that. Let's talk about it?"
(C): "It sounds like you are trying to control me by saying that I said to do that."
(D): "Counselors try not to give advice, but I'm glad that you were able to use that." | "Hmm...I don't remember saying that. Let's talk about it?" | B | Counselors do not give advice or make suggestions for clients because counseling is client-directed and counselors cannot be sure that their own advice or suggestions will be effective for the client or in their world outside of the session. If a counselor gives advice or makes suggestions that do not work out well for the client, the therapeutic bond can be ruptured and the client may feel betrayed. The best response is to acknowledge that this is not something the counselor would do and invite conversation to understand how the client has projected their ideas onto the counselor. Responses a and d are incorrect because counselors should never give advice or suggestions to clients, so, any response that indicates that the counselor did this would be incorrect. Stating that the client is trying to control the counselor is a defensive remark and may cause a rupture in the therapeutic relationship. Therefore, the correct answer is (B) | counseling skills and interventions |
706 | Name: Shelly Clinical Issues: Emotional dysregulation Diagnostic Category: Personality Disorders Provisional Diagnosis: F60.3 Borderline Personality Disorder Age: 41 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: Black Marital Status: Never married Modality: Individual Therapy Location of Therapy : Telehealth | The client's clothes are clean but her hair and make-up seem unkempt. She wears long sleeves but you notice some scarring on her left wrist when she steeples her hands together in front of her computer screen to answer a question. The client remains alert throughout the interview, though sometimes you have to repeat questions. She seems to be distracted by something off screen at times. She fidgets with a cigarette lighter. The client appears irritable and her affect is labile. The client is coherent. Her speech is unpressured though at times slightly slow. She is oriented to person and place but not time or situation. She is unsure of what day of the week it is and she does not seem to understand the significance of being court-ordered. Her thinking is mostly linear and goal-directed but at times tangential and unfocused. She displays persecutory thought content. Insight and judgment are poor. | First session You are a mental health therapist delivering telehealth therapeutic services. Your 41-year-old Black female client is sitting on her sofa with her arms crossed and an annoyed look on her face. When you first see the client, you are immediately attracted to her as she reminds you of your first wife. She has been mandated to therapy by the Court as part of the terms of her probation. She begins by telling you about her difficulties with her acting career. She recently auditioned for a new role but was turned down because the directors wanted to "go in a different direction." She also mentions relationship distress and tells you she has been dating a high-profile plastic surgeon on and off for two years. She tells you, "We just had a big fight. He said I was 'too high maintenance' and he was tied of 'all my drama' and left. Can you believe it? I was obviously upset and stopped for a drink on the way home and met a very nice gentleman who bought me a few more drinks. But I don't know they think I have a drinking problem." As the intake progresses, it becomes evident that the client's frustration and agitation stem from a deep feeling of abandonment. She expresses her distress over feeling overlooked and not validated in her acting career. She reveals her struggle with the expectations placed upon her as a Black woman in the entertainment industry, believing that systemic biases may be limiting her opportunities. This realization amplifies her anger and resentment, fueling her resistance to therapy and perceiving it as a means of forced compliance rather than genuine support. As you continue to gather information about her presenting problem, you notice that the client is becoming increasingly agitated. Her tone turns angry, and it becomes clear that she resents being in therapy, especially when she says you are "no more than hired help." You attempt to ease tensions and build rapport by sharing with her the names of two famous actors you have counseled. However, this does not change her demeanor or attitude toward you. You detect a recurring theme of self-sabotage that manifests in the client's relationships. She complains about her relationships with the high-profile surgeon and other men. You note the client's lack of trust in men as well as casual female acquaintances who she sometimes sees as "competition." Her relationships appear strained due to her unresolved issues, leading to conflicts and feelings of worthlessness. As you continue your assessment, it becomes apparent that a complex interplay of societal pressures, past traumas, and a deep-seated fear of abandonment negatively impacts her self-perception. You also learn that she worries about her precarious financial situation, which adds to her insecurity and instability. The fear of being unable to meet her basic needs is an artifact of her unstable childhood. You suggest that during the next session, you begin to explore what might be contributing to her current feelings and behaviors beyond just focusing on her career issues, mainly her emotional dysregulation and fears of being abandoned. She says, "I'm an actress and have auditions. How long is this going to take?" You reinforce that the client has been court-ordered to therapy and that therapy will continue for as long as it takes to address the mandated objectives in the court order. You schedule a follow-up appointment to meet with the client again next week. Sixth session The telehealth session starts like any other; you log in and wait for the appointment to begin. However, after several minutes of waiting, you are concerned that something is wrong with the client. When she eventually logs on, she is 15 minutes late and crying uncontrollably. When prompted about what happened, the client begins pouring out her anguish over her boyfriend's recent departure from town on business. She explains how he will not be coming home this weekend like they had planned - leaving her feeling empty and alone. Then, with tears streaming down her cheeks, she says, "I see no reason to go on if he will only cause me grief." At this point, you realize your client might be at risk of self-harm or worse. You spend the remainder of the session developing a safety plan together, which involves finding alternative ways to cope with loneliness and reaching out to friends and family members who can support the client during distress. Despite your best efforts in the session to establish a safety plan, you perceive her adherence to it as shaky. Her body language and verbal feedback clearly show that she struggles to accept the idea of seeking help from her network of friends and family. She confesses feeling like a burden to others, reflecting a deep-seated inferiority complex that seems central to her emotional distress. This, coupled with her inability to visualize the situation from a holistic perspective, implies that she might be caught in the throes of an existential crisis, unable to see beyond the immediate emotional turmoil. Tackling this crisis from an Adlerian lens, you gently challenge her self-defeating beliefs and attempt to imbue her with a sense of belonging and community. However, her tearful responses indicate a sense of discouragement and isolation, suggesting she perceives herself as alone in her struggle. It is apparent her social interest is significantly diminished. You note that this disconnection isolates her emotionally and poses a potential risk to her overall well-being. Despite your attempts to reassure her, she repeatedly questions her self-worth and viability without her boyfriend, mirroring feelings of inferiority and an over-reliance on external validation. In the face of such severe emotional turmoil and potential risk, you recognize that her current mental state may require a more intensive approach beyond the scope of telehealth sessions. This solidifies your intent to seek a higher level of care and immediate intervention for her, emphasizing the severity of the situation and your dedication to safeguarding her well-being. After the client leaves the session, you call her emergency contact and discuss your concerns. You tell the client you are considering referring her for further assessment by a psychiatrist or hospitalization to ensure her safety. You request the client's emergency contact person to call you if they see any indications that the client is decompensating. | The client shared significant details about her familial history, particularly on her father's side. She conveyed that her paternal relatives have contended with various mood disorders, although she could not provide specific diagnostic categories. As a result of her father's authoritarian parenting style of strict adherence to his rules and restrictions, she has rejected any limitations from any authority figures. Notably, she also revealed several severe distressing incidents within her family, including suicide attempts, multiple instances of divorce, and hospital admissions. According to the client, these incidents often emerged due to relational difficulties, culminating in elevated levels of emotional distress. Furthermore, the client reported a history of hospitalization, although her recollection of the admission circumstances was somewhat nebulous. She said that she was feeling "distraught" during that period. You determine that exploring this episode more thoroughly in future sessions when the client feels ready and comfortable could provide valuable insights into her emotional coping mechanisms and resilience. The client was recently arrested for driving under the influence (DUI). This was not her first encounter with law enforcement regarding such a matter, as she has been charged with three DUIs over the past five years. However, this recent incident was markedly different and considerably more severe. She lost control of her vehicle and collided with a residential building, resulting in physical injury to a child. She underwent legal proceedings after her involvement in this accident and was found guilty. As part of her sentence, she was placed on probation under the court's oversight and mandated to attend therapy. The client disclosed that her consumption of alcohol is primarily social in nature. However, she also appears to use alcohol to self-medicate in times of emotional dysregulation. Despite these circumstances and her ongoing encounters with the law, she maintains the belief that her alcohol use does not pose a significant problem. | What would you ask the client when she is in crisis? | Can you promise me you won't hurt yourself? | Why are you choosing to feel this way? | Do you have access to anything that could potentially harm yourself? | Who would you like me to contact? | (A): Can you promise me you won't hurt yourself?
(B): Why are you choosing to feel this way?
(C): Do you have access to anything that could potentially harm yourself?
(D): Who would you like me to contact? | Do you have access to anything that could potentially harm yourself? | C | This is an excellent question for determining whether the client has access to any dangerous means of self-harm. Therefore, the correct answer is (D) | intake, assessment, and diagnosis |
707 | Client Age: 32 Gender: Female Sexuality: Bisexual Ethnicity: Caucasian Counseling Setting: Agency Type of Counseling: Individual Presenting Problem: Binge-eating Diagnosis: Binge-Eating Disorder 307.51 (F50.8), Moderate | Mental Status Exam: The client presents as polite and cooperative. She was well-groomed and dressed appropriately for the situation. Her affect is blunted, and she is tearful when discussing episodes of binge eating. The client has poor eye contact and periodically bites her fingernails. Her thought content is clear. She does not endorse audiovisual hallucinations, and she is oriented to person, place, time, and situation. The client denies suicidal and homicidal ideations. She denies previous suicidal attempts but states that she used to engage in cutting when she was an adolescent | You are working at an agency serving clients from the metropolitan area. Your client is a 32-year-old bisexual female presenting with feelings of sadness, frustration, and shame due to increased episodes of binge eating. The client explains that she has tried unsuccessfully to manage her weight and control her eating. She states she is secretive when bingeing and feels “disgusted” afterward but “completely unable” to stop the compulsion. The client reports binge eating six times per week, with episodes worsening in the last two years. She identifies as bisexual and reports her binge eating increased after coming out to her family. She continues to struggle with depressive symptoms, including feelings of hopelessness, depressed mood, and anhedonia. The client’s weight places her in the category of obese, and she has recently been diagnosed with borderline diabetes. Towards the end of the session, the client states, “This is starting to affect my health. If I could change anything in my life, it would be to stop binge eating.” | The client reports that she started her week doing well but had a setback a few days ago, causing her to lose confidence in her ability to change. Despite her progress in reducing binge-eating episodes, the client remarks, “I’ll never control my eating.” She says she is frustrated and feels hopeless and unmotivated. You address her ambivalence to change, as well as obstacles she has experienced in the past. When discussing exercise, the client states, “You don’t understand! I’ve tried exercise, and it never works.” You provide the client with self-monitoring sheets to record the following in real-time: daily food intake, maladaptive eating patterns, and thoughts and feelings that accompany binge eating. She is hesitant but agrees to give it a try for one week | Using motivational interviewing to respond to the client’s attitude towards exercise, which statement represents an amplified reflection? | “You’re done with taking suggestions; there are no options left for you.” | “You’ve tried exercise and don’t think it will ever work for you.” | “You feel like nothing works, but you remain persistent. Making this change must be really important to you.” | “You’re frustrated at my suggestion, so much so that it seems like you’ve reached a boiling point.” | (A): “You’re done with taking suggestions; there are no options left for you.”
(B): “You’ve tried exercise and don’t think it will ever work for you.”
(C): “You feel like nothing works, but you remain persistent. Making this change must be really important to you.”
(D): “You’re frustrated at my suggestion, so much so that it seems like you’ve reached a boiling point.” | “You’re done with taking suggestions; there are no options left for you.” | A | The counselor’s response representing an amplified reflection is: “You’re done taking suggestions; it feels like there are no options left for you” Amplified reflections use the client’s original statement and over-emphasize their point or intent. The purpose is to push the client past ambivalence and toward change. A simple reflection is represented in answer A: “You’ve tried exercise and don’t think it will work” A simple reflection validates what the client has said and shows that you are listening to her concerns. Stating that it seems like the client may have reached a boiling point is not entirely accurate and illustrates a communication error, specifically a depth error. This occurs when the therapist reads too much into the client’s statements. Answer B, which states: “You feel like nothing works, but you remain persistent. Making this change must be really important to you,” is an example of reframing. Reframing is used to help the client see the problem from a different and generally more positive perspective. Therefore, the correct answer is (C) | counseling skills and interventions |
708 | 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 planning objective would best support Taylor's stated goal? | Taylor will apply at least one coping method and report successful anxiety reduction. | Taylor will become capable of managing her emotions during stressful transitions. | Taylor will learn at least three new coping methods and apply them within six months. | Taylor will identify and verbalize at least three triggers causing her underlying anxiety. | (A): Taylor will apply at least one coping method and report successful anxiety reduction.
(B): Taylor will become capable of managing her emotions during stressful transitions.
(C): Taylor will learn at least three new coping methods and apply them within six months.
(D): Taylor will identify and verbalize at least three triggers causing her underlying anxiety. | Taylor will learn at least three new coping methods and apply them within six months. | C | This is the best answer because it adequately covers SMART goal criteria of being specific, measurable, achievable, realistic, and timely. Answer a is not helpful for Taylor because it does not offer a treatment solution, as she has already presented several concerns causing her anxiety, she will likely be able to easily achieve this objective within the first session based on her presentation and what information you have already gathered. Answers b and d are not specific enough, nor do they offer a timeline for achievement. Therefore, the correct answer is (C) | treatment planning |
709 | 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. | The client has arrived 15 minutes late for your scheduled session. When you approach the waiting room, you find her loudly talking on her cell phone. She abruptly ends the call and follows you back to your office. She is visibly shaken and angry. She explains that her soon-to-be ex-husband is a “master manipulator” and is “ruining my life.” She remains confident that she can stop drinking but states she can only do so once her family situation is under control. After all, she states, “You would drink too if you had my problems.” She begins to de-escalate as the session progresses, and she is able to identify and prioritize treatment issues. Her sleep continues to be a concern. Upon further exploration, she indicates she is having nightmares and has been for quite some time. The two of you work together to prioritize treatment plan goals. Her mood and demeanor brighten as the session concludes | When discussing treatment issues, you ask, “How does drinking align or not align with your goal of improving relationships with your family?” What is the value of posing this question? | It allows for the focus to be kept on the client’s alcohol misuse. | It helps create incentive-based interventions used in contingency management. | It helps create a discrepancy between the client’s actions and personal values. | It assists with providing baseline measures for treatment plan goals. | (A): It allows for the focus to be kept on the client’s alcohol misuse.
(B): It helps create incentive-based interventions used in contingency management.
(C): It helps create a discrepancy between the client’s actions and personal values.
(D): It assists with providing baseline measures for treatment plan goals. | It helps create a discrepancy between the client’s actions and personal values. | C | According to Miller & Rollnick (2013), developing discrepancy between the client’s values and behaviors helps increase the client’s motivation to change. The onus is on the client, rather than the counselor, to argue for change. In doing so, you help elicit intrinsic motivation by emphasizing the conflict between the client’s drinking and the value she places on familial relationships. This question goes beyond simply focusing on the client’s alcohol use, making answer A incorrect. Developing discrepancy helps the client narrow down treatment plan goals, but it does not provide baseline measures for the treatment plan. Contingency management is a treatment approach that involves presenting clients with tangible rewards for attaining and maintaining abstinence. Therefore, the correct answer is (B) | treatment planning |
710 | Client Age: 7 Grade:2nd Sex: Male Gender: Male Ethnicity: African American Counseling Setting: Community Mental Health, School-Based Services Type of Counseling: Individual and Collateral Presenting Problem: Impulsivity; Inattention; Hyperactivity Diagnosis: Attention-Deficit Hyperactivity Disorder (ADHD) 314.01 (F90.2) | Mental Status: The client is dressed appropriately, and he is well groomed. His affect is bright when engaged in an activity of his choice, but he becomes irritable when asked to comply with a direct request (e.g., pick up the toys, walk in the hallway). He is energetic, eager to please, and interrupts your conversation with the mother, as evidenced by the client stating multiple times, “Watch this! Hey! Watch! Look what I can do!” The client has difficulty transitioning from your office and back to his classroom. He runs ahead of you in the hallway and does not respond to redirection. The client has not voiced suicidal or homicidal ideation. Developmenta | You are a clinical mental health counselor providing on-site school-based services in a public elementary school. Your client is a 7-year-old African American male enrolled in the 2ndgrade. The client is accompanied by his mother, who states that she is here because the school “requested an ADHD assessment.” The school reports that the client is disruptive, refuses to follow directions, disturbs others, and has difficulty staying on task. The mother describes the client as “energetic” and “strong-willed”—behaviors that she believes are “just typical for a boy.” She is upset that the school wants to conduct a formal evaluation to determine if the client qualifies for a more restrictive classroom setting. The school’s population is predominantly white, and the mother believes that her son is being treated unfairly because of his race. | You have been working with the client weekly and are meeting with the mother today to discuss interventions that she can use at home. She relays that her husband does not support the diagnosis of ADHD and has reached out to their faith community instead. The mother is conflicted about counseling and explains that it is viewed as a sign of weakness in her community. She continues to voice concern over the school’s lack of diversity and her belief that the client is being treated differently because of his race | Which statement accurately reflects the ACA Code of Ethics guideline for working with culturally diverse populations? | Counselors consider the client’s cultural background when providing assessment results and only use bias-free instruments. | Counselors seek supervision when they are at risk of a client imposing their values, attitudes, beliefs, and behaviors onto the counselor. | Counselors recognize existing historical and social prejudices in the misdiagnosis and pathologizing of certain individuals. | Counselors practice only within the boundaries of their competence based on their education, experience, and ability to engage with diverse client populations. | (A): Counselors consider the client’s cultural background when providing assessment results and only use bias-free instruments.
(B): Counselors seek supervision when they are at risk of a client imposing their values, attitudes, beliefs, and behaviors onto the counselor.
(C): Counselors recognize existing historical and social prejudices in the misdiagnosis and pathologizing of certain individuals.
(D): Counselors practice only within the boundaries of their competence based on their education, experience, and ability to engage with diverse client populations. | Counselors recognize existing historical and social prejudices in the misdiagnosis and pathologizing of certain individuals. | C | The ACA Code of Ethics states, “Counselors recognize historical and social prejudices in the misdiagnosis and pathologizing of certain groups and strive to become aware of and address such biases in themselves or others” (ACA, 2014, Section E5c). Section C2 addresses professional competence, stating, “Multicultural counseling competency is required across all counseling specialties, [and] counselors [must] gain knowledge, personal awareness, sensitivity, dispositions, and skills pertinent to being a culturally competent counselor working with a diverse client population” (ACA, 2014, Section C2a). Regarding assessment instruments, counselors must “use assessment as one component of the counseling process, taking into account clients’ personal and cultural context” (ACA, 2014, Section E). Because there is the potential for bias in nearly all assessments, counselors must consider using multiple methods and multiple informants to reduce cultural biases. Finally, counselors avoid imposing their values, attitudes, beliefs, and behaviors onto the client, making option D incorrect. Therefore, the correct answer is (A) | professional practice and ethics |
711 | Client Age: 9 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Private practice clinic Type of Counseling: Individual counseling with family involvement Presenting Problem: Behavioral problems and social skills issues Diagnosis: Autism spectrum disorder, without accompanying intellectual impairment (F84.0) | Mental Status Exam: The client is oriented to person, place, situation, and time. The client appears clean and is wearing season-appropriate clothing; however, his parents report that he often wears the same outfit for several days because he gets frustrated with having to change his clothes and showering. The client was minimally involved in the intake session and was instead focused on reading a video game walk-through | You are a private practice, licensed counselor. The client is 9 years old and comes to the first session with his parents. The client has been previously diagnosed with autism via use of the Autism Diagnostic Observation Schedule-Second Edition by a psychologist, and you receive supporting documentation for this diagnosis. The client demonstrates difficulties with normal back-and-forth communication with peers, difficulty maintaining eye contact during the session, and difficulty with imaginative play with peers as reported by his parents. The client and his parents also report what they call “OCD behavior”—for example, he often lines up toys and insists that they “have to be this way”—and that he has trouble with changes in schedule, often becoming aggressive toward the parents if changes occur. The parents report that he is very rigid and that certain activities and play have to be done a certain way or he becomes upset, which affect the home, social, and school settings. The client’s intellectual quotient is above average for his age per the supportive testing provided. The parents report that the client’s difficulty with changing plans or daily changes causes him to become angry and confrontational. | This session is occurring in the client’s home in order to observe behaviors in his natural environment. The client’s parents and 8-year-old brother are present. You are observing during this session in order to gather information and then to provide psychoeducation at the end of the session to the parents. The client and his brother are sitting on the floor playing with a building toy, which the client’s parents report is often a toy that causes him frustration because he plays very specifically with it and his brother does not want to play how he does. After about 5 minutes, the client becomes visibly frustrated as he is telling his brother to put a brick in a certain place because it is the same color and his brother says he is not going to and goes to build on his own. The client continues to build and asks for the piece repeatedly over a few minutes. The client then picks up what he is building and throws it against the wall and leaves the room | Which of the following would be the most appropriate intervention with regard to providing treatment for this client’s diagnosis? | Prompt the client to take a break and listen to music to calm down. | Prompt him to play with another toy. | Remind him of appropriate social skills. | Encourage the client and his brother to play separately. | (A): Prompt the client to take a break and listen to music to calm down.
(B): Prompt him to play with another toy.
(C): Remind him of appropriate social skills.
(D): Encourage the client and his brother to play separately. | Prompt the client to take a break and listen to music to calm down. | A | Prompting the client to calm down when you see that he is visibly upset, but before he throws the toy, is the most helpful intervention because it addresses the client’s difficulty with frustration management. Although social skills are helpful for individuals who have autism, the client was being very rigid in his thinking and needed to calm down prior to using appropriate social skills. Prompting the client to play with something else or separating the client from his brother would be avoiding dealing with the client’s difficulties with frustration management. Therefore, the correct answer is (D) | counseling skills and interventions |
712 | Client Age: 30 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Pacific Islander Relationship Status: Single Counseling Setting: Private practice counseling clinic Type of Counseling: Individual counseling Presenting Problem: The client and her boyfriend recently broke up, and she is “tired of being with the wrong guys.” She admits that she will often stay in relationships even if she knows they are wrong for her. Diagnosis: Provisional diagnosis: Dependent personality disorder (F60.7), personal history (past history) of spouse or partner violence, physical (Z69.11), and personal history (past history) of spouse or partner psychological abuse (Z91.411) | Mental Status Exam: The client is oriented to person, place, time, and situation. No hallucinations, delusions, or paranoia are reported. The client was anxious at the start of the session, but she was able to calm herself down by easing into the counseling relation | You are a professional counselor working in a private practice clinic. The client comes in and sits quietly. The client appears nervous because she avoids eye contact and waits for you to initiate conversation. You ask why she is in counseling, and she responds that she is just tired. You ask more about this, and she says that she is not ready to talk about it yet. You decide to cover demographics and other less intimidating topics and then ask if she is comfortable talking yet. The client says that she feels a little more comfortable. She begins to state that she and her boyfriend broke up the previous week and that she was with him for 2 years. She explains that she has been “in this type of relationship before,” continually finds the “wrong guy,” and that she always goes “all in” with her relationships. Through processing, she identifies the following behaviors and beliefs: difficulty making daily decisions without the input of her partner, doing anything to gain support and affection even if she does not want to do the task or activity, quickly moving on to another relationship when a relationship ends, feeling that she cannot care for herself when she is not with someone else, and acknowledging that she needs others to take responsibility for major areas of her life. The client says that she has experienced physical and psychological abuse from partners, but that she is not ready to discuss this. The client identifies that her most important goal is to not end up in “the same relationship” again or rush into a relationship that is not right for her. Throughout the session, you provide empathetic and active listening. You suspect that the client has dependent personality disorder. | ship. Family History: The client is close with her parents and her younger brother (28 years old). The client says that she was engaged twice before but that neither engagement progressed to marriage because her two fiancés both felt that she was too clingy and unable to care for herself. Psychodynamic therapy has proven to be effective in the treatment of dependent personality disorder | Psychodynamic therapy has proven to be effective in the treatment of dependent personality disorder. Which one of the following is a defining principle of psychodynamic therapy? | Childhood experiences and unconscious wishes and fears greatly shape an adult’s personality | Changing the narrative from “I’m a loser” to “my anxiety sometimes makes me think I’m a loser” | Focusing on the present moment using mindfulness techniques to accept thoughts and feelings without judgment | Using free association and dream interpretation to investigate conscious and unconscious thoughts | (A): Childhood experiences and unconscious wishes and fears greatly shape an adult’s personality
(B): Changing the narrative from “I’m a loser” to “my anxiety sometimes makes me think I’m a loser”
(C): Focusing on the present moment using mindfulness techniques to accept thoughts and feelings without judgment
(D): Using free association and dream interpretation to investigate conscious and unconscious thoughts | Childhood experiences and unconscious wishes and fears greatly shape an adult’s personality | A | The psychodynamic approach involves investigating childhood experiences and underlying wishes and fears because they often affect an adult’s personality and functioning. Focusing on the present and accepting thoughts and feelings are principles of acceptance and commitment therapy. Changing the narrative from “I’m a loser” to “my anxiety sometimes makes me think I’m a loser” is a principle of narrative therapy, which strives to externalize anxiety as not being part of the client. The use of free association and dream interpretation as well as investigating conscious and unconscious thoughts are parts of psychoanalysis. Therefore, the correct answer is (A) | counseling skills and interventions |
713 | Client Age: 51 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Divorced and single Counseling Setting: Local government mental health agency Type of Counseling: Individual counseling Presenting Problem: The client is experiencing a recent separation from her last partner who was verbally and physically abusive, and she is currently living in a domestic violence home. Diagnosis: Major depressive disorder, recurrent episode, moderate (F33.1) and post-traumatic stress disorder (PTSD) (F43.10) | Mental Status Exam: The client’s affect is flat, and she is hunched over in the chair. The client is oriented to person, place, time, and situation. She reports no hallucinations, paranoia, or depersonalization/dissocia | You are a licensed counselor working for a local government mental health agency in the counseling clinic. The client was referred to receive case management and counseling after experiencing homelessness due to leaving a physically and verbally abusive relationship with her last partner. The client is experiencing the following depressive symptoms: sadness more often than not, mental fogginess, suicidal ideation, insomnia, significant weight loss, feelings of worthlessness, and fatigue. The client experiences PTSD symptoms due to having experienced several abusive relationships, including recurrent distressing intrusive thoughts regarding the physical abuse, distressing dreams related to abuse, and physiological reactions (difficulty breathing, heart racing) when she goes near certain places that remind her of the abuse. She also explains that she has been avoiding triggers, believes that no one can be trusted, has an exaggerated startle response, and has had difficulty experiencing positive emotions. The client says that she does not know if therapy can help because she feels like these events have changed her and that she cannot get back to “normal,” but that she would like to make friends so she doesn’t feel so alone. | The client comes to this session, sits down, and starts talking about how she met a man and talked to him for about an hour and was frustrated at the end of the conversation because she feels that he is “like everyone I’ve been with before.” The client continues to explain that she knows these men are not good for her and that she wants something different, but she is still talking to him. The client becomes frustrated talking about this and begins crying and breathing heavily, stating that, “I am broken and can’t have a healthy relationship.” You support the client through her strong emotions and provide empathetic listening | Based on the client’s emotional reaction to talking about her relationship with this new man, which of the following would be the most clinically indicated response based on the client’s stage of change? | Validate the client’s emotions and support her in engaging in coping skills. | Empathize with the client to build rapport. | Validate the client’s emotions and support her beliefs because she has had difficult relationships and this would be the most genuine response. | Challenge the client’s cognitive distortion of labeling because the client is labeling herself based on past situations. | (A): Validate the client’s emotions and support her in engaging in coping skills.
(B): Empathize with the client to build rapport.
(C): Validate the client’s emotions and support her beliefs because she has had difficult relationships and this would be the most genuine response.
