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801 | Initial Intake: Age: 43 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Married Counseling Setting: Private Practice Type of Counseling: Individual | The client presents appropriately dressed in a long-sleeved t-shirt and jeans and is well-groomed. Her weight appears appropriate to height and frame. Her movements and speech demonstrate no retardation and she is cooperative and engaged. The client reports her mood as anxious, however you note her to be relaxed in speech and appearance. She reports no recent suicidal ideations and demonstrates no evidence of hallucinations or delusions. The client reports that she is in good health and takes no medication except birth control. She reports she has difficulty falling asleep at night because she worries whether her husband finds her attractive. She states she also frequently worries about the children or situations that have happened during the day, but is often able to dismiss these after a few minutes. | You are a counselor in a private practice setting. During the intake session, you learn that your client has been married for 15 years and has four children and is currently struggling with her marital relationship. She states her husband does not want to attend counseling with her. Your client complains of occasional feelings of unhappiness, irritation, difficulty sleeping, as well as worrying. These have been present for the past 8 to 10 months, with the worry being almost daily. She states she feels alone in the marriage because her husband is an introvert and is often too tired after work to engage emotionally with her. She views the marriage as “good” and they engage in sex at least 5 times per week, where she is often the initiator. She reports that she repeatedly asks her husband and best friend to reassure her that she is still attractive. She tells you that her best friend is encouraging, but her husband tells her he is tired of her constant, daily questioning and says she must be in a midlife crisis. She confides that her husband frequently looks at pornography and sometimes they watch pornographic movies together prior to sex. | Family History:
Approximately 6 years ago, the client’s family doctor prescribed a short course of Valium, while she and her husband were building their house. She also was diagnosed with postpartum depression after her first child was born. She reports she did not seek counseling at the time but her obstetrician prescribed antidepressants, which she took for 10 months with good results. Her doctor then prescribed the same antidepressants for 12 months as a preventative against postpartum depression prior to each of her subsequent births. | During the intake, your client talks frequently about her husband and the difficulties that his sexual drive and lack of concern for her worries causes in the marriage. Aware of being in the early stages of the therapeutic relationship, which of the following is your most appropriate response? | Offer support with reading materials for relating to a partner with a personality disorder | Gently redirect the client to focus on her own emotional concerns | Demonstrate empathy by normalizing the impact of living with someone who is uncaring, and focus on boundaries | Offer to help the client by providing counseling referrals for her husband's issues | (A): Offer support with reading materials for relating to a partner with a personality disorder
(B): Gently redirect the client to focus on her own emotional concerns
(C): Demonstrate empathy by normalizing the impact of living with someone who is uncaring, and focus on boundaries
(D): Offer to help the client by providing counseling referrals for her husband's issues | Gently redirect the client to focus on her own emotional concerns | B | Counselors must facilitate the therapeutic relationship while working objectively. The ACA Code of Ethics provides the counselor's primary responsibility is to promote the welfare of the client. This would require the counselor and client to focus on her concerns rather than her husband's. The Code additionally requires counselors to provide proper diagnosis only with appropriate assessment. Since the counselor has not met with the client's spouse, it would be inappropriate to provide referrals or to make assumptions about his feelings, issues, or personality. Therefore, the correct answer is (C) | counseling skills and interventions |
802 | 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. | Considering the information shared, which of the following assessment instruments would be most helpful in understanding the client's presenting issues? | Beck Anxiety Inventory (BAI) | Family genogram | Clinical Anger Scale (CAS) | Yale Brown Obsessive Compulsive Scale (YBOCS) | (A): Beck Anxiety Inventory (BAI)
(B): Family genogram
(C): Clinical Anger Scale (CAS)
(D): Yale Brown Obsessive Compulsive Scale (YBOCS) | Family genogram | B | The client's presenting issues include alcohol use and difficulty in interpersonal relationships. A family genogram will help the counselor and client identify patterns of interaction within the client's family of origin that may still be operating today. While irritability is a criterion for anxiety, there is little information provided that suggests the client is dealing with anxiety. The client admits to angry outbursts and the CAS may be helpful in tracking treatment efficacy in this area, but will not explore the reasons for his anger. The YBOCS measures obsessions and compulsions, however the client does not indicate these types of disturbances. Therefore, the correct answer is (A) | intake, assessment, and diagnosis |
803 | 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. | You discuss limits to confidentiality in terms that the client can understand. Under what condition would you be required to breach the client's confidentiality? | If the mother insists you reveal what is discussed in therapy | When counseling a minor whose parents are in the middle of divorce proceedings | If you discover that the client is sexually active with another minor | When discussing cases while under direct supervision or working with a clinical team | (A): If the mother insists you reveal what is discussed in therapy
(B): When counseling a minor whose parents are in the middle of divorce proceedings
(C): If you discover that the client is sexually active with another minor
(D): When discussing cases while under direct supervision or working with a clinical team | When discussing cases while under direct supervision or working with a clinical team | D | This is the correct answer because as a limited permit holder you are being supervised; everything will not remain confidential in all of your cases. Therefore, the correct answer is (B) | professional practice and ethics |
804 | Client Age: 26 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Community Mental Health Agency Type of Counseling: Individual Presenting Problem: Hallucinations and Delusions Diagnosis: Schizophrenia 295.90 (F20.9) | Mental Status Exam: The client displays an angry affect, and his mood is irritable. His speech is disorganized and pressured. He is oriented to person, place, time, and situation. He reports audiovisual hallucinations, which include seeing “the shadow man” and hearing voices others cannot hear. The client exhibits tangential and disconnected thinking. He is firm in his conviction that he is being poisoned and says he is exhausted from constantly trying to maintain vigilance. The client’s insight and judgment are poor. He denies suicidal ideation, homicidal ideation, and command hallucinations. The client first experienced symptoms of schizophrenia in his late teens but was misdiagnosed with bipolar disorder until rece | You are a counselor working in an outpatient community mental health center serving clients with severe psychiatric disorders. A 26-year-old male, accompanied by his caseworker, presents for counseling due to symptoms of schizophrenia. The caseworker reports that the client was doing well until he stopped taking his prescription medication. He resides in assisted living, where he was placed after being discharged from the hospital last month. The client claims someone he calls “the shadow man” is following him and putting poison in his food. The caseworker reports that the client has been more agitated recently and has engaged in verbal altercations with other residents. The client is refusing to take his medication because of the side effects. He had an initial therapeutic response to Haldol, an antipsychotic, but stopped taking it because it made him restless and nervous. He explains, “I felt like I constantly had to keep moving.” The client is adamant about his desire to stay off medication and becomes angry when his caseworker mentions the possibility of going back into the hospital. | The client is attending group therapy and reports it helps him feel less isolated and alone. He has learned from the group leader and group participants that other medications (i\. e., second-generation atypical antipsychotics) have fewer side effects, and he has requested a psychiatric medication evaluation. The client states he is constantly worrying about “the shadow man,” which has taken its toll physically. He recounts a recent visit with his parents where his father blamed him for his mother’s anxiety. During the same visit, his father criticized the client’s poor choices in life and, according to the client, “He guilt-tripped me for not being more like my brother.” The client believes his parents are to blame for his current situation because they ignored his needs once he reached adolescence and refused to help when he was struggling | Which one of the following is a leadership skill used to connect members and facilitate cohesion and universality? | Pacing | Linking | Sculpting | Chaining | (A): Pacing
(B): Linking
(C): Sculpting
(D): Chaining | Linking | B | Linking is the leadership skill used to connect members and facilitate cohesion and universality. Leaders promote group cohesion or a group’s sense of solidarity by creating a sense of belonging and connection. Universality involves learning that other people share similar thoughts, feelings, and experiences. Chaining is a behavioral intervention based on operant conditioning and is used to master complex sequences of behaviors. Chaining occurs through the association of responses such that each response acts as the stimulus for the following response. Pacing is a group leadership skill used to attend to the emotional intensity of a group. Sculpting is a human validation process family therapy technique used to position family members in a way that illustrates significant aspects of the family unit. Therefore, the correct answer is (D) | professional practice and ethics |
805 | 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 these core attributes will help the client identify emotions? | A non-judgmental stance | Conflict tolerance | Active listening and attending skills | Empathic responding, also called reflection of feelings | (A): A non-judgmental stance
(B): Conflict tolerance
(C): Active listening and attending skills
(D): Empathic responding, also called reflection of feelings | A non-judgmental stance | A | A non-judgmental stance is the most important core attribute that the counselor will need to employ at this time. The client is just learning to connect emotions and will likely be anxious at trying to explore such uncomfortable material within herself. Active listening and attending skills show the client that the counselor is present and available to them. This is important in all sessions, although listening and attending postures will not indicate acceptance of the client's attempts at identifying emotions as a non-judgmental stance will do. Reflections of feelings are core skills in which the counselor listens to what a client is saying and allows the counselor to name the feeling that corresponds with or underlies the client's statements (ie, "It sounds like you were sad"). Because the purpose of this intervention is to have the client connect her actions to feelings, it is not helpful for the counselor to take that role on instead. Conflict tolerance is a necessary skill for counselors to possess, however based on the information presented, the counselor and client are unlikely to experience conflict in the therapeutic relationship because helping the client identify emotions is done at the client's pace to facilitate a safe and trusting environment. Therefore, the correct answer is (A) | core counseling attributes |
806 | Client Age: 26 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: African American Relationship Status: Single Counseling Setting: Community Mental Health Center Type of Counseling: Individual Presenting Problem: Depressive Symptoms Diagnosis: Persistent Depressive Disorder (PDD) (Dysthymia) Diagnostic Criteria 300.4 (F34.1) | Mental Status Exam: The client is dressed in age-appropriate clothing and is well groomed. His affect is blunted and anxious at times. The client denies anxiety but discloses that he is nervous about the counseling process and doesn’t know what to expect. He is cooperative but hesitant to offer more information than is asked. The client is tearful when discussing his breakup and states that there are days when it is a struggle to get out of bed and go to work. He denies suicidal ideation, and he says that he has had no previous attempts. The client is oriented to person, place, time, and situation, and his thought content is organized. Fam | You are a counselor working in a community mental health center. Your initial intake appointment is with a 26-year-old African American male who presents with symptoms of depression. The client states that he has felt depressed since his teens, with symptoms increasing within the last couple of months. He reports feelings of worthlessness, fatigue, and occasional bouts of insomnia. In addition, the client indicates that his symptoms worsened after his girlfriend of 2 years broke things off with him. He explained that she grew tired of his low energy and pessimistic outlook on life. As a result, he has been hesitant to seek help, believing that he just needed to “man up” and handle his problems privately. The client is unsure of his insurance benefits but thinks his policy allows for a limited number of counseling sessions. | The client has responded well to identifying automatic thoughts and distorted thinking. Although some depressive symptoms have decreased, he reports continued distress stemming from the breakup with his girlfriend. He believes that he is “unworthy of love” and is destined to fail in his intimate relationships. Despite his progress in identifying cognitive distortions, the client reports feeling stuck. You and the client discuss your theoretical orientation, the therapeutic relationship, and the treatment plan goals and objectives. The client says that he values your collaborative approach, believes that the two of you have a strong working relationship, and agrees with the overall therapy goals. Despite slight improvement with his depressive symptoms, he is committed to therapy and trusts the process | To facilitate the client’s progress, which of the following would you use to help access the client’s underlying core beliefs about himself, others, and the world? | The hidden emotion technique | The memory rescripting technique | The scaling technique | The downward arrow technique | (A): The hidden emotion technique
(B): The memory rescripting technique
(C): The scaling technique
(D): The downward arrow technique | The downward arrow technique | D | The downward arrow technique helps facilitate the client’s progress by uncovering the client’s underlying core beliefs about himself, others, and the world. Core beliefs, generally rooted in childhood experiences, can drive automatic thoughts and lead to distorted thinking. The downward arrow technique identifies the intermediate beliefs impeding progress. The counselor then draws a downward arrow and challenges each rigidly held belief. For example: Client: “I’m destined to fail in all intimate relationships” Counselor: “And what does that mean?” Client: “I’m a failure” Counselor: “If you’re a failure, what does that suggest?” Client: “That I’m unlovable” Once the core belief is uncovered, it can be further explored and tested against sound logic and reason. Memory rescripting, or imagery rescripting, is a technique used with clients experiencing flashbacks originating from trauma. The goal of memory rescripting is to alter the memories leading to shame and self-blame. The hidden emotion technique brings to the forefront anxiety-provoking situations that are avoided or denied. Counselors who practice solution-focused therapy use scaling questions to help clients track their progress on an identified goal. Therefore, the correct answer is (A) | counseling skills and interventions |