(D): Challenge the client’s cognitive distortion of labeling because the client is labeling herself based on past situations. | Validate the client’s emotions and support her in engaging in coping skills. | A | Validating your client’s emotions and engaging in coping skills is the most appropriate response because the client is in the preparation stage of change and knows what the problem is but is not able to make changes yet. Validating emotions and helping the client cope in the moment deals with the client’s presenting emotions. Challenging cognitive distortions would be part of the action stage, and the client is not ready to engage in this step yet. Simply empathizing with the client may build rapport but will not help the client develop skills to manage strong emotions. Validating the client’s emotions and beliefs based on her past experiences may reinforce her labeling of herself and may also demonstrate that you think the client is incapable of changing her future experiences. Therefore, the correct answer is (A) | counseling skills and interventions |
714 | Name: Chad Clinical Issues: Maladaptive eating behaviors Diagnostic Category: Feeding and Eating Disorders Provisional Diagnosis: F50.2 Bulimia Nervosa, Moderate Age: 16 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: White Marital Status: Not Assessed Modality: Individual Therapy Location of Therapy : Agency | The client is appropriately dressed but disheveled. He is dressed in clothes associated with anime characters. Concentration is drifting. His speech is somewhat low, and he keeps his head low to avoid making eye contact with you. His mood is anxious. There is no suicidal ideation. Thought content shows no current homicidal ideation or plans. Thoughts are appropriate. The estimated level of intelligence is in the low average range with abstract thinking. | First session You are a mental health therapist who works for an agency specializing in helping teens with eating disorders. The client is 16 years old. He presents for therapy along with his mother. You start by welcoming both of them into your office. Then you introduce yourself, explain your role as a therapist, and briefly describe the experience you have in treating eating disorders. Next, you ask the client to explain and his mother to share with you why they came to see you today and what their expectations are for therapy. The mother begins by telling you, "My son is doing dangerous things to his body. He needs help, but he won't listen to me." The client rolls his eyes and replies, "She doesn't get it. Look at her. She's fat and is always overeating!" His mother's face turns red and she starts to yell at him. You remain neutral and ask them both take a few deep breaths and give each other some space. You explain that your goal is to create a trusting relationship with the client and his mother so that you can start working together towards understanding the issues that bring them to counseling and how to best help. You ask the mother to take a seat in the waiting room while you speak with her son for the first part of the session. She reluctantly agrees and leaves the room. Once the mother leaves, you start by letting the client know that you understand that this situation is difficult, and that you are here to help. You focus on building rapport with the client, emphasizing that you are here to help him. You ask him open-ended questions to get to know more about him, and to help him feel seen and understood. You acknowledge the client's feelings of being misunderstood and provide empathy by validating that it must feel difficult not having his mother understand what he is going through. You also recognize his mother’s concerns by saying, "It sounds like your mom is really worried about you." He tells you that his mother is constantly trying to control him and that he does not understand why she is always so angry all the time. You continue your assessment with structured questioning to understand the client’s current experiences with food, including what he likes to eat and how often he eats. At the end of your discussion with the client, you thank him for being open and honest with you. You acknowledge how brave it is to come in and start talking about his experiences. You invite him to bring his mother back in to the office so you can start working together and discuss the next steps. Fourth session It has been three weeks since the first counseling session, and you have agreed to meet for weekly sessions. You have been able to develop a positive rapport with the client, and he arrives to the scheduled session on time. When you ask him how he has been feeling, he tells you that he has been experiencing some anxiety. He has been having trouble sleeping and difficulty concentrating. He tells you that during his last cheerleading routine at a football game, he froze up and forgot what to do. You ask him if his anxiety may have anything to do with being bullied years ago. He tells you, "I don't wanna talk about that. My anxiety is about cheerleading. Ugh! Haven't you been listening to what I've been saying?" You remain calm and acknowledge the client's frustration. You reply, "You're angry with me because you feel that I'm not listening. Am I hearing you right?" He glares at you. You apologize, saying that you are sorry that something you said made him upset and ask him to tell you more about his anxiety. The client takes a few deep breaths and begins to tell you about the anxiety he feels towards cheerleading. He mentions that his mother used to be a cheerleader and she often tries to relive her glory days through him. He tells you he feels like his mother is always pushing him to do more and be better, but "she just doesn't get how hard it is for me." He also talks about feeling guilty when he fails to meet her expectations. You respond by saying, "It sounds like there's a lot of pressure on you from your mom. How do you cope with these expectations?" He says that he has been trying to distract himself from his feelings by watching television, playing video games, and eating. You take a moment to process this information and validate his feelings. You and the client agree to explore some healthier coping strategies, along with continuing to build a stronger connection between him and his mother. You also discuss the importance of having a support system of people who can lend an ear when he needs someone to talk to and provide emotional support. Sixth session It has been one and a half months since you began seeing the client for therapy. He followed up on the referral you gave him to see a psychiatrist and he is currently taking medication for his anxiety, but he reports that "the pills aren't really helping." He says he loves cheerleading and gymnastics and will never give them up. He reports he is still eating and exercising to excess but refuses to stop. He continues, "I'm aware of the dangers, but I don't care. All athletes go through pain to be successful." You assess the client's internal and external motivation as a strategy to separate the client from his denial that he has an illness. | The client does well in high school. He is concerned that he could quickly gain weight and no longer be in optimum shape for cheerleading and gymnastics. The client's self-esteem is closely related to his weight and body image, and he appears to lack insight into the dangers of his current eating behaviors. Stressors & Trauma: The client tells you throughout elementary school he was overweight. As a result, he was bullied by other boys and girls alike. They would leave notes on his desk saying "fatty" or "crispy crème." One student pushed him down in the schoolyard, and all the others stood in a circle around him and laughed as the client cried. Pre-existing Conditions: No significant medical issues were reported based on his last medical exam. He does, however, admit to eating four hamburgers and a large bag of French fries at a fast-food restaurant "as a treat" about four or five times a week. He shares that after these fast food "splurges," he goes home and purges to not gain weight. Feeling guilty after each episode, he does not eat anything the next day and doubles his workout routine. | You state, "When I was in high school, I also had an eating disorder. It was not until I realized I needed professional help that my life changed." What did you do here as the therapist? | Self disclosed your personal history | Crossed a boundary with the client | Encouraged the client to continue treatment | Focused on yourself over the client | (A): Self disclosed your personal history
(B): Crossed a boundary with the client
(C): Encouraged the client to continue treatment
(D): Focused on yourself over the client | Self disclosed your personal history | A | You are showing the client that you understand what he is going through. Self-disclosure can be very powerful in therapy when used appropriately. Therefore, the correct answer is (D) | professional practice and ethics |
715 | Name: Carter Clinical Issues: Developmental processes/tasks/issues Diagnostic Category: Neurodevelopmental Disorders Provisional Diagnosis: F90.0 Attention-Deficit/Hyperactivity Disorder, Predominately Inattentive Presentation; F81.2 Specific Learning Disorder with Impairment in Mathematics Age: 11 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Not Assessed Ethnicity: White Marital Status: Not Applicable Modality: Individual Therapy Location of Therapy : School | The client is of average build. He is dressed in a neat and appropriate manner for school. He is reluctant to engage in the conversation but does not display any hostility or aggression. The client displays a flat affect with occasional brief moments of animation which appear to be fueled by fleeting interests. His mood appears to be somewhat dysphoric as he often responds with a shrug or a one-word answer. The client’s thought process is non-linear and circumstantial. He is able to answer questions in a straightforward manner once he understands the topic being discussed. The client’s speech is of normal rate and volume for his age but it does contain some articulation errors due to his speech disorder. His memory appears intact as he can recall details from previous conversations with ease. | First session You are a mental health therapist in a public school. The client, an 11-year-old male, and his parents arrive at your office for the intake appointment per a referral from the committee on special education. The parents express concerns with their son's ongoing lack of concentration, being easily distracted, requiring multiple prompts and redirection throughout his day, and not following multi-step processes. The mother states that he tends to "drift off and is fidgety." He has trouble sitting still and cannot focus on anything for more than a few minutes. According to the parents, this behavior is present at both school and at home. As you progress with the intake session, you ask the parents to describe their current goals and any treatment barriers they have experienced up to this point. They state that they would like their son to be more focused throughout the day and be better able to follow instructions. They also mention that so far their efforts in trying to help him have been unsuccessful and he is still struggling. After gathering more insight into the client's home life, school performance, and developmental history from the parents, you turn your attention to the client. He has been looking around the room and has not been actively engaged in the conversation. When asked directly about his feelings about school, he shrugs and says, "It's okay." You ask him if there is anything that makes it hard for him to stay focused in class, and after a few seconds of reflection he admits that it is sometimes difficult because "there are too many things happening at the same time." He states that he cannot keep up with all of the activity going on around him and it is distracting. You inquire further as to what else may be contributing to his difficulty maintaining attention in school and he admits that sometimes he gets frustrated when tasks are too challenging for him. While he is answering your questions, he is looking at the small tabletop clock sitting on the corner of your desk. Once you feel that you have an accurate understanding of the current presenting issues, you discuss next steps with the parents. You discuss meeting with the client for individual weekly sessions to help him develop effective coping skills, build self-esteem, and manage emotions associated with frustration, failure, and low self-worth. You also suggest collateral sessions with the parents to check in with them about their son's progress and discuss strategies they can use at home to help him. They agree to this arrangement and ask if there are any tools or techniques they can try between now and the next time they meet with you. You suggest they start by creating a daily routine that will provide a sense of predictability and help to reduce chaos, and having a set time for homework, meals, and bedtime. You also mention that stimulant medication is often prescribed for children with ADHD, which can help to improve focus and concentration. Lastly, you let the parents know there is some evidence that certain foods can trigger or worsen ADHD symptoms, such as sugary, processed, or artificial foods. Fourth session Last week you met with the client's parents to discuss behavioral parent management training, educating them on how this approach can be used to decrease disruptive behavior and encourage positive behaviors. You taught them how to identify and reinforce desired behaviors and asked them to start keeping a log to record the client's behaviors during the day, what actions they took in response to his behaviors, and how he responded. Additionally, you suggested introducing rewards for meeting goals and discussed the importance of consistency. They followed up with you prior to today's appointment, stating that they believe the parent management training has been beneficial so far, as they have seen a slight decrease in disruptive behaviors and an increase in compliance. The client arrives for his fourth individual session with you. When you ask him how he has been feeling this week, he states that he does not want to go to math class because they "move too fast," and he cannot keep up. The client says he does not feel it is fair that "the teacher yells at me every day even when I'm trying my best." He says, "She's mean, and I won't go back to her class ever again!" He is displaying signs of anger and frustration. His arms and legs are tense, he is tapping his feet, and his facial expression is scrunched up in a frown. His breathing is shallow and rapid. You attempt to calm him down by guiding him in a breathing exercise that you first introduced during a previous session that involves taking slow, deep breaths. You repeat this exercise a few times with the client until he is feeling calmer. In order to further explore the client's feelings about math class, you ask that he draw a picture of the classroom and how it makes him feel. He draws an angry teacher standing in front of a chalkboard with a lot of numbers written on it in random order. The client says that this is how his math class feels to him: overwhelming and confusing. You explain to the client that you understand how overwhelmed and confused he feels, and that it can be really hard to focus on a task when it feels too hard. You also assess the client's perceptions of the teacher, noting his feelings of mistrust and apprehension. Additionally, you assess the client's ability to self-regulate in the classroom and his overall attitude towards class participation. You talk to him about some strategies to help him feel more comfortable in class, and you also reassure him that you are going to talk to his math teacher. | The client is currently a fifth grader participating in the general education curriculum. He has a disability classification with his school district as learning disabled. He receives consultant teacher services via classroom support aide for English Language Arts (ELA) and Math. In addition, he attends the resource room daily for added support. The client arrives to class prepared with necessary materials and homework assignments but requires prompts throughout his day to stay on track. He is conscientious about his grades and doing well academically but is easily distracted by environmental factors surrounding him. Three years ago, the client's triennial evaluation report indicated a classification of Speech Language Disorder. To date, staff suggests that the client's speech deficits manifesting as notably impaired speech do not seem to cause concern in social situations. Additional Characteristics: The client is a very pleasant, quiet, shy, reserved boy. He tends to lack confidence in his academic abilities, which seems to cause him stress. Small glimpses of the client's good sense of humor can often be seen in small group settings. | How does the client's level of insight affect your treatment plan? | Activities for the client should be haptically-oriented and developmentally appropriate. | Insight is a teachable skill which should be a top priority in your treatment plan. | The client should determine the direction of your treatment plan. | The client's level of insight should not affect your treatment plan. | (A): Activities for the client should be haptically-oriented and developmentally appropriate.
(B): Insight is a teachable skill which should be a top priority in your treatment plan.
(C): The client should determine the direction of your treatment plan.
(D): The client's level of insight should not affect your treatment plan. | Activities for the client should be haptically-oriented and developmentally appropriate. | A | A "hands on" approach will work better with a client with low insight and judgment. Therefore, the correct answer is (A) | treatment planning |
716 | Name: Bianca Clinical Issues: Difficulty adjusting to life changes Diagnostic Category: V-codes Provisional Diagnosis: Z60.0 Phase of Life Problem Age: 62 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: Black Marital Status: Separated Modality: Individual Therapy Location of Therapy : Agency | The client is a 62-year-old female, wearing work attire. She appears to be in good hygiene and her dress is neat and appropriate for the situation. Her facial expression is sad and she has tear tracks on her cheeks. Her mood is noticeably depressed, anxious, and tearful. Her affect is constricted. She has coherent thought processes with appropriate content. She expresses feelings of sadness over her failed marriage and overwhelm about being alone. The client has intact memory and concentration. She has fair insight into her current situation and is able to verbalize her feelings in a coherent manner. | First session The client comes to the agency practice where you currently work as a licensed mental health therapist. She is a 62-year-old female who recently retired from an accounting firm employment. She is seeking treatment after her marriage recently failed. A few months ago, he husband filed for a legal separation and is currently romantically involved with another woman. The client looks at you tearfully and says, "I can't believe this is happening at my age. I am all alone. What am I going to do?" She continues to cry uncontrollably. You focus on providing a safe and secure environment. You assure her that she will not be judged or criticized in any way, and all of the conversations during the session will remain confidential. You gently let her know that it is okay to cry, and you are there to listen without judgement. You also tell the client that it is natural to feel lost and alone after a separation, especially since she and her husband have been together for such a long time. She says, "I just feel like such a fool. He cheated on me once before - that I know of - and now he's done it again. I stayed with him for over 30 years, and now I have nothing." She describes having mixed feelings of anger, sadness, fear, and confusion. She states, "There are moments where I'm so mad at him for leaving. Mad enough that I could break something! Our marriage wasn't perfect, but I thought he was committed to me. Well, obviously he wasn't. Then I start to question what's wrong with me that made him leave. And then I think about the future and how I'm going to live by myself. It's all so overwhelming." She further discloses that she is worried about having panic attacks again because "that's what happened the last time something of this magnitude happened to me." You reinforce the idea that it is important to focus on the fact that she is not alone and many people in similar situations feel overwhelmed and uncertain about their future. You let her know she is in a safe space to explore her feelings, work through her loss, and develop a plan for moving forward. You encourage her to reach out for support during this challenging time rather than isolate herself as she goes through this difficult change. | null | Using rational emotive behavior therapy as a framework, what would you focus on in your work with the client? | Exploring the client's beliefs about being rejected by her husband and how they are contributing to her emotional distress | Helping the client find meaning in life by encouraging her to explore her sense of freedom and responsibility | Teaching the client mindfulness and emotion regulation skills to help her manage intense emotions | Focusing on the client's interpersonal relationships and helping her to become more aware of herself in the present moment | (A): Exploring the client's beliefs about being rejected by her husband and how they are contributing to her emotional distress
(B): Helping the client find meaning in life by encouraging her to explore her sense of freedom and responsibility
(C): Teaching the client mindfulness and emotion regulation skills to help her manage intense emotions
(D): Focusing on the client's interpersonal relationships and helping her to become more aware of herself in the present moment | Exploring the client's beliefs about being rejected by her husband and how they are contributing to her emotional distress | A | REBT focuses on exploring the client's irrational beliefs that contribute to their emotional distress. The goal is to challenge and replace irrational beliefs with more balanced, rational beliefs. In this case, it would be helpful to explore the client's beliefs about being rejected by her husband and how those beliefs are contributing to her distress. Therefore, the correct answer is (B) | counseling skills and interventions |
717 | 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. | What is the best way to respond to the client's belief that his wife is having an affair? | Validate the client's concerns and suggest that his fear is based on past abandonment issues | Suggest that he continue to investigate his wife's activities further | Continue to explore the client's fears | Recommend that the client join a support group | (A): Validate the client's concerns and suggest that his fear is based on past abandonment issues
(B): Suggest that he continue to investigate his wife's activities further
(C): Continue to explore the client's fears
(D): Recommend that the client join a support group | Continue to explore the client's fears | C | This is the first time the client mentioned worrying that his wife is having an affair. At this point, you should explore these feelings further with the client to determine the most appropriate next step. Therefore, the correct answer is (D) | counseling skills and interventions |
718 | 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 | An appropriate response by the counselor would be? | What if she chose to go with a girl, what harm is that? | Why don't you both tell me more. | Yes, I can see the issue. I am glad you brought her in. | I see that there seems to be conflict between you both- let's talk about it. | (A): What if she chose to go with a girl, what harm is that?
(B): Why don't you both tell me more.
(C): Yes, I can see the issue. I am glad you brought her in.
(D): I see that there seems to be conflict between you both- let's talk about it. | Why don't you both tell me more. | B | This choice is a neutral statement which prompts more information from both parties. Choice a seems to side with Nadia and choice b seems to side with Shar. When working with families it is important to remain objective and to also discourage splitting among family members. Choice c focuses on the negative by highlighting conflict. Therefore, the correct answer is (D) | counseling skills and interventions |
719 | Client Age: 25 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: In a Relationship Counseling Setting: Private Practice Clinic Type of Counseling: Individual Counseling Presenting Problem: Premature Ejaculation Diagnosis: Provisional | Mental Status Exam: The client is oriented to person, place, time, and situation. The client appears comfortable in the session as evidenced by his openness, congruent affect, and verbal express | You are a counseling resident at an outpatient clinic. Your 25-year-old male client reports he was in a bicycle accident a year ago and that, resultingly, he had reconstructive surgery to his penis. The client identifies that it takes approximately 30 seconds to a minute to ejaculate following vaginal penetration. The client reports that the symptoms occur every time he engages in sexual activities with his girlfriend. The client is a car salesman and also reports anxiety about performance at work and other areas of life. You suspect that the client may also have generalized anxiety disorder. The client reports that his girlfriend does not seem to mind that sex does not last long, but he feels bad because he also wants her to feel good during sex. | The client’s girlfriend comes to the session to give input about what she experiences when they have sex. The client started by saying he wanted to share his self-talk from the thought log. The client’s girlfriend denies any of the thoughts he thinks that she is having. You encourage the client to use her response as evidence for reframing his self-talk when he is nervous during sex. The client states, “the fact that she even has to say that means that I am inadequate.” The client’s girlfriend says she can tell that he is tense and “in his head” when they are having sex. She also notes that he appears sad after sex and often isolates himself for a while afterward. She also identifies that she feels tense when she notices that he is tense and that this makes her less likely to initiate sex. You empathize with the couple and provide psychoeducation regarding positive communication surrounding sex. The client asks to meet via online video for the next session | The client asks to meet via online video for the next session. All of the following are practical and ethical problems with video sessions EXCEPT: | Increased ability for a client to misrepresent themselves | Limitations to confidentiality | Access to nonverbal cues | Provision of interventions for a CBT approach | (A): Increased ability for a client to misrepresent themselves
(B): Limitations to confidentiality
(C): Access to nonverbal cues
(D): Provision of interventions for a CBT approach | Provision of interventions for a CBT approach | D | A CBT approach is still possible via telehealth; therefore, this is not a practical or ethical consideration. Access to nonverbal cues is limited when counseling is provided via telehealth. The client’s ability to misrepresent themselves is heightened when services are accessed via telehealth because the client’s identity can be manipulated in the case of audio-only sessions. Confidentiality is more difficult to guarantee when sessions are virtual because it cannot be guaranteed that the conversation is not being overheard on the client’s end and because general privacy settings may be breached. Therefore, the correct answer is (A) | professional practice and ethics |
720 | Initial Intake: Age: 45 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Married Counseling Setting: Private Practice Type of Counseling: Individual | The client appears his stated age and is dressed appropriately for the circumstances. He rates his mood as “happy” and this is congruent with his affect. He demonstrates some social awkwardness in presentation and conversation both in missing social cues and oversharing. He demonstrates some motor hyperactivity, indicated by fidgeting, shifting in his seat, and upon entering the office, is invited to sit as he was touching items on the bookshelf. He presents as very talkative, distractible, and tangential in his conversation. It is necessary to redirect him often as his explanations and responses include excessive and irrelevant details, and provides responses before the question is completely stated. He demonstrates limited insight into his presentation or the concerns others have shared with him. He demonstrates appropriate judgment, memory, and orientation. He reports no substance use, no sleep or waking problems, and does not smoke. He is emphatic in his negative responses to questions related to suicidal or homicidal thoughts and intentions. | You are a counselor in a private practice setting. Your client is a 45-year-old male who reports that his wife of two years suggested he seek help for what she says is “OCD.” The client says that several months after their marriage, his wife began complaining that the client had so many expectations for her and her children that they are overwhelmed and feel unable to please him. The client tells you that he has had friends tell him in the past that he is “OCD” and sometimes his employees make fun of him because he wants everything done a certain way. He says that they sometimes call him “the eye” because they say he is always watching to make sure they do things correctly. Some of his closer friends will “test me” sometimes by moving something to see if the client notices it. He tells you they are doing it in fun, and he doesn’t really mind because he automatically notices things, whether they moved something or it has accidentally got put in the wrong place. He admits that he is concerned that things are done well because he owns his own business and needs it to be managed correctly, but he doesn’t really understand his wife and stepchildren’s concerns. He tells you that he would like to know if he “is the problem” and if so, how he can make changes to help his marriage. He tells you that he doesn’t see a problem with how he runs his business and thinks that his employees are just “complainers.” | Family History:
The client reports being the youngest of two sons born to his parents. His parents have been married for 40-plus years. He tells you that his mother did complete high school with some difficulty and has never been employed. His father is now retired but was an accountant previously. He says his older brother had a difficult time several years ago with holding a job and going through a divorce, but is now doing much better. The client tells you that his family is still very close, his parents come over to visit often, and prior to buying his business, he often vacationed with family. He says that while growing up, their mother has always been overprotective of him and his brother and has always made sure that they did things the right way. The client states that until his marriage, he continued to live in his parent’s home in his childhood bedroom. He says that even though he took care of his own things, his mother still checked behind him every day to make sure the bed was made correctly and that nothing needed cleaning up. The client says that his parents were constantly frustrated with his brother because he didn’t take care of his room and things. The client reports that he completed a college degree in business and chose to open his own franchise business so that he could work for himself. He has owned his business for six years and enjoys it, although he rarely has time off. He tells you that his father and mother stop by the store frequently “just to help out.” He says his mother likes to help with cleaning and his father helps with the accounting. | Which of the following would be most helpful during this session? | Exploring how the client will do it differently next time | Exploring why the client delegated a task that had such importance to him | Exploring earliest memories of trying to be perfect | Exploring the client's anger and sadness | (A): Exploring how the client will do it differently next time
(B): Exploring why the client delegated a task that had such importance to him
(C): Exploring earliest memories of trying to be perfect
(D): Exploring the client's anger and sadness | Exploring earliest memories of trying to be perfect | C | OCPD requires the client to gain insight into his rigid and inflexible nature if he wishes to make personality changes. Exploring his earliest memories of trying to be perfect will help him link his past experiences with his present thoughts and behaviors, which can help him develop greater insight and self-awareness. Exploring the client's anger and sadness is not helpful in the session because clients with OCPD struggle with emotionality. Until the client has built sufficient insight and self-awareness, the client will avoid emotionality as it conflicts with his logic and rule adherence. Asking the client why he didn't do the job himself perpetuates the idea that the client should not delegate tasks without the assurance that his rules will be followed. This is not helpful in reducing the client's OCPD thoughts and behaviors. Exploring how the client will do it differently next time is not a helpful intervention because the client has not yet learned that the rigid and inflexible nature of his rules is what causes his dilemma, rather than other people who refuse to follow them. Therefore, the correct answer is (B) | counseling skills and interventions |
721 | Initial Intake: Age: 20 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Community Mental Health Agency Type of Counseling: Individual | The client presents looking appropriate to stated age and with positive signs of self-care related to hygiene and dress. Mood and affect are congruent, and motor activity is within normal limits. His interpersonal communication is cooperative, open, and forthcoming. His speech is within normal limits with respect to volume, tone, or rate. His thought processes appear within normal limits with insight into his thoughts and behaviors, including concerns others express about his situation. He demonstrates the ability to connect ideas with circumstances and choices. He reports no thoughts of suicide or self-harm. | You are a counselor in a community mental health agency setting. Your client presents as a 20 year old man with feelings of sadness, discouragement, being overwhelmed, and anxious. These feelings have been present for the past 4 to 5 years. He reports that while in high school, he had planned to commit suicide but did not follow through with it as he did not want to hurt his family and friends. The client tells you that he has moved frequently with his family; living overseas during his last two years of high school then beginning college in the United States. He states that he moved here 8 months ago because he wanted to be independent of his family and start “a new life without so many ups and downs.” He lives in a house that his paternal aunt left to his family when she died. His mother and father recently separated and his father provides him with financial support. Until recently, he reports having been employed as a server in a restaurant but was fired after being accused of disrespect to a coworker. Your client states that the coworker had never liked him and he had not been disrespectful of her; however, their manager chose to let him go. He is currently attending classes at the community college and is in a mechanical engineering program. He chose this program because he thought he would really like it but he has been struggling with his courses due to his work schedule and now his major concern is making a living so that he can stay in school. He says he’s beginning to doubt whether this is the right path for him. He reports having no friends or anyone to spend time with on his days off. | Family History:
The client is an only child. His parents have moved frequently with his father’s job and have lived in different areas of the world. His mother currently lives across the country and his father lives in the Middle East due to his work. They formally separated three months ago. Prior to moving here, the client lived with his mother but was concerned that she was “spending all our money.” His mother is retired and is supported by his father. He states he doesn’t want to be like her and live off of his father’s wealth. | Viewing this client through a cognitive behavioral theoretical (CBT) lens, which of the following best describes his current problem? | Client is experiencing reactive attachment issues related to his frequent moves | Client is experiencing an emotional cutoff because of family enmeshment | Client holds a core belief that friendships should not be trusted | Client holds a core belief that it is better to be lonely than to lose people | (A): Client is experiencing reactive attachment issues related to his frequent moves
(B): Client is experiencing an emotional cutoff because of family enmeshment
(C): Client holds a core belief that friendships should not be trusted
(D): Client holds a core belief that it is better to be lonely than to lose people | Client holds a core belief that it is better to be lonely than to lose people | D | CBT focuses on core beliefs that individuals hold and which may impact their emotional well-being. The client appears to believe that not attempting to make friends protects him from loss, although it leaves him lonely and without support. There is no information provided that suggests his past friends were hurtful or harmful to him and it is the loss of the friendship that is painful, rather than them being untrustworthy. Reactive attachment is a trauma-stressor related disorder often seen in children. The client evidences no history related to criteria of the disorder such as consistent emotional withdrawal from adult caregivers, social unresponsiveness or unexplained emotionality during unthreatening interactions with adult caregivers, or a history of social or emotional deprivation from caregivers, or frequent changes in caregivers limiting the opportunity to form stable emotional relationships with adult caregivers. Emotional cutoffs and family enmeshment are constructs from a family systems theoretical lens and are not used in CBT. Therefore, the correct answer is (D) | counseling skills and interventions |
722 | Client Age: 25 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: In a Relationship Counseling Setting: Private Practice Clinic Type of Counseling: Individual Counseling Presenting Problem: Premature Ejaculation Diagnosis: Provisional | Mental Status Exam: The client is oriented to person, place, time, and situation. The client appears comfortable in the session as evidenced by his openness, congruent affect, and verbal express | You are a counseling resident at an outpatient clinic. Your 25-year-old male client reports he was in a bicycle accident a year ago and that, resultingly, he had reconstructive surgery to his penis. The client identifies that it takes approximately 30 seconds to a minute to ejaculate following vaginal penetration. The client reports that the symptoms occur every time he engages in sexual activities with his girlfriend. The client is a car salesman and also reports anxiety about performance at work and other areas of life. You suspect that the client may also have generalized anxiety disorder. The client reports that his girlfriend does not seem to mind that sex does not last long, but he feels bad because he also wants her to feel good during sex. | The client comes to the session reporting that he and his girlfriend attempted to have sex the past week, and he wrote down some thoughts he was having on his CBT thought log. The client and the clinician reviewed his thoughts and engaged in cognitive reframing to support him in creating new scripts to use when engaging in sex. The client also wrote down physical responses to anxiety that he was experiencing before and during sex that included muscle tension and increased heart rate. The client states that he thinks that his girlfriend would be better off without him and that he should break up with her so she can find what she wants in a man. You decide to use the counseling skill of confrontation to challenge him | The client states that he thinks that his girlfriend would be better off without him and that he should break up with her so she can find what she wants in a man. You decide to use the counseling skill of confrontation to challenge him. Which of the following would demonstrate the most beneficial use of confrontation based on what you know about the client? | You tell the client that this is not an appropriate response because he is using all-or-nothing thinking and extrapolating his thinking about his own worth as a man as equated to her feelings about him. | You tell the client that responding to these feelings by breaking up might be risky because the client’s girlfriend has not shown that she is bothered by his sexual performance. | You tell the client that he would be making a big mistake by breaking up with his girlfriend because he might be able to improve their relationship. | You tell the client that he should continue to be with his girlfriend because although he has these thoughts it does not mean that they are the reality. | (A): You tell the client that this is not an appropriate response because he is using all-or-nothing thinking and extrapolating his thinking about his own worth as a man as equated to her feelings about him.
(B): You tell the client that responding to these feelings by breaking up might be risky because the client’s girlfriend has not shown that she is bothered by his sexual performance.
(C): You tell the client that he would be making a big mistake by breaking up with his girlfriend because he might be able to improve their relationship.
(D): You tell the client that he should continue to be with his girlfriend because although he has these thoughts it does not mean that they are the reality. | You tell the client that responding to these feelings by breaking up might be risky because the client’s girlfriend has not shown that she is bothered by his sexual performance. | B | It would be most helpful to support the client with identifying that his feelings are risky because he does not have evidence to support his thoughts to break up. Telling the client that his thoughts are not an appropriate response is an aggressive response that has not been proven to be a helpful confrontation technique. Although the focus of improving the relationship is helpful, it would validate the client’s thoughts and would not confront them. Telling the client that he should continue to be in this relationship just because he has thoughts about breaking up and how these may not be true would be more directive than confrontational. Therefore, the correct answer is (B) | counseling skills and interventions |
723 | Initial Intake: Age: 14 Gender: Female Sexual Orientation: Heterosexual Ethnicity: Hawaiian American Relationship Status: Single Counseling Setting: School-based mental health counseling Type of Counseling: Individual | Malik presents as well groomed, good hygiene and behavior within normal limits. She is highly anxious, evidenced by limited eye contact, tense expressions and fidgeting with her hands. Malik admits to having suicidal thoughts and has self-harmed by cutting herself in the past. She reluctantly shares that she had a traumatic event in Hawaii right before leaving but is unwilling to discuss it and begins crying. She then changes the subject and tells you moving out of Hawaii has been painful because “everything is different here, including how they do school and how people talk about each other.” She adds that she experiences at least one nightmare a week since moving. | Diagnosis: Major depressive disorder, single episode, unspecified (F32.9), Anxiety disorder, unspecified (F41.9)
Malik, a 14-year-old girl entering High School is referred to you for mental health counseling by her school counselor for reports of her leaving the classroom in tears and because of calls received by her mother stating that she has crying spells at home. After speaking with Malik’s mother, you learn her mother, stepfather and sisters have recently moved with her to the mainland states from the Hawaiian Islands and that she has been missing her father, friends, school, and other family members left behind. Malik spends most of her time in her room, appears depressed often, gets upset easily and is constantly on her phone. Her mother asks that you meet with her during school hours and help her understand what is going on. She says Malik has been crying since just before leaving Hawaii. | Family History:
Malik’s parents divorced while she was young but had always lived in Hawaii, making it easy for her to see both sides of her family at will. Malik has several siblings, cousins, and all her grandparents are still alive. Malik has a strained relationship with her father and stepmother and feels heavily influenced by her father’s opinion of her, stating “he just wants what is best for me, but he’s really harsh about it and it sometimes hurts my feelings and stresses me out.” She is struggling to connect with her mother now because she is working full-time, and she feels “doesn’t have time for her anymore.” Malik is also forced to do most of the household chores and care for her younger siblings on top of managing her schoolwork. All of this has made her feel overwhelmed. | Which approach should you try first to help Malik talk about her trauma with you? | Use caring confrontation with her about how unaddressed trauma increases depression. | Tell her the details about mistakes you have made in the past and that its normal. | Use reflecting, paraphrasing, silence and empathic attunement. | Remind her the purpose of her counseling is to get better by talking about it. | (A): Use caring confrontation with her about how unaddressed trauma increases depression.
(B): Tell her the details about mistakes you have made in the past and that its normal.
(C): Use reflecting, paraphrasing, silence and empathic attunement.
(D): Remind her the purpose of her counseling is to get better by talking about it. | Use reflecting, paraphrasing, silence and empathic attunement. | C | These basic counseling skills are non-judgmental, evidence-based techniques that build rapport and trust, and most effectively help clients feel heard and understood without feeling pressured. The mentioned trauma is possibly sexual in nature so using techniques in answer d are the best way to be sensitive to Malik's comfort level, respect the establishment of her boundaries, and honor the timeline of her willingness to share. Using these techniques may also support her in sharing about all things that are contributing to her emotional distress, leading her to discuss what she is most willing to address first. Helping her to understand that unaddressed trauma may lead to increase of depression. Educating Malik about how trauma can increase symptoms of depression as well as reflecting together on your treatment plan goals are both valuable interventions, however, it may be better to address this earlier in the session. Alternatively, it may be more effective to discuss these issues after all other interventions have been exhausted. Using self-disclosure techniques such as in answer c are to be considered on a case-by-case basis, and while this approach can support a teenager in therapy, it is important not to blur the lines of the counselor-client relationship by any actions that might mimic the dynamics of a peer-to-peer relationship. Therefore, the correct answer is (D) | counseling skills and interventions |
724 | Client Age: 30 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Pacific Islander Relationship Status: Single Counseling Setting: Private practice counseling clinic Type of Counseling: Individual counseling Presenting Problem: The client and her boyfriend recently broke up, and she is “tired of being with the wrong guys.” She admits that she will often stay in relationships even if she knows they are wrong for her. Diagnosis: Provisional diagnosis: Dependent personality disorder (F60.7), personal history (past history) of spouse or partner violence, physical (Z69.11), and personal history (past history) of spouse or partner psychological abuse (Z91.411) | Mental Status Exam: The client is oriented to person, place, time, and situation. No hallucinations, delusions, or paranoia are reported. The client was anxious at the start of the session, but she was able to calm herself down by easing into the counseling relation | You are a professional counselor working in a private practice clinic. The client comes in and sits quietly. The client appears nervous because she avoids eye contact and waits for you to initiate conversation. You ask why she is in counseling, and she responds that she is just tired. You ask more about this, and she says that she is not ready to talk about it yet. You decide to cover demographics and other less intimidating topics and then ask if she is comfortable talking yet. The client says that she feels a little more comfortable. She begins to state that she and her boyfriend broke up the previous week and that she was with him for 2 years. She explains that she has been “in this type of relationship before,” continually finds the “wrong guy,” and that she always goes “all in” with her relationships. Through processing, she identifies the following behaviors and beliefs: difficulty making daily decisions without the input of her partner, doing anything to gain support and affection even if she does not want to do the task or activity, quickly moving on to another relationship when a relationship ends, feeling that she cannot care for herself when she is not with someone else, and acknowledging that she needs others to take responsibility for major areas of her life. The client says that she has experienced physical and psychological abuse from partners, but that she is not ready to discuss this. The client identifies that her most important goal is to not end up in “the same relationship” again or rush into a relationship that is not right for her. Throughout the session, you provide empathetic and active listening. You suspect that the client has dependent personality disorder. | ship. Family History: The client is close with her parents and her younger brother (28 years old). The client says that she was engaged twice before but that neither engagement progressed to marriage because her two fiancés both felt that she was too clingy and unable to care for herself. Some ethical standards can be altered based on the situation | Some ethical standards can be altered based on the situation. Which of the following ethical standards would you likely not compromise on with this client? | Release of the client’s records to her | Fees | Boundaries | Interpretation of assessment results | (A): Release of the client’s records to her
(B): Fees
(C): Boundaries
(D): Interpretation of assessment results | Boundaries | C | This client will need you to establish very clear boundaries because she is likely to become somewhat dependent on you and your sessions with her. With other clients, small amounts of self-disclosure or answering emails outside of sessions may have benefits, but with this client, you may need to insert more explicit guidelines for them. Fees should be appropriate and negotiable as needed. Release of the client’s records is up to the counselor’s discretion if it might cause harm; otherwise, it is the client’s right to have access to her chart. If an assessment is provided, the client should be supported in interpreting the results. Therefore, the correct answer is (B) | professional practice and ethics |
725 | 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. | Based on the information given, which would be the most effective intervention with this client at this time? | Reframing | Self-disclosure | Highlighting here-and-now interactions | Reflection and paraphrases | (A): Reframing
(B): Self-disclosure
(C): Highlighting here-and-now interactions
(D): Reflection and paraphrases | Reflection and paraphrases | D | Based on the client's cultural information provided, reflection and paraphrases are the most effective intervention because they allow the client freedom to choose what is or is not discussed, let the client know that the counselor is listening, and provides the opportunity for the counselor to share with the client the thoughts and emotions that the client has been expressing. These techniques are non-directive and allow the client to feel listened to and valued. Reframing with this client is not likely to be effective at this time as she wrestles with cultural expectations. Reframing allows the counselor to provide a different perspective of a problem, but when culture is involved, the counselor is more likely to offer a perspective that may not take culture into account. Self-disclosure is one of the least used interventions because counselors must weigh whether the self-disclosure is more for the counselor's benefit or the client's. With this client, self-disclosure would not be appropriate, particularly if the counselor and client do not share the same culture, as any comparisons would not be similar due to differing cultural beliefs. Here-and-now interactions are useful when working on process versus content as they focus on metacommunication. In this case, the counselor must be careful not to make assumptions about what is said or not said because of the cultural differences between the client and the counselor. Therefore, the correct answer is (A) | counseling skills and interventions |
726 | Initial Intake: Age: 14 Gender: Female Sexual Orientation: Heterosexual Ethnicity: Hawaiian American Relationship Status: Single Counseling Setting: School-based mental health counseling Type of Counseling: Individual | Malik presents as well groomed, good hygiene and behavior within normal limits. She is highly anxious, evidenced by limited eye contact, tense expressions and fidgeting with her hands. Malik admits to having suicidal thoughts and has self-harmed by cutting herself in the past. She reluctantly shares that she had a traumatic event in Hawaii right before leaving but is unwilling to discuss it and begins crying. She then changes the subject and tells you moving out of Hawaii has been painful because “everything is different here, including how they do school and how people talk about each other.” She adds that she experiences at least one nightmare a week since moving. | Diagnosis: Major depressive disorder, single episode, unspecified (F32.9), Anxiety disorder, unspecified (F41.9)
Malik, a 14-year-old girl entering High School is referred to you for mental health counseling by her school counselor for reports of her leaving the classroom in tears and because of calls received by her mother stating that she has crying spells at home. After speaking with Malik’s mother, you learn her mother, stepfather and sisters have recently moved with her to the mainland states from the Hawaiian Islands and that she has been missing her father, friends, school, and other family members left behind. Malik spends most of her time in her room, appears depressed often, gets upset easily and is constantly on her phone. Her mother asks that you meet with her during school hours and help her understand what is going on. She says Malik has been crying since just before leaving Hawaii. | Family History:
Malik’s parents divorced while she was young but had always lived in Hawaii, making it easy for her to see both sides of her family at will. Malik has several siblings, cousins, and all her grandparents are still alive. Malik has a strained relationship with her father and stepmother and feels heavily influenced by her father’s opinion of her, stating “he just wants what is best for me, but he’s really harsh about it and it sometimes hurts my feelings and stresses me out.” She is struggling to connect with her mother now because she is working full-time, and she feels “doesn’t have time for her anymore.” Malik is also forced to do most of the household chores and care for her younger siblings on top of managing her schoolwork. All of this has made her feel overwhelmed. | Now that Malik is reporting no suicidal thoughts, how should you update her treatment plan? | Add "codependency" to her treatment plan goals. | Resolve SI treatment plan goal and add "monitor SI" as an objective under depression goal. | Mark SI treatment plan goal as "resolved" and focus more on other goals. | Continue to monitor SI using C-SSRS for the remaining duration of the SI treatment plan. | (A): Add "codependency" to her treatment plan goals.
(B): Resolve SI treatment plan goal and add "monitor SI" as an objective under depression goal.
(C): Mark SI treatment plan goal as "resolved" and focus more on other goals.
(D): Continue to monitor SI using C-SSRS for the remaining duration of the SI treatment plan. | Continue to monitor SI using C-SSRS for the remaining duration of the SI treatment plan. | D | You must continue to monitor for suicidal thoughts using a Suicidal Ideation specific treatment plan goal for its minimum duration required as defined by your agency or state laws. Following that period, if SI has been evidenced to be "low risk" or "very low risk" it would then be appropriate to mark the goal as "resolved" and add an SI monitoring goal underneath a depression goal as answer c states. Answer b is not correct as the client had a temporary change in affect for 1-2 weeks and she may still be suicidal. Answer d is a great option for this client but it is best practice to discuss the goal with your client first and ensure they understand it prior to adding it to their treatment plan. Most agencies and state laws also require that a parent sign a consent form for any major updates or changes to their child's treatment plan. Therefore, the correct answer is (A) | treatment planning |
727 | Name: Andie Clinical Issues: Gender identity development Diagnostic Category: Gender Dysphoria Provisional Diagnosis: F64.1 Gender Dysphoria Age: 12 Sex Assigned at Birth: Male Gender and Sexual Orientation: Female, Questioning Ethnicity: Caucasian Marital Status: Never married Modality: Individual Therapy Location of Therapy : Agency | The client is quiet in the session and clingy toward his mother. His head is bent down, and he refuses to make any eye contact. When an attempt is made to engage the client in conversation, he responds with short statements such as, "I guess; I don't know." | First session You are a mental health therapist for an agency where two parents and their 12-year-old child named Andie present for their first counseling session with you. The father looks irritated, and the mother seems depressed. She expresses that they have been concerned for some years regarding their son's confusion around his gender identity. They feel he is too young to make any decisions that will affect the rest of his life. The father speaks up, saying, "He's getting all of this nonsense from school just to fit in, and it needs to stop." The mother expresses that Andie always likes to dress up in his sister's clothes and believes that one day he will become a girl. Andie appears anxious and is afraid of the father as evidenced by his withdrawing behavior. You discuss your role as therapist and tell Andie that your job is to help make people feel better. You also provide the parents with your initial observations and make a recommendation to start therapy with weekly appointments. Fourth session During the previous two sessions, you focused on making Andie feel comfortable and spent time learning about his interests and strengths. You have established a strong rapport with Andie. Today, he is quiet and reluctant to speak. He tells you about his family and that his dad is always yelling at him and calling him a "sissy boy." He states feeling sad and does not understand why his dad will not love him if he wants to be a girl. he also states that he feels confused by his mother's seeming acceptance of him, but her unwillingness or inability to "be on his side" when his father berates him. He admits that he feels happy when he thinks of himself as a girl, especially when he is free to express himself in that way. He said all the boys at school are mean to him and call him names. he feels most at ease with the girls in his class, or with the teacher. You work with the client on how to express his thoughts and feelings appropriately to his father rather than holding them in. | The client has three sisters, loves his mother but has difficulties with his father. His parents differ in child-rearing styles. The client is the youngest and has three older sisters and wishes that he had been born a girl. He acts out at home when he feels that he's not being "understood" by his parents. He withdraws from his family quite often (will not leave his room) and usually has "screaming matches" with his father in regard to his expression of his preferred gender. The client does not get along with the other boys in his class but relates to the girls without difficulty. Before the initial interview with the client, his father related that he is concerned about his son's long-standing "girlish ways." His son avoids contact sports but has expressed an interest in ballet. | What would provide you with the most direct and reliable data indicating that therapy sessions have improved your client's outlook and self-acceptance? | The parents report noticing positive changes in the client's behavior at home. | Administer a written assessment specifically tailored to gender dysphoria. | The client's anxiety and depression symptoms decrease. | The client reports increased confidence and comfort expressing their gender identity. | (A): The parents report noticing positive changes in the client's behavior at home.
(B): Administer a written assessment specifically tailored to gender dysphoria.
(C): The client's anxiety and depression symptoms decrease.
(D): The client reports increased confidence and comfort expressing their gender identity. | The client reports increased confidence and comfort expressing their gender identity. | D | The client self-reporting increased confidence and comfort with their gender identity provides the most direct and reliable data on improved outlook and self-acceptance because it comes straight from the client, focuses specifically on their viewpoint of their gender identity, and captures internal changes in their feelings and perspective over the course of therapy. Therefore, the correct answer is (B) | counseling skills and interventions |
728 | Initial Intake: Age: 35 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Employee Assistance Program Type of Counseling: Individual | Harold comes into the office, visibly upset, stating, “I really don’t know why I am here, but I am sure you will see that too after some time together. And I am sure that anything I say here- you can’t report it to anyone anyway, right?” Harold did not display any self-awareness of his actions when speaking to the counselor. At times he showed defensiveness and irritability and other times he was making jokes and complimenting the counselor. | Harold, an accounting executive, was referred for counseling by his supervisor after Human Resources received several complaints about Harold’s attitude towards others.
History:
Harold has been successful in his career and is knowledgeable in his field. However, he stated that he is often not well liked. Harold attributes this to people being envious of him. Harold told the counselor that recently he was called to human resources because of complaints from his peers. Complaints included allegations of rude remarks, bullying, and Harold taking credit for work that others did. One coworker stated that Harold took frequent breaks and suspected he may be using drugs. | null | The counselor's statement is an example of? | Confrontation | Congruence | Reflection of feeling | Engagement | (A): Confrontation
(B): Congruence
(C): Reflection of feeling
(D): Engagement | Congruence | B | The counselor is showing congruence as he is being honest in his feedback regarding the client's progress and demeanor. The client's inconsistency may be because of his awareness and bringing this to the client's attention can be a turning point. Confrontation is the client confronting something within themselves, not the therapist confronting the client. Engagement is prompting or encouraging the client to actively participate. Therefore, the correct answer is (A) | counseling skills and interventions |
729 | Name: Alexei Clinical Issues: Substance use/addiction issues Diagnostic Category: Substance Use Disorders Provisional Diagnosis: F10.99 Unspecified Alcohol-Related Disorder Age: 32 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: German American Marital Status: Married Modality: Individual Therapy Location of Therapy : Private Practice | A 32-year-old German American man confidently enters your office. He is tall and slender and appears older than his stated age. His physical appearance is unkempt. The client's voice quality is strong and loud, and his command of English is minimal. His posture and gait are limp and unsteady at times. He is slurring his words and appears to be actively intoxicated. He portrays no accountability or responsibility for his actions with substance use. He denies any current thoughts of homicidal ideations. The client lacks insight, and his thought processes are not logical or appropriate. | First session You are a psychoanalytic therapist in private practice and often work with clients who struggle with substance use issues. You believe these issues often arise from unresolved conflicts and the inability to manage emotions. Today, you are seeing a 32-year-old German American male named Alexei, who was referred to you due to occupational disciplinary issues related to alcohol use. Alexei was referred to you by his employer, where he works in a manufacturing plant in the Midwest. His supervisor noticed marked changes in his behavior and productivity over the last few months and was concerned that Alexei might be dealing with a drinking problem. The supervisor initially suggested an employee assistance program, but Alexei was adamantly opposed to talking to anyone involved in his workplace. You introduce yourself and explain to Alexei that this is a safe and confidential space where he can discuss whatever is troubling him. You reassure him that the only people who will know about the details of this session are himself and yourself. Then, you begin to ask open-ended questions to assess Alexei's current state of mind and identify his current challenges. You are particularly interested in understanding his thoughts and feelings about his substance use and the occupational problems it has created. You notice that Alexei seems excessively relaxed as you establish the confidentiality of the session. As you delve deeper into his thoughts and feelings, you ask him to describe his relationship with substances, particularly how they have affected his daily life and work performance. Alexei hesitantly opens up, admitting that his substance use has become a coping mechanism to deal with mounting stress and anxiety. You listen empathetically and validate his emotions while gently probing into the factors that have contributed to this pattern of behavior. Alexei tells you that his boss has never liked him and is trying to get him fired. He reports that he sees nothing wrong with having a few drinks in the morning and after lunch. He has been late to work "only a few times" because of a hangover. Alexei states that he needs help finding a new job. You ask Alexei if he can tell you more about his drinking habits. He says he usually starts drinking around 9 am and has been drinking more in the past few weeks. He also admits to drinking at work a couple of times. He looks at you suspiciously, wondering why you need to know this. You explain that it is important to understand his drinking habits and the context of his behavior to provide the best care. As the session continues, you observe that Alexei's cognitive functioning appears impaired, as he struggles to maintain focus and has difficulty recalling important details. He expresses frustration and anger when discussing his work situation but minimizes the impact of his alcohol consumption on his professional life. Alexei's denial of his alcohol-related problems and the escalating pattern of his drinking behavior indicate a potential substance use disorder. Furthermore, his physical symptoms, such as sweating and slurred speech, suggest that he may be experiencing acute effects of alcohol during the session. It becomes evident that addressing Alexei's alcohol use and its consequences is crucial to provide appropriate care and support for him in his current situation. Fourth session You completed a risk assessment in the last session and worked on safety planning with Alexei. He arrives 15 minutes late to today's session. When you mention his tardiness, he begins yelling in German. When you appear confused, he switches over to English, saying you are harassing him just like his wife. You respond by acknowledging his feelings and gently reminding him that you are there to help him process his emotions in a safe and productive way. Once he is calm, you explore what it is about your presence that he may be perceiving as hostile or threatening. He takes a breath, apologizes to you for his outburst, and begins to talk about his wife and her disparaging comments. He explains that, when you asked why he was late, it felt like a reminder of how his wife often disregards his needs and makes him feel worthless. "She makes some negative comment like 'you're late' or 'you never do this right'. It make me just want to give up!" He begins talking about wanting to take a break from home and go back to Germany where he can "start fresh". He says that his wife's constant harassment is unbearable. Lately, he has been hoping that she will leave him. You spend the rest of the session planning with Alexei ways he can express his feelings of frustration in productive ways. | The client grew up in Germany and recently immigrated to America with his wife and mother. Both parents have a history of alcohol abuse and divorced when he was five. After his father left, his mother's enmeshment with her son intensified. She made him spend time with her rather than his school friends and used the threat of leaving him in an orphanage to control his behavior. Whenever he became upset or anxious, she would cuddle him and give him sips of whatever alcohol she consumed. The client was recently arrested for driving under the influence. The client's wife is contemplating separating because of her husband's continued drinking. He identifies a couple of bartenders as "friends" but cannot recall anyone he knows in an alcohol-free context. He has also been late or missed work due to hangovers and will likely lose his job. His co-workers have often complained that he smells of alcohol. Previous Counseling: The client has had suicidal thoughts thrice, all of which were recent. The initial occurrence was after a DUI incident, followed by a write-up at work, and the third after his wife proposed a separation. The client has shared that he has a specific plan in mind for ending his life, which involves either ingesting pills or cutting his wrists. | Taking into account the session's content, what should be your primary focus initially? | Process his feelings and thoughts regarding his wife and their relationship. | Continue to evaluate his level of lethality and update his safety plan. | Begin the psychoanalytic process of dealing with his past traumas | Encourage the client to explore productive ways he can express his frustrations. | (A): Process his feelings and thoughts regarding his wife and their relationship.
(B): Continue to evaluate his level of lethality and update his safety plan.
(C): Begin the psychoanalytic process of dealing with his past traumas
(D): Encourage the client to explore productive ways he can express his frustrations. | Continue to evaluate his level of lethality and update his safety plan. | B | The statement of feeling like giving up is ambiguous and needs to be explored and acted on. It is critical to know precisely to what extent this client will or will not act on these thoughts and to mutually agree in writing to not act on those feelings or thoughts. Determining his level of lethality provides a baseline determination of his current suicidal status. It simultaneously gives you a standard to compare when there is progress in the future. This also provides you with documentation of his verbal commitment to avoid self-harm as legal confirmation that you have addressed this concern professionally. Therefore, the correct answer is (A) | intake, assessment, and diagnosis |
730 | Name: Alex Clinical Issues: Hopelessness/depression Diagnostic Category: Depressive Disorders Provisional Diagnosis: F34.1 Persistent Depressive Disorder, Severe Age: 65 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: Multiracial Marital Status: Married Modality: Individual Therapy Location of Therapy : Private Practice | Appearance: The client is dressed in a manner that can be described as casual, suggesting that they might not have made any special effort to dress up for the session. Additionally, he is unshaven, which you note might indicate either personal preference, a decline in grooming habits, or possibly, decreased motivation and energy. Behavior: The client's overall behavior is withdrawn. Mood and Affect: His stated mood is depressed, implying feelings of sadness, hopelessness, or desolation. His affect, the observable manifestation of his feelings, is flat. Speech: His speech is both slowed and measured. Thought Process and Content: The client's thought process is tangential. He tends to veer off-topic and does not consistently answer questions directly or stay on point. The content of his thoughts is notably negative and self-defeating. Perceptual Disturbances: No delusions or hallucinations have been reported, indicating that the client has no gross misinterpretations of reality or perceptual disturbances. Orientation: The client is oriented to person, place, and time. Insight: It appears that the client has poor insight into his condition. Attitude: His attitude towards the evaluator is compliant and cooperative. | First session You are a licensed mental health therapist. Today you are seeing a 65-year-old male via distance counseling. You introduce yourself and ask him what prompted him to schedule an appointment to see you. He reports that he has felt "down in the dumps" for several years, and as he gets older, he feels more depressed and is in constant pain. As he is talking, he shifts around in his seat, appearing to have difficulty staying in a comfortable position. He continues by saying he feels depressed most of the time, has lost interest in activities that he once found enjoyable, feels hopeless, and is fatigued all the time. He also says he has lost his appetite and has difficulty sleeping. He states that "no one wants me around." Then he looks down and says, "I don't really blame them. I wouldn't want to be around me either." At work, he has difficulty concentrating and making decisions and is distressed that his co-workers see him negatively. When you ask him about his relationship with his wife, he says that while they live together, they have "not been close for a long time now." They both sleep in separate bedrooms and they lead separate lives. He explains, "We just kind of grew apart. We still love each other and would never get divorced, but now we're more like roommates. She's very social and involved in the community. I'm more of a homebody." After the client has shared why he is seeking counseling, you state, "I can hear that you are feeling very discouraged. It sounds like you have been going through a difficult time for quite some time now and it's taking a toll on your life. Let's explore what might be contributing to these feelings and how we can work together to help find solutions or ways to cope with the challenges you're facing." You use a solution-focused brief therapy technique and ask him visualize what successful treatment would look like. He contemplates it for some moments and says, "I'd feel better, I guess." You encourage the client to think more deeply about what successful treatment would look like and explain how this visualization process can help him gain clarity on his desired outcomes. He says, "Hmm, I'm not really sure. Can you give me some examples? This is my first time in therapy and I'm not really sure what to expect." You provide some examples of tangible goals that he might set for himself, such as improving sleep patterns, having better communication with family members and co-workers, and finding meaningful activities to engage in. The client is able to identify some areas that could be improved and formulates realistic, achievable goals. Together, you create an action plan for successful treatment, which includes specific steps he can take to reduce symptoms and increase positive outcomes. You schedule a follow-up appointment to meet with him next week. | The client reports that his relationships with family members were strained growing up, with his father often away for work and his mother struggling with her own mental health. He reports that his mother drank a lot, which the client defends saying, "I guess I'd drink a lot if I had 5 kids by the time I was 22 years old. The client grew up feeling unsupported and unimportant, which led to a disconnect from the rest of his family. Of his four siblings, the client keeps in touch with one brother, but "my other two brothers and sister live in different states and have different lives. I think they've struggled with depression, too. We don't talk much." Despite this difficulty in connecting, the client has an adult daughter whom he "loves very much and tries to stay in contact with. He wishes he could have done better for her during his parenting years, and despite their rocky past, has a deep desire to maintain a healthy relationship. He says, "I don't want her to think the same way I do about family and relationships. I want her to have good ones." The client is currently employed as a corrections officer and feels his job has no potential for advancement. He has been working there for 20 years and is ready to retire in less than a year. He expresses that it has been challenging and physically and mentally exhausting. In addition, he is tired of "dealing with both the inmates and the administration." He tells you his co-workers consider him a "slacker" because he is always tired and takes as many breaks as he can get away with. He is also worried about "word getting back to his co-workers" that he is in therapy. The client expresses that he has some drinks, especially after work, to calm down. He reports that he will drink in social settings as well. He states that his preferred drink of choice is whiskey. | What is irrelevant to consider when gathering data to establish a treatment plan for the client? | Is he averse to taking medication for depression? | What kind of support group does he have? | How willing is he to change his profession? | How often does he drink? | (A): Is he averse to taking medication for depression?
(B): What kind of support group does he have?
(C): How willing is he to change his profession?
(D): How often does he drink? | How willing is he to change his profession? | C | He has already stated being ready to retire, and after 20 years, this would be too big a change to consider unless specifically expressed as a priority for the client. Therefore, the correct answer is (B) | treatment planning |
731 | 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.” | You discover from the receptionist Lottie's mother has been complaining about you to your practice's front desk staff, that you told Lottie what she has learned about her parents' personal life is "inappropriate," and further that you are "pushing medication" on her. How should you handle this? | Inform your supervisor and have them speak with Lottie's mom on your behalf. | Explain to Lottie that you were not trying to offend her mother. | Request to have a discussion with mom after processing with your supervisor. | Ignore these comments due to the possibility of her attempting to split staff. | (A): Inform your supervisor and have them speak with Lottie's mom on your behalf.
(B): Explain to Lottie that you were not trying to offend her mother.
(C): Request to have a discussion with mom after processing with your supervisor.
(D): Ignore these comments due to the possibility of her attempting to split staff. | Request to have a discussion with mom after processing with your supervisor. | C | Issues such as complaints by clients should be processed with your immediate supervisor and/or licensure supervisor to ensure you are protected by their knowledge and support. Processing with them can help you to proceed mindfully and with the best clinical approaches suggested to handle whatever situation you are in. Ignoring these comments might harm your therapeutic relationship with Lottie, despite that they could very well be out of motivation to split staff or out of a histrionic response to feeling defensive or frustrated. However, prior knowledge of the mother's personality disorder should not deter you from addressing her very real concerns. Speaking directly with the child about this is inappropriate, and asking a supervisor to deal with the parent for you is unprofessional. Therefore, the correct answer is (B) | professional practice and ethics |
732 | Client s Age: Client 1: age 12 Client 2: age 14 Client 3: age 14 Client 4: age 16 Client 5: age 13 Client 6: age 16 Sex: Males Gender: Males Sexuality: Varying Ethnicity: Multiracial Relationship Status: Single Counseling Setting: Juvenile Justice Facility Type of Counseling: Group Counseling Presenting Problem: Involvement with the Justice System That Includes Various Mental Health Disorders and Crimes Diagnosis: Imprisonment (Z65.1) | Mental Status Exam: All of the clients appear to maintain appropriate hygiene, and they are all oriented to person, place, time, and situation. They are all somewhat reserved with regard to going into deeper topics, but they participate f | You are a licensed counselor working in a juvenile justice facility for teenage males. The group comprises six males that are required to attend as part of their incarceration with the expectation that it will shorten their sentences. The purpose of the group is to work on emotional regulation and to work together to share common experiences and identify goals that can be helpful in preventing reincarceration. During the intake session, you explained the purpose of the group and started with an ice-breakeractivity. The clients participated in the ice-breaker activity that required you to redirect them back to the activity several times because they would joke and get off task. You attempt to go a little deeper by encouraging your clients to start talking about what happened to get them incarcerated, and they appear to be taking pride in the reasons they were in juvenile detention and making fun of those with lesser sentences. You redirect the clients to another topic. | ully. Family History: Several clients report coming from a single-parent home, whereas others are from a two-parent home. All clients report that they have siblings. Several clients reported having parents that were or are involved in the justice system | Which of the following would be unethical for you regarding group counseling? | Confidentiality cannot be guaranteed because you cannot control what the clients share outside of sessions. | You do not have experience regarding incarceration, but you have been a therapist for 15 years and have experience in counseling. | You cannot force the clients to participate in sessions even though therapy is mandatory. | You are also the case manager for each individual; therefore, this is a dual relationship. | (A): Confidentiality cannot be guaranteed because you cannot control what the clients share outside of sessions.
(B): You do not have experience regarding incarceration, but you have been a therapist for 15 years and have experience in counseling.
(C): You cannot force the clients to participate in sessions even though therapy is mandatory.
(D): You are also the case manager for each individual; therefore, this is a dual relationship. | You do not have experience regarding incarceration, but you have been a therapist for 15 years and have experience in counseling. | B | The most common unethical situation in the group setting is a counselor that does not have the knowledge or skills to lead the group. There are many positions that require a counselor to be a group counselor and to have another role with the client such as in this juvenile detention facility, in group homes, or in other community mental health roles. Often, dual relationships cannot be avoided in group counseling and at times are part of therapy such as dialectical behavior therapy, which is often a mixture of group and individual counseling. It is true that, when multiple clients are present such as in group, family, or couples counseling, you cannot guarantee confidentiality from all members, but you should encourage all clients to maintain confidentiality for the benefit of the group process. Although the clients may be forced to be in the group, you cannot force anyone to do anything against their will, which includes participation in mandatory therapy. Therefore, the correct answer is (C) | professional practice and ethics |
733 | Client Age: 74 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Divorced Counseling Setting: Community Mental Health Center Type of Counseling: Individual and psychoeducation Presenting Problem: Memory impairment Diagnosis: Mild Neurocognitive Disorder (MND) Unspecified with Behavioral Disturbance (apathy and mood disturbance) 799.59 (R41.9) | Mental Status Exam: The client is appropriately dressed and cooperative. She is tearful at times and often glances over at her daughter when she is unsure of how to respond to a question. The client denies suicidal and homicidal ideations. She is oriented to the day, month, and year, but she could not recall the date or place. She recalls the city with prompting. The client’s sleep is fair, and her appetite is normal. She reports feeling sad most of the day, every day. To date, medical procedures used to determine the etiology of the client’s cognitive impairment have been inconclusive. She awaits an appointment for a positron emission tomography (PET) scan, which can help determine the presence of brain activity associated with Alzheimer’s disease. She denies substance use and says that she is a social drinker. Her judgment and awareness are fair, and she denies audio and visual hallucinations. Fam | You work in a mental health center and are conducting an initial assessment on a 74-year-old Caucasian female. The client and her daughter arrive today with a copy of the client’s recent neuropsychological evaluation. The evaluation shows cognitive functioning deficits, and the neuropsychologist has diagnosed the client with mild neurocognitive disorder (MND). The client and her daughter fear that her memory issues could worsen and impact her independence. The daughter has seen a gradual decline in the client’s memory, which coincides with episodes of depression. The client expresses embarrassment over her memory issues and states, “remembering the simplest things—like doctor’s appointments or paying bills—has started to become more and more difficult.” She states that she no longer participates in things she once enjoyed, including her book club, church services, and fitness classes. | ily and Work History: The client divorced nearly 15 years ago and has lived alone since. She has two adult children and four grandchildren who all live locally. She reports experiencing depression and anxiety for most of her life. She currently takes an antidepressant and has done so for years. The client’s career was in school administration, where she dedicated nearly 30 years of service until retiring 6 years ago. She reports that retirement caused an increase in depression as she grieved the “loss of (her) identity.” The client’s mother had Alzheimer’s disease, which placed significant stress on the client and her father. The client’s sister is diagnosed with bipolar disorder, and there are no other noted mental health or substance use disorders in the family | Which one of the following statements reflects a person-centered approach to the client’s retirement? | “Your heart is heavy after leaving a career that was once everything to you.” | “You’re grieving a heavy loss. How does that affect your present-day, here-and-now experiences?” | “Your sadness and the person you are today are likely the results of unconscious processes.” | “You have a deep conviction that some of your best years were before retirement.” | (A): “Your heart is heavy after leaving a career that was once everything to you.”
(B): “You’re grieving a heavy loss. How does that affect your present-day, here-and-now experiences?”
(C): “Your sadness and the person you are today are likely the results of unconscious processes.”
(D): “You have a deep conviction that some of your best years were before retirement.” | “Your heart is heavy after leaving a career that was once everything to you.” | A | A person-centered approach is reflected in the statement “Your heart is heavy after leaving a career that was once everything to you” Person-centered therapists facilitate unconditional positive regard, empathy, and genuineness. The aforementioned statement is an expression of empathy. The statement “You have a deep conviction that some of your best years were before retirement,” is an example of a cognitive-behavioral approach, with the client’s thoughts expressed as deep convictions. Psychoanalytic therapy is reflected in the statement “Your sadness and the person you are today are likely the results of unconscious processes” Person-centered therapists focus on the conscious rather than the unconscious. Finally, the statement, “You’re grieving a heavy loss. How does that affect your present-day, here-and-now experiences?” characterizes gestalt therapy. Therefore, the correct answer is (B) | counseling skills and interventions |
734 | Name: Jackson Clinical Issues: Behavioral problems Diagnostic Category: Depressive Disorders Provisional Diagnosis: F34.8 Disruptive Mood Dysregulation Disorder Age: 11 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Not Assessed Ethnicity: White Marital Status: Not Applicable Modality: Individual Therapy Location of Therapy : Private Practice | Appearance: The client is dressed in clothes associated with anime. He is well groomed and appears to be a few years younger than his chronological age. Orientation: The client is oriented X3. Mood: The client's mood is dysphoric. Affect: The client's affect is restricted. Speech: The client's speech is soft and hesitant. Thought Process: The client's thought process is slow and labored. Thought Content: The client's thought content is pessimistic and focused on negative themes. Perception: The client's perception is intact. Insight: The client's insight is poor. | First session You are a therapist in private practice specializing in working with children. The client is an 11-year-old male. His mother brought him to therapy because of the "latest incident at school," wherein he had an angry outburst and threatened to come to school with a gun and shoot everyone, including himself. The mother states that the police were notified, and the client was suspended from school for a week. The client was unwilling to discuss his emotions or the incident at school. He became agitated and defensive whenever the topic was brought up and now will not talk to you. He seemed to be in a state of denial, minimizing the impact of the incident at school. You observe a bald spot on the top of the client's head, indicating that the client has been pulling his hair out. The client was evasive when asked about the bald spot on his head and became increasingly anxious. He could not articulate why he was pulling his hair out and seemed embarrassed, avoiding the topic. He has difficulty identifying and expressing emotions outside of anger. His mother reports that he lashes out at home with family and classmates at school, aggressively arguing and making threats. He had difficulty engaging in self-reflection and could not make meaningful connections between his behavior and the consequences that may follow. His mother is extremely frustrated and worried that this school will also expel him. She is upset with the lack of progress his previous therapist made with her son and is now considering residential treatment options. The mother has been receiving conflicting diagnoses from previous therapists and is seeking a definitive diagnosis from you. Halfway through the session, you ask to speak with the client by himself for a few minutes. The mother exits the room, leaving you alone with the client. You take notice of his anime shirt and ask him more about anime. He quickly starts talking and making eye contact. | The client's biological father was diagnosed with Bipolar I Disorder. The biological father is unaware of the client's existence although the client knows that his step-father is not his biological father. The client has transitioned from school to school. Each time his behavioral problems have escalated. This is his third school. The client's issues have become so severe that his parents have been called to the school multiple times. They have been unable to get him to listen to them or follow directions. His outbursts are becoming more frequent and aggressive, and his refusal to do work or cooperate has become a problem for his teachers. The school has tried various approaches to try and help the client, but he has been resistant to them. He has been put on a behavior plan but has not followed through. The administration has also tried talking to him on multiple occasions to try and get him to open up, but he has been unresponsive. The administration has now exhausted all of its options and is at a loss as to what to do. They are willing to give him one more chance, but they will be forced to find another solution if he does not improve. Previous Counseling: The client has been seeing a pediatric psychiatric nurse twice a month for two years for his frequent temper outbursts at home and school. His irritable and angry mood is a daily occurrence, with verbal rages and physical aggression occurring three or more times a week. He is currently taking Respidol for emotional regulation. The medication affects his appetite and energy level. | What are considered symptoms of the client's diagnosis? | Depressed mood for most of the day | Sleep disturbances | Obsessions and compulsions | Severe recurrent temper outburst | (A): Depressed mood for most of the day
(B): Sleep disturbances
(C): Obsessions and compulsions
(D): Severe recurrent temper outburst | Severe recurrent temper outburst | D | This is a symptom of Disruptive Mood Dysregulation Disorder. Therefore, the correct answer is (C) | intake, assessment, and diagnosis |
735 | Client Age: 51 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Divorced and single Counseling Setting: Local government mental health agency Type of Counseling: Individual counseling Presenting Problem: The client is experiencing a recent separation from her last partner who was verbally and physically abusive, and she is currently living in a domestic violence home. Diagnosis: Major depressive disorder, recurrent episode, moderate (F33.1) and post-traumatic stress disorder (PTSD) (F43.10) | Mental Status Exam: The client’s affect is flat, and she is hunched over in the chair. The client is oriented to person, place, time, and situation. She reports no hallucinations, paranoia, or depersonalization/dissocia | You are a licensed counselor working for a local government mental health agency in the counseling clinic. The client was referred to receive case management and counseling after experiencing homelessness due to leaving a physically and verbally abusive relationship with her last partner. The client is experiencing the following depressive symptoms: sadness more often than not, mental fogginess, suicidal ideation, insomnia, significant weight loss, feelings of worthlessness, and fatigue. The client experiences PTSD symptoms due to having experienced several abusive relationships, including recurrent distressing intrusive thoughts regarding the physical abuse, distressing dreams related to abuse, and physiological reactions (difficulty breathing, heart racing) when she goes near certain places that remind her of the abuse. She also explains that she has been avoiding triggers, believes that no one can be trusted, has an exaggerated startle response, and has had difficulty experiencing positive emotions. The client says that she does not know if therapy can help because she feels like these events have changed her and that she cannot get back to “normal,” but that she would like to make friends so she doesn’t feel so alone. | The client comes to this session, sits down, and starts talking about how she met a man and talked to him for about an hour and was frustrated at the end of the conversation because she feels that he is “like everyone I’ve been with before.” The client continues to explain that she knows these men are not good for her and that she wants something different, but she is still talking to him. The client becomes frustrated talking about this and begins crying and breathing heavily, stating that, “I am broken and can’t have a healthy relationship.” You support the client through her strong emotions and provide empathetic listening. The client identifies that she has reasons to change and has a plan to change how she approaches relationships | The client identifies that she has reasons to change and has a plan to change how she approaches relationships. Which of the following identifies the client’s stage according to the transtheoretical model of change? | Preparation | Contemplation | Action | Precontemplation | (A): Preparation
(B): Contemplation
(C): Action
(D): Precontemplation | Preparation | A | The transtheoretical model of change proposes six stages of change: precontemplation, contemplation, preparation, action, maintenance, and termination. This client is in the preparation stage of change because she understands her problem and has a plan in place to address it. The client is not currently taking actions to make changes; therefore, she is not in the action phase of change. The precontemplation phase occurs prior to the client identifying the problem when the client may not have any intention of addressing her behavior. The contemplation phase involves the client knowing that there is a problem but not yet having a plan for action. Therefore, the correct answer is (A) | counseling skills and interventions |
736 | Initial Intake: Age: 22 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: African American Relationship Status: In a long-term relationship Counseling Setting: Adult inpatient psychiatric Type of Counseling: Individual | Mark was unable to complete a mental status exam as he was not speaking coherently and was displaying violent behavior towards hospital staff. The ER nurse interviewed Mark’s girlfriend, Erin. | Mark came into ER after his girlfriend Erin called 911 when Mark attacked someone on the bus.