807 | Name: Jeanne Clinical Issues: Fear and panic Diagnostic Category: Anxiety Disorders Provisional Diagnosis: F41.9 Unspecified Anxiety Disorder Age: 35 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: Latin American Marital Status: Married Modality: Individual Therapy Location of Therapy : Community Center | The client appears tearful and overwhelmed. Her affect is mood congruent with her reported symptoms of panic, stress, and guilt. The client has a poor sense of control over her current mental state, leading to ideas and fears of not being able to cope with her current circumstances. She reports having panic attacks and expresses feeling overwhelmed by the demands of motherhood and home life. The client has difficulty concentrating on tasks, as well as changes in her eating habits, sleeping patterns, and overall mood, leading to worries about managing her responsibilities as a mother. She expresses an understanding of her situation and an awareness that her current mental state is not sustainable in the long-term. She has also expressed a desire to seek counseling as a first step towards managing her anxiety. | First session You are a therapist at a community center. The client is a married, 35-year-old mother of two young children. She is a stay-at-home mother, and the family is financially dependent on her husband's income. He works long hours and is very tired when he finally gets home, leaving most of the household tasks and childrearing to the client. She tells you, "About eight months ago while driving my car, I began having hot flushes, sweating, and feeling like I was going to die. It has happened multiple times since then. What if my kids are with me, and it happens again while I'm driving? I can't stop thinking about it." She states that her husband drove her to the session today because she has been afraid to drive since her first panic attack. She describes another incident two weeks ago while getting her hair cut. She began feeling like she had a heart attack. She tells you, "I sat straight up in the middle of having my hair shampooed and just ran out the door. The room felt so small all of the sudden and I couldn't stand it. It's so embarrassing. It doesn't make any sense." As she wipes tears from her eyes, she shares, "I'm becoming more and more afraid to leave my house by myself. I'm not even going to church anymore. The idea of being in a closed room full of people freaks me out. I'm terrified I'm going to have another 'attack.' I can't tell when another one will come on, and I don't even know how long it will last. Please, help me. I'm no good to anyone right now - not me, my kids, or my husband." She tells you that she had a "bad experience" with medications in the past and wants to try counseling before considering medications again. She expresses feeling afraid that she will never "get better." She also states she feels like a "bad wife and mother" because she cannot control her anxiety. You discuss the principles of panic-focused CBT and mindfulness-based stress reduction to effectively treat her. Fourth session At the start of today's session, the client hands you a copy of a hospital discharge form. She went to the emergency room two days ago with severe dyspnea and fear of dying from a myocardial infarction. Upon arrival at the hospital, the client reported paresthesia, pounding heart, and chest pain. She appears "frazzled" and disheveled during today's session. She describes the circumstances leading up to her trip to the hospital. She reports that her husband has been emotionally distant and is becoming increasingly frustrated with her anxiety. Finally, he told her that "this has been going on long enough" and that she needed to "get her act together." After this conversation, the client experienced a panic attack and stated that she was "terrified" that she was dying. Her husband arranged for their neighbor to watch the kids and drive her to the hospital. You tell the client that she must stop thinking she will die or progress in therapy will be unlikely. You reassure her that the physical sensations she feels during a panic attack are not life-threatening, even though they may feel that way. You discuss the importance of her bringing compassion and attention to her body rather than jumping into "fight, flight, or freeze" mode. The client appears anxious and has poor eye contact with an averted gaze. She is continuously wringing her hands together and bouncing her legs. She has trouble concentrating, as evidenced by her asking you to repeat questions. The client tearfully states, "I'm ruining my family. What if I die? Who will take care of the kids?" You provide empathy and walk her through a relaxation technique. | The client has two young children, ages four and six, both of whom have been diagnosed with ADHD. She has been married for ten years. Her husband is 47, twelve years her senior. He works full-time, and she is a stay-at-home mom. For the past year, the client has reported feeling overwhelmed with the demands of motherhood and home life. She feels that her husband does not understand her struggles, nor does he contribute enough to their household responsibilities. This lack of support from her husband has caused her to feel a deep sense of resentment. She is also concerned that her children are not receiving the support they need from their father, as his involvement in their lives appears to be minimal. The client expresses frustration with her lack of motivation and has become increasingly more anxious and irritable over the past several months. She reports difficulty concentrating on tasks. She feels her stress levels are rising and she is having recurrent panic attacks. In addition, she has noticed changes in her eating habits, sleeping patterns, and overall mood. These changes have caused the client to worry about managing her responsibilities as a mother. The client has been a full-time stay-at-home mother since the birth of her older child. Before that, she was a salesperson and shift manager at a local women's clothing boutique for several years. Since becoming a stay-at-home mom, the client has felt increasingly isolated and disconnected from the outside world. She fears she has lost her ability to successfully manage conversations with strangers, her skills in sales and marketing have eroded, and she no longer feels as confident in herself. Previous Counseling: The client has been hospitalized as she feared she was having a heart attack which turned out to be a panic attack. According to he client, her husband (her designated emergency contact person) was responsible for creating the conditions that resulted in her being hospitalized. | What long-term goal will guide your overall treatment for the client's presenting issues? | Reduce the client's panic symptoms and her fear so she can drive again | Create an action plan for when the client feels the onset of an anxiety attack | Identify the connection between between panic attacks and internal and external stimuli | Reduce feelings of guilt and shame for not being able to control her anxiety | (A): Reduce the client's panic symptoms and her fear so she can drive again
(B): Create an action plan for when the client feels the onset of an anxiety attack
(C): Identify the connection between between panic attacks and internal and external stimuli
(D): Reduce feelings of guilt and shame for not being able to control her anxiety | Reduce the client's panic symptoms and her fear so she can drive again | A | This goal is most important for the client to regain her independence, as she has been relying on her husband to drive her to the session. It will also increase her self-confidence and be helpful in her day-to-day life, such as running errands or attending church. Therefore, the correct answer is (B) | treatment planning |
808 | Client s Age: Client 1: age 12 Client 2: age 14 Client 3: age 14 Client 4: age 16 Client 5: age 13 Client 6: age 16 Sex: Males Gender: Males Sexuality: Varying Ethnicity: Multiracial Relationship Status: Single Counseling Setting: Juvenile Justice Facility Type of Counseling: Group Counseling Presenting Problem: Involvement with the Justice System That Includes Various Mental Health Disorders and Crimes Diagnosis: Imprisonment (Z65.1) | Mental Status Exam: All of the clients appear to maintainappropriate hygiene, and they are all oriented to person, place, time, and situation. They are all somewhat reserved with regard to going into deeper topics, but theyparticipate f | You are a licensed counselor working in a juvenile justice facility for teenage males. The group comprises six males that are required to attend as part of their incarceration with the expectation that it will shorten their sentences. The purpose of the group is to work on emotional regulation and to work together to share common experiences and identify goals that can be helpful in preventing reincarceration. During the intake session, you explained the purpose of the group and started with an ice-breakeractivity. The clients participated in the ice-breaker activity that required you to redirect them back to the activity several times because they would joke and get off task. You attempt to go a little deeper by encouraging your clients to start talking about what happened to get them incarcerated, and they appear to be taking pride in the reasons they were in juvenile detention and making fun of those with lesser sentences. You redirect the clients to another topic. | ully. Family History: Several clients report coming from a single-parent home, whereas others are from a two-parent home. All clients report that they have siblings. Several clients reported having parents that were or are involved in the justice system. One goal of the first session is to set a positive tone for the group | One goal of the first session is to set a positive tone for the group. Which of the following would support this goal? | Explain group rules to ensure structure so that everyone can participate equally. | Get everyone to share. | With this specific group, speaking with authority to maintain control of the group and therefore ensuring that the group members know they do not have to fight for control. | Support the clients with feeling comfortable expressing frustration with the facility. | (A): Explain group rules to ensure structure so that everyone can participate equally.
(B): Get everyone to share.
(C): With this specific group, speaking with authority to maintain control of the group and therefore ensuring that the group members know they do not have to fight for control.
(D): Support the clients with feeling comfortable expressing frustration with the facility. | Get everyone to share. | B | Getting everyone to share encourages participation and also makes everyone feel like they are part of the group. You would not want to do this in a forceful way because each client has the right to choose if they will participate, but getting everyone to participate would further the group process. Explaining group rules establishes that the group is about rules and boundaries and not about being open. Although rules are important, this is not a helpful way to start. You should be in control, and a level of control can help members feel more secure; however, speaking with authority would likely feel off-putting to this group due to their setting in the facility. Allowing space for your clients to discuss their frustrations regarding the facility might be helpful in the future, but this would not start the group off on a positive note. Therefore, the correct answer is (D) | counseling skills and interventions |
809 | Client Age: 9 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Private practice clinic Type of Counseling: Individual counseling with family involvement Presenting Problem: Behavioral problems and social skills issues Diagnosis: Autism spectrum disorder, without accompanying intellectual impairment (F84.0) | Mental Status Exam: The client is oriented to person, place, situation, and time. The client appears clean and is wearing season-appropriate clothing; however, his parents report that he often wears the same outfit for several days because he gets frustrated with having to change his clothes and showering. The client was minimally involved in the intake session and was instead focused on reading a video game walk-through | You are a private practice, licensed counselor. The client is 9 years old and comes to the first session with his parents. The client has been previously diagnosed with autism via use of the Autism Diagnostic Observation Schedule-Second Edition by a psychologist, and you receive supporting documentation for this diagnosis. The client demonstrates difficulties with normal back-and-forth communication with peers, difficulty maintaining eye contact during the session, and difficulty with imaginative play with peers as reported by his parents. The client and his parents also report what they call “OCD behavior”—for example, he often lines up toys and insists that they “have to be this way”—and that he has trouble with changes in schedule, often becoming aggressive toward the parents if changes occur. The parents report that he is very rigid and that certain activities and play have to be done a certain way or he becomes upset, which affect the home, social, and school settings. The client’s intellectual quotient is above average for his age per the supportive testing provided. The parents report that the client’s difficulty with changing plans or daily changes causes him to become angry and confrontational. | book. Family History: The client reports that his parents are supportive of his issues that are a result of autism. The client says that his 8-year-old brother gets frustrated sometimes because his parents often support the client and focus on him more due to his autism. The client reports that he does not have any friends. The client appears uninterested in the session | The client appears uninterested in the session. Based on what you see, which of the following would be the most appropriate clinical intervention based on the client’s diagnosis and presentation? | You encourage the client to participate so that he can feel better. | You talk with the client about the video game book he is reading. | You attempt to process with the client about why he is not engaging. | You continue talking with the parents because they are providing helpful information and you know that building rapport with the client will be a long process. | (A): You encourage the client to participate so that he can feel better.
(B): You talk with the client about the video game book he is reading.
(C): You attempt to process with the client about why he is not engaging.
(D): You continue talking with the parents because they are providing helpful information and you know that building rapport with the client will be a long process. | You talk with the client about the video game book he is reading. | B | You engage with the client about what he is reading because you want to create a connection and this is a very simple one to make. Encouraging the client to participate might work, but it does not create a connection with the client. You have learned a lot about the client from his parents, but you also need to engage him in building a therapeutic relationship. Processing with the client regarding his lack of participation may be helpful, but considering his diagnosis and age, it would be more helpful to talk with him about the video game book. Therefore, the correct answer is (B) | counseling skills and interventions |
810 | Initial Intake: Age: 54 Gender: Male Sexual Orientation: Heterosexual Ethnicity: African American Relationship Status: Divorced, In a relationship Counseling Setting: Private Practice Type of Counseling: Individual | John presents as well-groomed with good hygiene and is dressed professionally. Motor movements are slightly fidgety, indicating nervousness or moderate anxiety. Eye contact is intermittent. Denies suicidal or homicidal ideation, no evidence of hallucinations or delusions. John tightens his fists when elaborating on situational issues between him and his ex-wife, with the same controlled expression and tense disposition when sharing about his girlfriend. John mentioned that his girlfriend is also unreasonable for complaining about how often John comes home smelling of alcohol, saying that meeting people for drinks is part of his job. He added the comment “I need to drink to deal with her attitude all the time.” | Diagnosis: Adjustment disorder with mixed disturbance of emotions and conduct (F43.25), provisional
John calls your practice asking to speak to a counselor to help him with his relationship. John tells you he’s never been to a counselor before and does not want anyone to know that he is seeing one, mentioning he will pay for sessions privately using cash. John admits to struggling with anger, specifically with his ex-wife of 15 years whom he divorced three years ago. John asks for availability in the evening hours and demonstrates hesitancy and reluctance to commit to more than a handful of sessions. In the initial assessment session, you notice he has difficulty making eye contact and is uncomfortable talking about his situation. After some rapport building, he begins to share that he is only seeing you because his girlfriend Sherry told him she would break up with him if he did not get his “anger issues under control.” John denied physically hitting Sherry, but alluded to several interactions that he stated, “got so heated I lost it on her, and she wouldn’t stop crying.” John complained of women he gets involved with being overly controlling of him and that he doesn’t understand why they are so “needy.” John works a demanding job in the sports marketing industry where he takes frequent trips out of state and spends long nights out, entertaining clients. He wishes he had the freedom to “do what he has to do” without “being treated like a child” by his romantic partners. | Family History:
John tells you he has two children, a 34-year-old son he had with a one-night stand in college and an 18-year-old daughter with his ex-wife the first year they were married. He has a decent relationship with his son and provides him and his family occasional financial support, visiting with his grandchild over social media video once a month. He reports once being close with his daughter but that their relationship became strained as she got older and that now they hardly speak, saying “she took her mother’s side during the divorce, so she doesn’t want anything to do with me right now.” While conducting further interviewing about John’s family health you learn that John’s father passed away at 56 after several heart attacks and his mother died of heart failure and diabetes complications at 49. John has no other living relatives besides an uncle in another state and his cousins who live near him. He tells you growing up he used to go to church with his mother every Sunday until she got sick and has not been to church since.
Work History:
John has a master’s degree in Business Marketing and made his connections with his current position through contacts he made while playing on collegiate basketball teams. John has always worked busy jobs with which he becomes heavily engaged in and puts in overtime hours. John prefers work that keeps him on the road and traveling often, as he does not like to engage in the same routine every day. He mentions when he was younger, he could not keep a 9-5 office job or at any place that did not encourage individuality, saying he “butted heads” with all his managers and bosses until he was older.