History:
Erin told the ER nurse that Mark has been displaying increasingly irrational behaviors. Erin shared that Mark recently took a trip to Africa. Since then, Mark told Erin that he was hearing the voice of God, telling him that it was his responsibility to rid the world of evil. At first Erin noticed Mark staying up late at night, writing all his thoughts in a journal. When Erin read the journal, the content was incoherent. Erin also shared that Mark was recently put on probation at work for going into the women’s restroom. Mark told his boss that God told him to keep an eye on one of his coworkers. | null | To establish an effective therapeutic relationship, the counselor must? | Collaborate with others to support the client | Have clinical knowledge | Be able to establish trust | Write an appropriate treatment plan | (A): Collaborate with others to support the client
(B): Have clinical knowledge
(C): Be able to establish trust
(D): Write an appropriate treatment plan | Be able to establish trust | C | One of the most important qualities that the counselor should have to establish an effective therapeutic relationship with a client is the ability to establish trust. This is especially important with a client who is suffering from delusions and hallucinations. Clinical knowledge and the ability to write appropriate plans are important skills to have but will not determine whether the counselor will be able to form a positive therapeutic relationship. Collaboration with others is also an important part of being a therapist. There may be family members or other providers who are integral in the care of the client. However, if the trust is not established, the client may be skeptical of the counselor speaking with others. Therefore, the correct answer is (B) | treatment planning |
737 | Initial Intake: Age: 45 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Asian Relationship Status: Single Counseling Setting: Community outpatient clinic Type of Counseling: Individual | During the intake she looked visibly anxious. She appeared jumpy and kept looking at her watch. Although hesitated at times when she was asked a question. The counselor was concerned when Li paused for a long time when asked if she ever thought of hurting herself. Li eventually responded no. The counselor noticed that Li’s clothes looked disheveled and soiled. Li was not forthcoming with information about her past.
| Li is a self-referral. She walked into the clinic and stated that she had been experiencing feelings of anxiety.
History:
Li came into the community outpatient clinic asking to pay a sliding scale fee in cash. When asked for identifying information, Li asked if she had to give that information. She explained that she was undocumented and was weary of leaving any information that may lead government officials to her. Li did not want to give the counselor much of her history and cut the intake session short, stating that she had to get back to work. | null | A symptom of Panic Disorder is? | Symptoms are only precipitated by social situations | Persistent worry about panic attacks and maladaptive change for 2 weeks | Caused by separation from home or attachment figures | Recurrent panic attacks | (A): Symptoms are only precipitated by social situations
(B): Persistent worry about panic attacks and maladaptive change for 2 weeks
(C): Caused by separation from home or attachment figures
(D): Recurrent panic attacks | Recurrent panic attacks | D | Panic Disorder is characterized by recurrent panic attack with symptoms such as sweating, trembling, nausea, dizziness or derealization. Persistent worry about panic attacks and or maladaptive changes must be present for at least a month. If panic attacks are caused by separation from home or attachment figures, this would be separation anxiety disorder. Additionally, if symptoms are only precipitated by social situations, this is indicative of social anxiety disorder. Therefore, the correct answer is (A) | intake, assessment, and diagnosis |
738 | 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. | In working with this client, which of the following counseling characteristics will be most needed during your time together? | Congruence | Empathy | Positive regard | Respect and acceptance for diversity | (A): Congruence
(B): Empathy
(C): Positive regard
(D): Respect and acceptance for diversity | Congruence | A | Each of these qualities are needed during counseling with this client and all clients. At the same time, because the client struggles with ambivalent attachment, congruence will be of the utmost importance in working with him. Those with ambivalent attachment experienced inconsistency from parental figures during childhood, never knowing if they would experience emotional availability or rejection. Congruence demonstrates authenticity or consistency between the counselor's internal and external self. Empathy allows the counselor to understand the client's feelings as he experiences them, which allows the client to feel heard and cared for. Positive regard allows the client to feel safe that he is not being judged when opening himself up to the counselor. Respect and acceptance for diversity is always imperative and will be demonstrated through the counselor's congruence, empathy, and positive regard. Therefore, the correct answer is (D) | counseling skills and interventions |
739 | Client Age: 19 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Private Practice Type of Counseling: Individual Presenting Problem: Suicidality related to body image Diagnosis: Body Dysmorphic Disorder 300.7 (F45.22), with absent insight/delusional beliefs | Mental Status Exam: The client’s mood is sad and irritable. His speech is pressured when discussing his appearance but is otherwise normal. He is appropriately groomed and wears a beanie covering his ears. He admits to repetitively dissecting his face in the mirror several hours a day. The client offers that he cannot hide his ears with his hair because “it is too thin.” He denies audio/visual hallucinations. The client’s thought content is organized and coherent, but he shows poor insight and delusional thinking about how he and others regard his appearance. The client avoids social settings and reports that sometimes, an entire week goes by where he doesn’t leave the house. He denies suicidality and currently does not have a plan or intent to harm himself or others. Appetite and sleep are fair. The client denies drug use and states he consumes alcohol occasionally. You provide an in-depth suicide assessment, and you and the client work together to create a suicide safety | You are working in private practice and conducting an initial intake session with a 19-year-old male who presents today with his mother. The client was recently admitted to a psychiatric hospital for suicidality and was discharged four days ago. His mother reports that the client tried to commit suicide by overdosing. The client reports feeling increasingly hopeless following a “failed” cosmetic surgery procedure. He explains that he had an otoplasty performed to change the proportion and position of his ears. He states he has always hated his ears and is convinced people are staring and laughing at his “deformity.” His mother reports that she reluctantly consented to the surgery a year and a half ago, despite believing it was unnecessary. The client does not leave the house without wearing a beanie or hoodie. He has completed high school with no interest in attending college. He is unemployed due to shame and embarrassment over his “defective” appearance. Two weeks ago, the hospital psychiatrist changed his medication and placed him on a selective serotonin reuptake inhibitor (SSRI). | You and the client review his safety plan. The client believes the antidepressant has helped decrease his feelings of hopelessness and suicidality. Despite the hot and humid conditions, the client arrives at his counseling session in a hoodie. He explains that he has been getting out of the house “some” but continues to avoid social situations because of overwhelming thoughts of others staring at him and mocking his appearance. The client was a no-show for his appointment last week and has requested distance counseling to avoid anxiety experienced when leaving the house. You and the client work together to set appropriate treatment plan goals; however, this is difficult due to poor insight into his presenting problem. You provide psychoeducation about BDD and ask about his goals for the future. You have discussed the client’s request for distance counseling with your supervisor, considered the potential risks and benefits, and have determined that honoring the client’s request is the best course of action | You have discussed the client’s request for distance counseling with your supervisor, considered the potential risks and benefits, and have determined that honoring the client’s request is the best course of action. Before implementation, which of the following “test” questions would you ask yourself to help finalize this decision according to the American Counseling Association’s (ACA)Practitioner’s Guide to Ethical Decision-Making? | Would I want my behavior reported in the press? | Can I faithfully fulfill this obligation? | Are there legal implications to this decision? | Would this decision harm the client? | (A): Would I want my behavior reported in the press?
(B): Can I faithfully fulfill this obligation?
(C): Are there legal implications to this decision?
(D): Would this decision harm the client? | Would I want my behavior reported in the press? | A | Asking yourself if you want your behavior reported in the press (publicity) best helps finalize this decision. The American Counseling Association’s (ACA)Practitioner’s Guide to Ethical Decision-Makingprovides a framework emphasizing the following steps, “1. Identify the problem. 2. Apply the ACA Code of Ethics. 3. Determine the nature and dimensions of the dilemma. 4. Generate potential courses of action. 5. Consider the potential consequences of all options and determine a course of action. 6. Evaluate the selected course of action. 7. Implement the course of action (Forester-Miller & Davis, 2016)” When evaluating the selected course of action, there are three tests to help ensure the action is appropriate. The tests honor the principles of justice, publicity, and universality. According to the framework: “Justice: In applying the test of justice, assess your sense of fairness by determining whether you would treat others the same in this situation. Publicity: For the test of publicity, ask yourself whether you would want your behavior reported in the press. Universality: The test of universality asks you to assess whether you could recommend the same course of action to another counselor in the same situation (Forester-Miller & Davis, 2016)” Asking if there are legal implications to this decision is a consideration for step 1 of the decision-making model. The question regarding faithful fulfillment (fidelity) of this obligation is reviewed in step 3. According to the ACA’s decision-making framework, step 3 uses the core principles of autonomy, justice, beneficence, nonmaleficence, and fidelity to examine the dimensions of the dilemma. Asking if this decision would harm the client applies the principle of nonmaleficence. Therefore, the correct answer is (D) | professional practice and ethics |
740 | Client Age: 27 Sex: Female Gender: Female Sexual Orientation: Heterosexual Ethnicity: Caucasian Relationship Status: Married Counseling Setting: Career Counseling Center Type of Counseling: Individual Presenting Problem: Employment-related Stress; Anxiety Diagnosis: Adjustment Disorder with Anxiety 309.24 (F43.22) | Mental Status: The client was well-groomed and dressed appropriately. She appears nervous and jittery and quickly places her hands under the table when she notices them shaking. The client states that she is not sleeping well and says it is difficult making it to work each day knowing that “things rarely go as planned.” She explains that she has irritable bowel syndrome, which is exacerbated by stress. The client reports that there are no known medical conditions that would cause her chronic headaches. The client denies homicidal or suicidal ideations but remarks that she has felt like this in the past. Wor | You work in a career counseling center, and your intake is a 27-year-old white female employed as a fourth-grade elementary schoolteacher. The client has been a teacher for 3.5 years and has become increasingly dissatisfied with her job. The client explains that she is “at her breaking point” and relays that her stress level has increased sharply within the past 3 months. This is her first school year with a newly hired principal who has been “unreasonably demanding and unsupportive.” The client states that she was already second-guessing her career choice and explains that disruptive students and a lack of parental involvement have made teaching incredibly challenging. She reports “stress-induced physical symptoms,” which include acute stomach distress and chronic headaches. She worries that her skill set is nontransferable. | k and Family History: The client obtained her bachelor’s degree in teaching and is currently a certified teacher. She comes from a family of educators, with her mother working as a teacher and her father as a high school guidance counselor. Before college graduation, she worked odd jobs, including waiting tables and working in a public library with preschool groups. She remembers enjoying her student teaching position but states that the class was “nothing like” what she has now. She explains that her student-teaching classroom contained 16 students and that she now struggles to stay on top of her current class of 24. She plays on a tennis team and serves as a “big sister” to a child through a local nonprofit organization. The client is married, and she and her husband do not have children. She reports that her husband has a high-stress job working as an attorney. The client says that he has “little patience with me when I complain about my job stress.” You ask the client to tell you about a time when her problem did not exist or was less severe | You ask the client to tell you about a time when her problem did not exist or was less severe. Which one of the following approaches reflects this stance? | Solution-focused brief therapy | Gestalt therapy | Freudian psychoanalysis | Transactional analysis | (A): Solution-focused brief therapy
(B): Gestalt therapy
(C): Freudian psychoanalysis
(D): Transactional analysis | Solution-focused brief therapy | A | One technique of solution-focused brief therapy is to ask the client about a time when her problem did not exist or was less severe; this technique is known as the exception question. Solution-focused brief therapy is a short-term, solution-oriented best practice used to help clients establish and reach goals by improving motivation and creating measurable behavioral change. Freudian psychoanalysis focuses on how a client’s unconscious influences affect how they think, act, and feel. Eric Berne, credited with developing transactional analysis, used techniques such as script analysis to explore the interaction of ego states (eg, parent, adult, and child). Gestalt therapists emphasize the integration of mind and body through an awareness of the present moment. Therefore, the correct answer is (B) | counseling skills and interventions |
741 | Name: Dana Clinical Issues: Relationship distress with mother during divorce Diagnostic Category: Depressive Disorders;V-codes Provisional Diagnosis: F33.1 Major Depressive Disorder, Moderate, Recurrent Episodes; Z62.820 Parent-Child Relational Problem Age: 15 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: Multiracial Marital Status: Never married Modality: Individual Therapy Location of Therapy : Under Supervision | The client is dressed in black attire. She sits with her hands folded and slumped over in the chair. She makes little eye contact and seems to distrust you. Her mood seems flat. During the intake, the mother complains about how her daughter "does not listen," "acts out all the time," and "picks fights with her sister." The client is reticent and shrugs her shoulders. The client reported several other symptoms indicative of a depressive episode, including feelings of worthlessness, anhedonia, and lethargy. She also said having recurrent thoughts of self-harm that had become pervasive throughout her day-to-day life. On objective examination, the patient demonstrated psychomotor retardation, appearing to move and speak in a lethargic and sluggish manner. Cognitively, the patient's attention span was limited, and her concentration was impaired. She could not sustain her train of thought and had difficulty forming coherent sentences. Her mood was notably depressed, and her affect was constricted. This suggests a severe depressive episode, and these symptoms will likely require aggressive treatment. | First session You are a limited permit holder under direct supervision. The client is a 15-year-old multiracial female who presents to the first counseling session with her mother. The session begins with the client's mother monopolizing the conversation, and it is difficult for the client to get a word in edgewise. The client's mother continually brings up her husband as a source of her daughter's problems. The mother says, ""Our daughter is not doing well in school and has been talking back to her teacher. I think it comes from the relationship she's had with her father." The client interrupts and says, "It's not Dad's fault! You're the one who abuses me!" The mother is incredulous and begins to yell, saying that she would never hit her daughter and that the client is lying. The mother tells you that her daughter is a "liar, a thief, and creates problems." She reports that Child Protective Services (CPS) has been to their house several times, and she believes that these visits are her husband's fault. The client is visibly upset, and her mother continues to berate her. You intervene and explain that the client's disclosure is serious and should be taken seriously. You explain that you must speak to the client alone before deciding the best course of action. While speaking alone with the client, you notice that she is shaking and close to tears. You encourage her to take deep breaths and explain that she can take some time to regroup before continuing. After a few minutes, she appears calmer and begins to describe her home situation. It becomes clear that the client's home life is chaotic and that she is being subjected to verbal and emotional abuse from her mother. She tells you that she wants to live with her father. The client also states that she has been bullied in school, and this has been going on for some time. You explain to the client that she has a right to feel safe and that you will do everything in your power to ensure her safety. You continue asking question to assess her level of distress, and you note the client's self-reported symptoms consistent with depression, including insomnia, fatigue, and a significant decrease in her appetite. She is also alienating herself from her peers and family. After completing the initial session, you schedule an appointment to see the client and her mother next week to continue your assessment to determine the best course of action. Third session During last week's session, the client's mother accompanied her to the session. Throughout that session, the mother continued to talk about her own personal issues, and you could not gather information from her daughter's point of view. The client's mother presents with her daughter again to today's session. After a few minutes, you realize that the mother is monopolizing the counseling session by talking about her personal life and making snide comments aimed at her daughter. You suggest that it might be better for the client's mother to wait outside while you talk alone with the client. When the mother leaves, the client immediately relaxes and opens up about some of the struggles she has been going through. She shares that life at home has been difficult. She describes her mother as being "very mean" to her, and her grandmother makes fun of her. On the other hand, both adults are nice to her younger sister. The client states that she wishes she had never been adopted and that her life is "miserable." She expresses a desire to live with her father. Her behavior toward her parents has changed drastically since they started fighting in front of her, but she is not sure how to deal with their constant bickering. She has not told anyone at school about living in a "broken home" because she does not want any extra attention from her classmates. However, she has opened up more during therapy sessions, like today's meeting, telling you that music makes her feel better when upset. As homework, you ask the client to put together a playlist of music that is meaningful to her and bring it with her to the next session. Following today's session, the client's father calls you during off-hours to complain about his soon-to-be ex-wife. | The client has experienced a great deal of distress due to the chaotic environment of her home life. Her adoptive parents are in the middle of a "messy divorce," and it has been difficult for her to process, as she has had to witness her parents' arguments and the shifting dynamics of her family. This strain has been further compounded by her mother and grandmother's favoritism towards her younger sister, leading to the client feeling neglected and overlooked. In addition, her attempts to connect with her mother and sister have often been met with hostility, leading to frequent arguments and further exacerbating her feelings of alienation and loneliness. The client has also expressed feelings of anxiety and depression due to her current living situation. She has expressed a strong desire to live with her father and escape the hostile environment of her mother's home, yet her mother has continuously denied this request. This has resulted in the client feeling trapped and powerless to alter her current situation, leading to a sense of hopelessness. The client's relationship with her mother is strained, and she has difficulty trusting her. As a result, she is often guarded around her mother and expresses her distrust and resentment, resulting in further conflict and tension between them. The client's school environment has affected her mental health. She is constantly subjected to verbal and physical bullying from her peers, leading to feelings of worthlessness and insecurity. Her academic performance is suffering, and she cannot concentrate in class, leading to further isolation from her classmates. Previous Counseling: The client has been in and out of therapy with many different professionals. She has been diagnosed with Major Depressive Disorder. Her mother is also in therapy and believes her daughter needs "help." The client states that her mother has abused her before, and Child Protective Service (CPS) has been to the house numerous times but has not found any evidence of abuse. | Which of the following would be most helpful for the client? | Helping her discern the barriers that are keeping her from reaching her goals | Helping her find equanimity with living with her mother | Helping her live more harmoniously with her adoptive sister. | Helping her to come to terms with her relationship with her father. | (A): Helping her discern the barriers that are keeping her from reaching her goals
(B): Helping her find equanimity with living with her mother
(C): Helping her live more harmoniously with her adoptive sister.
(D): Helping her to come to terms with her relationship with her father. | Helping her discern the barriers that are keeping her from reaching her goals | A | In order to realistically move toward her goals, the client needs to have a good sense of the things that stand in her way. Therefore, the correct answer is (B) | counseling skills and interventions |
742 | Initial Intake: Age: 20 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Community Mental Health Agency Type of Counseling: Individual | The client presents looking appropriate to stated age and with positive signs of self-care related to hygiene and dress. Mood and affect are congruent, and motor activity is within normal limits. His interpersonal communication is cooperative, open, and forthcoming. His speech is within normal limits with respect to volume, tone, or rate. His thought processes appear within normal limits with insight into his thoughts and behaviors, including concerns others express about his situation. He demonstrates the ability to connect ideas with circumstances and choices. He reports no thoughts of suicide or self-harm. | You are a counselor in a community mental health agency setting. Your client presents as a 20 year old man with feelings of sadness, discouragement, being overwhelmed, and anxious. These feelings have been present for the past 4 to 5 years. He reports that while in high school, he had planned to commit suicide but did not follow through with it as he did not want to hurt his family and friends. The client tells you that he has moved frequently with his family; living overseas during his last two years of high school then beginning college in the United States. He states that he moved here 8 months ago because he wanted to be independent of his family and start “a new life without so many ups and downs.” He lives in a house that his paternal aunt left to his family when she died. His mother and father recently separated and his father provides him with financial support. Until recently, he reports having been employed as a server in a restaurant but was fired after being accused of disrespect to a coworker. Your client states that the coworker had never liked him and he had not been disrespectful of her; however, their manager chose to let him go. He is currently attending classes at the community college and is in a mechanical engineering program. He chose this program because he thought he would really like it but he has been struggling with his courses due to his work schedule and now his major concern is making a living so that he can stay in school. He says he’s beginning to doubt whether this is the right path for him. He reports having no friends or anyone to spend time with on his days off. | Family History:
The client is an only child. His parents have moved frequently with his father’s job and have lived in different areas of the world. His mother currently lives across the country and his father lives in the Middle East due to his work. They formally separated three months ago. Prior to moving here, the client lived with his mother but was concerned that she was “spending all our money.” His mother is retired and is supported by his father. He states he doesn’t want to be like her and live off of his father’s wealth. | Which of the following cognitive behavioral therapy (CBT) interventions will be most helpful for the counselor to encourage the client to complete in between sessions? | Utilize relaxation and stress reduction techniques prior to drinking alcohol | Utilize a daily journal to process feelings of depression and anxiety | Utilize behavioral experiments with classmates for social interaction | Utilize role playing to practice social skills to help build relationships with others | (A): Utilize relaxation and stress reduction techniques prior to drinking alcohol
(B): Utilize a daily journal to process feelings of depression and anxiety
(C): Utilize behavioral experiments with classmates for social interaction
(D): Utilize role playing to practice social skills to help build relationships with others | Utilize behavioral experiments with classmates for social interaction | C | Behavioral experiments are a CBT intervention that the client can use at school and work to determine whether his beliefs (predictions) about his ability to make friends and that others have no time to socialize are true or whether these predictions keep him isolated. Using a journal and relaxation exercises are good homework assignments for clients and can be beneficial for this client; however, the client's current alcohol use does not present as inappropriate or anxiety-based and he presents as dealing well with his emotions with the help of medication. Role playing to practice social skills is a good intervention to use within sessions but given the client's current isolation, would be an unlikely intervention to assign for between session practice. Therefore, the correct answer is (B) | counseling skills and interventions |
743 | 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. During the session, the client states, “I don’t think I can provide for my family like I need to, so I’m worthless | During the session, the client states, “I don’t think I can provide for my family like I need to, so I’m worthless.” Which one of the following areas needs to be explored following this statement? | Anxiety | Self-esteem | Depression | Work skills | (A): Anxiety
(B): Self-esteem
(C): Depression
(D): Work skills | Self-esteem | B | As evidenced by his frustration with unemployment and feelings of worthlessness, the client’s self-esteem is affected by his current situation. This would be important to investigate further. The client’s depression and depressed mood have already been identified and are therefore not new symptoms. The client has demonstrated that he has work skills, and although it is within your role to support the client in finding new opportunities that match his skill set, the focus should be on the underlying root of the client’s statement. Therefore, the correct answer is (C) | intake, assessment, and diagnosis |
744 | Initial Intake: Age: 4 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: African American Relationship Status: Single Counseling Setting: Community Clinic Type of Counseling: Individual | Destiny was engaging with the counselor throughout the interview although her affect was flat. She played by herself while the counselor spoke to Darlene and Tony. She did not look up at her parents or engage with them during the entire session. | Destiny is a 4-year-old who was referred for therapy by her preschool teacher. Destiny arrived at the intake session with her adoptive parents, Darlene and Tony Mase. Darlene and Tony shared that they were concerned about Destiny because she never wants to interact with other children, rarely smiles or laughs, and has mood fluctuations with little or no pattern or trigger. Reactions include irritability, sadness, and tearfulness.
History:
Destiny arrived at the Mases’ when she was two years old and was nonverbal at the time. Destiny also showed cognitive delays in her early intervention screening. Darlene and Tony noticed Destiny’s lack of interest in playing with other children when Destiny arrived and she did not want to interact with the other children in the home. The irritability and mood fluctuations began over a year ago. Darlene and Tony were hopeful that once Destiny started preschool that she would start interacting with others, however this is not the case. | null | What source of information is least important at this time? | Behavioral observation from teacher | Relationship with birth parents | Traumatic life events | Current household members | (A): Behavioral observation from teacher
(B): Relationship with birth parents
(C): Traumatic life events
(D): Current household members | Current household members | D | Information about current household members may not be as important at this time. Foster homes are screened and there is no indication or mention of issues surrounding the foster home or anyone living in it. A main problem area for Destiny is her interaction with other children. What happens in a school setting can provide great information. It is important to understand Destiny's relationship with her birth parents to see what the short term and long-term permanency goals are. Finally, it is important to get a comprehensive trauma history to better understand Destiny's early experiences. Therefore, the correct answer is (D) | intake, assessment, and diagnosis |
745 | Initial Intake: Age: 26 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Married Counseling Setting: Private Practice Type of Counseling: Individual | Molly was initially guarded, but pleasant, during the intake session. After some time, she became tearful. Molly stated to the counselor that although she always had a level of anxiety, she never came to counseling before because she thought that only unsuccessful people with serious issues get counseling.
| Molly came into individual counseling due to increased feelings of anxiety.
History:
Molly began showing symptoms of anxiety when she was in high school. Molly was star of the track team and on the honor roll. During her senior year she was writing for the yearbook and preparing to attend college at an Ivy League university. She successfully finished college and law school. Despite the symptoms she experienced throughout her educational career, she was able to ride it out and has been extremely successful in her law career. | null | In determining the course of treatment, the counselor should first consider? | What treatment would take the shortest amount of time because of the client's financial situation. | A holistic view of the client. | What has worked in the past for similar clients. | What treatment has been successful with this client thus far. | (A): What treatment would take the shortest amount of time because of the client's financial situation.
(B): A holistic view of the client.
(C): What has worked in the past for similar clients.
(D): What treatment has been successful with this client thus far. | A holistic view of the client. | B | In determining the course of treatment, it is important for the counselor to not look at just fragments of the clinical picture. By looking at the client's history, culture and physical and mental health, an effective treatment plan can be more effectively established. Although what has worked in the past with similar cases can be helpful, each person is unique. In addition, although the client may have tried things in the past that did not work, does not mean they may not be successful in trying it again. Finally, putting a short timeframe on the course of treatment because of monetary constraints is not ethical. Therefore, the correct answer is (D) | intake, assessment, and diagnosis |
746 | 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 least important area to focus on currently is? | Helping Shar develop coping skills | Psychoeducation on Shar's diagnosis | Shar's relationship with their mother | Shar's decline in school functioning | (A): Helping Shar develop coping skills
(B): Psychoeducation on Shar's diagnosis
(C): Shar's relationship with their mother
(D): Shar's decline in school functioning | Shar's decline in school functioning | D | Although Shar's academic functioning has suffered, this is likely a result of other symptoms Shar is experiencing. Once those are addressed, Shar's grades are likely to improve. Shar and Nadia used to have a positive relationship. Nadia can be a support to Shar as they go through this difficult time. Shar needs some coping skills as evident by their feelings of anger and hopelessness. It would also be beneficial for Shar to receive psychoeducation on their diagnosis, so they understand that their feelings of not belonging are not unique to them. Therefore, the correct answer is (B) | intake, assessment, and diagnosis |
747 | 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 | The best modality of therapy to utilize with Molly would be? | Gestalt Therapy | Psychoanalysis | Cognitive Behavioral Therapy | Humanistic Therapy | (A): Gestalt Therapy
(B): Psychoanalysis
(C): Cognitive Behavioral Therapy
(D): Humanistic Therapy | Cognitive Behavioral Therapy | C | Cognitive Behavioral Therapy would be beneficial for Molly at this time as it is short term, structured and task oriented. It can address her irrational/rational thoughts and help her to examine the narrative she has in her head surrounding her father's death. Psychoanalysis is a long-term therapy which examines how the past influences current issues. In this case, we know that the factor which influenced Molly's symptoms is the death of her father. Also because of her recent hospitalization and consideration of cutting, it is important to address those things immediately. Some techniques in Gestalt therapy may be beneficial, such as the empty chair technique. However, it is important to address Molly's declination in functioning as well as the consideration of cutting which requires more immediate interventions. Additionally, the therapist's role in Gestalt therapy is more of a facilitator and it seems that Molly needs a more directive modality at this time. Although Humanistic Therapy is a positive approach which could be beneficial, it is typically unstructured and may not provide immediate relief of specific complaints. Currently Molly needs a short term, directive form of therapy. Therefore, the correct answer is (C) | intake, assessment, and diagnosis |
748 | Initial Intake: Age: 18 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Chinese Relationship Status: Single Counseling Setting: College Counseling Center Type of Counseling: Individual | The counselor noticed that Darrel’s clothes look disheveled, he had bags under his eyes and made very little eye contact. When asked, Darrel stated that he was working late the day before and he just needed to rest.
| Darrel is an 18-year-old freshman who comes into the college counseling center for some career counseling.
History
Darrel is a transfer student from China, living with a boarding family close to the college campus. He is an Advertising major at college. Darrel stated that he is unhappy at school. He didn’t know if he was unhappy with his major selection even though he couldn’t see himself doing anything else. Darrel described how recently he just doesn’t like anything he used to, including anything that has to do with Advertising. Darrel stated that his parent would be greatly disappointed if they knew that he was switching his major. He questioned why he had to do what they want anyway. The counselor suspected that the issues may be deeper than Darrel’s initial intake suggested. | null | The ACA code of ethics states that counselors should consider diversity when assessing and diagnosing a client. A possible diversity factor which may have been overlooked in the intake/assessment process is? | Darrel's feelings about his assertiveness | Darrel's desire to not allow his parents to make decisions in his life | Darrel's stage of Racial identity | Darrel's lack of eye contact during the intake | (A): Darrel's feelings about his assertiveness
(B): Darrel's desire to not allow his parents to make decisions in his life
(C): Darrel's stage of Racial identity
(D): Darrel's lack of eye contact during the intake | Darrel's lack of eye contact during the intake | D | Darrel's lack of eye contact during the assessment process can be misconstrued as being evasive, when it is often a sign of respect in Asian cultures. It is important for counselors to take into consideration verbal and non-verbal behavior with a multi-cultural lens. Darrel's dissonance about his desire to not allow his parents to make decisions in his life is developmentally appropriate considering the life stage he is in. This idea was also openly stated by Darrel when he questioned why he had to do what they wanted anyway. Issues regarding racial identity and Darrel's feelings about assertiveness were shared in the second therapy session, so they were not relevant during the intake/assessment process. Therefore, the correct answer is (A) | intake, assessment, and diagnosis |
749 | 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. | 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. | As part of your post doctoral research, you have quantified the severity of the client's depressive episodes and found that the highest value is the same as 60% of your other samples. Which measure of central tendency have you found? | Median | Mean | Mode | Range | (A): Median
(B): Mean
(C): Mode
(D): Range | Mode | C | The mode is the most common number in a data set. The median is the middle of the set of numbersThe mean is the average of a data set. Therefore, the correct answer is (C) | professional practice and ethics |
750 | Name: Gregory Clinical Issues: Behavioral problems Diagnostic Category: Disruptive/Impulse-Control/Conduct Disorders Provisional Diagnosis: F91.3 Oppositional Defiant Disorder Age: 14 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Not Assessed Ethnicity: Black Marital Status: Not Assessed Modality: Individual Therapy Location of Therapy : Private Practice | The client appears obese and his clothing is unkempt. His behavior is uncooperative. He finds people "annoying" and can at times be vindictive toward people he finds "annoying." His mood is angry and affect is irritable. His flow of thought is coherent and goal-directed. His overall responses at times show themes of low self-esteem. He denies any current thoughts of suicide or homicide. He does not display any signs of hallucinations or delusions. His vocabulary is age-appropriate, but his speech is at times sarcastic. He answers questions coherently. Thought process is linear and coherent. He is oriented X3. Memory is intact for recent, remote, and immediate. Insight and judgement are poor. | First session You are a mental health counselor working in private practice. Gregory, a 14-year-old male, presents to the initial session with his mother. She reports that her son has been skipping school, hanging out with a negative peer group, and his grades are starting to slip. He refuses to listen to his mother, saying she is "strict and unfair." Gregory, who up to this point has been sitting quietly with his arms crossed, rolls his eyes and says, "She should be in therapy, not me." Gregory's mother continues on to express concern over his decline in school performance, noting that "he is having problems with some teachers and staff." Last week, he got up in the middle of class and when told to sit down, he said, "I have to go to the bathroom." He walked out and slammed the door behind him. He was sent to the principal's office as a consequence. He has also become vindictive toward certain classmates. When asked why, he states, "because they think they're better than me." His mother reports that at home, Gregory has become increasingly isolated, spending most of his free time alone in his room or out with a group of teenagers she does not recognize. He has has become increasingly hostile and verbally abusive toward his mother and brothers, resulting in frequent arguments. He routinely ignores his curfew and refuses to participate in family activities. You thank the mother for sharing her concerns and ask to speak with Gregory alone to give him a chance to express himself freely. You want to obtain his assent to join in therapy and understand what is causing him to act out. Third session Today is your third session with Gregory and you are meeting him on a weekly basis. Last week, you met with him alone and explored his feelings about his family and triggers for his anger and irritability. He reiterated that his mother and brothers were the problem, not him. You recommended meeting with Gregory and his mother for today's session to develop a treatment plan to address Gregory's issues. As you prepare for his appointment, you hear yelling in the waiting room and find Gregory screaming at his mother. She is sitting in the chair, shaking her head. You call them both into your office. His mother yells, "I've had enough of you today! This time, I'm going to talk!" Gregory rolls his eyes and mocks her. According to his mother, Gregory was "caught by the school resource officer today with a vape on him." She chokes back tears, saying, "I don't know who my son is anymore." Gregory responds, "You're overreacting. That's all you do. Big deal. It's just a vape. Get over it." His mother looks at you and says, "He's not getting better even with therapy. He won't listen to anyone, and dealing with him is a constant pain. He's spiteful and working against me. How do I get my son back?" Gregory has been exhibiting increasingly concerning behaviors since he began using a vape. He has become easily frustrated, struggles to regulate his emotions, and often resorts to aggressive outbursts. He continues to be defiant and uncooperative, straining his relationship with his mother. Despite her best efforts, Gregory remains uninterested in following your guidance, further complicating his mother's efforts to help him. 10th session You have been seeing Gregory for therapy every week for the past three months. You have worked to improve the parent-child relationship and incorporated parent-management training into his treatment plan. You have taught Gregory's mother techniques to improve his behavior and support his emotional functioning. Also included in Gregory's treatment plan is improving impulse control, learning problem-solving skills, and improving social skills. You have used CBT interventions, structured activities, games, and role-playing exercises with Gregory to achieve these goals. Today, Gregory begins the session by taking a paper from his backpack and handing it to you. You see that he received a high grade on his mid-term in Global Studies. You praise him for his hard work. Then, you ask him how it felt to get his grades back up. There is a long silence. Gregory is fidgeting with the string on his backpack. He turns, looks out the window, and whispers, "Good, I guess." You notice the client has tears in his eyes. You draw his attention to his behavior and affect and ask, "Why are you upset after being successful with your exam?" He shrugs his shoulders, looks at you, says, "Would you stop asking me so many questions?" and walks out of the office. You follow him into the waiting room and hear him tell his mom, "I'll be in the car." His mom looks confused. You say to her, "Is something going on or did something happen with Gregory that I should know about? He seemed upset after showing me his good exam grades." She thinks for a moment and tells you that he found a box of old family pictures and has been going through them. She wonders if this is related to his reaction today. | The client resides with his mother and three older brothers. He describes his brothers and mother as "annoying" and tells you that none of them listens to him. 18 months ago, his father passed away after a long illness. The client says that his dad was the only family member who understood him. The client feels he has no one to talk to and does not get along with his family members. He reports difficulty trusting others and is guarded in his relationships. He has become more irritable and vindictive since his father's death. The client denies drug or alcohol use and responds to your question, saying, "What? Are you an idiot? Do I look like someone that would be stupid enough to do drugs?" The client scoffed and continued, "Why would I waste my time and energy risking my future for something so pointless." He then crossed his arms and stared defiantly, clearly not interested in discussing the matter further. | Using a Gestalt approach, what could you have done differently when you noticed that Gregory appeared sad and withdrawn? | Remained empathic | Used an exercise in locating his emotions | Introduced the empty chair technique | Engaged in a role-playing exercise | (A): Remained empathic
(B): Used an exercise in locating his emotions
(C): Introduced the empty chair technique
(D): Engaged in a role-playing exercise | Used an exercise in locating his emotions | B | Using this technique, you would ask the client to name the emotion they are feeling and identify where they feel the emotion in their body. This is particularly helpful with clients who don't know how or why they are responding in the moment. Therefore, the correct answer is (A) | counseling skills and interventions |
751 | Name: Tina Clinical Issues: Maladaptive eating behaviors Diagnostic Category: Feeding and Eating Disorders Provisional Diagnosis: F50.01 Anorexia Nervosa, Restricting Type Age: 21 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: Italian American Marital Status: Not Married Modality: Individual Therapy Location of Therapy : University counseling center | The client presented with a slender physique and was observed wearing conservative, dark-colored attire. Her overall demeanor was reserved, displaying noticeable nervousness and a tendency to withdraw from interactions. Upon conversing with her, it became evident that her train of thought often deviated from the topic at hand, hinting at a tangential pattern. This difficulty in maintaining concentration appears to be a consequence of her heightened anxiety levels. Delving deeper into her thought content, a recurring theme of obsessions surrounding food and body weight emerged. Additionally, a palpable fear of judgment from her peers and the broader society was evident. In terms of her cognitive functioning, she was found to be alert and fully oriented to her personal details, as well as her current location and time. However, a significant concern is her limited insight into her present circumstances and the implications of her behaviors. Throughout the assessment, there were no indications of any memory impairments. | First session You are a mental health therapist working in a university counseling center. The client, a 21-year-old female, presents issues related to anxiety, poor body image, and eating. You begin the session by introducing yourself and explaining your role as a therapist. You also explain how confidentiality is handled and make sure that she understands her rights as a client. After the initial introductions, you ask her to tell you about her current situation and what led her to seek out therapy. She reports that she has been feeling anxious for a while, but it has gotten worse since a basketball game when someone in the audience yelled to the referee "thunder thighs over there needs to get her act together!" Even though the comment was not directed at her, she internalized it. She explains that she was already feeling uneasy due to her stepfather's comments about her weight from a few years ago, and the recent insult at the game made it "all come crashing down" for her. Now, she cannot stop ruminating about her appearance. She saw a poster in her dorm room promoting counseling services and decided to make an appointment. You continue your interview by asking about her current eating behaviors. She explains that she avoids carbohydrates, sugar, and most dairy "since that stuff makes you fat." When you ask her to describe what she eats during a typical day, she says, "I usually have a fruit smoothie with almond milk for breakfast, an apple and 12 nuts for lunch, and then some steamed vegetables or a salad for dinner." When asked about exercise or other physical activity besides basketball, she reports that she runs at least seven miles on a nearby trail every morning and spends two hours swimming laps at the indoor gymnasium pool every evening before bed. She says, "The pool is pretty quiet at night. I don't like to be around a lot of people when I'm exercising." As you continue your dialogue, you ask the client open-ended questions to explore her relationship with her parents, especially her stepfather. She reports that her stepfather has always had negative remarks about her size and shape. She states that she feels like he views her as "less-than" because of her weight, which has led to feelings of shame and worthlessness. You explore the dynamic further by inquiring about how these comments have impacted her self-esteem. She reports feeling anxious, embarrassed, and inadequate when her stepfather is critical. You validate her feelings and explain that comments like these can be very damaging to a person's self-image. You ask the client what she hopes to accomplish in therapy. After some thought, the client says that she wants to learn how to manage her anxiety. She looks at your shyly and says, "I also want to be able to eat a piece of chocolate. I know that sounds crazy, but I just want to be able to enjoy it, without feeling guilty or like I'm going to get fat." You affirm her desires and explain that a key part of the therapeutic process will be to help her build self-confidence and develop healthier relationships with food. Sixth session You have been working with the client in intensive outpatient therapy and have been meeting with her two times per week. She is under medical care at the university's health center and has started taking an anti-anxiety medication that was prescribed by her physician. You have also referred her to a nutritionist for specialized guidance on developing a healthier relationship with food. You have established a strong, trusting relationship, and she has told you that she feels comfortable talking to you. Today, the client brings up an issue that has been bothering her for a while: anxiety about eating around other people. She tells you that she usually gets her food "to go" from the cafeteria and eats at a bench outside or alone in her dorm room. She avoids eating in front of others when possible. However, at least once or twice a week, her teammates all go out to lunch after practice. This usually requires her to order food in front of them and she feels very anxious about it. She has been ordering the same salad with dressing "on the side" for several months because that is what makes her feel the most comfortable. One of her teammates commented on her "same old salad" and asked why she never got anything else to eat. Everyone at the table got quiet and turned to look at her. The client reports that the comment made her feel embarrassed and ashamed, like everyone was laughing at her. You ask her how she responded in the moment and she shares that she just laughed it off, but internally, she felt very embarrassed and anxious. You explore this further by asking her what emotions arise when she is around food, particularly in social settings. She reports feeling ashamed for wanting to eat "fattening food" because of her father's comments about her size. She skipped the last team lunch because she was so anxious about someone drawing attention to her food choices again. She closes her eyes and takes a breath. When she opens her eyes, you can see that she is struggling to hold back tears. She says, "Everyone eats their food like it's no big deal. But it's a huge deal for me. It's all I can think about. I just want to be able to eat a meal without feeling guilty or like I'm going to get fat. I'm so tired of worrying about food all the time!" You consider using exposure and response prevention techniques to address her fear and anxiety related to eating. You continue the session by identifying a list of foods and situations that trigger her anxiety and negative feelings about her body. You ask the client if she would like to meet with you for her next session right after practice and bring a lunch to eat in your office. She appears relieved and grateful to have a break from eating in front of her teammates. | The client's parents divorced when she was six years old. Her mother remarried 12 years ago. The client has a younger half-brother who lives with her mother and stepfather. She is close to her mother, but "my stepfather is a different story." She reports that he is critical of her and often remarks on how she looks or what she is eating. She states that he has commented on her weight and body shape since middle school. Her mother tries to intervene, but her stepfather continues to be critical. She tells you she couldn't wait to graduate high school and move out of the house. She tells you, "I remember that when I went home for a visit during winter break during my freshman year, my stepdad had this shocked look on his face when he saw me. He told me I had gained so much weight that I didn't even look like myself anymore. I've never forgotten that. And it's not like he's the picture of health." Previous Counseling: The client has a history of anxiety. She saw a therapist for a few sessions in high school after being referred by her school counselor, but she did not feel comfortable with the therapist and refused to continue attending sessions. She did not receive a clinical diagnosis related to her anxiety. The client reports that she has been feeling more anxious lately and is struggling to cope with her anxiety. She says that she feels "on edge," and that makes it difficult for her to concentrate. She is interested in exploring therapy to manage her anxiety. Additional Characteristics: The client is currently on the school's basketball team. She was voted most valuable player two years in a row. | Which of the following would be an example of an exposure response prevention exercise? | To sit in the cafeteria with teammates during lunch and eat a small portion of food | To avoid interactions that trigger anxiety | To bring a lunch to eat by herself after basketball practice | To visit with teammates while they eat but refrain from eating during this time | (A): To sit in the cafeteria with teammates during lunch and eat a small portion of food
(B): To avoid interactions that trigger anxiety
(C): To bring a lunch to eat by herself after basketball practice
(D): To visit with teammates while they eat but refrain from eating during this time | To sit in the cafeteria with teammates during lunch and eat a small portion of food | A | Exposure involves facing or confronting one's fears repeatedly until the fear subsides, called habituation. Response prevention consists in refraining from compulsions, avoidance, or escape behaviors. Therefore, the correct answer is (A) | treatment planning |
752 | Name: Dawn Clinical Issues: Maladaptive eating behaviors Diagnostic Category: Feeding and Eating Disorders Provisional Diagnosis: F50.01 Anorexia Nervosa, Restricting type Age: 17 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: White Marital Status: Single Modality: Individual Therapy Location of Therapy : University Counseling Center | The client presents as a female in her late teens who appears malnourished and underweight, dressed in loose, concealing clothing. She exhibits poor eye contact and a guarded, closed-off posture with arms protectively crossed. Her affect is tense and anxious. Speech is logical and goal-directed, with no evidence of hallucinations or delusions. She denies any suicidal or homicidal ideation. Cognition is grossly intact for person, place, and time. Her insight and judgment appear limited, as evidenced by unresolved conflict with her parents and changing college majors without considering long-term career goals. She reports a strained relationship with authoritarian parents who were often physically and emotionally absent, leaving her feelings of neglect. She exhibits low self-confidence and an inability to trust her thoughts and desires. She continues to seek parental approval but feels unable to assert her needs. Her mood is anxious and frustrated due to perceived external control and lack of autonomy. | First session You are a mental health counselor in a university counseling center. Dawn, a 17-year-old college student, is referred to you by her physician. The client's parents recently visited during their parents' weekend at the university campus and were very concerned when they saw their daughter, who appeared severely underweight. They had not seen her for several months and immediately contacted the family physician for guidance. After performing a complete physical exam, the physician could not determine any medical causes for the client's low weight. The physician noted, however, that the client expressed that she did not understand her parents' concern about her weight. During the physician's examination interview, she reported feeling intense anxiety about gaining weight and implied that she was unhappy with her appearance. Dawn reported feeling stressed and anxious about her schoolwork, friendships, and body image concerns. She explained that she often skips meals or severely restricts her food intake in an effort to maintain control. Dawn acknowledged that her eating habits have become more disordered over time and expressed openness to learning new coping strategies. While Dawn initially resisted her parents' efforts to intervene, their concern made an impression. She agreed to continue counseling to address the underlying issues driving her unhealthy behaviors. Dawn wants to improve her well-being despite lingering uncertainties. In today's initial counseling session, you focus on establishing trust and providing the client with a safe space to share her feelings without fear of judgment or reprisal. You begin by asking the client how she feels today and if there are any particular topics she would like to discuss. You also explore her feelings about her parents and brother and ask targeted questions to better understand the family dynamics and how they have impacted her self-esteem. You provide the client with psychoeducation regarding healthy eating habits, body image, and the consequences of not caring for oneself. Lastly, you discuss possible resources and referrals that may be helpful for the client during this time. Dawn seemed receptive to discussing her feelings and experiences in a judgment-free environment. She sometimes became emotional when describing her struggles but appeared relieved to openly share things she had kept private. Dawn stated the counseling session felt like a positive first step. After reviewing healthy coping tools and strategies, Dawn agreed to keep a daily food and feelings journal. She also committed to reaching out for support if feeling triggered or unable to care for herself. Dawn left the session with referrals for a nutritionist and an eating disorder support group. | The client has a 25-year-old brother who is a Navy Seal. The client's parents have government jobs and frequently travel to foreign countries for work. When the client moved away to live on campus, her parents immediately turned her old bedroom into a home gym, which the client found unsettling. The client says that while she knows her parents love her, they have never been very affectionate or spent much time with her. When she was younger, the client traveled with her family for a few weeks during the summer but was often left alone during their trips. She describes her relationship with her parents as "strained" but states that she does have a positive relationship with her brother. She plans to see him when he is on leave from the Navy. The client is a freshman at the university and has already changed her major from pre-med to music history. She is anxious about telling her parents that she switched majors and is worried they will be disappointed. She reports that she has always felt a lot of pressure from her parents to excel in school as her brother did. Since she was a child, her parents have expressed their desire to see her become a physician. Her parents have always set high expectations for her academic performance. Their authoritarian parenting style has left her doubting her confidence in her own capabilities. She is frustrated by this dynamic because she does not feel like she can think for herself or pursue her own goals without outside approval. | What detail shared by the client meets one of the diagnostic criteria for her diagnosis? | The client's lack of confidence in her abilities | The client's difficulty maintaining eye contact during the session | The client's intense anxiety about gaining weight | The client's strained relationship with her parents | (A): The client's lack of confidence in her abilities
(B): The client's difficulty maintaining eye contact during the session
(C): The client's intense anxiety about gaining weight
(D): The client's strained relationship with her parents | The client's intense anxiety about gaining weight | C | According to the DSM-5-TR, the criteria for Anorexia Nervosa are: (1) a persistent restriction of energy intake leading to significantly low body weight; (2) intense fear of weight gain or becoming fat, or persistent behavior that interferes with weight gain despite having a significantly low body weight; (3) disturbance in the individual’s perception of their body shape and size. Therefore, the correct answer is (D) | intake, assessment, and diagnosis |
753 | Name: Luna Clinical Issues: Developmental processes/tasks/issues Diagnostic Category: Neurodevelopmental Disorders Provisional Diagnosis: F81.0 Specific Learning Disorder, with Impairment in Reading Age: 13 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: Hispanic Marital Status: Not Applicable Modality: Individual Therapy Location of Therapy : School | The client is an average-built individual who is alert. The client is casually dressed and adequately groomed. Speech volume is quiet, and speech flow is slow. She has difficulty maintaining eye contact for extended periods and often looks down at her feet. She demonstrates irritability at times during the interview and sighs several times. Her thought process is logical. Her estimated level of intelligence is in the low average range, with limited abstract thinking. Concentration is intact. The client shows no problems with memory impairment. | First session As the mental health therapist working in a school setting, you welcomed your new client and her parents into your office. They explained their daughter's struggle with reading and how it caused her to freeze when faced with a spelling or math test. After listening to them closely, you asked the client why she did not enjoy reading. She said that words confused her and made no sense, so she found it difficult to remember what she read. You consider possible solutions for your client, who was having difficulty with schooling due to a lack of literacy skills. You proposed an idea: "Let's try incorporating creative activities as part of our therapy sessions." Doing so, we can develop strategies for improving written language comprehension and expression while making learning fun for your daughter." The parents were hesitant but agreed to try it after seeing their daughter's enthusiasm about trying something different than traditional methods like instruction books or worksheets, as those have not been effective in the past. During the session, you brainstormed ideas around stories, role-playing games, and drawing activities focusing on using everyday experiences as inspiration for creating unique narratives within each session – not only reinforcing literacy skills but also providing an opportunity for emotional growth through storytelling exercises. | The client says she is only poor at reading and "good at everything else." She says that she feels stressed when she has to read. The client's IQ is 89. A reading specialist assessed her, and her reading skills are abnormally low. Throughout elementary school, teachers noted the client has difficulty reading and that, in turn, it has adversely affected the client's academic achievement. As a result, special needs are implemented in the client's school setting. The client has an active Individualized Education Plan (IEP). Pre-existing Conditions: The client has also been diagnosed with epilepsy and is on medication for seizures. The client had frequent seizures for many years until a medication that lessened the occurrence of her symptoms was prescribed. The client fell when she was eight, hit her head, and fractured her skull. She was not diagnosed with any traumatic brain injury, but she did need stitches. Additional Characteristics: The client portrays positive interactions with both staff and peers at school. The client does state she feels she is "stupid" when it comes to reading and wishes she could get better. The client's family is supportive and values education. They are hands-on in supporting the client in any way they can. | What would be considered operating outside your scope of practice as a school counselor when working with this client? | Providing a professional opinion regarding medication for the client | Encouraging the client's family to be involved in the process | Assisting with the Individualized Education Plan process | Collaborating with student support professionals | (A): Providing a professional opinion regarding medication for the client
(B): Encouraging the client's family to be involved in the process
(C): Assisting with the Individualized Education Plan process
(D): Collaborating with student support professionals | Providing a professional opinion regarding medication for the client | A | Providing opinions about medication is outside your scope of practice as a therapist. This would be done a professional who can perform medication evaluations such as a physician, psychiatrist, etc. Therefore, the correct answer is (C) | professional practice and ethics |
754 | 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.” | What would be the best technique to use with Bob as you continue this discussion of him leaving? | confrontation | empathic validation | motivational interviewing | reality therapy | (A): confrontation
(B): empathic validation
(C): motivational interviewing
(D): reality therapy | motivational interviewing | C | The best technique to use with clients who disagree with course of treatment or in this case decide to leave a clinical program against medical advice (AMA) is motivational interviewing through conversation. This strategy employs a person-centered perspective that attempts to move an individual away from a specific negative behavior or maladaptive decision and towards using their own motivations to make positive changes. Using nonjudgmental, empathic questioning, you are more likely to uncover Bob's underlying motivations and help him develop a better safety plan. Validating Bob's feelings empathically as with answer a) is always appropriate; however, Bob is hyper-focused on making an unhealthy choice and is not currently sharing his feelings. Furthermore, validating Bob's stated choices can be confusing and render ineffective any attempts at getting him to stay in treatment. Reality therapy is also a client-centered form of CBT that focuses on improving present relationships and circumstances, but its intention is to avoid discussion of past events which is not ideal in the situation of trying to help Bob build insight into how past events have led him to where he is now. While its key concepts focus on choice, responsibility, and commitment to change, it is an exploration of processing what behaviors a client is displaying and whether it is interfering with them meeting their needs. It is an excellent choice of strategies for longer-term therapeutic techniques once Bob has decided to commit to the counseling program but will meet too many challenges if Bob is resistant and unwilling to engage. Confrontation is the preferred method by operational staff in many treatment facilities as it is usually conducted with appropriate clinical intentions by peers who can help a client in distress feel supported; but it is not an evidence-based method that a mental health counselor would choose in an individual session and especially not with a senior adult presenting as defensive. Confronting a client in this situation when they are within their legal right to leave a voluntary treatment program may result in the client making an even riskier departure which might further cause harm. Therefore, the correct answer is (C) | counseling skills and interventions |
755 | 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 has attended and actively participated in all group therapy sessions. You are preparing the group for termination and discussing a “graduation” ceremony. The client has taken on a leadership role in the group, and you have asked him if he would be your “assistant” for the next group of neurodiverse men. The client approaches you, shakes your hand, and uses eye contact as he politely thanks you for the offer. You state you are pleased he has accepted. He then says, in a matter-of-fact tone, “Absolutely, I see that you really need help with offering better refreshments and teaching certain skills.” You conduct a pre-test and post-test measuring each group member’s social skills and conclude that the group was ineffective | You conduct a pre-test and post-test measuring each group member’s social skills and conclude that the group was ineffective. If COVID-19 occurred between the pre-test and post-test, which factor likely served as a threat to the study’s internal validity? | History | Attrition | Maturation | Statistical regression | (A): History
(B): Attrition
(C): Maturation
(D): Statistical regression | History | A | The One Group Pre-test Post-test design is a non-experimental design. Non-experimental designs do not have a control group and lack internal validity due to the possibility for an unaccounted third variable, known as a spurious variable. Internal validity measures the cause-and-effect relationship between the independent variable and the dependent variable. In this study, the independent variable is the group intervention. The dependent variable is the pre-test/post-test outcome measure associated with improved social skills. The spurious variable is known as history. History influences outcomes when an event occurs between the first and second outcome measure. COVID-19 is the event that likely affected outcome variables in this study, particularly one on social skills. Statistical regression occurs when subjects score extremely high (or low) on the pre-test and show improvement simply due to the passage of time between each measure. Maturation affects internal validity when subjects are impacted by the passage of time (ie, in projects lasting several years). Attrition, or subjects dropping out of the study, also serves as a threat to internal validity. Therefore, the correct answer is (D) | intake, assessment, and diagnosis |
756 | Initial Intake: Age: 26 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Married Counseling Setting: Private Practice Type of Counseling: Individual | Molly was initially guarded, but pleasant, during the intake session. After some time, she became tearful. Molly stated to the counselor that although she always had a level of anxiety, she never came to counseling before because she thought that only unsuccessful people with serious issues get counseling.
| Molly came into individual counseling due to increased feelings of anxiety.
History:
Molly began showing symptoms of anxiety when she was in high school. Molly was star of the track team and on the honor roll. During her senior year she was writing for the yearbook and preparing to attend college at an Ivy League university. She successfully finished college and law school. Despite the symptoms she experienced throughout her educational career, she was able to ride it out and has been extremely successful in her law career. | null | All of the following are relevant areas of information for Molly's assessment, except? | Eating and sleeping habits | Social support | Parent/child relationship issues | Levels of daily stress | (A): Eating and sleeping habits
(B): Social support
(C): Parent/child relationship issues
(D): Levels of daily stress | Parent/child relationship issues | C | Although the quality of her relationship with her parents can lend some important information, this does not seem to be an issue at this point. Molly identified anxiety as the reason she came in. It is important to examine Molly's existing supports. Asking about her eating and sleeping patterns can help identify the severity of her symptoms and how they may be affecting her functioning. Stress seems to be a trigger for Molly so asking about her existing levels of stress would be relevant. Therefore, the correct answer is (A) | counseling skills and interventions |
757 | 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 | An important part of goal setting in this instance is? | Only setting long term goals | Getting parent approval | Involving the school in goal setting | Ensuring the school counselor agrees | (A): Only setting long term goals
(B): Getting parent approval
(C): Involving the school in goal setting
(D): Ensuring the school counselor agrees | Involving the school in goal setting | C | Since Michael's difficulties seem to center around school, it would benefit Michael to have the school involved in his goals. Although the parent may be involved in the planning process, it is not necessary for them to approve of the goals. It is also not necessary for the counselor to agree on the goals, as goals should be client driven. Setting both short term goals and long-term goals allows for the likelihood of success. Therefore, the correct answer is (B) | treatment planning |
758 | 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 | Harold is having difficulty thinking of goals that he needs to work on. The counselor should? | Tell Harold some goals that have been successful in similar situations | Terminate sessions with Harold | Ask Harold what are some things he would like to see changed | Ask Harold's supervisor for some suggestions | (A): Tell Harold some goals that have been successful in similar situations
(B): Terminate sessions with Harold
(C): Ask Harold what are some things he would like to see changed
(D): Ask Harold's supervisor for some suggestions | Ask Harold what are some things he would like to see changed | C | Asking Harold some things he would like to see changed highlights the standard of client centered therapy. The process of making goals in therapy can be daunting, especially for someone who does not feel like they need to be in therapy. Even though Harold's supervisor and HR recommended counseling, it would not be appropriate for Harold's supervisor to make his goals as goals should be client centered regardless of the reason for counseling. This helps to ensure success and motivation. Although the counselor may have done research in what types of goals can be effective, each person is individual and their goals should be as well. Therefore, the correct answer is (D) | intake, assessment, and diagnosis |
759 | 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 is the most appropriate action when referring a client to another provider? | Make a copy of the client's full chart and give it to the client to take to the provider | Have client contact referral and sign a release of records when completing intake forms | Telephone the new provider and give client's name, contact information, and request provider reach out to schedule an appointment, but do not give diagnosis | Have client sign release of records then send letter to referring provider with client summary | (A): Make a copy of the client's full chart and give it to the client to take to the provider
(B): Have client contact referral and sign a release of records when completing intake forms
(C): Telephone the new provider and give client's name, contact information, and request provider reach out to schedule an appointment, but do not give diagnosis
(D): Have client sign release of records then send letter to referring provider with client summary | Have client sign release of records then send letter to referring provider with client summary | D | Having the client sign a release of records while your office facilitates connection between the referring and referral provider. The referring provider then can send a letter introducing the client, the reason for referral, and contact information. This minimizes miscommunication between the client and referral provider and may facilitate getting John into the provider more quickly. Confidentiality rules require that a counselor never divulges any identifying information about a client, even for referral, without a client's signed consent, so calling without that form would be inappropriate. You can have the client make an appointment and sign a release at the referral source's office, however, without the consent, the process could be delayed. Additionally, having signed the consent, the client is more likely to follow through with scheduling an appointment, particularly if contacted by the referred provider. Counselors do not provide clients with a complete chart. Upon request, clients may review their charts with a counselor and may request copies of progress notes. However, therapy notes are not shared with the client or when records are requested. Therefore, the correct answer is (C) | professional practice and ethics |
760 | Client Age: 30 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Married Counseling Setting: Counseling clinic Type of Counseling: Individual counseling Presenting Problem: The client is engaging in restrictive eating daily. The client engages in bingeing when her husband is away for business trips and engages in exercise as compensatory behavior. Diagnosis: Anorexia nervosa, binge eating/purging type, moderate (F50.02) | Mental Status Exam: The client is oriented to person, place, time, and situation. She reports no hallucinations or paranoia. The client was engaged in the session, but she had trouble accepting that her weight and self-talk were problem | You are a licensed counselor working in your own private practice, and you specialize in eating disorders. The client comes to counseling after her primary care physician (PCP) provided a referral to counseling due to restrictive eating that has led to a low body mass index of 16.5. The client says that she has lost about 30 pounds over the past 6 months and that she still feels that she is overweight. The client says that she usually consumes about 500 calories each day and that she fears that if she eats more, she will gain weight. The client’s mother, who was overweight, passed away at age 46 due to an aneurysm, which has contributed to the client’s perception that her mother’s death was weight related. The client expresses that she also has a fear that if she gains weight, then her husband will not love her. She describes experiencing anxiety resulting from the belief that she is currently overweight and is therefore already at risk of both her husband not loving her and of dying. The client says that she generally restricts eating when her husband is home, but when he is on business trips she binges and then forces herself to throw up. | You meet with the client, and she comes and sits down and appears happy because she is smiling and sitting with an open posture. The client’s food log shows improvement in engaging in healthier eating habits and minimal restriction. You and the client review her progress in treatment and agree that she has met all of the treatment goals. The client reports several situations in which she wanted to restrict, purge, and binge, but instead she engaged in cognitive reframing and was able to manage her reaction to the trigger. You praise the client and express that she should be proud of herself for her management of her symptoms. The client reports that she has gained weight and is in a healthy weight range at this point. She continues that her husband has made comments of concern about her weight gain and that the frequency of sex has decreased recently. The client says that she and her husband have been arguing about her eating recently and that she does not feel that he supports her in recovering from her eating disorder. You empathize with the client. You are frustrated because the client’s husband does not support her progress | You are frustrated because the client’s husband does not support her progress. Which one of the following is the most appropriate first response? | You support the client in developing communication skills to discuss her progress and health with her husband. | You provide a referral for couples counseling. | You and the client discuss coping skills in order to help her cope with her husband’s expression of frustration. | You encourage the client to invite her husband to another session in order to discuss his frustration with her weight gain. | (A): You support the client in developing communication skills to discuss her progress and health with her husband.
(B): You provide a referral for couples counseling.
(C): You and the client discuss coping skills in order to help her cope with her husband’s expression of frustration.