Legal History:
John has had two arrests made for domestic disturbances in his home that his wife called in after heated arguments that left his wife afraid for her life. He was always able to make bail and was never tried or sentenced as charges were usually dropped thereafter. John admits to one drinking and driving accident when he was 19 where he served community service and fines as punishment. | Which goal is John least likely to agree upon based on his presentation? | Develop and demonstrate anger management skills | Develop new communication skills to reduce interpersonal conflicts | Resolve the core conflict that is the source of mood dysregulation | Learn how to control impulsive behaviors and cope with frustration | (A): Develop and demonstrate anger management skills
(B): Develop new communication skills to reduce interpersonal conflicts
(C): Resolve the core conflict that is the source of mood dysregulation
(D): Learn how to control impulsive behaviors and cope with frustration | Resolve the core conflict that is the source of mood dysregulation | C | It is unlikely based on John's presentation of affect, perspective of blame towards his partners, and lack of insight into his problem, that he would be willing to engage in resolution of deep inner conflict believed to be the cause of his issues. As John's counselor you could work towards inclusion of this goal after successful interventions within his agreed upon goals. Therefore, the correct answer is (B) | treatment planning |
811 | 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. The client’s neuropsychological testing scores on a normal distribution place her one standard deviation below the mean | The client’s neuropsychological testing scores on a normal distribution place her one standard deviation below the mean. The client scored as well as or better than approximately what percent of the normed population? | 3% | 85% | 48% | 16% | (A): 3%
(B): 85%
(C): 48%
(D): 16% | 16% | D | The client scored one standard deviation below the mean. This signifies that she scored as well as or better than 16% of the population because the percentage of the normed population that scores plus or minus one standard deviation is 68% and the percentage that scores greater than one standard deviation is an additional 16%. In that case, an individual who scores less than one standard deviation of the mean would be scoring as well as or better than the remaining 16% who scored more than one standard deviation less than the mean. The normal curve is symmetrically distributed. Almost two-thirds of the scores lie one standard deviation from the mean. Roughly 3% of the population tested scored two standard deviations below the mean. Generally, standardized tests have a mean score of 100. With a mean of 100, one standard deviation below the mean would be a score of 85 rather than 85% (whereas one standard deviation above the mean would be a score of 115). If the client scored at least two standard deviations below the mean, she would likely receive the diagnosis of major neurocognitive disorder. Therefore, the correct answer is (B) | intake, assessment, and diagnosis |
812 | 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. | Since the intake, you have provided professional development training for school staff on transgender and gender nonconforming (TGNC) individuals. The administration supports your recommendations for keeping the client and others safe at school. The client continues to miss school, but they have had fewer absences this month. You learn that the client’s desire to be rid of their male secondary sex characteristics has become more persistent. They say that they have seen media coverage of individuals who have undergone sex reassignment surgeries and wondered what that would be like. The client also states they are confused about their sexual orientation. The client appreciates being an active participant in their treatment, and together you create relevant treatment plan goals. You discuss the upcoming family session with the client’s parents. The client articulates appropriate topics for this session and reports increased anxiety concerning their father’s participation | Based on the client’s diagnosis, which treatment plan goal would you select for the client? | To reduce distress caused by the desire to identify as another gender | To reduce distress caused by sexual orientation uncertainty | To reduce incongruence between gender expression and gender identity | To reduce incongruence between nonbinary and cisgender identity | (A): To reduce distress caused by the desire to identify as another gender
(B): To reduce distress caused by sexual orientation uncertainty
(C): To reduce incongruence between gender expression and gender identity
(D): To reduce incongruence between nonbinary and cisgender identity | To reduce distress caused by the desire to identify as another gender | A | Based on the client’s diagnosis, an appropriate treatment plan goal would be to reduce distress caused by the desire to identify as another gender. The DSM-5 replaced the term gender identity disorder with gender dysphoria to avoid pathologizing one’s identity, which was maintained in the most recent version, the DSM-5-TR. Gender expression is defined as the outward expression of one’s gender and may or may not align with one’s gender identity. Gender identity is defined as one’s inner sense of being male, female, a combination of both, or neither. One’s gender at birth may or may not coincide with one’s gender identity or gender expression. Sexual orientation uncertainty is unrelated to gender dysphoria, making this answer option incorrect. Gender dysphoria is defined as the incongruence between one’s expressed or experienced gender and one’s assigned gender. Individuals who are nonbinary do not identify as male or female but instead identify as something in between or no gender at all. Cisgender describes individuals whose gender identity is consistent with their birth identity. Reducing incongruence between nonbinary and cisgender identity is not possible because the two are mutually exclusive. Therefore, the correct answer is (A) | treatment planning |
813 | Initial Intake: Age: 48 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Divorced Counseling Setting: Acute Inpatient Psychiatric Hospital Type of Counseling: Individual | Sandy wandered into the ER waiting room asking for a police officer. After further conversation, it was clear that Sandy thought she was in a police station and repeatedly called once of the nurses Officer McKinney, as if she knew him.
During the intake, the nurse practitioner mentioned that she was running a temperature, had a rapid heartbeat and breath smelled foul. In addition, her hands were trembling as well as her tongue and lips. Sandy’s behavior was somewhat irritable and erratic. At one point she was seemed to be hallucinating and stated that that she saw rats.
| Sandy was sent to the inpatient psychiatric from the emergency department for symptoms of hallucinations, memory loss, and disorientation.
History:
Sandy currently lives alone and is unemployed. She has a history of alcohol abuse and has been admitted to the hospital before because of this. Sandy has gotten into trouble with the law and has alienated most of her family and friends because of her alcohol use. She currently attends alcoholics anonymous. | null | A modality of treatment that is person centered and focuses on helping the client through the stages of change is called? | Aversion therapy | Medicated assisted treatment | Motivational interviewing | Behavior therapy | (A): Aversion therapy
(B): Medicated assisted treatment
(C): Motivational interviewing
(D): Behavior therapy | Motivational interviewing | C | Motivational Interviewing uses unconditional positive regard and empathy to examine the client's motivation to change and helps them progress through the stages to get there. Medicated assisted treatment uses a combination of medication as well as counseling and behavioral therapies. Aversion therapy suppresses unwanted behaviors by associating it with a negative experience and behavior therapy focuses on modifying harmful behaviors associated with psychological distress. Therefore, the correct answer is (B) | treatment planning |
814 | 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. | rail. Family History: The client got divorced about 1 year ago. He states that his wife left him because he lost his job and because of his fentanyl use. The client has two children that are 18 and 22 years old. The client no longer has contact with his ex-wife or children. The client reports no known mental health history or substance use history in his family | Which one of the following controlled substances is also an opioid? | Heroin | Cocaine | Marijuana | LSD | (A): Heroin
(B): Cocaine
(C): Marijuana
(D): LSD | Heroin | A | Heroin is an opioid along with morphine, fentanyl, Oxycontin, oxycodone, and many more. Opioids are very effective in treating intense pain but are easily abused due to their effects. Cocaine is a stimulant, and stimulants increase the activity of the central nervous system. Marijuana is a psychoactive drug because it affects the functioning of the nervous system by altering consciousness, mood, perception, behavior, and cognition. LSD is a hallucinogenic drug that affects consciousness, thoughts, and emotions and oftentimes causes hallucinations and distortions in perception. Therefore, the correct answer is (C) | professional practice and ethics |
815 | Initial Intake: Age: 32 Gender: Female Sexual Orientation: Bisexual Ethnicity: Caucasian Relationship Status: In a relationship Counseling Setting: Community mental health agency Type of Counseling: Individual via Telehealth | Melanie is unkempt, looks tired and is casually dressed. Motor movements are within normal limits, eye contact is appropriate. Melanie reported passive suicidal ideation intermittently throughout her depressive episode as a means for escaping her feelings but has no plan or intent. Melanie reluctantly admits to several instances of past trauma which include losing her son’s father to a tragic car accident four years ago where her son witnessed him die, as well as having three other older children, all with separate fathers, with whom she has no contact. Her only support system is her boyfriend who takes great care of her and her son’s school, which provides help with his Individualized Education Plan. | Diagnosis: Dysthymic disorder (F34.1), provisional, Anxiety disorder, unspecified (F41.9), Post-traumatic stress disorder (PTSD) (F43.1)
Melanie has been in mental health counseling for several years through your agency and was referred to you by her last counselor who obtained a position with a local University and was leaving your company. Melanie is a 32-year-old Caucasian female who lives in a house with her boyfriend and her 9-year-old son, Gus, who suffers from ADHD, anxiety, and PTSD. Melanie is receiving psychiatric medication from your agency’s Psychiatrist, another Psychiatric practice by a Nurse Practitioner in a different city and is being treated medically by a Gastroenterologist who has also prescribed medications. Melanie is complaining of ongoing depression caused by her chronic nausea and a cyclic vomiting syndrome and does not want to leave her bed out of helplessness and hopelessness that nothing will ever change. She also reports experiencing anxiety and panic-like attacks when she is around others which causes her to socially isolate for sometimes days at a time. She is upset she cannot care for her son the way she desires and wants to continue counseling to help her feel better. | Family History:
Melanie has what she states is a “complicated” relationship with her family, including her mother, whom she believes wants no involvement with her or her son, and has no contact with anyone else. Melanie states her falling out with her mother began when she was just a child. She comments that her father and her were “very close”, but his new wife makes it “challenging to communicate with him.” Melanie has lived on her own for much of her life and has not engaged in or sustained any relationship with her first three children. She adds that in each instance they were either unfairly taken away by the father or the state and that she has tried to initiate contact, but it has not been successful. Melanie continues to deflect from discussing family dynamics, causing gaps in your initial interviewing process.
Work History:
Melanie reports never having an “official” job but always being able to make money “somehow.” She has been on Medicaid for most of her life and continues to survive off government support and the charity of others. She tells you she has dreams of writing a book or even owning her own bakery but does not demonstrate willingness to take the steps at achieving those goals.
Legal History:
Melanie has incurred a criminal record for failing to pay child support several times over the past nine years and continues to receive notices and warnings to ensure she is making her payments on time. | You need more information on Melanie's prescriptions to understand her cognitive state of mind prior to treatment planning. Which approach is the most appropriate? | Ask Melanie for her to list her medications and how they are making her feel | Submit a Release of Information to her outside providers requesting documentation | Discuss planning a conference call with all her providers to coordinate her care | You do not need any of this information | (A): Ask Melanie for her to list her medications and how they are making her feel
(B): Submit a Release of Information to her outside providers requesting documentation
(C): Discuss planning a conference call with all her providers to coordinate her care
(D): You do not need any of this information | Ask Melanie for her to list her medications and how they are making her feel | A | Simply asking Melanie to share with you the medications she is on and how she is reacting with them is sufficient at this phase of the counseling relationship. The information Melanie can provide will support your understanding of how these medications might be interacting, affecting her diagnosable conditions and helpful for you to be following up with her on maintaining them if you notice any cognitive or behavioral changes. Should you require the medical documentation at some point in your course of care for her, having her sign a release of information with her provider prior to your request will be expected. Discussing Melanie's treatment with all her providers at the same time is highly unlikely to occur and is not necessary. As a counselor you may feel at the time that knowing Melanie's medication list is not important or unnecessary, however medication management is a key component of mental health wellness, and you could be missing vital information about treating your clients without it. Therefore, the correct answer is (A) | treatment planning |
816 | Name: Bianca Clinical Issues: Difficulty adjusting to life changes Diagnostic Category: V-codes Provisional Diagnosis: Z60.0 Phase of Life Problem Age: 62 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: Black Marital Status: Separated Modality: Individual Therapy Location of Therapy : Agency | The client is a 62-year-old female, wearing work attire. She appears to be in good hygiene and her dress is neat and appropriate for the situation. Her facial expression is sad and she has tear tracks on her cheeks. Her mood is noticeably depressed, anxious, and tearful. Her affect is constricted. She has coherent thought processes with appropriate content. She expresses feelings of sadness over her failed marriage and overwhelm about being alone. The client has intact memory and concentration. She has fair insight into her current situation and is able to verbalize her feelings in a coherent manner. | First session The client comes to the agency practice where you currently work as a licensed mental health therapist. She is a 62-year-old female who recently retired from an accounting firm employment. She is seeking treatment after her marriage recently failed. A few months ago, he husband filed for a legal separation and is currently romantically involved with another woman. The client looks at you tearfully and says, "I can't believe this is happening at my age. I am all alone. What am I going to do?" She continues to cry uncontrollably. You focus on providing a safe and secure environment. You assure her that she will not be judged or criticized in any way, and all of the conversations during the session will remain confidential. You gently let her know that it is okay to cry, and you are there to listen without judgement. You also tell the client that it is natural to feel lost and alone after a separation, especially since she and her husband have been together for such a long time. She says, "I just feel like such a fool. He cheated on me once before - that I know of - and now he's done it again. I stayed with him for over 30 years, and now I have nothing." She describes having mixed feelings of anger, sadness, fear, and confusion. She states, "There are moments where I'm so mad at him for leaving. Mad enough that I could break something! Our marriage wasn't perfect, but I thought he was committed to me. Well, obviously he wasn't. Then I start to question what's wrong with me that made him leave. And then I think about the future and how I'm going to live by myself. It's all so overwhelming." She further discloses that she is worried about having panic attacks again because "that's what happened the last time something of this magnitude happened to me." You reinforce the idea that it is important to focus on the fact that she is not alone and many people in similar situations feel overwhelmed and uncertain about their future. You let her know she is in a safe space to explore her feelings, work through her loss, and develop a plan for moving forward. You encourage her to reach out for support during this challenging time rather than isolate herself as she goes through this difficult change. Fifth session The client has been seeing you for individual therapy sessions every week. You have developed a strong rapport with her and collaborated on treatment goals, with her overall goal being to have a positive outlook on her life. During the last session, you gave her a homework assignment to begin keeping a journal, using the ABC model of rational emotive behavior therapy to identify self-defeating beliefs and understand how they are contributing to her emotional distress. You have also been working with her to process her feelings about her separation and develop coping skills. During today's session, she seems depressed, as she tells you her husband met with an attorney and officially filed for divorce. You explore her journal entries, noting one in particular in which she describes an experience in which she was driving and saw her husband sitting outside a café with "the other woman." She circled back a few times in her car, hoping he would see her. In her mind, she fantasized that he would leave his new girlfriend and drive away with her, and everything would return to normal. You ask her to tell you more about what "normal" means to her. She says, "I guess I just want things to go back to how it was before. When I mattered, when I felt loved, and when he was committed to our marriage." You acknowledge her feelings and explain that while it may not be possible to go back to exactly how things were, there is still hope for the future. You express compassion and understanding, emphasizing that there is no right or wrong way to feel. She states, "I just have mixed feelings about everything! I feel angry and betrayed by my husband, but sometimes I want him to come back. I start to feel lonely and realize the reality of my situation and that I have no purpose anymore and am alone. What's the point? My kids don't care; I have nothing in my life now. Things are so painful I'd be better off dead." You reassure her that you are here to support her as she works through all of her difficult emotions. | null | Given the client's age and presenting issues, what stage is she experiencing from an Eriksonian perspective? | Identity vs Role Confusion | Intimacy vs Isolation | Generativity vs Stagnation | Trust vs Mistrust | (A): Identity vs Role Confusion
(B): Intimacy vs Isolation
(C): Generativity vs Stagnation
(D): Trust vs Mistrust | Generativity vs Stagnation | C | Stage 7: Generativity versus Stagnation
These are the middle adult years, 40 to 65 years old. If an adult gets stuck in this stage, they may experience several negative consequences. These can include feeling unproductive, unfulfilled, and purposeless. Additionally, they may think that their life is going nowhere and that they are not contributing anything meaningful to society. Therefore, the correct answer is (A) | intake, assessment, and diagnosis |