(D): You encourage the client to invite her husband to another session in order to discuss his frustration with her weight gain. | You support the client in developing communication skills to discuss her progress and health with her husband. | A | As your first response, it would be most helpful to support the client in having an effective conversation with her husband regarding her health and progress. If this is unhelpful, providing a referral for couples counseling might be the next best course of action. You would not invite the husband to sessions because you are the client’s individual therapist and would therefore not be an appropriate fit as the couple’s therapist due to the potential for bias. It can be helpful to support the client in coping with her husband’s level of frustration, but this is not the most helpful course of action because it implies acceptance of a situation that is potentially harmful to her progress. Therefore, the correct answer is (B) | professional practice and ethics |
761 | Client Age: 19 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Private Practice Type of Counseling: Individual Presenting Problem: Suicidality related to body image Diagnosis: Body Dysmorphic Disorder 300.7 (F45.22), with absent insight/delusional beliefs | Mental Status Exam: The client’s mood is sad and irritable. His speech is pressured when discussing his appearance but is otherwise normal. He is appropriately groomed and wears a beanie covering his ears. He admits to repetitively dissecting his face in the mirror several hours a day. The client offers that he cannot hide his ears with his hair because “it is too thin.” He denies audio/visual hallucinations. The client’s thought content is organized and coherent, but he shows poor insight and delusional thinking about how he and others regard his appearance. The client avoids social settings and reports that sometimes, an entire week goes by where he doesn’t leave the house. He denies suicidality and currently does not have a plan or intent to harm himself or others. Appetite and sleep are fair. The client denies drug use and states he consumes alcohol occasionally. You provide an in-depth suicide assessment, and you and the client work together to create a suicide safety | You are working in private practice and conducting an initial intake session with a 19-year-old male who presents today with his mother. The client was recently admitted to a psychiatric hospital for suicidality and was discharged four days ago. His mother reports that the client tried to commit suicide by overdosing. The client reports feeling increasingly hopeless following a “failed” cosmetic surgery procedure. He explains that he had an otoplasty performed to change the proportion and position of his ears. He states he has always hated his ears and is convinced people are staring and laughing at his “deformity.” His mother reports that she reluctantly consented to the surgery a year and a half ago, despite believing it was unnecessary. The client does not leave the house without wearing a beanie or hoodie. He has completed high school with no interest in attending college. He is unemployed due to shame and embarrassment over his “defective” appearance. Two weeks ago, the hospital psychiatrist changed his medication and placed him on a selective serotonin reuptake inhibitor (SSRI). | plan. Family History: The client’s parents are divorced and he lives with his mother and two younger siblings. There is a history of child protective services (CPS) involvement due to reports of domestic violence between his parents. The client witnessed these incidents between that ages of 10 and 12. His parents subsequently divorced and the client has had minimal contact with this father since. The client’s maternal aunt is diagnosed with obsessive-compulsive disorder. His mother previously attended therapy for anxiety and other trauma-related symptoms. The client began experiencing symptoms of body dysmorphic disorder at age 13, with symptoms worsening after starting high school | Which of the following instruments uses a 21-item self-report questionnaire to determine one’s current intensity, frequency, and duration of suicidality? | Hamilton Depression Scale (HDS or HAM-D) | Suicide Probability Scale (SPS) | Columbia Suicide Severity Rating Scale (C-SSRS) | The Beck Scale for Suicide Ideation (SSI) | (A): Hamilton Depression Scale (HDS or HAM-D)
(B): Suicide Probability Scale (SPS)
(C): Columbia Suicide Severity Rating Scale (C-SSRS)
(D): The Beck Scale for Suicide Ideation (SSI) | The Beck Scale for Suicide Ideation (SSI) | D | The Beck Scale for Suicide Ideation (SSI) is a 21-item scale measuring the intensity, frequency, and duration of suicidal attitudes, plans, and behaviors in the last 7 days. Measurements include the number of previous suicide attempts, deterrents to suicide, and the amount of time spent preparing and contemplating the last attempt. In addition to determining a suicide probability score, the Suicidal Probability Scale (SPS) measures suicidal ideation, hopelessness, hostility, and negative self-evaluation. The SPS is a 36-item self-report inventory. The Hamilton Rating Scale for Depression (HRSD) is an interviewer-administered measure of depression and suicidality. Finally, the Columbia Suicide Severity Rating Scale (C-SSRS) calculates suicidal risk, assesses suicidal attitudes and behaviors, and determines risk and protective factors. Therefore, the correct answer is (A) | intake, assessment, and diagnosis |
762 | Name: Becky Clinical Issues: Behavioral problems Diagnostic Category: Disruptive/Impulse-Control/Conduct Disorders Provisional Diagnosis: F91.1 Conduct Disorder, Childhood-onset Type Age: 10 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Not Assessed Ethnicity: White Marital Status: Not Applicable Modality: Family Therapy Location of Therapy : School | Appearance: Female with crossed arms, avoiding eye contact, and a blank expression. Affect: Flat affect. Speech: Responses are brief and monotone, lacking emotion. Thought Process: Poor focus, easily distracted, and unable to maintain a cohesive conversation. Thought Content: Negativity-focused on herself, blaming others for her difficulties; no suicidal or homicidal ideation reported. Perception: No evidence of hallucinations or delusions. Cognition: Difficulty with problem solving, difficulty shifting focus between tasks, and poor organization skills. Insight/Judgment: Poor insight into her situation; judgment impaired due to her inability to see the consequences of her actions. | First session You are a school counselor and often work with families whose children are having behavioral issues. A 10-year-old female student named Becky comes to your office with her parents. Becky's teacher notified you of behavioral problems she noticed in the classroom. You arranged to meet with Becky and her parents to discuss the teacher's concerns and determine how you can best support Becky's needs. You explain your role as a school counselor, providing short-term counseling for students and making referrals if long-term therapy is deemed appropriate. Becky's parents tell you that "it wasn't a surprise to get your phone call," as their daughter's behavior is poor at home, too. They are at their "wit's end" due to their daughter's constant "back talking" and "arguing" with them and any other authority figures in her life. Becky blames others when confronted at school and has become physically aggressive toward her classmates and teacher. You attempt to build rapport with Becky, but this proves challenging as she is not responsive to your efforts. Becky seemed to be quite guarded and disconnected during the initial assessment. She demonstrated defensive behaviors, such as crossed arms, avoiding eye contact, and evasive responses. She appeared to be dissociated from her current environment and seemingly uninterested in the conversation. However, she did demonstrate a certain level of compliance when her parents attempted to redirect her focus. Her parents reported that Becky has been displaying these behaviors for months, escalating in intensity as time has passed. She has been increasingly defiant and aggressive both at home and at school. They are concerned that her behavior could pose a risk to her safety and have already attempted different strategies to help her, such as removing privileges and providing additional structure. Still, she continues to be uncooperative and argumentative. Clearly, the family was feeling overwhelmed and needed help managing Becky's behaviors. | The client is currently failing in school. Her teacher has called for a conference to begin the process of making an individualized education plan (IEP) to address the client's disruptive behavior. The client has been referred to you for therapy. She has a history of aggressive behavior toward peers and teachers, including physical attacks and verbal aggression. She has also been observed to demonstrate non-compliant behavior, such as refusing to wear a face mask when interacting with other students. Additionally, she has been observed to demonstrate oppositional behavior, such as sticking her tongue out at the teacher. These behaviors have been consistently reported by the teacher and other school staff and have been increasing in frequency and intensity. These behaviors have significantly impacted the client's academic performance and have resulted in her current failure in school. Her teacher has called for a conference to begin the process of making an individualized education plan (IEP) to address the client's disruptive behavior. | What information would be most relevant to consider to establish a treatment plan for this client? | Age range, client's current behavior in class, and client's demeanor during intake | Age range, physical health, and client's behavior during the session | Mother and father's parenting style, current behavior in class, and trauma history | Trauma history, client's demeanor during intake, and social interactions with peers | (A): Age range, client's current behavior in class, and client's demeanor during intake
(B): Age range, physical health, and client's behavior during the session
(C): Mother and father's parenting style, current behavior in class, and trauma history
(D): Trauma history, client's demeanor during intake, and social interactions with peers | Age range, client's current behavior in class, and client's demeanor during intake | A | Age range would be important to consider for determining age-appropriate treatment goals. In addition, the client's current behavior in class has been noted as one of the presenting problems as the client's demeanor toward the therapist during intake. Therefore, the correct answer is (D) | treatment planning |
763 | Name: Dana Clinical Issues: Relationship distress with mother during divorce Diagnostic Category: Depressive Disorders;V-codes Provisional Diagnosis: F33.1 Major Depressive Disorder, Moderate, Recurrent Episodes; Z62.820 Parent-Child Relational Problem Age: 15 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: Multiracial Marital Status: Never married Modality: Individual Therapy Location of Therapy : Under Supervision | The client is dressed in black attire. She sits with her hands folded and slumped over in the chair. She makes little eye contact and seems to distrust you. Her mood seems flat. During the intake, the mother complains about how her daughter "does not listen," "acts out all the time," and "picks fights with her sister." The client is reticent and shrugs her shoulders. The client reported several other symptoms indicative of a depressive episode, including feelings of worthlessness, anhedonia, and lethargy. She also said having recurrent thoughts of self-harm that had become pervasive throughout her day-to-day life. On objective examination, the patient demonstrated psychomotor retardation, appearing to move and speak in a lethargic and sluggish manner. Cognitively, the patient's attention span was limited, and her concentration was impaired. She could not sustain her train of thought and had difficulty forming coherent sentences. Her mood was notably depressed, and her affect was constricted. This suggests a severe depressive episode, and these symptoms will likely require aggressive treatment. | First session You are a limited permit holder under direct supervision. The client is a 15-year-old multiracial female who presents to the first counseling session with her mother. The session begins with the client's mother monopolizing the conversation, and it is difficult for the client to get a word in edgewise. The client's mother continually brings up her husband as a source of her daughter's problems. The mother says, ""Our daughter is not doing well in school and has been talking back to her teacher. I think it comes from the relationship she's had with her father." The client interrupts and says, "It's not Dad's fault! You're the one who abuses me!" The mother is incredulous and begins to yell, saying that she would never hit her daughter and that the client is lying. The mother tells you that her daughter is a "liar, a thief, and creates problems." She reports that Child Protective Services (CPS) has been to their house several times, and she believes that these visits are her husband's fault. The client is visibly upset, and her mother continues to berate her. You intervene and explain that the client's disclosure is serious and should be taken seriously. You explain that you must speak to the client alone before deciding the best course of action. While speaking alone with the client, you notice that she is shaking and close to tears. You encourage her to take deep breaths and explain that she can take some time to regroup before continuing. After a few minutes, she appears calmer and begins to describe her home situation. It becomes clear that the client's home life is chaotic and that she is being subjected to verbal and emotional abuse from her mother. She tells you that she wants to live with her father. The client also states that she has been bullied in school, and this has been going on for some time. You explain to the client that she has a right to feel safe and that you will do everything in your power to ensure her safety. You continue asking question to assess her level of distress, and you note the client's self-reported symptoms consistent with depression, including insomnia, fatigue, and a significant decrease in her appetite. She is also alienating herself from her peers and family. After completing the initial session, you schedule an appointment to see the client and her mother next week to continue your assessment to determine the best course of action. | The client has experienced a great deal of distress due to the chaotic environment of her home life. Her adoptive parents are in the middle of a "messy divorce," and it has been difficult for her to process, as she has had to witness her parents' arguments and the shifting dynamics of her family. This strain has been further compounded by her mother and grandmother's favoritism towards her younger sister, leading to the client feeling neglected and overlooked. In addition, her attempts to connect with her mother and sister have often been met with hostility, leading to frequent arguments and further exacerbating her feelings of alienation and loneliness. The client has also expressed feelings of anxiety and depression due to her current living situation. She has expressed a strong desire to live with her father and escape the hostile environment of her mother's home, yet her mother has continuously denied this request. This has resulted in the client feeling trapped and powerless to alter her current situation, leading to a sense of hopelessness. The client's relationship with her mother is strained, and she has difficulty trusting her. As a result, she is often guarded around her mother and expresses her distrust and resentment, resulting in further conflict and tension between them. The client's school environment has affected her mental health. She is constantly subjected to verbal and physical bullying from her peers, leading to feelings of worthlessness and insecurity. Her academic performance is suffering, and she cannot concentrate in class, leading to further isolation from her classmates. Previous Counseling: The client has been in and out of therapy with many different professionals. She has been diagnosed with Major Depressive Disorder. Her mother is also in therapy and believes her daughter needs "help." The client states that her mother has abused her before, and Child Protective Service (CPS) has been to the house numerous times but has not found any evidence of abuse. | What do you need to clarify with the mother based on the session? | Identify who the client is | Whether the ex-husband needs to be involved in the client's therapy | Suggest the mother needs to continue seeing her therapist | The quality of the mother's interactions with her child. | (A): Identify who the client is
(B): Whether the ex-husband needs to be involved in the client's therapy
(C): Suggest the mother needs to continue seeing her therapist
(D): The quality of the mother's interactions with her child. | Identify who the client is | A | The daughter is the client, but the mother takes over the session. You may need the parent to come into the session if something is wrong or in danger; however, you need your client's trust to develop rapport. That will not happen if the mother continues to monopolize the session. You must clarify who the client is. Therefore, the correct answer is (A) | professional practice and ethics |
764 | 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 | In developing Molly's treatment plan, which of the following would NOT be included in her short-term goals? | Crisis planning | Organizing a bereavement support group at her school | Development of existing strengths to increase coping skills | Joint sessions between Molly and her mother to help improve their relationship | (A): Crisis planning
(B): Organizing a bereavement support group at her school
(C): Development of existing strengths to increase coping skills
(D): Joint sessions between Molly and her mother to help improve their relationship | Organizing a bereavement support group at her school | B | Although this may be a future goal, at this time it seems that this would be a very large step for Molly. She is newly engaged in the therapeutic process and has not yet processed her grief. Molly has given up on one of the things she enjoyed doing- softball. It would help Molly to find other things to help her cope with her grief and building on her strengths would be better than starting a new hobby she has not mastered yet. It is important for Molly to also build her support network. She and her mother may have a tenuous relationship now, but only since her father's death. Bringing Molly's mother into sessions will help identify the cause of the relationship breakdown and find ways to improve it. Crisis planning is important to do with Molly to help her identify her triggers and to establish effective coping skills. If Molly does not have effective coping skills, creating a crisis plan can be a way to start building them. This is especially important since Molly was considering cutting as a way of coping. Therefore, the correct answer is (B) | intake, assessment, and diagnosis |
765 | Client Age: 30 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Agency Type of Counseling: Outpatient Presenting Problem: Recent Hospital Discharge Diagnosis: Borderline Personality Disorder (BPD) 301.83 (F60.3) | Mental Status Exam: The client is wearing a low-cut blouse and short shorts. Her affect and mood are labile, and her speech is pressured. She is fidgety at times and sits with her arms crossed. The client states that she has had three previous suicide attempts and has been cutting since her late twenties. Her last suicide attempt was an overdose, which resulted in her recent hospitalization. She stated that this was the result of her last boyfriend “ghosting” her. The client denies audiovisual hallucinations but states that she often feels that others are conspiring against her. She says that she continues to have suicidal thoughts but denies having a current plan. Fam | You are a mental health counselor in an outpatient setting. Your client is a 30-year-old white female who was released from the hospital 48 hours ago. The client presents today for a postdischarge follow-up appointment. The hospital clinician diagnosed the client with borderline personality disorder(BPD) and substance use disorder. The client has a history of suicidality, impulsivity, and relational instability. She explains that she has a “quick temper,” which occurs when she is feeling rejected. She explains that she has a long history of being treated poorly by others, including her last boyfriend, former employers, and family members. During these times, the client admits to substance misuse and self-mutilation (i.e., cutting). She states that there are times when she drinks to black out and that she is more inclined to do so when her feelings become intolerable. The client has had multiple hospital admissions and has been in the care of several counselors. She questions your credentials and your ability to “work with someone like (her).” | The client no-showed for her last session without calling to cancel. She arrives today, appearing disheveled and irritable. The client states that she has not been sleeping well. She explains that she was talking to someone on an online dating site and had planned a face-to-face meeting this past weekend. She says she waited at the bar for more than an hour and finally realized that her date had stood her up. She explained that she was in so much shame after the incident that she engaged in self-harm. The client reveals superficial razor cuts on her thigh and upper arm. She says she feels like she is a failure and undeserving of love. The client has difficulty identifying and differentiating overwhelming emotions | The client has difficulty identifying and differentiating overwhelming emotions. What technique could help her experience gradations of feeling? | Mood monitoring | Affect labeling | Cue identification | Escalation point recognition | (A): Mood monitoring
(B): Affect labeling
(C): Cue identification
(D): Escalation point recognition | Affect labeling | B | Affect regulation consists of affect labeling, recognition of escalation points, mood monitoring, and cue identification. Affect labeling helps clients experience gradations of feeling by identifying and differentiating overwhelming emotions. Because individuals with BPD experience black-and-white thinking, there is a tendency to label feelings using polarized terms (eg, “I’m either angry or calm”). Helping clients identify and articulate gradations of feeling (eg, irritated, relieved) allows for the acknowledgment of shades of gray and eventually the client learning to tolerate a range of emotions. Recognition of escalation points breaks down the client’s thinking, acting, and behaving before an unregulated emotional event. Mood monitoring is used to help clients keep track of patterns and changes in moods. Finally, cue identification helps identify problematic behaviors that can be altered. This is done by having the client identify internal cues rather than external triggers. Therefore, the correct answer is (C) | counseling skills and interventions |
766 | Name: Roger Clinical Issues: Physical/emotional issues related to trauma Diagnostic Category: Neurocognitive Disorders Provisional Diagnosis: F02.81 Major Neurocognitive Disorder Due to Traumatic Brain Injury, with Behavioral Disturbance Age: 36 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: White Marital Status: Married Modality: Individual Therapy Location of Therapy : Outpatient clinic | The client presents as tired. He reports a mild headache at the intake appointment, which he says is likely due to coming in from the bright day outside. Memory is slightly impaired. Mood is depressed, though he says this is impermanent, and his mood changes within a day, though the depressed mood is more prevalent and longer-lasting. | First session The client returned home from Afghanistan last month after separating from the Navy after 12 years of service. He states he is tired of trying to get an appointment at the VA Hospital, so he Googled locations that treat brain injuries, and your office was on the results page. He called to arrange a consultation with you. You have been practicing as a licensed mental health therapist at the outpatient clinic for over a decade, and you have worked with many clients diagnosed with traumatic brain injury. The client complains about difficulty sleeping, bad headaches, and feeling like he is on a roller coaster - feeling happy one minute and then down in the dumps the next. He states that the happy times don't last long, and he is "down in the dumps" most of the time. When asked why he left the Navy, he replies: "Toward the end of my last deployment, I just got sick and tired of everything and couldn't deal with it anymore. I couldn't sleep, was jumpy all the time, and didn't even want to go outside during the day." Now, I'm finally back home, but things only seem worse. My wife keeps nagging me to get a job, my kids look at me like I'm a monster, and nobody understands how I feel. I want to lay in bed all day and drink a couple of beers. I think something isn't right, and I can't take it anymore." Near the end of the session, the client asked what he could expect if a medical professional recommended medication management to treat NCD. The client discloses experiencing a highly distressing and psychologically damaging event during his military service in Afghanistan. While on patrol with his unit, their convoy was ambushed, and a fellow soldier directly next to the client was seized by insurgents. The client painfully witnessed his peer and friend being brutally beheaded, describing the horrific sight and sounds as permanently seared into his memory. Helplessly observing the brutal murder firsthand left him stunned and overwhelmed with grief and terror at the moment. The grotesque violence and knowing that could have just as quickly been his fate continues haunting him years later. The constant stress of combat and imminent danger already had the client in a perpetual state of hypervigilance and anxiety during his deployment. He shares that coming to terms with the abrupt, unfair loss of life was a daily reality there. While transporting supplies between bases in a standard jeep convoy, his vehicle triggered an IED explosion or was directly hit by artillery fire. The client was violently jolted and knocked completely unconscious as the blast disabled their jeep. He remained in and out of consciousness for over 24 distressing hours, being evacuated while critically injured to a military hospital. Once stabilized, he was thoroughly examined and diagnosed with a traumatic brain injury concussion along with other shrapnel wounds. Fourth session You and the client decided to meet for weekly sessions based on his current needs. You have established a trusting relationship with him, and he feels more comfortable knowing that you have experience in working with military populations. You provided psychoeducation regarding the effects of traumatic brain injuries and what he can expect from the counseling process. You were able to instill hope that he could recover emotionally following his injury and learn new skills along with coping mechanisms. He presents for today's session in a depressed mood which he states began the previous night. He reports that his family appears to now better understand what he is going through and they are getting along better. He is still drinking three beers at night to help him fall asleep, and his headaches have decreased in intensity due to finally getting a medication consult from the VA. However, he is still sensitive to light. He shares that he is ready to look for work but is concerned about finding a job and performing due to his ongoing symptoms. Ninth session Rober arrives elated at the session, appearing happy, talkative, and smiling. He states that he has felt this way for four days now, which has not been the typical length of time or the intensity of his positive mood episodes. He reports that his family relationships are satisfactory, and he has been somewhat successful at his part-time job at the local lumberyard. However, he is angry with his manager, who says he has been too distracted this past week and spends more time talking with customers than working. He is still drinking three beers at night to sleep but reports that he has not had to sleep much this past week and feels "wide awake." He says he is ready to open his own business but isn't sure what he wants to do yet. Roger reports feeling energized, creative, and motivated over the past several days. He has come up with many new business ideas that he is eager to pursue, including opening a restaurant, starting a landscaping company, and developing a crypto blockchain. Roger stays up late into the night brainstorming ideas and making extensive plans. He feels compelled to act on his ideas immediately and has already taken steps to register business names and research loans. However, the next day, Roger often changes course, dropping previous ideas for new ones that seem even more exciting. His friends notice his frenzied pace in bouncing from idea to idea, worrying he has taken on too much. But Roger reassures them this surge of creativity allows him to see endless possibilities for his future business success. Though well-intended, their skepticism only pushes him to work harder to bring his visions to life. Roger also mentions experiencing increased sociability and talkativeness lately. He says he has frequently called and texted friends and family to share his business ideas and other excited thoughts. Roger speaks rapidly, his thoughts racing as he tries to get loved ones as enthused as he feels. Though some gently try to interject realistic concerns, he remains unchecked in his ambitious optimism. A few close friends have expressed concern over Roger's intensified pace and plans, but he brushes them off, feeling very optimistic and self-assured about his ideas. Roger's confidence borders on grandiose as he envisions an incredibly successful entrepreneurial future. Attempts by caring friends and family to restrain his inflated self-assurance are met with irritation, as Roger feels unable to focus on anything but chasing his next big idea. He's optimistic that his new crypto blockchain will rival and surpass Bitcoin in a matter of months. | The client drinks three beers every night before bed to help him fall asleep. He started this pattern a few years ago after struggling with insomnia and finding it challenging to relax his mind. Though effective at first in inducing drowsiness, he has built up a growing tolerance and now needs to drink three beers minimum to feel any sedative effects. He discloses that he knows consuming alcohol regularly can be unhealthy, but he feels dependent on having those beers to wind down from the stresses of his day and quiet his anxious thoughts enough to get adequate rest. During his time serving in the military, the client reported smoking cannabis on occasion when it was available. However, he did not enjoy the experience or feel compelled to use it. He mainly partook when offered by peers to be social. Since his discharge five years ago, he states he has not had any cannabis. The client currently smokes approximately one pack of cigarettes per week, a habit he picked up during his military service as a way to cope with boredom and nerves. He expresses some interest in trying to cut back for health reasons but also shares smoking provides a sense of relief and routine. | Given the client's altered behavioral presentation and the description of several new symptoms since the last session, what factors should you consider? | The client is presently grappling with thoughts of self-harm or suicide. | The client is currently experiencing a psychotic state. | The client is currently in the midst of a depressive episode. | The client is currently in a hypomanic state. | (A): The client is presently grappling with thoughts of self-harm or suicide.
(B): The client is currently experiencing a psychotic state.
(C): The client is currently in the midst of a depressive episode.
(D): The client is currently in a hypomanic state. | The client is currently in a hypomanic state. | D | The client's talkativeness at work, lack of need for sleep, elated mood, increased goal-directed activity, and these symptoms lasting for four days suggest hypomania. Therefore, the correct answer is (C) | intake, assessment, and diagnosis |
767 | Client Age: 25 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Counseling Clinic Type of Counseling: Individual Presenting Problem: Depression and Suicidal Ideation Diagnosis: Major Depressive Disorder, Recurrent, Mild (F33.0) | Mental Status Exam: The client appears to not have bathed recently because his hair is greasy and unkempt. The client has food stains on his clothing; however, he is dressed appropriately for the season. His motor movements are within normal limits. He is engaged in therapy, but he appears anxious as evidenced by hesitating before speaking and by his hand wringing. The client reports suicidal ideation with no plan or intent. The client reports a depressed mood more often than not and difficulty enjoying most activities. The client is oriented to person, place, time, and situation. The client reports that his appetite has increased lately and that he is experiencing hyperso | You are a resident in counseling practicing in a private practice agency. During the initial counseling session, the 25-year-old single male client reports feeling depressed and hopeless. He has difficulty enjoying activities that he has enjoyed in the past and feels unsatisfied with most areas of his life. The client identifies that he is not happy at work and wants to make a career change. The client verbalizes feeling sad more often than not, and that this has been going on for about 2 years. The client decided to start counseling when he began experiencing suicidal thoughts. The client reports no plan or intent to attempt suicide but is concerned about his own well-being. | The client reports that he has been sleeping more than usual and that this is affecting his ability to get to work on time. He reports that his boss started noticing his tardiness and has given him a verbal warning. Combined with the fear of losing his job, he expressed worry regarding increased conflict with his girlfriend and feeling more “on edge.” Due to the client’s difficulty with sleep, you provide psychoeducation on sleep hygiene | Due to the client’s difficulty with sleep, you provide psychoeducation on sleep hygiene. Sleep hygiene involves all of the following foci EXCEPT: | Room temperature | Time of initiation of sleep and time of waking | Maintaining 9 to 12 hours of sleep per 24 hours for a 25-year-old | Mindfulness activities prior to bed | (A): Room temperature
(B): Time of initiation of sleep and time of waking
(C): Maintaining 9 to 12 hours of sleep per 24 hours for a 25-year-old
(D): Mindfulness activities prior to bed | Maintaining 9 to 12 hours of sleep per 24 hours for a 25-year-old | C | At age 25, it is recommended to get at least 7 hours of sleep per night. The 9- to 12-hour range is more appropriate for the age range of 6 to 12 years old. Consistent times of sleep initiation and waking are important in improving sleep. The room temperature also impacts the quality of sleep, although temperature needs vary from person to person. Mindfulness and relaxation activities can help calm the body as a means to better prepare him for sleep. Therefore, the correct answer is (C) | treatment planning |
768 | Name: Deb Clinical Issues: Worry and anxiety Diagnostic Category: Other Mental Disorders and Additional Codes Provisional Diagnosis: 300.9 Unspecified Mental Disorder Age: 40 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 general appearance is of a 40-year-old female of average height and obese weight. Her hygiene is within normal limits. The client seems a bit nervous when you begin your initial interview. She says, "It's 'wine Wednesday' right? I wish I had a glass of wine right now to steady my nerves. A couple of glasses would really help right about now." The client is alert and oriented x4, cooperating fully with the exam. Motor activity is within normal limits. Speech is within normal limits for rate, articulation, verbosity, and coherence. There are no signs of impairment in attention, concentration, or memory. There are some signs during the exam of deficits in impulse control. | First session You are a mental health therapist in a private practice setting. The client, a 40-year-old female, arrives for the intake and discloses concerns about her physical health. She has felt that the "doctors are missing something" for years. She "feels sick all the time" but cannot describe specific symptoms other than general fatigue. The client reports feeling incredibly frustrated by the "lack of care" she receives. She was provided with a referral to contact you and is asking for your help in determining what steps she should take to ensure her health and safety. You notice that the client is becoming tearful as she describes her situation. You complete a biopsychosocial assessment and explore various aspects of the client's life and history, including her family dynamics, current living situation, lifestyle habits, and any stressors in her environment. The client indicates that she has a supportive family and has been open with them about her concerns regarding her health. She is also actively working to improve her diet and exercise, but has found this process to be challenging due to lack of motivation. Although she does not have any diagnosable mental illnesses, the client reports feeling anxious and overwhelmed lately, particularly when it comes to work. The client discloses feeling overwhelmed by her new role as charge nurse and is worried that she might not be able to manage all of her responsibilities effectively. She also expresses concern over how her weight may affect her ability to be successful in her career. | The client has a strong support network. She says that she is especially close with her mother, aunt, and two older sisters. The client goes on to explain that growing up she was close with her sisters, but because they were so far apart in age, they did not always get along. She remembers feeling like the black sheep amongst her older sisters since she was the youngest and had different interests from them. Her father was often away for work, which meant that her mother was the primary caretaker. Despite this, she speaks fondly of her parents and credits them for providing a stable home life. She indicates that her father was recently admitted to a nursing home for dementia. The client reflects on how her father's illness has been hard to process. She remembers when he began to forget familiar places and people, as well as not being able to recognize himself in the mirror. His illness has been difficult for the family to accept, but they are working on a schedule to make sure that a family member sees him every day. The client has been working in the healthcare profession for over 15 years, and she currently works as a nurse at a local hospital. She discloses that she recently received a promotion to a "charge nurse." She has mixed feelings about the promotion. She states that she loves nursing, but sometimes worries about how she is perceived by her colleagues due to her weight. She fears being seen as lazy and unmotivated because of her appearance, which she believes is not in line with the expectations of a charge nurse. Overall, she experiences low self-esteem and difficulty feeling confident in her professional role due to her weight. She is also concerned that her co-workers may find out that she is seeing a therapist and will think less of her. Pre-existing Conditions: The client states that she is 75 pounds overweight according to her physician. She has been preoccupied with having an illness for several years and has seen multiple medical specialists. She is concerned that she has cancer or a heart condition "because those issues run in my family." There is no medical evidence to support any of her concerns, and during her last annual check-up, her primary care physician made a referral for her to see you. | Which assessment tool would be most relevant to use given the client's statements during the Mental Status Examination? | California Psychological Inventory (CPI) | Self-Directed Search Form (SDS) | Mini Mental Status Exam (MMSE) | CAGE Questionnaire | (A): California Psychological Inventory (CPI)
(B): Self-Directed Search Form (SDS)
(C): Mini Mental Status Exam (MMSE)
(D): CAGE Questionnaire | CAGE Questionnaire | D | This is a short questionnaire you can present to your client to determine whether your client's alcohol consumption has become hazardous to her health. Therefore, the correct answer is (C) | intake, assessment, and diagnosis |
769 | 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. | You have attempted to arrange a family session with the mother, but she is unable to take off work to attend. The client arrives for his second session eager to share that he is “on green” this morning, which means the client’s behavior for the day has been good. You praise him for staying in his seat and keeping his hands and feet to himself. The client responds well to your praise. When engaging in a feelings identification activity, the client identifies feeling unhappy and worried when his father doesn’t show up for scheduled visitation. The client explains that his parents frequently argue about “how to take care of me” and “sometimes push each other.” He quickly abandons the feelings activity and asks if he can go back to class. You deny the client’s request to leave and instead give him the option of selecting another activity. The client refuses to do so and begins to kick your file cabinet repeatedly. He proceeds to knock papers off your desk. When redirected, the client’s behavior escalates. He quickly becomes inconsolable as he cries and yells, “I hate counseling, this school, and everyone in it!” You arrive at school one morning and find the child’s father in the main office. He is requesting to talk to you about his son | You arrive at school one morning and find the child’s father in the main office. He is requesting to talk to you about his son. What is the best way for you to proceed? | Tell the father that you can listen to his concerns but cannot disclose any information. | Explain to the father that you can only see him if the client’s mother provides written consent. | State that you cannot disclose whether or not the child is your client and cannot meet with him. | Tell the father you only work by appointment and arrange to see him the following week. | (A): Tell the father that you can listen to his concerns but cannot disclose any information.
(B): Explain to the father that you can only see him if the client’s mother provides written consent.
(C): State that you cannot disclose whether or not the child is your client and cannot meet with him.
(D): Tell the father you only work by appointment and arrange to see him the following week. | Tell the father you only work by appointment and arrange to see him the following week. | D | You can arrange to meet with the father by appointment, which would not breach confidentiality as he is the client’s biological father. Since this client’s mother has physical custody, the father also has the right to participate in counseling when clinically appropriate. When determining applicable legal and ethical guidelines regarding confidentiality, it is essential for you to first differentiate between legal custody and physical custody. Parents with legal custody can make unilateral decisions regarding their child’s treatment. In cases where the courts have established legal custody, you must obtain a copy of the court order before initiating counseling services. With physical custody, the issue of consent is irrelevant. That is, both parents can make treatment decisions on behalf of their child, and both parents have the right to request their child’s mental health records. By making an appointment with the father, you establish professional boundaries and allow yourself time to seek supervision and consultation for this complex ethical matter. Although state laws vary, if there is a court order (ie, an emergency protective order (EPO) or a domestic violence order (DVO) against the father, then he would be violating this order simply by being at the child’s school. If you believe the father poses an imminent risk to the child at any point in therapy, you are mandated to make child protective services (CPS) report. You may also refuse to see the father if you feel that your safety is compromised or believe your contact with the father is detrimental to the client’s treatment. In these complex cases, you must follow an ethical decision-making model and seek supervision and consultation to determine the best course of action. Therefore, the correct answer is (C) | professional practice and ethics |
770 | Client Age: 8 Sex: Male Gender: Male Sexuality: Unknown Ethnicity: Hispanic Relationship Status: Single Counseling Setting: Home Health Outpatient Therapy Type of Counseling: Individual with Family Involvement Presenting Problem: Behavioral Issues Diagnosis: Oppositional Defiant Disorder, Severe (F91.3) | Mental Status Exam: The client was argumentative and did not engage in the entire intake session. The client was oriented to person, place, situation, and time. He was dressed appropriately for the weather and appeared well groomed. The client appeared clean and had appropriate hyg | You are a home health outpatient therapist working with an 8-year-old male in the home setting. The client’s parents will be actively involved in counseling due to the client’s age. The client was referred to receive counseling by his school social worker. He has been having behavioral issues in school that have led to difficulty staying in the classroom and is resultantly falling behind in academics. During the first session, the client refuses to engage and leaves the room. The client’s parents prompt him to return, and he calls them “jackasses” and leaves the room again. The parents finish the intake session with you and provide you with a report on their observations in the home and reports from the school social worker. The client reportedly often loses his temper and is generally easily annoyed or angered. The client has trouble taking direction from his teachers and parents. The client’s parents also state that he often blames his younger sister for things that he does and often tries to annoy her. The parents have trouble identifying any of the client’s friends and state that he does not get along with his peers. | iene. Family History: The client’s parents are married, and he has a younger sister who is 6 years old. The client often deliberately annoys or angers his younger sister and has difficulty following directions from his parents | At this point in counseling, what referrals might be appropriate to consider in addition to individual/family therapy? | Applied behavior analysis | Occupational therapy | Play therapy | Psychiatry for medication management | (A): Applied behavior analysis
(B): Occupational therapy
(C): Play therapy
(D): Psychiatry for medication management | Play therapy | C | Play therapy may be beneficial because it can help children to improve communication and explore/express their emotions. Applied behavior analysis would not be indicated because the client is able to engage in cognitive counseling, which means talk therapy would be more beneficial. Medication management may be beneficial at some point, but there are no Food and Drug Administration-approved medications for oppositional defiant disorder, and therapy tends to be more effective than medication. Occupational therapy is not indicated because the individual appears to have no cognitive, physical, or sensory issues that would require skill development. Therefore, the correct answer is (D) | counseling skills and interventions |
771 | Client s Age: Client 1: age 12 Client 2: age 14 Client 3: age 14 Client 4: age 16 Client 5: age 13 Client 6: age 16 Sex: Males Gender: Males Sexuality: Varying Ethnicity: Multiracial Relationship Status: Single Counseling Setting: Juvenile Justice Facility Type of Counseling: Group Counseling Presenting Problem: Involvement with the Justice System That Includes Various Mental Health Disorders and Crimes Diagnosis: Imprisonment (Z65.1) | Mental Status Exam: All of the clients appear to maintainappropriate hygiene, and they are all oriented to person, place, time, and situation. They are all somewhat reserved with regard to going into deeper topics, but theyparticipate f | You are a licensed counselor working in a juvenile justice facility for teenage males. The group comprises six males that are required to attend as part of their incarceration with the expectation that it will shorten their sentences. The purpose of the group is to work on emotional regulation and to work together to share common experiences and identify goals that can be helpful in preventing reincarceration. During the intake session, you explained the purpose of the group and started with an ice-breakeractivity. The clients participated in the ice-breaker activity that required you to redirect them back to the activity several times because they would joke and get off task. You attempt to go a little deeper by encouraging your clients to start talking about what happened to get them incarcerated, and they appear to be taking pride in the reasons they were in juvenile detention and making fun of those with lesser sentences. You redirect the clients to another topic. | You meet with the group, and they appear to be starting to become more comfortable with one another. You noticed that throughout the past week, when you saw your clients on their unit, they were spending more time together and that they are all talking when they come in for the session. During the session, you and the clients discuss past experiences that led to them engaging in the crimes that led to their incarceration. During this conversation, client 1 is talking about his father and how he killed a pedestrian while driving. Client 4 then asserts that client 1’s father is going to hell for killing someone. You cut off client 4 and redirect the attention back to client 1 | According to Tuckman’s stages of group development, which stage is this group in? | Performing | Forming | Storming | Norming | (A): Performing
(B): Forming
(C): Storming
(D): Norming | Storming | C | The storming phase focuses on group members establishing a hierarchy and often involves conflict even as group cohesion is developing. The forming stage is the initial stage in which the group comes together and becomes acquainted. The storming phase follows the forming stage. The norming phase is when the group members agree on how the group should be run and how individuals should interact. The performing stage is when the group is most productive and is working toward their goals. Therefore, the correct answer is (D) | intake, assessment, and diagnosis |
772 | Name: Camron Clinical Issues: Worry and anxiety Diagnostic Category: Anxiety Disorders Provisional Diagnosis: F40.10 Social Anxiety Disorder Age: 20 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: White Marital Status: Never married Modality: Individual Therapy Location of Therapy : University Counseling Center | The client looks anxious and uneasy, presenting with a "nervous" laugh. He twirls his thumbs and shakes his legs while seated. Mood is anxious and frustrated. He feels isolated and misunderstood by his family and peers. Speech is soft and hesitant. Eye contact is sporadic. Thought process is concrete and linear. He has some difficulty with abstract concepts. Thought content reveals fear of social interactions, feeling judged by others, and feeling inadequate. He seems to recognize the negative consequences associated with his anxiety and behavior, but he has limited insight with regard to recognizing the source of his anxiety. He reports difficulty recalling past experiences or conversations due to anxiety levels. No suicidal or homicidal ideation noted. | First session Your client is a 20-year-old male who has been seeing your colleague at the university counseling center where you both work as mental health therapists. The client requested to be transferred to another therapist because his former therapist reminded him too much of his father and therapeutic progress could not be made. The client's former therapist contacted you as a referral, and you agreed to transfer the client to your caseload. When you meet with the client today, he seems very anxious and laughs nervously. You can see he is shaking his legs as he sits, twirling his thumbs, and making little eye contact with you. You explain the therapy process and that you need to go over some intake questions. You ask him who his ICE (in case of emergency) contact is, and he says it is his roommate. You continue with your assessment, gathering information about his presenting problem and what he would like to accomplish in counseling. He continues by telling you, "I thought that going to college would alleviate my social anxiety, but I'm not doing well here. I want to be social, but I can't." The client feels frustrated and overwhelmed by his fears of interacting with others. He tells you that when he is feeling anxious, he punches bathroom mirrors to try to distract himself from the anxiety. He notes that the anxiety is crippling, preventing him from doing the things he loves, and has resulted in him feeling isolated. He is afraid that others are judging him and is constantly worried that he will make a mistake and feel embarrassed. | The client grew up in an authoritarian house where all of his actions and behaviors were scrutinized by his father. His father demanded obedience from his son and would not accept anything but perfection from him. He graduated from high school at the top of his class and has been waiting to attend college to get out from "under the thumb" of his father. The client's parents are paying all of his college expenses. The client is experiencing difficulties adapting to college life. He states that he stays in his room because he believes he always says and does the wrong thing, and everyone can see what a "loser" he is. He further states that he rarely leaves his dorm room except to go to his work-study position. The client has experienced two panic attacks; one occurred when he was required to give a presentation in class, and the second happened when he was required to meet with a small group to discuss his input for their group project. The client has missed many classes in which he is expected to participate or present projects. He is currently failing three classes. The client is in danger of losing his work-study job on campus due to frequent absences. He is competent and conscientious when his job does not require customer interaction. Personal/Social Relationships: The client is interested in exploring social relationships but is anxious as his father never allowed him to interact with his peers. As a result, his level of social functioning is relatively low. He has talked with a few students in his dorm and classes when required, but he feels extremely uncomfortable and inept. The client has not developed any friendships because of his anxiety. | How might you initiate the first meeting with this client? | You review the client's chart for accuracy, obtain his informed consent, and proceed with treatment. | You obtain the client's roommate's contact information. | You seek permission from the client's father to proceed with therapy. | You obtain a signed release from the client for case notes from previous treatment. | (A): You review the client's chart for accuracy, obtain his informed consent, and proceed with treatment.
(B): You obtain the client's roommate's contact information.
(C): You seek permission from the client's father to proceed with therapy.
(D): You obtain a signed release from the client for case notes from previous treatment. | You review the client's chart for accuracy, obtain his informed consent, and proceed with treatment. | A | The client and his file have been transferred to your caseload. You'll need to do a thorough review of the client's chart, obtain informed consent, and discuss his diagnosis and treatment plan. Therefore, the correct answer is (A) | professional practice and ethics |
773 | Name: Anxiety Group Therapy Clinical Issues: Worry and anxiety Diagnostic Category: Anxiety Disorders Provisional Diagnosis: F41.1 Generalized Anxiety Disorder Age: 0 Sex Assigned at Birth: Female Gender and Sexual Orientation: Not applicable, Ethnicity: Various Marital Status: Not Applicable Modality: Group Therapy Location of Therapy : Agency | The group members appear to be insightful about their illness. Clients ages are 25 and older. All members are well-groomed and present with clean hygiene. | First session You are a therapist in an agency starting a group for clients with anxiety. The group will consist of seven participants. It is a homogeneous, closed group which will meet once a week on Wednesday evenings for an hour and a half for twelve weeks. The group's goal is to help clients diagnosed with Generalized Anxiety Disorders and other anxiety-related issues. An intern will co-facilitate the group with you. You are forming an outline for the group's goals, screening questions, and termination process. You will be observing candidates for the group to facilitate participant selection. | null | Ideally, the initial session of the group should involve: | Reminding members that confidentiality is guaranteed | Urging members to refrain from discussing all of their feelings | Encouraging members to confront others' behavior to build norms | A review of group structure and basic tasks | (A): Reminding members that confidentiality is guaranteed
(B): Urging members to refrain from discussing all of their feelings
(C): Encouraging members to confront others' behavior to build norms
(D): A review of group structure and basic tasks | A review of group structure and basic tasks | D | This should be reviewed in the initial stage of the group. Therefore, the correct answer is (C) | treatment planning |
774 | 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. | 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 meets the criteria for a S.M.A.R.T. goal? | The client will sleep eight hours at night, increasing her sleep from four hours of sleep at night. She will complete this goal over three months. | The therapist will treat the client’s trauma symptoms. | The client will sleep eight hours at night, increasing her sleep from four hours of sleep at night. She will complete this goal in two weeks. | The client will challenge her negative thoughts about the world. | (A): The client will sleep eight hours at night, increasing her sleep from four hours of sleep at night. She will complete this goal over three months.
(B): The therapist will treat the client’s trauma symptoms.
(C): The client will sleep eight hours at night, increasing her sleep from four hours of sleep at night. She will complete this goal in two weeks.
(D): The client will challenge her negative thoughts about the world. | The client will sleep eight hours at night, increasing her sleep from four hours of sleep at night. She will complete this goal over three months. | A | This goal meets all the criteria of a SMART. Specifying a specific amount of time to achieve this goal focuses on the T (time-sensitive) criteria of a SMART. goal in treatment in particular. Therefore, the correct answer is (B) | treatment planning |
775 | Initial Intake: Age: 68 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Widow Counseling Setting: Community Agency Type of Counseling: Individual | The client presents appearing thin for height and older than her stated age. She is dressed in jeans and a shirt, no make-up and appropriate hygiene. Her mood is identified as euthymic and her affect is congruent. She is talkative and tells stories about herself and others, although she appears very distractible and changes subjects easily. She demonstrates appropriate insight, judgment, memory, and orientation using mental status exam questions. She reports never having considered suicide and never consider harming herself or anyone else. | You are a counselor in a community agency and your client presents voluntarily, though at the request of her family members. She tells you that her stepson and daughter-in-law told her they are concerned about her because she lives alone and they don’t believe that she can take care of herself at her home. She tells you that she is very happy living alone and is never lonely because she has over 20 indoor and outdoor cats that she feeds and they keep her company. During the intake, the client tells you that her husband of 33 years died five years ago from lung cancer. When asked why her family wanted her to come to counseling, your client says that she gets along well on her own; however, she believes that her stepson is looking for ways to take over her property. She tells you she owns a large section of land that includes two trailer homes, one of which is in better shape than the other so that is where she lives; ten or eleven vehicles, some that run and some that do not; and five large carports that hold the items that she and her husband used to sell at the daily flea market before it closed 15 years ago. She tells you that she sometimes finds uses for some of these items around her house but keeps all of them because they may “come in handy” at some point. She currently has no help on her property for mowing or upkeep, unless a neighbor or her son-in-law volunteers to help. | Family History:
The client reports that her parents divorced when she was a young teenager and she did not see her father again after that time. She reports he was an alcoholic as was her mother and they often argued. She relates that her mother did not work and she grew up with government assistance for food and shelter. She tells you that several years after the divorce, her mother’s mobile home was destroyed in a fire and the two of them lived in a friend’s trailer until they were able to buy another one to put on their property. She reports that she quit high school in 10th grade after having trouble reading for many years, married at age 16, had one daughter, and then divorced at 19 due to her husband’s continuing drug use. She tells you that her daughter has not been around for the “past few years” because she lives in another state and has some “mental problems, like bipolar something.” She tells you that she married again at age 20 and remained married to her husband until his death. She tells you her husband was a “good man” though he had many problems related to his military service in Vietnam and health problems due to smoking. She reports he had lung cancer and lived for 20 years although the doctors did not expect him to live so long. This was a second marriage for both of them and she tells you that her husband had one son. The client tells you she has not been close with her stepson because he has never helped them out and it has been worse since she stopped letting him keep his hunting dogs on her property. She tells you that he never took care of them and she had to feed them every day because he did not. The client tells you that she is close to her stepdaughter-in-law and that she trusts her much more than she does her stepson. The client tells you that she and her husband worked at the local flea market for many years selling things they had collected, but since the flea market closed 15 years ago, they lived on Social Security and the money her husband made doing “odd jobs” around town. | Which of the following would be most appropriate to say to the client? | It sounds like you have quite a lot more to deal with at home than you told me last time. | It sounds like your family is worried about taking care of you, not your property | I wonder what it is like for you to hear your DIL share her concerns about you. | I wonder if we need to figure out a way to help you get all that stuff cleaned out. | (A): It sounds like you have quite a lot more to deal with at home than you told me last time.
(B): It sounds like your family is worried about taking care of you, not your property
(C): I wonder what it is like for you to hear your DIL share her concerns about you.
(D): I wonder if we need to figure out a way to help you get all that stuff cleaned out. | I wonder what it is like for you to hear your DIL share her concerns about you. | C | Asking the client what it was like to hear her DIL express her concerns about the client and her living space allows the counselor to observe the client's insight, defensiveness, and assess symptoms of paranoid delusions while giving the client the opportunity to hear her family's perspective in a safe environment. This helps build trust in the counselor-client relationship. Statements shown in Options b and d are confrontational as they call attention to the discrepancy between what the client originally presented and what her DIL is now saying. Confrontations or suggestions that the client may not be truthful are not helpful in facilitating trust in the client-counselor relationship. While helping the client reduce and recover from hoarding may be an ultimate goal, suggesting this at this time is likely to cause the client to become anxious and suspicious of the counselor's motives as this has not been discussed between them. Therefore, the correct answer is (C) | intake, assessment, and diagnosis |
776 | Client Age: 20 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Asian Relationship Status: Single Counseling Setting: College counseling clinic Type of Counseling: Individual counseling Presenting Problem: Panic attacks Diagnosis: Provisional diagnosis: panic disorder (F41.0) | Mental Status Exam: The client is oriented to person, place, time, and situation. The client does not appear anxious or depressed and was friendly and eng | You are a counselor working in a college counseling department. The client comes in after being late to class several times over the last month due to reported “freak-outs” in the morning. The client experiences the following panic symptoms: accelerated heart rate, sweating, shaking, shortness of breath, and a feeling of impending doom. The client reports a feeling of impending doom when she wakes up on days when she has classes, and this anxiety tends to escalate into fear of having a panic attack on a daily basis, often making her late to her first class. The client is worried that she will have panic attacks every day for the rest of her life. She says that her parents have put a lot of pressure on her to get a high grade point average at college. The client is worried about how this pressure and the panic attacks are going to affect her doing well at college and engaging socially. | aged. Family History: The client reports that she is close with her parents but that they often have high expectations of her and that she worries about disappointing them. The client has an older brother who is 25 and is a lawyer. The client says some of the pressure is wanting to be as successful as her brother because she thinks her parents are really proud of him | Although you suspect that the client has panic disorder, all of the following diagnoses or areas should be assessed as differential diagnoses, EXCEPT: | The possibility of generalized anxiety disorder | The possibility of major depressive disorder | Cognitive processes that occur when experiencing a panic attack | Whether the panic attacks are expected, unexpected, or both | (A): The possibility of generalized anxiety disorder
(B): The possibility of major depressive disorder
(C): Cognitive processes that occur when experiencing a panic attack
(D): Whether the panic attacks are expected, unexpected, or both | The possibility of major depressive disorder | B | Major depressive disorder is not indicated as a possible differential diagnosis for this client, although depression and anxiety often present together. Generalized anxiety disorder and other anxiety disorders should be assessed because the client might be having panic attacks that are based on underlying anxiety that she is experiencing. Panic disorder is characterized by unexpected panic attacks; therefore, it would be helpful to determine if the attacks are related to other anxious thoughts and cognitive processes or if they occur on their own. Therefore, the correct answer is (C) | intake, assessment, and diagnosis |
777 | Client Age: 26 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Community Mental Health Agency Type of Counseling: Individual Presenting Problem: Hallucinations and Delusions Diagnosis: Schizophrenia 295.90 (F20.9) | Mental Status Exam: The client displays an angry affect, and his mood is irritable. His speech is disorganized and pressured. He is oriented to person, place, time, and situation. He reports audiovisual hallucinations, which include seeing “the shadow man” and hearing voices others cannot hear. The client exhibits tangential and disconnected thinking. He is firm in his conviction that he is being poisoned and says he is exhausted from constantly trying to maintain vigilance. The client’s insight and judgment are poor. He denies suicidal ideation, homicidal ideation, and command hallucinations. The client first experienced symptoms of schizophrenia in his late teens but was misdiagnosed with bipolar disorder until rece | You are a counselor working in an outpatient community mental health center serving clients with severe psychiatric disorders. A 26-year-old male, accompanied by his caseworker, presents for counseling due to symptoms of schizophrenia. The caseworker reports that the client was doing well until he stopped taking his prescription medication. He resides in assisted living, where he was placed after being discharged from the hospital last month. The client claims someone he calls “the shadow man” is following him and putting poison in his food. The caseworker reports that the client has been more agitated recently and has engaged in verbal altercations with other residents. The client is refusing to take his medication because of the side effects. He had an initial therapeutic response to Haldol, an antipsychotic, but stopped taking it because it made him restless and nervous. He explains, “I felt like I constantly had to keep moving.” The client is adamant about his desire to stay off medication and becomes angry when his caseworker mentions the possibility of going back into the hospital. | ntly. Family History: The client has an older brother who transports the client to appointments and periodically checks in with the client. Hospital records indicate that the client becomes increasingly agitated during visits with his parents. The hospital social worker noted that his father was critical and dismissive toward the client during family therapy. The client’s mother is diagnosed with generalized anxiety disorder and had to quit her job due to the overwhelming burden of the client’s care. The father blames the client for the excessive toll his illness has placed on the family | How should you respond to the client’s desire to stay off medication and out of the hospital? | Tell him you will work with him to avoid rehospitalization if he agrees to be evaluated for a different medication. | Tell him you will grant an extended trial period off medication and re-assess at his next visit. | Tell him you will work with him to avoid rehospitalization if he agrees to take his medication. | Tell him you will work with him to avoid rehospitalization, and he is not obligated to take medication. | (A): Tell him you will work with him to avoid rehospitalization if he agrees to be evaluated for a different medication.
(B): Tell him you will grant an extended trial period off medication and re-assess at his next visit.
(C): Tell him you will work with him to avoid rehospitalization if he agrees to take his medication.
(D): Tell him you will work with him to avoid rehospitalization, and he is not obligated to take medication. | Tell him you will work with him to avoid rehospitalization, and he is not obligated to take medication. | D | The most ethically sound response is to tell him you will work with him to avoid rehospitalization, and he is not obligated to take medication. Counselors have the ethical obligation to abide by the principles outlined in the American Counseling Association Code of Ethics (2014). Answer C honors the principles of autonomy and justice. Autonomy involves allowing individuals to control the direction of their lives. Justice necessitates fair and equitable treatment. At this juncture, the client is oriented and is not a harm to himself or others. Trust is the cornerstone of counseling, and it is the counselor’s responsibility to ensure the counseling environment is safe. All other answer options reflect the notion of a transactional relationship between taking medication and avoiding hospitalization, which creates a power imbalance between the client and counselor and can impede the client’s growth and autonomy. Therefore, the correct answer is (C) | counseling skills and interventions |
778 | 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. | You have attempted to arrange a family session with the mother, but she is unable to take off work to attend. The client arrives for his second session eager to share that he is “on green” this morning, which means the client’s behavior for the day has been good. You praise him for staying in his seat and keeping his hands and feet to himself. The client responds well to your praise. When engaging in a feelings identification activity, the client identifies feeling unhappy and worried when his father doesn’t show up for scheduled visitation. The client explains that his parents frequently argue about “how to take care of me” and “sometimes push each other.” He quickly abandons the feelings activity and asks if he can go back to class. You deny the client’s request to leave and instead give him the option of selecting another activity. The client refuses to do so and begins to kick your file cabinet repeatedly. He proceeds to knock papers off your desk. When redirected, the client’s behavior escalates | Given the severity of the client’s emotional and behavioral difficulties, as well as the disruptive behavior displayed during this session, what would be your next best step? | Arrange for an alternative school placement. | Initiate an immediate psychiatric medication evaluation. | Refer the family for intensive in-home family therapy services. | Conduct a crisis risk assessment. | (A): Arrange for an alternative school placement.
(B): Initiate an immediate psychiatric medication evaluation.
(C): Refer the family for intensive in-home family therapy services.
(D): Conduct a crisis risk assessment. | Conduct a crisis risk assessment. | D | The client, who initially had a good morning, quickly becomes inconsolable and destructive when recalling his parents’ domestic violence. Conducting a crisis risk assessment prioritizes safety concerns, making it an essential step in providing vital services to a client with multiple risk factors (eg, bullying, trauma, attachment, poor school performance, hopelessness, and mood instability). A comprehensive risk assessment helps determine the intensity of treatment services required to meet the client’s current needs. A referral to a psychiatrist or to an in-home treatment provider would likely be part of a crisis plan of care but are inadequate as stand-alone interventions. An appointment with a psychiatrist may take time to secure, and parental consent is required before placing a child on medication. Also, certain medications take time to build up in the client’s system before symptom reduction occurs. As part of a crisis plan, a referral for intensive in-home therapy may be helpful as the mother’s work schedule compromises her availability. However, wrap-around services, such as intensive-in-home treatment and a referral for case management, are likely to be identified and prioritized after analyzing the risk assessment results. The client is already in the process of being evaluated for special education; therefore, you cannot unilaterally arrange for an alternative school placement. Federal laws require the client to be placed in the least restrictive environment, with specific procedural standards outlined in PL 94-142 (the Individuals with Disabilities Education Act). Therefore, the correct answer is (B) | intake, assessment, and diagnosis |
779 | Age: 9 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Private practice Type of Counseling: Individual counseling Presenting Problem: The client has been engaging in behavior that has gotten him suspended from school several times over the past year, which also causes significant distress for the client’s family at home. Diagnosis: Conduct disorder, childhood-onset type, with limited prosocial emotions, severe (F91.1) | Mental Status Exam: The client was minimally engaged in the session. The client’s behavior was withdrawn, argumentative, and la | You are a professional counselor, and you specialize in working with children and adolescents. The client comes to this session with his parents. You review informed consent with the client and his parents and begin to ask the client about what brings him to counseling. The client responds by saying “shut the hell up” and leaves the room to go to the lobby. The client’s father gets up and follows him out, and after a few minutes they return. The client sits down and faces away from you. The client does not engage in the intake session aside from cursing at his parents when they report specific behavioral incidents and he disagrees with them about the facts of the events. The client’s parents say that he has had “bad behavior” over the past 2 years and that his behavior has “gotten worse” over the past 5 months. The parents outline the following behavioral problems that the client engages in, in all settings: bullying, physical fighting, kicking and throwing items at his dog, intentionally breaking others’ property, lying to others to get items or have access to activities, stealing items from others, truancy, and leaving the house at night without permission or supervision. | bile. Family History: The client has two younger brothers who are 6 and 7 years old. The client often engages in physical fights and arguments with his younger siblings and often will break or steal their toys. The client takes advantage of his 6-year-old sibling by conning him out of items and activities by convincing him that a certain trade or decision is better for him, when it is usually better for the client. The client’s parents report that these behaviors occur at school and that the client does not have any friends as far as they are aware. The client’s parents state that the client is adopted and that he was in foster care from when he was 2 until he was 4 years old. The client’s parents state that his basic needs were neglected because his birth mother was heavily using drugs | Which one of the following would be considered a differential diagnosis for conduct disorder? | Reactive attachment disorder | Antisocial personality disorder | Major depressive disorder | Autism spectrum disorders | (A): Reactive attachment disorder
(B): Antisocial personality disorder
(C): Major depressive disorder
(D): Autism spectrum disorders | Major depressive disorder | C | Major depressive disorders often present in children and adolescents as aggression, irritability, and conduct problems; therefore, it is important to rule out depressive disorders when assessing a child that presents this way. Reactive attachment disorder involves an unstable attachment with caregivers, and it is not considered a differential diagnosis for conduct disorder. Although antisocial personality disorder and conduct disorder both involve the violation of the rights of others, a diagnosis of antisocial personality disorder requires the child to be at least 15 years of age. Autism spectrum disorders are at times characterized by behavioral dysfunction that stems from having difficulty feeling empathy, but they are not defined by an intentional violation of the rights of others. Therefore, the correct answer is (B) | intake, assessment, and diagnosis |
780 | 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 an appropriate goal to focus on based on this session? | Explore reentering the workforce | Focus on improving hygiene and daily living skills | Continue the current focus | Reconnect with family | (A): Explore reentering the workforce
(B): Focus on improving hygiene and daily living skills
(C): Continue the current focus
(D): Reconnect with family | Explore reentering the workforce | A | The client is showing signs that he is prepared to explore reentering the workforce. The client has accomplished 10 weeks of sobriety, consistent participation in all services with the local government agency, and maintained housing for 7 weeks. Engaging in work can provide the client with a sense of purpose, meet some social needs for the client, and is part of adult life that the client will need in order to maintain consistent housing and meet his additional financial needs and desires. The client’s family does not appear to be ready to reengage with him at this point because they do not respond to phone calls. The client’s daily living skills were not mentioned in the session note and are therefore not indicated as an immediate or current need. The current focus of therapy should not be continued because the client’s situation has improved significantly and he has maintained progress. Therefore, the correct answer is (B) | treatment planning |
781 | Client Age: 25 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Counseling Clinic Type of Counseling: Individual Presenting Problem: Depression and Suicidal Ideation Diagnosis: Major Depressive Disorder, Recurrent, Mild (F33.0) | Mental Status Exam: The client appears to not have bathed recently because his hair is greasy and unkempt. The client has food stains on his clothing; however, he is dressed appropriately for the season. His motor movements are within normal limits. He is engaged in therapy, but he appears anxious as evidenced by hesitating before speaking and by his hand wringing. The client reports suicidal ideation with no plan or intent. The client reports a depressed mood more often than not and difficulty enjoying most activities. The client is oriented to person, place, time, and situation. The client reports that his appetite has increased lately and that he is experiencing hyperso | You are a resident in counseling practicing in a private practice agency. During the initial counseling session, the 25-year-old single male client reports feeling depressed and hopeless. He has difficulty enjoying activities that he has enjoyed in the past and feels unsatisfied with most areas of his life. The client identifies that he is not happy at work and wants to make a career change. The client verbalizes feeling sad more often than not, and that this has been going on for about 2 years. The client decided to start counseling when he began experiencing suicidal thoughts. The client reports no plan or intent to attempt suicide but is concerned about his own well-being. | The client contacted you to reschedule a session sooner than the one you had originally scheduled. The client reported that he continues to have difficulty getting to work on time and was told that he needs to meet with his supervisor on Friday. The client expresses anxiety surrounding this because he worries about getting fired. The client began to cry during the session when talking about worry regarding being unemployed. The client came to the session in clothes that had stains on them, and his hair was messy and appeared greasy | Which of the following is the least appropriate way to support a client who is crying during a therapy session? | Using immediacy | Using empathy | Providing self-disclosure so the client does not feel alone | Normalizing the client’s emotions | (A): Using immediacy
(B): Using empathy
(C): Providing self-disclosure so the client does not feel alone
(D): Normalizing the client’s emotions | Providing self-disclosure so the client does not feel alone | C | Although self-disclosure may be appropriate at times in order to connect, it should only be used when it is relevant to the subject at hand. Because of the sensitivity and specificity required in using self-disclosure, it is the least appropriate way to support a client who is crying. Rather, this moment should be used to provide space for the client to experience their emotions and process their feelings. Empathy helps a client feel heard, and normalizing emotions assists clients with feeling that their feelings are valid. Immediacy focuses on inviting the client to evaluate what is happening internally in the moment when an emotion is experienced. Therefore, the correct answer is (B) | professional practice and ethics |
782 | Name: Jeff Clinical Issues: Referral following hospitalization for suicidal ideation Diagnostic Category: Bipolar and Related Disorders Provisional Diagnosis: F31.32 Bipolar I Disorder, Moderate, Most Recent Episode Depressed Age: 33 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: White Marital Status: Never married Modality: Individual Therapy Location of Therapy : Private Practice | The client's overall presentation during the examination is disheveled. He is thin, taller than average, and hunches over in his chair. He appears tired and exhibits low energy. Several times during the examination, he massages his neck and shoulders. He has inconsistent eye contact and often looks down at the floor. Speech is quiet and slow. You have to wait several seconds for him to answer questions. Thought content reveals negative themes. At various times he appears numb and indifferent but then shifts to tearfulness. Memory is slightly impaired, and he has difficulty staying focused. He denies homicidal ideations but states having past suicidal ideations. | First session You are a clinical mental health therapist working in a private practice setting. The client is a 33-year-old male referred to you by an ER physician as a follow-up after being hospitalized due to suicidal ideation. This is not the first time the client has been hospitalized. During the initial counseling session, the client discloses, "I don't know why I'm here. No one can help me. My sister made this appointment for me because I got this referral when I left the hospital. She drove me here and is sitting out in the waiting room." He continues with a tearful eye, "I'm a total failure. No one cares about. My sister looks after me, but I think it's because she feels sorry for me." You continue with your assessment to gain a more thorough understanding of his current situation. He tells you that there are times when he feels "really low" and his mind tells him that he would be better off dead. Other times, he feels "pretty good" with a lot of energy, a positive self-image, and motivation to complete various projects. You ask about his relationships with friends and family, and the client reveals that he has lost contact with most of his close friends due to a "series of negative events" in his life. He further discloses that he has difficulty maintaining relationships. He expresses feelings of loneliness and disconnection from the world. He is worried that his sister will eventually "give up" on him. When asked about his parents, he softly laughs and says, "They took the easy way out and died. Mom in a car crash and Dad from cancer. They are the ones who deserve to suffer and instead, they've got it easy." You discuss your role as a therapist and what the client can expect from the counseling process. You also review the parameters of confidentiality involved in therapy. He tells you that he would like to "give counseling a try" and see you for another session. You schedule an appointment to see him the following week. Fourth session The client appears energetic during this session. He presents as much more carefully groomed and in an elevated mood. He states, "It sure has been a journey these past few days." He reports that he met a woman at a local bar, and after spending the night together at a local hotel, they ended up taking a spontaneous road trip to Florida. He talks about the weekend as "mind-blowing", and states that this adventure has helped him design his new goal, which will be "life-changing." He goes on to say that his boss "didn't appreciate my free spirit because I had a bunch of voicemails from her waiting for me when I got home." He laughs when he relates that he had turned his phone off, so he didn't have to be "brought down." He recognizes that he had made commitments to work over the weekend, but he states, "If you met this girl, you'd know why I did it." Then laughs. You listen to the client's story intently and encourage him to talk more about his experience. Then you explore his feelings around the situation and his decision to leave work without making prior arrangements to cover his absence. You also discuss with the client the potential consequences of his actions and help him consider how to move forward in a way that is not harmful or dangerous. You ask him to think about his goals and create an action plan to help him reach those goals. Together, you and the client come up with strategies for the client to move forward in a healthy way. | The client's parents divorced when he was ten years old. He has an older sister who he currently lives with. He recalls his childhood memories as traumatic and reports experiencing verbal and physical abuse by both parents. The client states that he lived with his dad after his mom died when he was 14 years old. He explains that living with his dad was difficult, saying, "Being around my dad was like being around a ticking time bomb. There were times when he was calm and seemed interested in what I was doing, but there were other times when he would become very angry and I was never sure what might set him off." The client works in a local pizza shop. He says he is written up weekly for being late to work. He reports verbal altercations with his coworkers because they will not listen to him. In his teen years, the client used alcohol to cope with his family situation. Since that time, he only drinks socially. | Which action would be least effective when formulating an effective treatment plan? | Create SMART long-term goals and assess any difficulties in your treatment plan | Examine safety plans, which may include medication management | Develop short-term objectives designed to address the client's behavior deficits | Generate short-term goals using the SMART format and assess any barriers in your treatment plan | (A): Create SMART long-term goals and assess any difficulties in your treatment plan
(B): Examine safety plans, which may include medication management
(C): Develop short-term objectives designed to address the client's behavior deficits
(D): Generate short-term goals using the SMART format and assess any barriers in your treatment plan | Develop short-term objectives designed to address the client's behavior deficits | C | Treatment plans are designed to be strength-based to help empower the client to prioritize goals. Highlighting the client's areas of weakness is counterproductive to moving forward in therapy. Therefore, the correct answer is (A) | treatment planning |
783 | Client Age: 13 Sex Assigned at Birth: Male Gender: Transgender; Gender Nonconforming (TGNC) Ethnicity: Caucasian Counseling Setting: Child and Family Agency, School-Based Services Type of Counseling: Individual and Family Presenting Problem: Truancy; Gender Dysphoria Diagnosis: Gender Dysphoria, Provisional (F64.1); Social Exclusion or Rejection V62.4 (Z60.4) | Mental Status Exam: The client is dressed in age-appropriate clothing. They wear eye makeup and chipped black fingernail polish, and they have bitten most fingernails down to the quick. The client’s mood is irritable, and they are quick to show anger toward their mother when misgendered. Their thoughts are coherent, and they deny audio/visual hallucinations. The client acknowledges feeling sad and hopeless but denies suicidal ideation. They attribute increased levels of anxiety at school to bullying, particularly with select peers. They explain that a select group of students threaten the client and call them offensive and derogatory names. Family History and History of th | You are a school-based mental health counselor in a public middle school. Your client is a 13-year-old Caucasian 7th grader who presents for the initial intake with their mother. The mother says that the client has had several unexcused absences from school because “he is confused about his gender.” The client adamantly denies being confused and explains that they self-identify as transgender. The client’s preferred pronouns are “they/them.” The client further states that they have had a strong desire to be a different gender since early childhood, and this desire and their distress have recently intensified. The mother reports that the client is chronically irritable, spends a lot of time alone, and has “basically shut everyone out.”The client reports experiencingbullying—both verbal and physical—in school “nearly every day.” In addition to the bullying, the client says that certain teachers refuse to allow them to use the bathroom aligned with their identified gender. To prevent this conflict, the client does not eat breakfast or lunch at school. | e The client’s mother and father are both realtors. The mother states that she used to see a therapist for anxiety, which she now manages with medication. The father works long hours, and the mother returns home early to attend to the client’s needs. The mother states that she realized that the client wished to be another gender when they were younger, but she believed it was just a phase. She explains that the father is not supportive and refuses to discuss the issue. The mother is concerned about the client’s truancy and desires to be supportive but has mixed feelings about it. She says that she is fearful every day and believes that if she accepts the client’s truth, it will set the child up for “a lifetime of prejudice and discrimination | Which one of the following is an accurate depiction of gender identity? | One’s conception of being either male, female, or something else | Congruence between one’s gender identity, gender expression, and gender assigned at birth | Incongruence between one’s experienced/expressed gender and gender assigned at birth | One’s outward expression as being either male, female, or something else | (A): One’s conception of being either male, female, or something else
(B): Congruence between one’s gender identity, gender expression, and gender assigned at birth
(C): Incongruence between one’s experienced/expressed gender and gender assigned at birth
(D): One’s outward expression as being either male, female, or something else | One’s conception of being either male, female, or something else | A | Gender identity is a person’s conception of being either male, female, or something else. Gender expression is defined as one’s outward expression as being either male, female, or something else. Cisgender is the congruence between one’s gender identity, gender expression, and gender assigned at birth. Cisgender can be described as a cisgender man or a cisgender woman. Gender dysphoria occurs when there is incongruence between one’s experienced/expressed gender and their gender assigned at birth. Gender dysphoria also includes possible destress from the incongruence between one’s experienced and assigned genders. All conceptions of gender are culturally determined. Therefore, the correct answer is (A) | professional practice and ethics |
784 | Name: Alberto Clinical Issues: Sexual functioning concerns Diagnostic Category: Sexual Dysfunctions Provisional Diagnosis: F51.22 Erectile Disorder, Situational Age: 43 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: White Marital Status: Married Modality: Individual Therapy Location of Therapy : Agency | The client is dressed in casual clothing and appears to be clean and well-groomed. He is of average height and build, with short black hair. He is noticeably tense and avoids eye contact when describing his symptoms. His speech is audible and clear. He is able to express himself clearly and articulately. The client reports feeling frustrated, embarrassed, and confused concerning issues with his wife. He denies any suicidal or homicidal ideation. His mood is anxious and affect is flat. He is able to recall pertinent events and information. He has no difficulty understanding the session process or comprehending instructions. He appears to be alert and oriented to person, place, and time. The client displays average insight into his current situation and expresses willingness to explore relevant issues in more depth with the therapist. He displays average judgment when answering questions. | First session The client, a 43-year-old male, presents for his first Telehealth session through the agency where you are an intern, finishing your final hours for licensure under clinical supervision. You begin the session by striving to create a safe, comfortable, and non-judgmental environment. You provide the client with an introduction to yourself, your qualifications, and your approach to therapy. You also explain how Telehealth works and provide the client with an opportunity to ask questions about the process. Next, you review his informed consent and other paperwork that was filled out prior to the session. You explain the policies and procedures for confidentiality within your agency. He nods his head and verbally acknowledges understanding. You then begin to explore the client's presenting issues and goals for therapy. You ask what prompted him to schedule an appointment for counseling, and he responds saying, "I don't know what is wrong with me, but lately, I've been having trouble with my wife....on an intimate level. It's been very frustrating and embarrassing, and it's causing a lot of tension between us. My wife is getting frustrated and accusing me of cheating on her. We have two children. I never thought this would happen to me." The client has seen a urologist and has no sign of prostate cancer but is in poor health. The client appears anxious when describing his symptoms. He is fidgeting and has trouble maintaining eye contact as you explore the issue more deeply. This is your first client who presents with this particular issue, and you are not entirely sure of how to proceed. You take a few moments to pause and reflect on what he has said while also noting his body language. As you consider the best way forward, you remember the importance of validation in establishing rapport. You nod your head and say, "I can see how this has been difficult for you and your wife. It's understandable why it might be causing tension between the two of you." | The client is an only child. As he grew up, he reports that his father was often vocal about his dissatisfaction with his sex life. The client also reports that his mother often expressed resentment toward him from the day he was born. This has left him with a deep-seated dislike of his mother, as well as resentment of women in general. Currently, his parents are facing health issues, with his father drinking heavily and his mother having lung cancer. The client feels overwhelmed and stressed due to his job and family responsibilities. He is worried about his parents' health and is not happy about the potential of having to take care of his mother if his father passes away. After a decade of working as an illustrator designing greeting cards, the client has recently been promoted to creative director of his department. Because of his introverted nature, he is now feeling overwhelmed with the new responsibilities and having to communicate with other departments within the company. The client drinks weekly and occasionally smokes marijuana. The client drinks at least one beer every other night after work with dinner. He will finish two six-packs on some weekends if they have company over to watch football. He says he rarely drinks hard liquor. The client has reported that his alcohol use or smoking marijuana is not causing any impairments in his ability to carry out his daily responsibilities, but he is overweight because of his inactivity and indicates he would like to return to his normal weight. He also says that he has never experienced any adverse physical or psychological effects due to his substance use. | Your client has expressed concern that you appear so young and questions your professional experience since you are not licensed. What is the best response to the client’s concerns? | "I understand your concern about my age. This is my last week of internship, and I've already passed my licensing exam. I'm sure I can address your problem regardless of how young I may appear." | "I understand your concern. I'm a supervised intern and have been trained in the same way as the other therapists at the agency." | "I understand your concern, but I'm a qualified Registered Mental Health Counselor Intern. I'm certain I can help you, regardless of the fact that I haven't been at the agency as long as other therapists working here." | "I understand your concern, but age doesn't make a difference in my ability to help you. I'm confident I will provide you with the quality of care you need." | (A): "I understand your concern about my age. This is my last week of internship, and I've already passed my licensing exam. I'm sure I can address your problem regardless of how young I may appear."