817 | Name: Ruth and Dale Clinical Issues: Parenting/co-parenting conflicts Diagnostic Category: V-codes Provisional Diagnosis: Z63.0 Relationship Distress with Spouse or Intimate Partner Age: 41 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: White Marital Status: Married Modality: Couples Therapy Location of Therapy : Agency | Appearance: The client is casually dressed and adequately groomed. She appears healthy, and her age is consistent with her stated age. Behavior: The client's behavior is tense and purposeful. She is cooperative with adequate rapport. Speech: Speech volume is normal, and speech flow is normal and spontaneous. Mood: The client's mood is dysphoric and anxious. Thought Process: Thought process is logical. Thoughts are negative. Affect: The client's affect is broad and appropriate to the discussion. Cognition: The estimated level of intelligence is within average range with abstract thinking. Concentration is intact. The client shows no problems with memory impairment. Insight and Judgment: Insight is fair. Impulse control and judgment appear to be below average. | First session You are a therapist working at a marriage counseling agency. Ruth is a 41-year-old female who comes to your office with her husband. The couple has been married for seven years and have two children, ages five and one. The husband also has a 16-year-old daughter from a previous marriage who lives in the home. The client is a stay-at-home mom, and her husband works at a correctional institution. Their five-year-old has been removed from three separate daycare facilities because of her defiant behavior. In addition, the 16-year-old was recently arrested for shoplifting. At the end of the session, the client turns to her husband and says, "I'm the one who has to stay home with the kids all day. You just don't get it. You don't know what it's like having no time for yourself and no quiet place to relax. You think all this stuff with the kids is a normal phase and everyone will grow out of it. Well, I don't think it's normal, and I'm tired of it! I've been talking to my ex-husband lately because he listens to me, and I feel better after I talk to him." Ruth demonstrates elevated stress and anxiety levels, as evidenced by her verbalization of feeling overwhelmed by the demands of caring for their children and lack of personal time. She also expresses feelings of frustration with her husband, who she perceives as not understanding her struggles. Her husband's absence during the day and the children's challenging behaviors have likely contributed to the client's feelings of isolation and burnout. Ruth's decision to reach out to her ex-husband for emotional support may indicate that she is not receiving adequate support from her current partner. Third session In accordance with Ruth's decision at the last session, she ceased communication with her ex-husband. After affirming this, she turns to her husband and says, "He called twice last week, but I didn't answer. At least someone wants to talk with me!" Dale gives her an exasperated look, folds his arms over his chest, and shakes his head in disgust, at which Ruth says, "See? That's all I ever get! Nothing!" and begins to cry. Dale seems angry but remains quiet. Dale sighs and rubs his temples. "This is why I don't talk about it," he says. "You always make it about you. Do you think I don't want to talk to you? Do you think I don't care?" Ruth sniffs and wipes her eyes. "Of course not, but it feels like you don't want to talk to me. Like you don't care. You never talk to me, and then you get quiet when I try to talk to you." Dale rolls his eyes. "That's because you don't listen when I try to talk to you. You just jump to your own conclusions and then get mad at me when I don't do what you think I should do. I'm tired of it. I'm tired of trying to talk to you, but you never listen." Ruth bristles, tears streaming down her face. "Well, what am I supposed to do? You never tell me what you want me to do, so how am I supposed to know?" Dale throws his hands and walks away in frustration. "I don't know, Ruth. I really don't know." Tenth session The couple enters in better spirits than previously. They have been speaking with each other in the lobby while waiting. They enter laughing. Ruth reports that the communication techniques you shared seem to have helped. She no longer feels the need to leave her husband. They report that the 16-year-old daughter arrived home from her time at the crisis center somewhat subdued by the experience, although still showing challenging behaviors. They also say that the five-year-old still exhibits defiant behaviors at home and school. The couple had worked hard to repair their communication and marriage, which is paying off. The husband and wife have found a new understanding and mutual respect. They have developed newfound patience and empathy for one another, helping to create a more harmonious environment at home. The couple had also applied the communication techniques they had learned to their interactions with their children. As a result, Ruth and her husband are now workings together to find a way to better understand and respond to their children's needs. They have set up a school conference to determine how to handle their children's behavior. | Ruth's parents died in a boating accident while she was in college. She has two brothers and one sister, but they are not close, partially due to the strain of losing their parents. Her husband's first wife left him soon after their daughter was born. She does not discuss her place in the family's dysfunction but talks about other family members who need help. Ruth has been unable to heal her relationship with her sister and feels guilty about it. She also expresses concern for her husband's well-being after his first wife's divorce, which she was partly responsible for. Additionally, Ruth struggles with depression and anxiety due to trauma related to the death of her parents. Personal/Social Relationships: Ruth feels that her husband minimizes their children's problems and is to blame for their lack of improvement. Ruth feels her marriage is "on the rocks.'" Her husband knows his wife is unhappy but does not know what to do. Finally, you learn that Ruth recently reconnected with her ex-husband and is seriously considering having an affair. Previous Counseling: The client has been working on her low self-esteem through therapy but says she is not getting any better. Her husband says, "I know Ruth is unhappy. That much is obvious. She's stressed out all the time, and she's stopped talking to me. She gets in the car, is gone for hours, and isn't home when I arrive after work. I'm worried I will lose her, but I don't know what to do." | What would be the best additional service given the disclosures during this session? | Play therapy for their five year old | Family Therapy | Parent support group | Individual therapy for the daughter | (A): Play therapy for their five year old
(B): Family Therapy
(C): Parent support group
(D): Individual therapy for the daughter | Family Therapy | B | In this case, there are several issues at hand. You have helped the couple improve communication and trust up to this point. This entire family, however, appears to be struggling to manage their feelings toward each other and mesh as a whole. Family therapy would be the next logical step for your client to improve communication and identify areas of need and structure for the children to focus on their goals. Therefore, the correct answer is (D) | treatment planning |
818 | 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 and reports that he and his wife have been getting along better since the last session following some conversations about what they can do to get through this situation together. The client says that he wants to work on figuring out what he is going to do for work next. You and the client discuss possible options, and he says a friend offered him a job at his restaurant. The client says that he is considering it just for the money but that he has never been a server before and has some reservations. You conduct a career interest assessment and discuss the results. You encourage the client to use natural supports during this time because it can be helpful to have other people provide support | You encourage the client to use natural supports during this time because it can be helpful to have other people provide support. All of the following would be considered a natural support EXCEPT: | An acquaintance from the client’s Bible study group | A childhood friend | A sibling who the client is close to | The therapist because you meet with the client regularly | (A): An acquaintance from the client’s Bible study group
(B): A childhood friend
(C): A sibling who the client is close to
(D): The therapist because you meet with the client regularly | The therapist because you meet with the client regularly | D | A natural support is a relationship that occurs naturally. Although the therapist is a regular support, they are not a naturally occurring support. A childhood friend and a sibling would be strong natural supports because these relationships have lasted for the long term. An acquaintance can also be a natural support. This one is an especially good support because he is in the client’s Bible study and can provide further support for his spiritual needs. Therefore, the correct answer is (D) | counseling skills and interventions |
819 | Client Age: 45 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Divorced, single Counseling Setting: Private practice Type of Counseling: Individual counseling Presenting Problem: The client is experiencing difficulty in functioning in all areas of his life due to inhalant use. Diagnosis: Inhalant use disorder, severe (F18.20) | Mental Status Exam: The client is oriented to person, place, time, and situation. The client does not appear to be under the influence of inhalants because he does not display any symptoms of use. The client is friendly and engaged in the ses | You are a licensed counselor working in a private practice. You specialize in substance use disorders. The client comes into the session, is very friendly, and states that although his sessions are court ordered, he wants to get help with his inhalant use. The client spent the first half of the session explaining what happened to lead to him getting his third charge of driving under the influence of inhalants. The client says that he had twin sons 13 years ago and they both were in the ICU; one of his sons died after about a month. The client began drinking alcohol to excess daily for about 6 months, which then transitioned to inhalant use. The client says that he uses contact cement, model glue, paint, and permanent markers to become intoxicated. The client identified the following symptoms of inhalant use disorder: increase in frequency and amount of use over the past 5 years, several failed attempts at cessation of inhalant use, craving inhalants throughout every day, losing several jobs because of his inability to get to work on time due to inhalant use, use that has affected his ability to have visits with his children and maintain employment, use that increases the risk of harm to himself and others such as driving under the influence, increased tolerance, and continued use even when he knows it is negatively affecting his life. The client wants to become sober, improve his relationship with his children, and maintain employment. | sion. Family History: The client has three sons that are 11, 13, and 16 years old. The client is divorced as of 3 years prior and reports a contentious relationship with his ex-wife due to his difficulty following through with visits with their children. The client and his ex-wife were married for 17 years and dated for about 5 years before they were married. The client states that he loves his ex-wife but that she has currently been dating another man for the past 2 years and he knows they likely will not reconcile. He says that he understands why she does not want to be with him, and he thinks that he is not good for her or his children at this time | To better understand the client’s behavior and relationship patterns, which of the following would be the most useful? | Conduct a mental status exam during each session. | Request a release of information in order to communicate with the client’s ex-wife to get input on his behavior. | Complete a genogram. | Assign the client homework to complete a thought log regarding inhalant use and his relationships. | (A): Conduct a mental status exam during each session.
(B): Request a release of information in order to communicate with the client’s ex-wife to get input on his behavior.
(C): Complete a genogram.
(D): Assign the client homework to complete a thought log regarding inhalant use and his relationships. | Complete a genogram. | C | A genogram would give more information regarding family dynamics, relationship quality and status, family patterns, and family substance use. Genograms are a great tool to use to understand how the client’s family contributed to where he is at currently. Discussing the genogram will give a lot more information because it presents many opportunities to discuss his relationships and history. You will conduct a mental status exam each session, but this will likely not provide much information regarding behavior and is more about the client’s presentation in session. A thought log would be helpful over time to understand how the client processes information and is also helpful for the client to become more aware of how thoughts, feelings, and behaviors affect his functioning, but the genogram would be more helpful in providing information and encouraging conversation regarding his behavior and his past relationships. It might be helpful to communicate with the client’s ex-wife; however, she would likely be a biased party, which could complicate the counseling relationship. Therefore, the correct answer is (B) | intake, assessment, and diagnosis |
820 | Client Age: 30 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Agency Type of Counseling: Outpatient Presenting Problem: Recent Hospital Discharge Diagnosis: Borderline Personality Disorder (BPD) 301.83 (F60.3) | Mental Status Exam: The client is wearing a low-cut blouse and short shorts. Her affect and mood are labile, and her speech is pressured. She is fidgety at times and sits with her arms crossed. The client states that she has had three previous suicide attempts and has been cutting since her late twenties. Her last suicide attempt was an overdose, which resulted in her recent hospitalization. She stated that this was the result of her last boyfriend “ghosting” her. The client denies audiovisual hallucinations but states that she often feels that others are conspiring against her. She says that she continues to have suicidal thoughts but denies having a current plan. Fam | You are a mental health counselor in an outpatient setting. Your client is a 30-year-old white female who was released from the hospital 48 hours ago. The client presents today for a postdischarge follow-up appointment. The hospital clinician diagnosed the client with borderline personality disorder(BPD) and substance use disorder. The client has a history of suicidality, impulsivity, and relational instability. She explains that she has a “quick temper,” which occurs when she is feeling rejected. She explains that she has a long history of being treated poorly by others, including her last boyfriend, former employers, and family members. During these times, the client admits to substance misuse and self-mutilation (i.e., cutting). She states that there are times when she drinks to black out and that she is more inclined to do so when her feelings become intolerable. The client has had multiple hospital admissions and has been in the care of several counselors. She questions your credentials and your ability to “work with someone like (her).” | You are a mental health counselor in an outpatient setting. Your client is a 30-year-old white female who was released from the hospital 48 hours ago. The client presents today for a postdischarge follow-up appointment. The hospital clinician diagnosed the client with borderline personality disorder(BPD) and substance use disorder. The client has a history of suicidality, impulsivity, and relational instability. She explains that she has a “quick temper,” which occurs when she is feeling rejected. She explains that she has a long history of being treated poorly by others, including her last boyfriend, former employers, and family members. During these times, the client admits to substance misuse and self-mutilation (i\. e., cutting). She states that there are times when she drinks to black out and that she is more inclined to do so when her feelings become intolerable. The client has had multiple hospital admissions and has been in the care of several counselors. She questions your credentials and your ability to “work with someone like (her).” ily and Work History: The client attended 3 years of college and reports dropping out due to “depression, anxiety, and anger issues.” She has worked off and on as a server at several restaurants and says she usually quits after coworkers or employers “reject or betray her.” The client’s mother was a teenager when the client was born. Her mother is diagnosed with bipolar disorder, which first appeared after childbirth. She reports moving back and forth between caretakers when she was younger. Her maternal grandmother eventually became her legal guardian and died when the client was in her early twenties. The client reports that she constantly fears abandonment and has “never been successful in a relationship.” She has limited contact with her mother, and the identity of her father is unknown | The client experiences multiple symptoms indicative of BPD EXCEPT which of the following? | Intense anger | Suicidality | Fear of abandonment | Grandiosity | (A): Intense anger
(B): Suicidality
(C): Fear of abandonment
(D): Grandiosity | Grandiosity | D | The client does not experience grandiosity as a symptom indicative of BPD. Grandiosity is a symptom of narcissistic personality disorder. BPD is characterized by fear of real or imagined abandonment, suicidality, and intensive anger. According to the DSM-5-TR, BPD is a pervasive pattern of instability in social relationships, self-image, and affect, coupled with marked impulsivity. Recurrent suicidal behavior is a criterion that is separate from desperate attempts to escape real or imagined feelings of abandonment and impulsivity. The client’s fear of abandonment manifests in her romantic and interpersonal relationships. Although suicidal behavior is a separate criterion, worries about separation or abandonment can contribute to acts of suicide or self-harm. Therefore, the correct answer is (D) | intake, assessment, and diagnosis |
821 | 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. Second session After your initial session with the client, the school performed a risk assessment and concluded that the client could return to school. You have requested to meet with the client and his mother every week. Today is your second session, during which time you spend the first thirty minutes talking with the mother and the second half talking with the client. During your conversation with his mother, she shared that she believes her son might have Autism. She says she has been debating whether to tell you this because she is "concerned about the stigma associated with Autism" and the possibility of her son being treated differently. She has been anxious about her son's issues and wants to have him tested to get him the "right help." Jackson's mother appeared very anxious during the session. She shared concerns that he may have Autism but has hesitated to disclose this for fear of stigma. She has been struggling with getting him properly assessed and finding adequate support. Her anxiety around Jackson's issues was evident in her tense body language and rapid speech. She is worried about her son's well-being and future. However, the stigma she associates with an Autism diagnosis seems to be preventing her from getting Jackson the help he likely needs. You recognize that Jackson's mother feels overwhelmed and alone trying to understand her son's difficulties. Her eagerness to have him tested indicates she believes an Autism diagnosis would provide answers and open up access to services. Yet she is torn about the potential labeling and discrimination Jackson could face. Her desire to protect her son's privacy competes with her need to get him help. This is causing Jackson's mother significant inner turmoil. She presented today as a caring parent under great strain. In the second part of the session with the client, you find him disinterested and bored until you start talking about gaming. Then, he appears to perk up and becomes talkative. When you ask why he thinks he is here, he tells you about an incident at school. A student in another room texted his entire class, saying he was "short." This angered him, and he left the classroom and started a fistfight with that student, resulting in disciplinary action. Jackson told this story with clenched fists, still visibly upset. He explained that the school was unfair and justified his violent reaction by stating he has Autism. This suggests Jackson feels his neurodiversity excuses poor behavior. Rather than take responsibility, he blamed external factors for the altercation. Jackson's body language and tone indicated he remained defensive and saw himself as the wronged party. Jackson believed his Autism diagnosis makes aggression an inevitable response in certain situations. By citing Autism as the cause of his actions, he abdicated any sense of personal responsibility. Without intervention, he may continue acting out when provoked and making excuses based on his diagnosis. There is a risk that Jackson will not develop appropriate coping skills or learn to navigate his interpersonal conflicts. He appears fixed in the view that others are at fault, while his neurodiversity pardons any misdeeds. | 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 is the most appropriate response to the client's statement? | Acknowledge the client’s feelings and provide support | Reassure the client you will help him learn to control his temper | Ask the client why he thinks the school is being unfair. | Ask the client more questions about the incident. | (A): Acknowledge the client’s feelings and provide support
(B): Reassure the client you will help him learn to control his temper
(C): Ask the client why he thinks the school is being unfair.
(D): Ask the client more questions about the incident. | Acknowledge the client’s feelings and provide support | A | Acknowledging the client's feelings and providing support is essential in maintaining trust and rapport with the client. This should be your first response to the client's statement. Therefore, the correct answer is (A) | counseling skills and interventions |
822 | Name: Shelly Clinical Issues: Emotional dysregulation Diagnostic Category: Personality Disorders Provisional Diagnosis: F60.3 Borderline Personality Disorder Age: 41 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: Black Marital Status: Never married Modality: Individual Therapy Location of Therapy : Telehealth | The client's clothes are clean but her hair and make-up seem unkempt. She wears long sleeves but you notice some scarring on her left wrist when she steeples her hands together in front of her computer screen to answer a question. The client remains alert throughout the interview, though sometimes you have to repeat questions. She seems to be distracted by something off screen at times. She fidgets with a cigarette lighter. The client appears irritable and her affect is labile. The client is coherent. Her speech is unpressured though at times slightly slow. She is oriented to person and place but not time or situation. She is unsure of what day of the week it is and she does not seem to understand the significance of being court-ordered. Her thinking is mostly linear and goal-directed but at times tangential and unfocused. She displays persecutory thought content. Insight and judgment are poor. | First session You are a mental health therapist delivering telehealth therapeutic services. Your 41-year-old Black female client is sitting on her sofa with her arms crossed and an annoyed look on her face. When you first see the client, you are immediately attracted to her as she reminds you of your first wife. She has been mandated to therapy by the Court as part of the terms of her probation. She begins by telling you about her difficulties with her acting career. She recently auditioned for a new role but was turned down because the directors wanted to "go in a different direction." She also mentions relationship distress and tells you she has been dating a high-profile plastic surgeon on and off for two years. She tells you, "We just had a big fight. He said I was 'too high maintenance' and he was tied of 'all my drama' and left. Can you believe it? I was obviously upset and stopped for a drink on the way home and met a very nice gentleman who bought me a few more drinks. But I don't know they think I have a drinking problem." As the intake progresses, it becomes evident that the client's frustration and agitation stem from a deep feeling of abandonment. She expresses her distress over feeling overlooked and not validated in her acting career. She reveals her struggle with the expectations placed upon her as a Black woman in the entertainment industry, believing that systemic biases may be limiting her opportunities. This realization amplifies her anger and resentment, fueling her resistance to therapy and perceiving it as a means of forced compliance rather than genuine support. As you continue to gather information about her presenting problem, you notice that the client is becoming increasingly agitated. Her tone turns angry, and it becomes clear that she resents being in therapy, especially when she says you are "no more than hired help." You attempt to ease tensions and build rapport by sharing with her the names of two famous actors you have counseled. However, this does not change her demeanor or attitude toward you. You detect a recurring theme of self-sabotage that manifests in the client's relationships. She complains about her relationships with the high-profile surgeon and other men. You note the client's lack of trust in men as well as casual female acquaintances who she sometimes sees as "competition." Her relationships appear strained due to her unresolved issues, leading to conflicts and feelings of worthlessness. As you continue your assessment, it becomes apparent that a complex interplay of societal pressures, past traumas, and a deep-seated fear of abandonment negatively impacts her self-perception. You also learn that she worries about her precarious financial situation, which adds to her insecurity and instability. The fear of being unable to meet her basic needs is an artifact of her unstable childhood. You suggest that during the next session, you begin to explore what might be contributing to her current feelings and behaviors beyond just focusing on her career issues, mainly her emotional dysregulation and fears of being abandoned. She says, "I'm an actress and have auditions. How long is this going to take?" You reinforce that the client has been court-ordered to therapy and that therapy will continue for as long as it takes to address the mandated objectives in the court order. You schedule a follow-up appointment to meet with the client again next week. | The client shared significant details about her familial history, particularly on her father's side. She conveyed that her paternal relatives have contended with various mood disorders, although she could not provide specific diagnostic categories. As a result of her father's authoritarian parenting style of strict adherence to his rules and restrictions, she has rejected any limitations from any authority figures. Notably, she also revealed several severe distressing incidents within her family, including suicide attempts, multiple instances of divorce, and hospital admissions. According to the client, these incidents often emerged due to relational difficulties, culminating in elevated levels of emotional distress. Furthermore, the client reported a history of hospitalization, although her recollection of the admission circumstances was somewhat nebulous. She said that she was feeling "distraught" during that period. You determine that exploring this episode more thoroughly in future sessions when the client feels ready and comfortable could provide valuable insights into her emotional coping mechanisms and resilience. The client was recently arrested for driving under the influence (DUI). This was not her first encounter with law enforcement regarding such a matter, as she has been charged with three DUIs over the past five years. However, this recent incident was markedly different and considerably more severe. She lost control of her vehicle and collided with a residential building, resulting in physical injury to a child. She underwent legal proceedings after her involvement in this accident and was found guilty. As part of her sentence, she was placed on probation under the court's oversight and mandated to attend therapy. The client disclosed that her consumption of alcohol is primarily social in nature. However, she also appears to use alcohol to self-medicate in times of emotional dysregulation. Despite these circumstances and her ongoing encounters with the law, she maintains the belief that her alcohol use does not pose a significant problem. | Given the client's substance use history, you determine that will be important to monitor her for signs of continued drug or alcohol use. What would be most indicative that the client is currently using drugs? | Disheveled appearance, muscle retardation, slow speech, dysphoric affect, and slow thought process | Altered thought process, disorganized speech, poor coordination, and cloudy sensorium | Unkempt appearance with body odor, withdrawn behavior, disorganized speech, flat affect with congruent mood, and nonlinear thought process | Clear sensorium, congruent and organized thought process, good judgement and insight | (A): Disheveled appearance, muscle retardation, slow speech, dysphoric affect, and slow thought process
(B): Altered thought process, disorganized speech, poor coordination, and cloudy sensorium
(C): Unkempt appearance with body odor, withdrawn behavior, disorganized speech, flat affect with congruent mood, and nonlinear thought process
(D): Clear sensorium, congruent and organized thought process, good judgement and insight | Altered thought process, disorganized speech, poor coordination, and cloudy sensorium | B | This combination of characteristics would infer possible substance use. Therefore, the correct answer is (B) | intake, assessment, and diagnosis |
823 | Initial Intake: Age: 58 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Married Counseling Setting: Private Practice Type of Counseling: Individual | The client reports that in the past six months she has lost 40 pounds, which leaves her looking thinner than seems appropriate for her 5’8” frame. Her hair is combed and neat, but looks thin and lacks a healthy shine. Her clothes, while clean, appear rumpled as if they have been slept in. She is cooperative and engaged, but moves slowly and pauses in her speech, causing you to wonder if she is lost in thought or if speaking is too painful. She reports she has difficulty falling asleep at night and never feels like she has any energy, though she does go to work each day. She denies any suicidal thoughts but states she feels sad all the time and “can’t wait to see him again.” She admits she blames herself for not keeping him home that evening, which would have prevented his death. | You are a counselor in a private practice setting. You receive a telephone call from an attorney that would like to refer their client, who is engaged in a civil suit, to you for counseling treatment. The attorney provides you with a detailed description of a traumatic event, death of her son, and expresses concerns about the client’s well-being. The attorney requests that you work with their client and be prepared to testify in court when the case goes to trial. | Family History:
During the intake session, the client reports that her youngest son was killed in a car accident eighteen months ago, which was caused by an impaired driver. Her son was the youngest of her five children and while she said she loves them all equally, she reported that her children have always said their youngest brother was her favorite. | Which of the following information is critical to gather prior to determining the treatment plan? | What client has been doing to manage her symptoms to date | All of the above | Previous experiences with death and loss | How client is functioning at work | (A): What client has been doing to manage her symptoms to date
(B): All of the above
(C): Previous experiences with death and loss
(D): How client is functioning at work | All of the above | B | Knowing how the client has handled loss in the past, how she is functioning in the professional realm, and what she is doing to manage her symptoms assesses resilience, coping skills, and level of functioning. Many of the client's symptoms could be caused by medical reasons which need to be ruled out. The appropriateness of the court case has not been identified by the client as a counseling concern. Therefore, the correct answer is (D) | treatment planning |
824 | 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. | Which theoretical approach would work most effectively with this client given his disclosures about his affair? | Gestalt therapy | Cognitive-behavioral therapy | Interpersonal psychotherapy | Jungian analysis | (A): Gestalt therapy
(B): Cognitive-behavioral therapy
(C): Interpersonal psychotherapy
(D): Jungian analysis | Cognitive-behavioral therapy | B | This theory base addresses behavioral components and cognitive structure. The client has anxiety that he needs to gain control of and has confessed to intimacy issues which led him to have an affair. The client has stated that he feels that his wife is not supportive of him. This could be a faulty thought process that led him to have an extramarital affair. Exploring the link between the client's thoughts and behaviors would be most beneficial for this client. Therefore, the correct answer is (A) | professional practice and ethics |
825 | Client Age: 7 Grade:2nd Sex: Male Gender: Male Ethnicity: African American Counseling Setting: Community Mental Health, School-Based Services Type of Counseling: Individual and Collateral Presenting Problem: Impulsivity; Inattention; Hyperactivity Diagnosis: Attention-Deficit Hyperactivity Disorder (ADHD) 314.01 (F90.2) | Mental Status: The client is dressed appropriately, and he is well groomed. His affect is bright when engaged in an activity of his choice, but he becomes irritable when asked to comply with a direct request (e.g., pick up the toys, walk in the hallway). He is energetic, eager to please, and interrupts your conversation with the mother, as evidenced by the client stating multiple times, “Watch this! Hey! Watch! Look what I can do!” The client has difficulty transitioning from your office and back to his classroom. He runs ahead of you in the hallway and does not respond to redirection. The client has not voiced suicidal or homicidal ideation. Developmenta | You are a clinical mental health counselor providing on-site school-based services in a public elementary school. Your client is a 7-year-old African American male enrolled in the 2ndgrade. The client is accompanied by his mother, who states that she is here because the school “requested an ADHD assessment.” The school reports that the client is disruptive, refuses to follow directions, disturbs others, and has difficulty staying on task. The mother describes the client as “energetic” and “strong-willed”—behaviors that she believes are “just typical for a boy.” She is upset that the school wants to conduct a formal evaluation to determine if the client qualifies for a more restrictive classroom setting. The school’s population is predominantly white, and the mother believes that her son is being treated unfairly because of his race. | You meet with the client’s mother today to update the client’s treatment plan. Since the beginning of the school year, the client has been suspended for a combined total of 8 days. He has responded poorly to many of the behavioral classroom interventions. The mother has reluctantly granted the school permission to begin testing to determine if the client qualifies for an Individualized Education Program. You inform the mother of her parental rights pertaining to this process, particularly as they apply to protections against disability-related discrimination and the maximum number of disability-related suspensions. She is encouraged by the possibility of the client receiving additional supports that consider the client’s strengths and challenges. Behavior management for ADHD is grounded in contingency theory and social learning theory | Behavior management for ADHD is grounded in contingency theory and social learning theory. Which of the following is a component of social learning theory? | Discrete trial training | Differential reinforcement | Modeling | Counterconditioning | (A): Discrete trial training
(B): Differential reinforcement
(C): Modeling
(D): Counterconditioning | Modeling | C | One component of social learning theory is modeling. The theoretical underpinnings of behavior management include contingency theory, social learning theory, and cognitive components. Social learning takes place when behaviors are observed, modeled, and imitated. Discrete trial training teaches a skill step by step and behaviorally reinforces successful approximations to an overall goal. Counterconditioning is the reversal of earlier learning. Finally, differential reinforcement is a behavioral modification principle used to stop undesirable behaviors by positively reinforcing desirable behaviors. Therefore, the correct answer is (C) | counseling skills and interventions |
826 | Initial Intake: Age: 14 Gender: Male Sexual Orientation: Heterosexual Race/Ethnicity: Hispanic - Mexican American Relationship Status: Single Counseling Setting: School-based Type of Counseling: Individual | Raul presents as irritable and anxious, with congruent mood and affect. Raul is casually dressed, appears to be overweight for his age and height, and is sweating with nervous hand motions. Raul has difficulty making eye contact, takes long pauses prior to answering questions, and often asks you to repeat the question after a long pause. Raul denies SI/HI or hallucination/delusion. He refers to an incident in his past he considers to be “trauma” but is uncomfortable discussing with you. When asked about his father, he sheds a tear which he immediately wipes away and returns to a scowl on his face with arms crossed, saying “there’s nothing to talk about.” Raul does admit to several instances of aggression with others such as “shoving a kid,” “kicking a desk” and “cursing out the principal.” You ask if he has ever been on medication for ADHD. He says, “No, I don’t think so. My doctor told my mom a few times to fill out some forms, but I don’t think she ever did.” | Diagnosis: Attention-deficit hyperactivity disorder, predominantly inattentive type (F90.0), Conduct disorder, unspecified (F91.9)
You are a counseling intern working for an agency that sends counselors into grade schools to work with their students on longer-term mental health issues. Raul is referred to you by his assistant principal for multiple in classroom infractions of interrupting, bullying, and being a “class clown.” In meeting with Raul and his mother, she shares that the principal accused Raul of bullying kids on the bus, and defacing property. She says, “Kids will be kids, they’re probably just too sensitive.” Raul’s mother works full-time and has an active social life, leaving Raul to stay at home alone frequently after school or on weekends. His mother appears very casual and does not seem concerned about Raul’s behaviors. She does mention Raul’s diagnosis of ADHD was given by his pediatrician, but he has never received psychiatric services. In front of his mother, Raul is quiet and acts well-behaved; after his mother leaves, he tells you he gets frustrated with her for leaving him alone but would never admit it to her directly. He refuses to state that he feels lonely, sharing that he spends most of his alone time playing live video games with other people across the country. He also denies bullying other kids. | Education History:
Raul’s teachers inform you of his behaviors throughout his freshman year in high school, that have according to them been ongoing since Raul’s middle school years. Raul is often reported for being inappropriate in class by making impulsive remarks to try and get others to laugh, disrupting the class, or falling asleep and appearing distracted. The school is concerned with his academic progress and has discussed moving his status up a higher-level Tier so he can be monitored further and made available to special programming geared towards students in jeopardy of failing.