(B): "I understand your concern. I'm a supervised intern and have been trained in the same way as the other therapists at the agency."
(C): "I understand your concern, but I'm a qualified Registered Mental Health Counselor Intern. I'm certain I can help you, regardless of the fact that I haven't been at the agency as long as other therapists working here."
(D): "I understand your concern, but age doesn't make a difference in my ability to help you. I'm confident I will provide you with the quality of care you need." | "I understand your concern. I'm a supervised intern and have been trained in the same way as the other therapists at the agency." | B | This is the most appropriate response. You have acknowledged the client’s concern and emphasized your qualifications and training. Therefore, the correct answer is (B) | counseling skills and interventions |
785 | Initial Intake: Age: 45 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Asian Relationship Status: Single Counseling Setting: Community outpatient clinic Type of Counseling: Individual | During the intake she looked visibly anxious. She appeared jumpy and kept looking at her watch. Although hesitated at times when she was asked a question. The counselor was concerned when Li paused for a long time when asked if she ever thought of hurting herself. Li eventually responded no. The counselor noticed that Li’s clothes looked disheveled and soiled. Li was not forthcoming with information about her past.
| Li is a self-referral. She walked into the clinic and stated that she had been experiencing feelings of anxiety.
History:
Li came into the community outpatient clinic asking to pay a sliding scale fee in cash. When asked for identifying information, Li asked if she had to give that information. She explained that she was undocumented and was weary of leaving any information that may lead government officials to her. Li did not want to give the counselor much of her history and cut the intake session short, stating that she had to get back to work. | null | Li should be referred to? | Care manager | A group for human trafficking survivors | All of the above | Employment counselor | (A): Care manager
(B): A group for human trafficking survivors
(C): All of the above
(D): Employment counselor | All of the above | C | All of the above would be helpful for Li. Being part of a group for human trafficking survivors can provide support for Li while helping her to see that she is not alone. An employment counselor can help her target a job congruent with her skills and interests. A care manager can help Li to coordinate her services. Therefore, the correct answer is (D) | professional practice and ethics |
786 | Initial Intake: Age: 32 Gender: Female Sexual Orientation: Heterosexual Ethnicity: Caucasian Relationship Status: Divorced Counseling Setting: Community Mental Health Agency, state-run Type of Counseling: Individual and family | Shania is disheveled, has tangential and fast rate speech and is fidgety with twitching in her motor movements. Shania makes consistent eye contact and leans in close when she becomes upset and begins to cry. Shania admits to having suicidal thoughts and attempt behaviors in her past, but says she no longer feels suicidal. Shania denies homicidal ideations, hallucinations, or delusions. She shares how when she was heavily using drugs and alcohol, she would become paranoid and frequently experience delusional thinking with manic presentation but only while actively on psychoactive substances. Shania has an extensive physical and emotional abuse history since childhood but is a poor historian with the timeline of events. She attributes her anxiety to her trauma as she remembers feeling anxious around her parents since she was a child. She tells you she has no desire to use drugs again but is frequently worried about her temptations to drink when she is stressed or around members of her extended family who drink. Shania’s depression and anxiety have increased more recently due to her family being evicted from their rental apartment and having to stay in a hotel room for the past few weeks. | Diagnosis: Major Depressive Disorder, recurrent, unspecified (F33.9), Anxiety Disorder, unspecified (F41.9), Alcohol dependence, uncomplicated, in early remission (F10.20), Cocaine Use Disorder, unspecified with cocaine-induced mood disorder, in remission (F14.94)
You are an intern providing mental health counseling sessions to adults and children struggling with economic and legal issues and are given a referral to conduct an evaluation for Shania, a 32-year-old woman with three children. Shania has temporary guardianship of her youngest two daughters but is undergoing a custody battle to win back full custody of all her kids. Her oldest, age 12, is under guardianship of her parents in another state. Shania tells you in the intake session that her father beats her 12-year-old with his belt and her mother verbally abuses her, but that she isn’t taken seriously when reporting. Shania says because of her legal and substance use history, and due to her reports often being vague on details and directly attempting to influence her court hearing results, officials do not follow through on investigations. Shania further shares that her youngest daughter is struggling with psychiatric and behavioral issues, has used violence against her when angry and cannot sit still, most nights only sleeping for two or three hours. She can no longer afford medications and no longer has health insurance. | Substance Use History:
Shania has been in long and short-term treatments several times in her 20s for alcohol dependency and cocaine use. She had all her children while under the influence or in remission from using substances and has had minimal contact with their fathers. The man she is currently living with is not the biological father of the children but has taken to caring for them as his own while he is in a relationship with Shania.
Work History:
Shania has never been able to keep a job for long because of her substance use, which has contributed to her depression and has caused suicidality in her past. Shania has worked in several retail, food and other merchandising chains but has just recently become unemployed again. This is what contributed to her inability to pay rent and eviction. She asks you for help with getting government assistance as she has no family she can rely upon for support. | Which of Malia's observable behaviors presented as diagnostic of ADHD? | impaired ability to follow multi-step directions | impulsivity and inability to sit still | All behaviors give diagnostic impression of ADHD. | impulsivity and defiance | (A): impaired ability to follow multi-step directions
(B): impulsivity and inability to sit still
(C): All behaviors give diagnostic impression of ADHD.
(D): impulsivity and defiance | All behaviors give diagnostic impression of ADHD. | C | The DSM-5 classifies ADHD as a Neurodevelopmental disorder and requires criteria from several categories be met to diagnose ADHD. Malia's symptoms of impulsivity, inattention, hyperactivity, defiance, inability to follow multi-step directions are all symptoms present in children with ADHD. Therefore, the correct answer is (D) | intake, assessment, and diagnosis |
787 | 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. | Attention and concentration deficits
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 type of therapy encompasses teaching emotion regulation and distress tolerance that would be helpful for Avery in case of future behavioral outbursts? | Holistic Therapy | Cognitive Behavioral Therapy | Applied Behavior Analysis | Dialectical Behavioral Therapy | (A): Holistic Therapy
(B): Cognitive Behavioral Therapy
(C): Applied Behavior Analysis
(D): Dialectical Behavioral Therapy | Dialectical Behavioral Therapy | D | Emotion regulation and distress tolerance are taught facets from the school of Dialectical Behavioral Therapy (DBT) which would be helpful for Avery in learning how to manage his emotions, tolerate frustration and regulate his affect. This is especially a good choice for a client who has little insight into their problem (either from a maturity standpoint, age, cognitive ability, or to help with personality disorder) and needs help controlling their bodily reactions immediately without necessarily understanding the underlying reasons why they react the way they do. Cognitive behavioral therapy (CBT) approaches will also be useful for Avery but focus on identifying and changing negative beliefs and thought patterns that contribute to maladaptive behaviors, which is critical for long term change. Applied Behavior Analysis (ABA) is the preferred intervention for autism, and holistic therapies can be considered to provide additional support but are not all clinically evidence-based and do not directly apply to the interventions listed in the question. Therefore, the correct answer is (B) | counseling skills and interventions |
788 | 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. | 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. | Which of the client's symptoms best supports her diagnosis? | Her tumultuous relationships with co-workers, friends, and family | Her excessively talkative behavior | Her desire to be liked | Comments of her being "like an emotional roller coaster" | (A): Her tumultuous relationships with co-workers, friends, and family
(B): Her excessively talkative behavior
(C): Her desire to be liked
(D): Comments of her being "like an emotional roller coaster" | Comments of her being "like an emotional roller coaster" | D | Cyclothymia causes emotional ups and downs, but they are not as extreme as those seen in Bipolar I or II Disorder. With Cyclothymia, the client experiences periods when the mood noticeably shifts up and down from the baseline. Therefore, the correct answer is (A) | intake, assessment, and diagnosis |
789 | Initial Intake: Age: 16 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: African American Relationship Status: Single Counseling Setting: Community Health Type of Counseling: Individual | The client presents as a thin young woman, whose weight is appropriate for her age. Her clothing is appropriate for her age and to the situation. She identifies her mood as happy and her affect is congruent. The client shows some retardation in movement but no spasticity or physical or abnormal movements. The client appears open and honest in her responses, though responses are short. She responds to closed questions without pause but appears to struggle to answer open-ended questions as evidenced by staring and smiling without speaking or saying “I don’t know.” On examination, the client shows little insight into her mother’s concerns and uses childlike judgement when responding to hypothetical questions. The client denies suicidal or homicidal ideations or intent, delusions, or hallucinations, but does admit to playing a game with children at her maternal grandmother’s house where they attempt to see ghosts in the bathroom mirror. | You are a counselor in a community health setting which includes in-office sessions as well as home visits. Your client is a 16 year-old female who presents with a history of academic difficulties, problems following rules at home, and fighting with her sister, which recently included threatening to cut her sister with a kitchen knife. Her mother tells you that the client has always had some problems in school but they are getting worse. Her teachers say that she doesn’t pay attention and struggles with simple concepts, but is always polite and friendly to others. When asked to tell you how she thinks things are going, she answers “good” and smiles. You notice that she often smiles while her mother is talking but when her mother talks about the problems at home, the client looks away from both of you and stares out the window. The client’s mother reports that the client does not clean her room, has to be told to attend to her hygiene, and does not complete chores when they are assigned, such as cleaning out the refrigerator or vacuuming the living room. Mother reports that the client stays at home alone or with her two younger sisters when her mother or mother’s boyfriend are at work or away from home during the day. | Family History:
The client is the oldest of three children born to her mother. Her siblings have different fathers and her youngest sister’s father currently lives in the home and is identified as “mom’s boyfriend” or “Robert.” Client’s mother reports no family history of mental health disorder or substance abuse. The client reports that she often spends several nights a week with her grandmother “to give Mom a break” and plays games and spends time with the neighborhood children. The client states that her grandmother “makes me sit and she reads the Bible to me” for several hours each day. She reports that she likes spending time at her grandmother’s house because she and her sister watch “scary movies” including movies about monsters, murders, and witchcraft. | Which of the following interventions will be most beneficial during termination when the client and client's mother object to your not working with them? | Offer to talk with the supervisor and see if a change can be made to your caseload | Tell them that the counselor they will be going to is better than you so they shouldn't worry | Acknowledge the trust they have in you and focus on the new counselor's trustworthiness | Explain that you understand their pain but this is company policy and has to be done | (A): Offer to talk with the supervisor and see if a change can be made to your caseload
(B): Tell them that the counselor they will be going to is better than you so they shouldn't worry
(C): Acknowledge the trust they have in you and focus on the new counselor's trustworthiness
(D): Explain that you understand their pain but this is company policy and has to be done | Acknowledge the trust they have in you and focus on the new counselor's trustworthiness | C | Termination can be frightening for clients who have built trust in a provider. Acknowledging that trust and helping the new clinician build that same trust will be important. This may include focusing on times you and the clinician have worked together and your trust in that individual or focusing on the skills that the clients used to build trust with you which they can, in turn, use with the new provider. It is never helpful to position the agency as unyielding or uncaring and that a client's care is just a matter of policy. This engenders distrust of the agency. Additionally, offering to see if the termination can be stopped demonstrates a lack of objectivity on the part of the counselor. When a counselor loses objectivity with a client, a referral is helpful for the client's continued growth. Telling clients that another counselor is better than you, is likely to be received as untruthful, superficial and/or patronizing. Therefore, the correct answer is (A) | professional practice and ethics |
790 | Name: Roger Clinical Issues: Physical/emotional issues related to trauma Diagnostic Category: Neurocognitive Disorders Provisional Diagnosis: F02.81 Major Neurocognitive Disorder Due to Traumatic Brain Injury, with Behavioral Disturbance Age: 36 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: White Marital Status: Married Modality: Individual Therapy Location of Therapy : Outpatient clinic | The client presents as tired. He reports a mild headache at the intake appointment, which he says is likely due to coming in from the bright day outside. Memory is slightly impaired. Mood is depressed, though he says this is impermanent, and his mood changes within a day, though the depressed mood is more prevalent and longer-lasting. | First session The client returned home from Afghanistan last month after separating from the Navy after 12 years of service. He states he is tired of trying to get an appointment at the VA Hospital, so he Googled locations that treat brain injuries, and your office was on the results page. He called to arrange a consultation with you. You have been practicing as a licensed mental health therapist at the outpatient clinic for over a decade, and you have worked with many clients diagnosed with traumatic brain injury. The client complains about difficulty sleeping, bad headaches, and feeling like he is on a roller coaster - feeling happy one minute and then down in the dumps the next. He states that the happy times don't last long, and he is "down in the dumps" most of the time. When asked why he left the Navy, he replies: "Toward the end of my last deployment, I just got sick and tired of everything and couldn't deal with it anymore. I couldn't sleep, was jumpy all the time, and didn't even want to go outside during the day." Now, I'm finally back home, but things only seem worse. My wife keeps nagging me to get a job, my kids look at me like I'm a monster, and nobody understands how I feel. I want to lay in bed all day and drink a couple of beers. I think something isn't right, and I can't take it anymore." Near the end of the session, the client asked what he could expect if a medical professional recommended medication management to treat NCD. The client discloses experiencing a highly distressing and psychologically damaging event during his military service in Afghanistan. While on patrol with his unit, their convoy was ambushed, and a fellow soldier directly next to the client was seized by insurgents. The client painfully witnessed his peer and friend being brutally beheaded, describing the horrific sight and sounds as permanently seared into his memory. Helplessly observing the brutal murder firsthand left him stunned and overwhelmed with grief and terror at the moment. The grotesque violence and knowing that could have just as quickly been his fate continues haunting him years later. The constant stress of combat and imminent danger already had the client in a perpetual state of hypervigilance and anxiety during his deployment. He shares that coming to terms with the abrupt, unfair loss of life was a daily reality there. While transporting supplies between bases in a standard jeep convoy, his vehicle triggered an IED explosion or was directly hit by artillery fire. The client was violently jolted and knocked completely unconscious as the blast disabled their jeep. He remained in and out of consciousness for over 24 distressing hours, being evacuated while critically injured to a military hospital. Once stabilized, he was thoroughly examined and diagnosed with a traumatic brain injury concussion along with other shrapnel wounds. | The client drinks three beers every night before bed to help him fall asleep. He started this pattern a few years ago after struggling with insomnia and finding it challenging to relax his mind. Though effective at first in inducing drowsiness, he has built up a growing tolerance and now needs to drink three beers minimum to feel any sedative effects. He discloses that he knows consuming alcohol regularly can be unhealthy, but he feels dependent on having those beers to wind down from the stresses of his day and quiet his anxious thoughts enough to get adequate rest. During his time serving in the military, the client reported smoking cannabis on occasion when it was available. However, he did not enjoy the experience or feel compelled to use it. He mainly partook when offered by peers to be social. Since his discharge five years ago, he states he has not had any cannabis. The client currently smokes approximately one pack of cigarettes per week, a habit he picked up during his military service as a way to cope with boredom and nerves. He expresses some interest in trying to cut back for health reasons but also shares smoking provides a sense of relief and routine. | Which is an accurate statement when providing psychoeducation about NCDs and medication? | Research indicates that effective medication management can address symptoms and decelerate the advancement of NCDs. | Medication management can help prevent the development of NCDs. | Medication management is a risky treatment choice due to the unwanted side effects. | Research has indicated that medication management can potentially reverse the effects of NCDs. | (A): Research indicates that effective medication management can address symptoms and decelerate the advancement of NCDs.
(B): Medication management can help prevent the development of NCDs.
(C): Medication management is a risky treatment choice due to the unwanted side effects.
(D): Research has indicated that medication management can potentially reverse the effects of NCDs. | Research indicates that effective medication management can address symptoms and decelerate the advancement of NCDs. | A | This response is accurate and provides the client with hope while not overpromising the likely effects of medication. Therefore, the correct answer is (C) | counseling skills and interventions |
791 | 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 | The approach the counselor chose is consistent with? | Cognitive Behavioral therapy | Behavior therapy | Adlerian therapy | Feminist therapy | (A): Cognitive Behavioral therapy
(B): Behavior therapy
(C): Adlerian therapy
(D): Feminist therapy | Cognitive Behavioral therapy | A | The approach described above is cognitive behavior therapy. The focus in cognitive behavior therapy is to demonstrate to the client their faulty beliefs. It is short term and directive. Adlerian therapy is longer term and looks at childhood experiences and family constellations. Behavior therapy does not look at the causes of behavior but focuses on repeating positive behaviors and extinguishing negative. Since there are no gender specific issues that Elaine would like to work on, Feminist therapy would not be an ideal modality. Therefore, the correct answer is (A) | intake, assessment, and diagnosis |
792 | 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. | You are on maternity leave, and your supervisor is covering your cases while you are out of the office. The supervisor meets with the client and daughter for the first time today and discusses the client’s progress and her treatment plan goals. The client and her daughter report measurable improvements with symptoms of depression and apathy. During today’s session, the supervisor also learns that you and the daughter went to high school together and share multiple acquaintances. There is no documentation in the client’s chart indicating that the risks and benefits of multiple relationships were reviewed with the client. At the end of the session, the supervisor asks the client for her copay. The daughter and the client state that you have “always just waived the copay,” indicating that the final bill would eventually be “written off by the agency.” Which of the following statements best reflects the supervisor and counselor’s ethical responsibility for collecting the client’s agreed-upon fees (i\. e | Which of the following statements best reflects the supervisor and counselor’s ethical responsibility for collecting the client’s agreed-upon fees (i.e., copays)? | Collecting copays is not permissible because there was a verbal agreement that the fees would be “written off.” | Waiving copays is permissible only if a predetermined fee-splitting contract exists between the counselor and the supervisor. | Collecting copays through a collection agency is permissible if the client was originally informed of this possibility and previous efforts were made to collect copays. | Waiving copays is permissible when it contributes to the public good (pro bono publico.) | (A): Collecting copays is not permissible because there was a verbal agreement that the fees would be “written off.”
(B): Waiving copays is permissible only if a predetermined fee-splitting contract exists between the counselor and the supervisor.
(C): Collecting copays through a collection agency is permissible if the client was originally informed of this possibility and previous efforts were made to collect copays.
(D): Waiving copays is permissible when it contributes to the public good (pro bono publico.) | Collecting copays through a collection agency is permissible if the client was originally informed of this possibility and previous efforts were made to collect copays. | C | In terms of the supervisor’s and counselor’s ethical guidelines for collecting outstanding copays, standard A10d of the ACA Code of Ethics states, “If counselors intend to use collection agencies or take legal measures to collect fees from clients who do not pay for services as agreed upon, they include such information in their informed consent documents and also inform clients in a timely fashion of intended actions and offer clients the opportunity to make payment”Pro bono publicorefers to providing services with little or no financial return. Applying this concept to eliminating a client’s copay after billing insurance is prohibited when billing the Centers for Medicare & Medicaid Services and is ethically risky otherwise. Fee splitting is listed as an unacceptable business practice in sanction A10b of the ACA Code of Ethics. Lastly, verbal agreements about the copays being written off may be a consideration, but this is not the best reflection of the supervisor’s or counselor’s ethical responsibility. Therefore, the correct answer is (C) | professional practice and ethics |
793 | 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. The client has not followed up with psychiatry referrals that you provided and is continuing to struggle with managing her manic symptoms | The client has not followed up with psychiatry referrals that you provided and is continuing to struggle with managing her manic symptoms. Which would be the most appropriate next step? | Respect the client’s personal decision not to follow up. | Provide psychoeducation on the benefits of a combination of medicine and therapy for bipolar disorders. | Encourage or remind the client to follow up with the referrals. | Evaluate cognitive barriers or reservations about medication. | (A): Respect the client’s personal decision not to follow up.
(B): Provide psychoeducation on the benefits of a combination of medicine and therapy for bipolar disorders.
(C): Encourage or remind the client to follow up with the referrals.
(D): Evaluate cognitive barriers or reservations about medication. | Evaluate cognitive barriers or reservations about medication. | D | The most appropriate answer is to evaluate the client’s cognitive barriers and reservations about medication. This opens up a conversation about what makes it hard for the client to follow up and to address the anxiety or other barriers caused by manic behavior. The client’s personal decision to not take medication is very important and should be respected; however, this is the second session and you have not fully processed the client’s feelings about medication. It might help to provide psychoeducation about the benefits of medication and therapy, but this should have been done when you provided the referral, and it may feel like nagging to the client. You can encourage or remind the client to follow up, but this may not address what kept her from following up and therefore may not provide any practical solutions or support. Therefore, the correct answer is (A) | professional practice and ethics |
794 | Client Age: 27 Sex: Female Gender: Female Sexual Orientation: Heterosexual Ethnicity: Caucasian Relationship Status: Married Counseling Setting: Career Counseling Center Type of Counseling: Individual Presenting Problem: Employment-related Stress; Anxiety Diagnosis: Adjustment Disorder with Anxiety 309.24 (F43.22) | Mental Status: The client was well-groomed and dressed appropriately. She appears nervous and jittery and quickly places her hands under the table when she notices them shaking. The client states that she is not sleeping well and says it is difficult making it to work each day knowing that “things rarely go as planned.” She explains that she has irritable bowel syndrome, which is exacerbated by stress. The client reports that there are no known medical conditions that would cause her chronic headaches. The client denies homicidal or suicidal ideations but remarks that she has felt like this in the past. Wor | You work in a career counseling center, and your intake is a 27-year-old white female employed as a fourth-grade elementary schoolteacher. The client has been a teacher for 3.5 years and has become increasingly dissatisfied with her job. The client explains that she is “at her breaking point” and relays that her stress level has increased sharply within the past 3 months. This is her first school year with a newly hired principal who has been “unreasonably demanding and unsupportive.” The client states that she was already second-guessing her career choice and explains that disruptive students and a lack of parental involvement have made teaching incredibly challenging. She reports “stress-induced physical symptoms,” which include acute stomach distress and chronic headaches. She worries that her skill set is nontransferable. | k and Family History: The client obtained her bachelor’s degree in teaching and is currently a certified teacher. She comes from a family of educators, with her mother working as a teacher and her father as a high school guidance counselor. Before college graduation, she worked odd jobs, including waiting tables and working in a public library with preschool groups. She remembers enjoying her student teaching position but states that the class was “nothing like” what she has now. She explains that her student-teaching classroom contained 16 students and that she now struggles to stay on top of her current class of 24. She plays on a tennis team and serves as a “big sister” to a child through a local nonprofit organization. The client is married, and she and her husband do not have children. She reports that her husband has a high-stress job working as an attorney. The client says that he has “little patience with me when I complain about my job stress | Adjustment disorders are associated with an increased risk of which of the following? | Completed suicide | Panic attacks | Drug and alcohol misuse | Poor concentration | (A): Completed suicide
(B): Panic attacks
(C): Drug and alcohol misuse
(D): Poor concentration | Completed suicide | A | According to DSM-5-TR, adjustment disorders are associated with an increased risk of suicide attempts, both successful and unsuccessful. Poor concentration often accompanies anxiety-related disorders, but individuals with adjustment disorders are not at an increased risk of poor concentration. Individuals with neurocognitive disorders and individuals with substance/medication-induced sexual dysfunction may be at an increased risk for drug and alcohol misuse. Panic attacks are symptoms of anxiety and other mental disorders and are not a risk factor for adjustment disorders. Therefore, the correct answer is (A) | intake, assessment, and diagnosis |
795 | 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.” | With the information gained about this client and her diagnosis, which of the following concurrent treatment services would not be the most appropriate referral to recommend at this time. | Participating in a suicide prevention support group | Participating in family therapy sessions | Participating in a skills building group | Participating in an interpersonal growth group | (A): Participating in a suicide prevention support group
(B): Participating in family therapy sessions
(C): Participating in a skills building group
(D): Participating in an interpersonal growth group | Participating in a suicide prevention support group | A | This client has a past history of suicide attempts that appear to be related to real or imagined feelings of abandonment. A group like this can be supportive for clients who are currently struggling with suicidal ideation; however, this client appears to be stable in this area. Interpersonal growth groups for individuals with BPD are helpful as they recreate their interpersonal relations within the group and receive feedback on how their interactions impact others. Skills building groups are often used in combination with individual therapy when applying a dialectical behavioral approach for BPD. Family therapy sessions have been shown to have some value in working with clients experiencing BPD as it helps the family to understand the obstacles the client faces and helps the family and client develop strategies for working with BPD. Therefore, the correct answer is (A) | treatment planning |
796 | 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 | Harold is showing symptoms of? | Unspecified Personality Disorder | Antisocial personality disorder | Histrionic Personality Disorder | Narcissistic personality Disorder | (A): Unspecified Personality Disorder
(B): Antisocial personality disorder
(C): Histrionic Personality Disorder
(D): Narcissistic personality Disorder | Narcissistic personality Disorder | D | Harold meets the criteria of narcissistic personality disorder as evidenced by his grandiose sense of self-importance, belief that he is irreplicable at his company, his sense of entitlement, bullying of others and the belief that others envy him. Antisocial personality disorder is ruled out as there is no evidence of aggression, disregard for safety or failure to conform to social norms. Histrionic personality disorder is ruled out as it is characterized by attention seeking behavior with symptoms such as inappropriate sexualized behavior, shallow expressions of emotions, dramatic in the expression of emotion and the use of physical appearance for attention. Unspecified personality disorder is used when one does not meet the full criteria for a specific personality disorder. Therefore, the correct answer is (C) | intake, assessment, and diagnosis |
797 | 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 interventions support the objective to improve Avery's ability to identify positive traits and talents about himself? | Develop with Avery a list of positive affirmations about himself and assign him to read it daily | Reinforce verbally Avery's use of confidence and positive affirmations about himself | Present Avery with a piece of candy for each positive trait he can identify every session | Watch a video with Avery about a character who defeats his struggle with schoolwork | (A): Develop with Avery a list of positive affirmations about himself and assign him to read it daily
(B): Reinforce verbally Avery's use of confidence and positive affirmations about himself
(C): Present Avery with a piece of candy for each positive trait he can identify every session
(D): Watch a video with Avery about a character who defeats his struggle with schoolwork | Reinforce verbally Avery's use of confidence and positive affirmations about himself | B | Verbal reinforcement is the best way to help Avery remember how it feels to reflect positively on himself as it signals an immediate praise-based reward each time he uses a positive affirmation on his own. Making a list is a great way to remember his positive traits however assigning him to read on his own might only exacerbate his frustrations with reading and cause aversion towards the content since reading is what is making him feel bad. Use of prizes may cause immediate compliance and increased alertness with activities in session however is only reinforcing extrinsic or external motivation to do so and will not provide lasting change. Videos with engaging content are helpful tools to use occasionally, however this is not an optimal choice with this child's low attention span and hyperactivity. Therefore, the correct answer is (B) | counseling skills and interventions |
798 | Name: Anxiety Group Therapy Clinical Issues: Worry and anxiety Diagnostic Category: Anxiety Disorders Provisional Diagnosis: F41.1 Generalized Anxiety Disorder Age: 0 Sex Assigned at Birth: Female Gender and Sexual Orientation: Not applicable, Ethnicity: Various Marital Status: Not Applicable Modality: Group Therapy Location of Therapy : Agency | The group members appear to be insightful about their illness. Clients ages are 25 and older. All members are well-groomed and present with clean hygiene. | First session You are a therapist in an agency starting a group for clients with anxiety. The group will consist of seven participants. It is a homogeneous, closed group which will meet once a week on Wednesday evenings for an hour and a half for twelve weeks. The group's goal is to help clients diagnosed with Generalized Anxiety Disorders and other anxiety-related issues. An intern will co-facilitate the group with you. You are forming an outline for the group's goals, screening questions, and termination process. You will be observing candidates for the group to facilitate participant selection. | null | During the screening/intake for this group, which would be an advantageous step to take to ensure that group therapy is successful? | Request that each member present a detailed autobiography | Only hold individual screening appointments | Suggest the members participate in a mindfulness exercise | Encourage clients interview the group leaders about their experience and how they run groups | (A): Request that each member present a detailed autobiography
(B): Only hold individual screening appointments
(C): Suggest the members participate in a mindfulness exercise
(D): Encourage clients interview the group leaders about their experience and how they run groups | Encourage clients interview the group leaders about their experience and how they run groups | D | This empowers clients to become more active participants of their therapy experiences rather than just being passive interviewees. It sets a positive atmosphere for the group experience to come. Therefore, the correct answer is (D) | counseling skills and interventions |
799 | 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. | The client is seen for the first time since the initial intake due to being suspended the previous week. He displays an angry affect, sits with his arms closed, and faces the wall. You begin to establish rapport by engaging the client in a game. The client starts to open up and discloses that he feels angry every day and attributes this to his mom “always bothering” him and “everybody always picking” on him. He believes that his teacher doesn’t like him, and he is unhappy that his desk is no longer with the other students but instead right next to the teacher. He states that when he feels angry, his heart races, he clenches his fists, and he feels a tightness in his chest | What is the logical error demonstrated when the client is asked to identify anger triggers? | Polarized thinking | Overgeneralization | Emotional reasoning | Personalization | (A): Polarized thinking
(B): Overgeneralization
(C): Emotional reasoning
(D): Personalization | Overgeneralization | B | The client attributes his angry feelings to his “mother always” bothering him and “everybody always” picking on him—both untrue statements. This is an example of overgeneralization. Overgeneralization is a faulty belief system that occurs when general assumptions are made based on one or two experiences. The wordsalwaysandneverare often a part of an overgeneralized statementPersonalization occurs when individuals erroneously attribute external events to their own actions. (“My behavior caused the entire class to lose recess; I ruined everyone’s day!”)Polarized thinking happens when one engages in black-and-white or dichotomous thinking. (“If I can’t be the best, then I’m nothing”)Emotional reasoning is the result of believing that one’s feelings are facts, despite conflicting evidence. (“I feel worthless, so I must be”). Therefore, the correct answer is (D) | counseling skills and interventions |
800 | Name: Jeff Clinical Issues: Referral following hospitalization for suicidal ideation Diagnostic Category: Bipolar and Related Disorders Provisional Diagnosis: F31.32 Bipolar I Disorder, Moderate, Most Recent Episode Depressed Age: 33 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: White Marital Status: Never married Modality: Individual Therapy Location of Therapy : Private Practice | The client's overall presentation during the examination is disheveled. He is thin, taller than average, and hunches over in his chair. He appears tired and exhibits low energy. Several times during the examination, he massages his neck and shoulders. He has inconsistent eye contact and often looks down at the floor. Speech is quiet and slow. You have to wait several seconds for him to answer questions. Thought content reveals negative themes. At various times he appears numb and indifferent but then shifts to tearfulness. Memory is slightly impaired, and he has difficulty staying focused. He denies homicidal ideations but states having past suicidal ideations. | First session You are a clinical mental health therapist working in a private practice setting. The client is a 33-year-old male referred to you by an ER physician as a follow-up after being hospitalized due to suicidal ideation. This is not the first time the client has been hospitalized. During the initial counseling session, the client discloses, "I don't know why I'm here. No one can help me. My sister made this appointment for me because I got this referral when I left the hospital. She drove me here and is sitting out in the waiting room." He continues with a tearful eye, "I'm a total failure. No one cares about. My sister looks after me, but I think it's because she feels sorry for me." You continue with your assessment to gain a more thorough understanding of his current situation. He tells you that there are times when he feels "really low" and his mind tells him that he would be better off dead. Other times, he feels "pretty good" with a lot of energy, a positive self-image, and motivation to complete various projects. You ask about his relationships with friends and family, and the client reveals that he has lost contact with most of his close friends due to a "series of negative events" in his life. He further discloses that he has difficulty maintaining relationships. He expresses feelings of loneliness and disconnection from the world. He is worried that his sister will eventually "give up" on him. When asked about his parents, he softly laughs and says, "They took the easy way out and died. Mom in a car crash and Dad from cancer. They are the ones who deserve to suffer and instead, they've got it easy." You discuss your role as a therapist and what the client can expect from the counseling process. You also review the parameters of confidentiality involved in therapy. He tells you that he would like to "give counseling a try" and see you for another session. You schedule an appointment to see him the following week. | The client's parents divorced when he was ten years old. He has an older sister who he currently lives with. He recalls his childhood memories as traumatic and reports experiencing verbal and physical abuse by both parents. The client states that he lived with his dad after his mom died when he was 14 years old. He explains that living with his dad was difficult, saying, "Being around my dad was like being around a ticking time bomb. There were times when he was calm and seemed interested in what I was doing, but there were other times when he would become very angry and I was never sure what might set him off." The client works in a local pizza shop. He says he is written up weekly for being late to work. He reports verbal altercations with his coworkers because they will not listen to him. In his teen years, the client used alcohol to cope with his family situation. Since that time, he only drinks socially. | Which of the following questions would be irrelevant when considering a diagnosis of Bipolar I Disorder, Moderate, Most Recent Episode Depressed? | Have you ever found yourself not knowing or remembering your name? | Has anyone commented on how quickly you talk? Have they stated that it is hard to follow? | Have you felt that you have needed much less sleep than usual? | Have you experienced pleasure-seeking behaviors which have negative consequences? | (A): Have you ever found yourself not knowing or remembering your name?
(B): Has anyone commented on how quickly you talk? Have they stated that it is hard to follow?
(C): Have you felt that you have needed much less sleep than usual?
(D): Have you experienced pleasure-seeking behaviors which have negative consequences? | Have you ever found yourself not knowing or remembering your name? | A | Dissociative symptoms are NOT part of Bipolar I Disorder criteria and would be irrelevant for this client. This would be a question more consistent with the criteria of Dissociative Amnesia. Therefore, the correct answer is (A) | intake, assessment, and diagnosis |
Subsets and Splits