Family History:
Raul lives with his mother and occasionally one of his mother’s boyfriends who come and go intermittently. Raul has one older sister who lives in the next town. Raul’s father lives in Mexico with several of his half and step siblings with whom Raul has minimal contact. Raul’s father is unable to enter the U.S. and has been absent most of Raul’s life. Raul reports his father is an alcoholic, but that where he lives, they “don’t think of things like that” because that is what his father told him. Raul’s grandmother also lives in Mexico but has been a continual presence in his life via phone calls, mail, and is his primary caretaker when he does visit Mexico, which has occurred twice. | Which objective does not need to be prioritized in Raul's counseling treatment plan? | Family functional interventions | Learn prosocial behaviors and implement changes | Processing trauma and learning coping skills | Referral for psychiatric testing and evaluation | (A): Family functional interventions
(B): Learn prosocial behaviors and implement changes
(C): Processing trauma and learning coping skills
(D): Referral for psychiatric testing and evaluation | Family functional interventions | A | Referring Raul for psychiatric testing of ADHD and evaluation for medication would be a significant step to work on with Raul's mother to help Raul get closer to being treated adequately. Teaching Raul appropriate behaviors and discussing how to make behavioral changes considering his values, motivations and needs is paramount at this stage of Raul's critical development prior to advancing in school. If Raul is willing to engage in some trauma work once safety and trust have been established, perhaps root issues can be resolved early in his life rather than later once his antisocial behaviors have increased. Engaging in Family Functional therapy is not needed at this time, although individual and joint sessions with his mother would be advantageous in supporting Raul's improvement. Therefore, the correct answer is (A) | treatment planning |
827 | 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. During this session, you identify that the client’s girlfriend does not send any signals that sex is not pleasurable | During this session, you identify that the client’s girlfriend does not send any signals that sex is not pleasurable. Which of the following terms defines the use of focusing on the information available to manage thoughts and feelings? | Mindfulness | Relaxation skills | Cognitive challenging | Cognitive reframing | (A): Mindfulness
(B): Relaxation skills
(C): Cognitive challenging
(D): Cognitive reframing | Mindfulness | A | Mindfulness is focusing on the present situation, which would be helpful in conjunction with using evidence to counteract cognitive distortions. Cognitive reframing and challenging are helpful techniques in managing cognitive distortions, but they do not directly focus on present evidence for beliefs. Relaxation skills are helpful, but they do not focus on cognitive functions. Therefore, the correct answer is (A) | counseling skills and interventions |
828 | 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 | How does the client's mental health history affect your treatment plan? | The client's mental health history will dictate what topics and goals are discussed in therapy. | The client's mental health history will determine the length of therapy needed to reach desired outcomes. | The client's mental health history will likely present a barrier to treatment because she is at a higher risk for future issues. | The client's mental health history provides insight into how past experiences may be affecting the client's current emotional state. | (A): The client's mental health history will dictate what topics and goals are discussed in therapy.
(B): The client's mental health history will determine the length of therapy needed to reach desired outcomes.
(C): The client's mental health history will likely present a barrier to treatment because she is at a higher risk for future issues.
(D): The client's mental health history provides insight into how past experiences may be affecting the client's current emotional state. | The client's mental health history provides insight into how past experiences may be affecting the client's current emotional state. | D | The client's mental health history can provide important information about what kind of interventions may be most helpful in treating their current situation. By understanding past issues, we are better able to tailor our treatment plan to specifically address the current needs of this individual. Additionally, taking into account any mental health conditions (such as anxiety or depression) that the client may have can help determine what interventions will be most effective in helping them cope and manage their emotions. Ultimately, this information can be used to create an individualized treatment plan that is tailored to the unique needs of the client. Therefore, the correct answer is (B) | treatment planning |
829 | Name: Alberto Clinical Issues: Sexual functioning concerns Diagnostic Category: Sexual Dysfunctions Provisional Diagnosis: F51.22 Erectile Disorder, Situational Age: 43 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: White Marital Status: Married Modality: Individual Therapy Location of Therapy : Agency | The client is dressed in casual clothing and appears to be clean and well-groomed. He is of average height and build, with short black hair. He is noticeably tense and avoids eye contact when describing his symptoms. His speech is audible and clear. He is able to express himself clearly and articulately. The client reports feeling frustrated, embarrassed, and confused concerning issues with his wife. He denies any suicidal or homicidal ideation. His mood is anxious and affect is flat. He is able to recall pertinent events and information. He has no difficulty understanding the session process or comprehending instructions. He appears to be alert and oriented to person, place, and time. The client displays average insight into his current situation and expresses willingness to explore relevant issues in more depth with the therapist. He displays average judgment when answering questions. | First session The client, a 43-year-old male, presents for his first Telehealth session through the agency where you are an intern, finishing your final hours for licensure under clinical supervision. You begin the session by striving to create a safe, comfortable, and non-judgmental environment. You provide the client with an introduction to yourself, your qualifications, and your approach to therapy. You also explain how Telehealth works and provide the client with an opportunity to ask questions about the process. Next, you review his informed consent and other paperwork that was filled out prior to the session. You explain the policies and procedures for confidentiality within your agency. He nods his head and verbally acknowledges understanding. You then begin to explore the client's presenting issues and goals for therapy. You ask what prompted him to schedule an appointment for counseling, and he responds saying, "I don't know what is wrong with me, but lately, I've been having trouble with my wife....on an intimate level. It's been very frustrating and embarrassing, and it's causing a lot of tension between us. My wife is getting frustrated and accusing me of cheating on her. We have two children. I never thought this would happen to me." The client has seen a urologist and has no sign of prostate cancer but is in poor health. The client appears anxious when describing his symptoms. He is fidgeting and has trouble maintaining eye contact as you explore the issue more deeply. This is your first client who presents with this particular issue, and you are not entirely sure of how to proceed. You take a few moments to pause and reflect on what he has said while also noting his body language. As you consider the best way forward, you remember the importance of validation in establishing rapport. You nod your head and say, "I can see how this has been difficult for you and your wife. It's understandable why it might be causing tension between the two of you." Fourth session It has been a month since you began therapy with the client. You have been meeting with him weekly. Today, the client states he and his wife attempted to have sex last week, and he could not maintain an erection. He says she called him "a lousy cheat with a beer belly who can't satisfy her." He lets you know that this remark triggers him as it reminds him of his relationship with his mother. He reports that sex feels like a "chore," and it is not fun anymore. "Sometimes, I fantasize about being with an ex-girlfriend of mine just to get an erection." The client seems sad and looks down at his feet. You and the client discuss his wife's comments, and he expresses feeling overwhelmed and helpless. You ask him to reflect on how he feels about his wife's reaction, and he reports feeling "hurt and rejected." You then discuss the possibility of exploring underlying issues that may be impacting his ability to find pleasure in sex. You then ask if he is able to recall any past experiences or traumas contributing to his difficulty with erectile dysfunction. He has never felt anxious about past experiences with erectile dysfunction, but now he sees to be struggling with feelings of guilt and shame. You then discuss strategies for improving communication with his wife and ways to build trust within their relationship. You encourage the client to explore his feelings and identify potential triggers impacting his ability to enjoy sex. Lastly, you role-play a scenario in which the client communicates his feelings to his wife in a non-confrontational manner. At the end of the session, he tells you that he is beginning to understand how he can relate better to his wife. He states, "I guess it's important to tell each other what we need and want." | The client is an only child. As he grew up, he reports that his father was often vocal about his dissatisfaction with his sex life. The client also reports that his mother often expressed resentment toward him from the day he was born. This has left him with a deep-seated dislike of his mother, as well as resentment of women in general. Currently, his parents are facing health issues, with his father drinking heavily and his mother having lung cancer. The client feels overwhelmed and stressed due to his job and family responsibilities. He is worried about his parents' health and is not happy about the potential of having to take care of his mother if his father passes away. After a decade of working as an illustrator designing greeting cards, the client has recently been promoted to creative director of his department. Because of his introverted nature, he is now feeling overwhelmed with the new responsibilities and having to communicate with other departments within the company. The client drinks weekly and occasionally smokes marijuana. The client drinks at least one beer every other night after work with dinner. He will finish two six-packs on some weekends if they have company over to watch football. He says he rarely drinks hard liquor. The client has reported that his alcohol use or smoking marijuana is not causing any impairments in his ability to carry out his daily responsibilities, but he is overweight because of his inactivity and indicates he would like to return to his normal weight. He also says that he has never experienced any adverse physical or psychological effects due to his substance use. | During this session, you decided to use role-playing with the client. Why did you choose to use role-playing instead of psychodrama? | Role-playing allowed the client to act out his personal issues in a safe environment | Role-playing allowed the client to gain insight into his own behavior | Role-playing and Psychodrama are terms both describe the same process | Role-playing explored different perspectives on the client's situation | (A): Role-playing allowed the client to act out his personal issues in a safe environment
(B): Role-playing allowed the client to gain insight into his own behavior
(C): Role-playing and Psychodrama are terms both describe the same process
(D): Role-playing explored different perspectives on the client's situation | Role-playing explored different perspectives on the client's situation | D | Role-playing is used to explore different perspectives and practice communication and problem-solving skills, allowing the counselor and their client to stay in control of the experiences they are creating. In role-playing, therapists act out different situations while their clients practice responding. This practice can help them become more confident interacting with other people in real-life situations. Role-play activities also provide a safe way to explore difficult topics without having to experience unpleasant emotions or situations. Therefore, the correct answer is (D) | counseling skills and interventions |
830 | Client Age: 26 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: African American Relationship Status: Single Counseling Setting: Community Mental Health Center Type of Counseling: Individual Presenting Problem: Depressive Symptoms Diagnosis: Persistent Depressive Disorder (PDD) (Dysthymia) Diagnostic Criteria 300.4 (F34.1) | Mental Status Exam: The client is dressed in age-appropriate clothing and is well groomed. His affect is blunted and anxious at times. The client denies anxiety but discloses that he is nervous about the counseling process and doesn’t know what to expect. He is cooperative but hesitant to offer more information than is asked. The client is tearful when discussing his breakup and states that there are days when it is a struggle to get out of bed and go to work. He denies suicidal ideation, and he says that he has had no previous attempts. The client is oriented to person, place, time, and situation, and his thought content is organized. Fam | You are a counselor working in a community mental health center. Your initial intake appointment is with a 26-year-old African American male who presents with symptoms of depression. The client states that he has felt depressed since his teens, with symptoms increasing within the last couple of months. He reports feelings of worthlessness, fatigue, and occasional bouts of insomnia. In addition, the client indicates that his symptoms worsened after his girlfriend of 2 years broke things off with him. He explained that she grew tired of his low energy and pessimistic outlook on life. As a result, he has been hesitant to seek help, believing that he just needed to “man up” and handle his problems privately. The client is unsure of his insurance benefits but thinks his policy allows for a limited number of counseling sessions. | ily and Work History: The client grew up in a home with his mother, father, and maternal grandmother. He has a 22-year-old sister who he believes also experiences depression, but he is unsure if she has received treatment. The client says that he attends church “most Sundays” with his family, primarily because he knows it is important to his grandmother. The client holds an associate degree in information technology and is a computer network support specialist. He has worked for the same company for the past 4 years. You would like to use the Beck Depression Inventory-II (BDI-II) but are concerned about the possibility of racial bias. You find a study stating, “The recommended cutoff score of 14 for screening for depression appears to be appropriate for African American patients in the primary care setting” (Dutton et al., 2004). This cutoff yielded a specificity of 84% | You would like to use the Beck Depression Inventory-II (BDI-II) but are concerned about the possibility of racial bias. You find a study stating, “The recommended cutoff score of 14 for screening for depression appears to be appropriate for African American patients in the primary care setting” (Dutton et al., 2004). This cutoff yielded a specificity of 84%. How do you interpret these findings? | 84% of respondents with depression scored above 14. | 84% of respondents have a high probability of scoring above 14. | 84% of respondents without depression scored below 14. | 84% of respondents have a low probability of scoring above 14. | (A): 84% of respondents with depression scored above 14.
(B): 84% of respondents have a high probability of scoring above 14.
(C): 84% of respondents without depression scored below 14.
(D): 84% of respondents have a low probability of scoring above 14. | 84% of respondents without depression scored below 14. | C | The study shows a high proportion of people without depression with low scores. BDI-II scoring is as follows: A score of 0–13 is considered in the minimal range, 14–19 is mild, 20–28 is moderate, and 29–63 is severe. Specificity measures (ie, the true negative rate) are the proportion of people without depression with a low score on the BDI-II. In other words, a specificity of 84% indicates that 84% of individuals without depression did not score above a cutoff score of 14. This also means that the study yielded few false negatives. The same study yielded a sensitivity score of 88%. A sensitivity score is a true positive rate because 88% of those with depression scored above the cutoff score of 14 on the BDI-II. Probability is unrelated to specificity and sensitivity and is used to determine the likelihood or chance of an event occurring. Therefore, the correct answer is (A) | intake, assessment, and diagnosis |
831 | 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. | 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. | Why might you choose the Gestalt technique of the empty chair as an effective way to help the client resolve his interpersonal conflicts? | This Gestalt technique can help clients integrate the many different parts of themselves into one to gain further insight into themselves. | This Gestalt technique can help clients by enhancing client-therapist rapport through activity. | This Gestalt technique can help to allow projection of the client's relationship with his father on you. | This Gestalt technique can help younger clients engage in physical activities, which helps maintain engagement. | (A): This Gestalt technique can help clients integrate the many different parts of themselves into one to gain further insight into themselves.
(B): This Gestalt technique can help clients by enhancing client-therapist rapport through activity.
(C): This Gestalt technique can help to allow projection of the client's relationship with his father on you.
(D): This Gestalt technique can help younger clients engage in physical activities, which helps maintain engagement. | This Gestalt technique can help clients integrate the many different parts of themselves into one to gain further insight into themselves. | A | It is beneficial for a client experiencing Gender Dysphoria as it allows the individual to accept who he or she is and who he or she is becoming. Therefore, the correct answer is (C) | counseling skills and interventions |
832 | Name: Aghama Clinical Issues: Cultural adjustments and sexual identity confusion Diagnostic Category: V-codes Provisional Diagnosis: Z60.3 Acculturation Difficulty Age: 18 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Bisexual Ethnicity: Nigerian Marital Status: Never married Modality: Individual Therapy Location of Therapy : University Counseling Center | The client comes to your office and sits rigidly and makes little eye contact. She is dressed neatly and appropriately for the weather with overall good hygiene. She appears cooperative and open to the therapeutic process. She expresses a willingness to discuss her experiences, thoughts, and feelings, but show some hesitation due to her unfamiliarity with therapy. The client's mood is depressed. Her affect is congruent with her mood, displaying a flat or subdued demeanor, but shows some variability when discussing her family or life in Nigeria. Her speech is clear, fluent, and coherent. She has no difficulty expressing herself in English and seems to have a good command of the language. Her speech is slightly slow. The client's thought process appears linear and goal-directed. She is able to articulate her concerns and goals; her thoughts seem to be dominated by her feelings of sadness, loneliness, and homesickness. The client demonstrates some insight into her situation and the impact of her homesickness on her overall well-being. She appears to be motivated to seek help and improve her situation. There is no evidence of suicidal ideation or intent. The client does not express any thoughts of self-harm or harm to others. However, her ongoing feelings of sadness and loneliness warrant close monitoring and support during the therapeutic process. | First session You are a licensed mental health counselor working at a university counseling center and take a humanistic approach in your work with clients. Today you are meeting with an 18-year-old student who recently moved to the United States from Nigeria. She tells you that she moved to the United States one month ago after missionaries in Nigeria granted her a scholarship. She feels lonely, misses her family, and is questioning her decision to come to the United States. She indicates she has never been to therapy before but was told by her academic advisor that it might be helpful to make an appointment with a counselor. You continue the intake session by exploring the client's current psychological functioning. She expresses that she is homesick and is struggling to find her place in a new environment. She describes having difficulty making friends at college and feels isolated. She does not feel comfortable talking about her personal life with people she does not know well, which makes it even more difficult for her. Additionally, she is struggling with the pressure of living up to the expectations of the members of her church that gave her the scholarship to attend the university. She is currently pursuing a nursing degree at the university. You ask her to share some details about her family and cultural background in order to gain a better understanding of the context of her situation. She tells you that her parents are both teachers and she has two siblings. The family is very close-knit and they typically speak in their native language at home. You also ask about how she is managing her academic obligations, any specific challenges or barriers she might be facing, and how she is spending her free time. She says that her courses are challenging, but she is managing them well. In between classes, she spends most of her time in the library studying. You discuss the therapeutic process and what she hopes to gain from counseling. She expresses that she would like to learn how to better cope with her homesickness and loneliness. She says, "I'm worried that I'll be a disappointment. It took a lot of money and effort to get me here, and I don't want to let them down. I was so excited when I first got the scholarship, but maybe it would have been better if it went to someone else." You validate her feelings and explain that it is natural to feel overwhelmed when faced with a new culture and environment. You further explain the importance of focusing on her strengths, as she has already accomplished so much by making the decision to attend college abroad. You describe therapy as an opportunity for her to explore her feelings, develop coping strategies, and adjust to her new environment. At the end of the session, she tells you she is on a "tight schedule" and needs to know when she can see you for therapy so she can plan accordingly. You provide her with your availability and suggest that an ideal therapy schedule would involve weekly sessions. You also explain the importance of consistency in order to allow her to make meaningful progress during therapy. You schedule an appointment for the following week. | null | Based on the client's initial presentation, what assessment instrument would yield additional data regarding a possible comorbid disorder? | Addiction Severity Index - ASI | Ages and Stages Questionnaire | Barratt Impulsiveness Scale - BIS-11 | State-Trait Anxiety Inventory - STAI | (A): Addiction Severity Index - ASI
(B): Ages and Stages Questionnaire
(C): Barratt Impulsiveness Scale - BIS-11
(D): State-Trait Anxiety Inventory - STAI | State-Trait Anxiety Inventory - STAI | D | The State-Trait Anxiety Inventory is designed to assess anxiety as well as distinguish it from depression. The test differentiates between "state anxiety" (temporary) and "trait anxiety" (more general and long-term). The STAI can be completed in 10-20 minutes. Therefore, the correct answer is (A) | intake, assessment, and diagnosis |
833 | 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. Second session After your initial session with the client, the school performed a risk assessment and concluded that the client could return to school. You have requested to meet with the client and his mother every week. Today is your second session, during which time you spend the first thirty minutes talking with the mother and the second half talking with the client. During your conversation with his mother, she shared that she believes her son might have Autism. She says she has been debating whether to tell you this because she is "concerned about the stigma associated with Autism" and the possibility of her son being treated differently. She has been anxious about her son's issues and wants to have him tested to get him the "right help." Jackson's mother appeared very anxious during the session. She shared concerns that he may have Autism but has hesitated to disclose this for fear of stigma. She has been struggling with getting him properly assessed and finding adequate support. Her anxiety around Jackson's issues was evident in her tense body language and rapid speech. She is worried about her son's well-being and future. However, the stigma she associates with an Autism diagnosis seems to be preventing her from getting Jackson the help he likely needs. You recognize that Jackson's mother feels overwhelmed and alone trying to understand her son's difficulties. Her eagerness to have him tested indicates she believes an Autism diagnosis would provide answers and open up access to services. Yet she is torn about the potential labeling and discrimination Jackson could face. Her desire to protect her son's privacy competes with her need to get him help. This is causing Jackson's mother significant inner turmoil. She presented today as a caring parent under great strain. In the second part of the session with the client, you find him disinterested and bored until you start talking about gaming. Then, he appears to perk up and becomes talkative. When you ask why he thinks he is here, he tells you about an incident at school. A student in another room texted his entire class, saying he was "short." This angered him, and he left the classroom and started a fistfight with that student, resulting in disciplinary action. Jackson told this story with clenched fists, still visibly upset. He explained that the school was unfair and justified his violent reaction by stating he has Autism. This suggests Jackson feels his neurodiversity excuses poor behavior. Rather than take responsibility, he blamed external factors for the altercation. Jackson's body language and tone indicated he remained defensive and saw himself as the wronged party. Jackson believed his Autism diagnosis makes aggression an inevitable response in certain situations. By citing Autism as the cause of his actions, he abdicated any sense of personal responsibility. Without intervention, he may continue acting out when provoked and making excuses based on his diagnosis. There is a risk that Jackson will not develop appropriate coping skills or learn to navigate his interpersonal conflicts. He appears fixed in the view that others are at fault, while his neurodiversity pardons any misdeeds. Fifth session As today's session starts, the client's mother says she is at her "wit's end" because her son is getting worse. As a result, the school may not let the client come back next year. In addition, there has been a major incident at home. The mother, stepfather, and younger sister went for a drive without the client. When they returned, the client was upset and claimed that no one in the family loved him; he wanted to live with his grandmother. The mother responded that his behavior was unacceptable and that he would not live with his grandmother. Jackson went into his bedroom and began throwing objects around the room in anger after his family left without him. He broke a lamp and overturned his dresser. Jackson's destructive outburst caused damage to his possessions and his room. After his mother told Jackson a second time that he could not live with his grandmother, he started shouting insults at her and his stepfather. Jackson then told them they were not fit parents and only cared about themselves. In response, his mother told him he was not getting his laptop back until his behavior improved. The client grabbed a dish, threw it against the wall, and threatened to break more items in the home. He said he would continue his destructive behavior until his family realized how much they hurt him on a daily basis and then ran out the door. The stepfather found him wandering the neighborhood and drove him home. Jackson told his stepfather he wished he was dead and not part of their family. You note that the client is pulling his hair as he tells you this. You also notice that he is decompensating. You spend the remainder of the session practicing self-calming skills with him. | 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 is the most appropriate intervention for this client in this situation? | Create a token economy | Cognitive restructuring | Mindfulness-focused therapy | Practice self-calming skills | (A): Create a token economy
(B): Cognitive restructuring
(C): Mindfulness-focused therapy
(D): Practice self-calming skills | Practice self-calming skills | D | Self-calming skills, such as deep breathing and mindfulness, can help the client to regulate their emotions and reduce their distress. This intervention will allow the client to better manage their emotions and better cope with the feeling that their family does not love them. Therefore, the correct answer is (D) | counseling skills and interventions |
834 | 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. | atic. Family History: The client has two siblings: a younger brother (29) and an older sister (32). The client says that her older sister is obese and she is worried that her body would deal with food similarly, causing her to gain weight easily if she ate more. The client has been married for about 1 month at this point and has lived with her husband for about 6 months total. She says that she feels pressure from her husband to be thin, and although he places this expectation on her, she says that she has felt this way prior to meeting him, but has lost more weight since they have been living together | Which of the following would be appropriate homework following the intake session? | Complete a daily food log. | Ask the client to create a hierarchy of internal and external triggers for bingeing and purging. | Encourage the client to try foods that she thinks are off limits and to write down thoughts and feelings that she is experiencing when doing so. | Recommend that the client read a book regarding anorexia. | (A): Complete a daily food log.
(B): Ask the client to create a hierarchy of internal and external triggers for bingeing and purging.
(C): Encourage the client to try foods that she thinks are off limits and to write down thoughts and feelings that she is experiencing when doing so.
(D): Recommend that the client read a book regarding anorexia. | Complete a daily food log. | A | Appropriate homework for this client after her first session would be to encourage her to complete a daily food log so you can have baseline data on her current eating habits. Providing psychoeducation is helpful, but a book might be too much for a client just starting therapy, and you are also still in the information-gathering phase. Behavioral experiments such as trying triggering foods and creating a hierarchy are both activities that the therapist needs to guide to ensure that no harm is caused; therefore, these interventions are not appropriate for homework. Therefore, the correct answer is (A) | intake, assessment, and diagnosis |
835 | Initial Intake: Age: 32 Gender: Female Sexual Orientation: Heterosexual Ethnicity: Caucasian Relationship Status: Divorced Counseling Setting: Community Mental Health Agency, state-run Type of Counseling: Individual and family | Shania is disheveled, has tangential and fast rate speech and is fidgety with twitching in her motor movements. Shania makes consistent eye contact and leans in close when she becomes upset and begins to cry. Shania admits to having suicidal thoughts and attempt behaviors in her past, but says she no longer feels suicidal. Shania denies homicidal ideations, hallucinations, or delusions. She shares how when she was heavily using drugs and alcohol, she would become paranoid and frequently experience delusional thinking with manic presentation but only while actively on psychoactive substances. Shania has an extensive physical and emotional abuse history since childhood but is a poor historian with the timeline of events. She attributes her anxiety to her trauma as she remembers feeling anxious around her parents since she was a child. She tells you she has no desire to use drugs again but is frequently worried about her temptations to drink when she is stressed or around members of her extended family who drink. Shania’s depression and anxiety have increased more recently due to her family being evicted from their rental apartment and having to stay in a hotel room for the past few weeks. | Diagnosis: Major Depressive Disorder, recurrent, unspecified (F33.9), Anxiety Disorder, unspecified (F41.9), Alcohol dependence, uncomplicated, in early remission (F10.20), Cocaine Use Disorder, unspecified with cocaine-induced mood disorder, in remission (F14.94)
You are an intern providing mental health counseling sessions to adults and children struggling with economic and legal issues and are given a referral to conduct an evaluation for Shania, a 32-year-old woman with three children. Shania has temporary guardianship of her youngest two daughters but is undergoing a custody battle to win back full custody of all her kids. Her oldest, age 12, is under guardianship of her parents in another state. Shania tells you in the intake session that her father beats her 12-year-old with his belt and her mother verbally abuses her, but that she isn’t taken seriously when reporting. Shania says because of her legal and substance use history, and due to her reports often being vague on details and directly attempting to influence her court hearing results, officials do not follow through on investigations. Shania further shares that her youngest daughter is struggling with psychiatric and behavioral issues, has used violence against her when angry and cannot sit still, most nights only sleeping for two or three hours. She can no longer afford medications and no longer has health insurance. | Substance Use History:
Shania has been in long and short-term treatments several times in her 20s for alcohol dependency and cocaine use. She had all her children while under the influence or in remission from using substances and has had minimal contact with their fathers. The man she is currently living with is not the biological father of the children but has taken to caring for them as his own while he is in a relationship with Shania.
Work History:
Shania has never been able to keep a job for long because of her substance use, which has contributed to her depression and has caused suicidality in her past. Shania has worked in several retail, food and other merchandising chains but has just recently become unemployed again. This is what contributed to her inability to pay rent and eviction. She asks you for help with getting government assistance as she has no family she can rely upon for support. | What element of an active treatment plan would involve Shania attending recovery groups regularly? | long-term goal | objective within a long-term goal | intervention to support an objective | discharge recommendation | (A): long-term goal
(B): objective within a long-term goal
(C): intervention to support an objective
(D): discharge recommendation | objective within a long-term goal | B | Peer-led recovery support groups have been proven effective for individuals in substance use and dependency recovery as part of an evidence-based treatment plan goal to maintain sobriety, therefore "sobriety maintenance" can be considered the long-term goal. An objective within this goal might read "Shania will maintain weekly attendance at her local Alcoholics Anonymous meetings throughout duration of counseling episode," which is why the answer is c). Based on the way the question is phrased, a discharge recommendation is not an element of an "active treatment plan" but of a "discharge plan", making answer c) the better choice. An intervention to support this objective like answer d) suggests might read "Therapist will monitor weekly attendance to recovery groups and engage Shania in discussion over what she has reflected upon within each group meeting," as interventions are the therapist-led component. Therefore, the correct answer is (C) | treatment planning |
836 | Name: Dave Clinical Issues: Worry and anxiety Diagnostic Category: Anxiety Disorders;Substance Use Disorders Provisional Diagnosis: F41.9 Unspecified Anxiety Disorder; F10.99 Unspecified Alcohol-Related Disorder Age: 42 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: White Marital Status: Married Modality: Individual Therapy Location of Therapy : Agency | The client presents at the intake session biting his nails and cannot keep his legs from shaking. He feels anxious about his wife and work. He continually places his hands on his head and complains of headaches and nausea. He admits to drinking a bit more than he should. He denies thoughts of self-harm but sometimes wishes that he could "disappear." | First session You are a counseling intern at an agency that works with clients from various socioeconomic backgrounds. Your client is a 42-year-old married male massage therapist who owns two therapeutic massage practices. Over the past nine months, his business has been reduced by fifty percent. He is having great difficulty paying the bills for the business, and he has exhausted his personal savings. His wife is currently not working due to a back injury. He has difficulty concentrating during the day and is irritable around his employees, friends, and family. He states that he drinks "too much" in order to relax at night and admits that his hangover adds to his anxiety the next day. His wife has begun to complain, and their relationship has been strained over the past three months. The client is concerned about paying for the sessions due to financial issues. He offers to exchange massage sessions for therapy. The client is aware that anxiety and alcohol use are impacting his work and family life negatively, but he does not know how to get a handle on them. He reports feeling overwhelmed with worry about the future of his business and whether he will be able to continue providing for his family. The client has been avoiding people lately, including old friends, and only sees his mother occasionally due to her health problems. In terms of self-care, the client acknowledges that he tends to put everyone else's needs before his own, which leads to feelings of exhaustion and anxiety. Additionally, he finds it difficult to recognize or accept compliments from others and has difficulty expressing gratitude for their help. During the intake session, you identify anxiety as one of the primary issues the client is seeking help with. You also discuss the role that alcohol is playing in his anxiety and suggest strategies for reducing anxiety without relying on it as a coping mechanism. The conversation then turns to developing a plan with the client for addressing these issues, such as scheduling regular self-care activities, limiting or eliminating alcohol use, and exploring cognitive behavioral therapy techniques for managing anxiety levels. | The client has been married for ten years. He and his wife have two children together, a son, age 10, and a daughter, age 12. The client does not speak to his father, who divorced his mother when he was four years old. The client and his mother have a good relationship. The mother lives 15 minutes away from the client and helps his wife with the children. During the past nine months, his massage therapy practice revenue has decreased by fifty percent, and it has been difficult to pay the bills. The client has exhausted all personal savings. The client is the sole income provider for his family, as his wife is not working while recovering from a back injury. | What is the most appropriate course of action to take regarding the client's concern about paying for therapy sessions? | Tell the client that you do not believe this arrangement will be a problem but that you will follow up with him after speaking with your supervisor. | Consult with your supervisor and seek appropriate guidelines. | Accept the client's offer and set up an equitable exchange for therapy and massage sessions. | Decline the client's offer but agree to offer pro bono therapy services. | (A): Tell the client that you do not believe this arrangement will be a problem but that you will follow up with him after speaking with your supervisor.
(B): Consult with your supervisor and seek appropriate guidelines.
(C): Accept the client's offer and set up an equitable exchange for therapy and massage sessions.
(D): Decline the client's offer but agree to offer pro bono therapy services. | Consult with your supervisor and seek appropriate guidelines. | B | Consulting with your supervisor is the correct answer because you are a counseling intern. Your supervisor is there to discuss cases with you. The client's suggestion could be viewed as bartering, or it could be a boundary issue. Your supervisor can discuss your feelings about the request and offer options for handling the situation. Therefore, the correct answer is (A) | professional practice and ethics |
837 | Initial Intake: Age: 26 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Private Practice Type of Counseling: Individual | The client appears his stated age and is dressed appropriately for the circumstances in clean jeans and a t-shirt. He identifies his mood as “anxious but a little excited” because he “is hopeful that he can finally let his anger go.” He tells you he is tired because he has difficulty falling asleep and staying asleep most nights. His affect is pleasant with emotional lability evident. He demonstrates appropriate insight and judgment, memory, and orientation. He reports never “seriously” having considered suicide but acknowledges that there were times when he wondered “if dying would make this pain go away.” He has never attempted suicide and states he would never consider harming himself or anyone else. | You are a counselor in a private practice setting. Your client is a 26-year-old male who presents for counseling at the request of his family and his employer, with whom he is close and who knows his history. The client tells you that he has been angry for the past 15 years, beginning a year after the death of his father from a heart attack. He says that his anger is triggered very quickly when frustrated by people or situations and that his “fuse is very short these days.” He states that he has been in some “loud arguments” with his mother, and later his stepfather. He admits that there have been times in the past when he and his stepfather have “almost come to blows” but his mother stepped in and made them stop. He admits to having hit or kicked walls at times in his anger, but has never hit a person. He tells you that he doesn’t want to feel this way because it interferes with his relationships and his former girlfriends have never understood that when the anniversary of his dad’s death comes around, he just wants to be alone for a couple days and not have to talk to anyone. He tells you that he has never had a long-term relationship with a woman because either he gets “depressed” for a few days during certain times of the year (i.e., father’s birthdate and death date) or because he is too quick to get angry and then says things he doesn’t mean. He says that he has been in a relationship with a woman now for eight months and really wants to get himself together because he feels “she’s the one.” | Family History:
The client reports a family history of being the youngest of three siblings born to his mother and father. He reports a “great life” with his family and that they regularly spent time together playing, camping, traveling, and “just being a family.” He tells you that he is sure there were occasional arguments but that he doesn’t remember anything significant, except that he had been mad at his dad the night he died because his dad wouldn’t let him stay up late, but that before the client went to bed, he had come down, apologized to his dad, and they had both said “I love you.” He states his parents had been married for 15 years prior to his father’s death, which occurred when the client was 11 years old. He states his dad died of a heart attack while sleeping, so while he did not see it, he knew something had happened because his mother woke him and his siblings and rushed them over to the next door neighbors’ house. He said that his mother went to the hospital with his father in the ambulance and came home that night to tell him and his siblings that their father had died. He tells you that he and his siblings are still very close and that they now have three much younger siblings born after his mother married his stepfather. He says that he is very close to his mother and stepfather, although he lives three hours away from them. He tells you that he tries to get home for big family events, like birthdays. He states that his stepfather adopted him and his siblings after the wedding and the client loves him very much. He tells you that he and his stepfather have gotten in what the client thinks are “typical teenager/parent” conflicts but that they have often been made worse by the client’s anger that seems to always be inside and erupts quickly. | In working with the client on bereavement, which of the following will be most effective in helping him understand and engage in "good grief"? | Help the client survey friends about how they view grieving and what is "normal" | Help the client identify the helpful grief traditions in his own and extended family | Help the client recognize that grief is individual so whatever he feels is appropriate | Help the client use a grief workbook so that he can align his emotions with what he reads | (A): Help the client survey friends about how they view grieving and what is "normal"
(B): Help the client identify the helpful grief traditions in his own and extended family
(C): Help the client recognize that grief is individual so whatever he feels is appropriate
(D): Help the client use a grief workbook so that he can align his emotions with what he reads | Help the client identify the helpful grief traditions in his own and extended family | B | Families have different traditions for grieving, which the client will be familiar with, even if these have not been available to him due to his PTSD-related anger. Identifying what traditions have been helpful for past family losses and might be helpful for him now as he grieves his father, will provide him with action steps and a family support system that is likely to help him engage in those traditions. Helping the client embrace the individuality of the grief process is both positive and negative. The client has spent 15 years in a grief process that has been ineffective and emotionally harmful due to the trauma involved in his loss. While grief is experienced differently by individuals, there are emotions and actions that are not helpful in resolving grief, which has been exemplified in this case study. Surveying friends provides information on the different ways families, individuals, and cultures grieve, but will not take into account the client's unique situation, the nature of his grief, or the ways that the client may have seen others in his family grieve well. Traditions for grieving are helpful for clients as they share those traditions with others in their culture and allow people to grieve together rather than in isolation. Many individuals may find a workbook or other structured guide helpful for grieving and learning about grief. While helpful, workbooks or guides are generic in structure and are not able to capture each individuals' specific grief story and needs. It would be inappropriate then for the client to plan to align his own emotions with a workbook. Therefore, the correct answer is (C) | counseling skills and interventions |
838 | Client Age: 38 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Married Counseling Setting: Private Practice Type of Counseling: Individual Presenting Problem: Marital Difficulties Diagnosis: Obsessive-Compulsive Personality Disorder 301.4 (F 60.5) | Mental Status Exam: The client is meticulously dressed and immaculately groomed. He frequently checks his watch and states he has owned his watch since adolescence and it “still works like new.” His speech is even, and his affect is blunted. At times, he is defensive and attempts to talk over you. He exhibits poor insight into his marital problems and is excessively preoccupied with perfectionism, structure, and order. Fam | You are a counselor working in private practice and meeting your client for the first time today. The client is here at his wife’s insistence, who has threatened divorce if he does not seek and comply with therapy. The client explains that he is swamped at work and has already lost an hour of productivity traveling to your office. He discloses that he has been married just over four years and has a daughter who is 3½. The couple dated briefly and married when the client’s wife discovered she was pregnant. The client believes that if he didn’t leave his wife a schedule and checklist, “things would never get done.” He states that they would be in “so much debt” if it weren’t for his detailed household budget. In his estimation, conflict occurs each time his wife tried to do things “her way” because “it is never the right way.” You paraphrase and clarify the client’s concerns. | The client states that his wife now refuses to follow the client’s to-do lists, and he is growing more frustrated with her defiance. Their daughter turned four this past week, and he felt like he made it clear to his wife that throwing a party for a four-year-old was costly and unnecessary. After working all weekend, he returned home and found that his wife had thrown a party anyway. He stated he “hit the roof” and expressed feeling disrespected despite all the effort he makes towards establishing a detailed budget “with no room for error.” The conversation turns to his upbringing, and he discloses that he was placed in therapeutic foster care in early childhood and remained there until he turned 18. You discuss the implications of early childhood attachment with the client | What are you trying to accomplish by discussing the implications of early childhood attachment with the client? | Demonstrate the connection between biopsychosocial factors and symptom severity. | Illustrate the relationship between temperament and unrelenting standards. | Show the association between unmet childhood needs and maladaptive schemas. | Establish the connection between adverse childhood experiences and risk level for perpetration. | (A): Demonstrate the connection between biopsychosocial factors and symptom severity.
(B): Illustrate the relationship between temperament and unrelenting standards.
(C): Show the association between unmet childhood needs and maladaptive schemas.
(D): Establish the connection between adverse childhood experiences and risk level for perpetration. | Show the association between unmet childhood needs and maladaptive schemas. | C | The goal of discussing attachment with the client is to determine the association between unmet childhood needs and maladaptive schemas. Schema therapy is an integrative approach used to treat individuals with personality disorders. The theory integrates elements of attachment theory, cognitive-behavioral therapy, and object relations to address maladaptive schemas. A schema is an influential belief system acquired about oneself, others, and society at large. Maladaptive schemas originate from early childhood experiences and create emotional, cognitive, and behavioral impairments. Since there are no indications that the client’s child is at risk for victimization, determining the client’s risk level for perpetration is unnecessary. Temperament is inborn rather than environmental. While determining the role temperament plays in social and relational interactions is essential, the client’s upbringing in foster care provides more insight into attachment and object relations. A biopsychosocial assessment uses a holistic approach to determine biological, social, and psychological influences on a client’s presenting problem. The connection would need to be made between biopsychosocial factors and attachment rather than symptom severity. Therefore, the correct answer is (A) | counseling skills and interventions |
839 | Name: Sierra Clinical Issues: Adjustment related to physical loss/injury/medical condition Diagnostic Category: Trauma and Stressor Related Disorders Provisional Diagnosis: F43.23 Adjustment Disorder with Mixed Anxiety and Depressed Mood Age: 16 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: Native American (Cherokee) Marital Status: Not Applicable Modality: Individual Therapy Location of Therapy : Private Practice | The client's appearance is slightly disheveled. Her behavior is withdrawn. She has her arms crossed throughout the session. The client's affect is congruent. Her mood is depressed during the initial intake. She reports that she sometimes "doesn't feel like existing" when thinking about her injury. She shares that the thought of not being able to dance ever again is "too much to bear." Exploration of thought content reveals that she has considered how she might harm herself. She reports that her father has guns locked in a safe, but she knows the passcode. The client denies she would ever act on this impulse and identifies three friends she could contact for support. | First session You are a mental health therapist in a rural private practice setting. A 16-year-old female is referred to you by her pediatrician for concerns about her mood, behavior, and low appetite. She is accompanied by her mother and father. You begin by speaking with all three family members, reviewing the informed consent process and how confidentiality will be handled with the daughter. They all acknowledge and sign the appropriate paperwork. Next you meet one-on-one with the parents to understand their concerns. They are extremely concerned about their daughter's mental health and wellbeing. They share that their daughter has been crying more often lately and she has become incredibly sensitive to criticism. She is often irritable and "snaps" at them over minor issues. She withdraws from social interaction with friends, which is out of character for her. She appears increasingly withdrawn from activities she used to enjoy like drawing and playing the piano. She is also sleeping more and eating less than usual, resulting in weight loss. The parents confirm that they have limited insight into their daughter's actual feelings, as she often refuses to discuss them. The mother tells you, "She had a ballet injury a couple of months ago, and she seems to be struggling with it. We've been trying to stay positive and supportive, but she's just not getting better. Her physical therapist said that keeping up a positive attitude is really important in the recovery process, but our daughter doesn't seem to care." After you feel you have obtained a thorough understanding of the parents' concerns, you ask the parents to wait in your waiting room and invite the daughter back into your office. You begin by expressing your understanding of the situation that lead her parents to bring her in for therapy. You state, “From what your parents have told me, I understand you have been going through a difficult time lately with your physical injury and the changes that it has caused in your life.” After establishing this understanding, you ask her to tell you about her experience with the injury, how it has impacted her life, and how she has been feeling since it occurred. She tells you she has a hard time concentrating at school because she is unable to dance. She becomes tearful when you attempt to find out about how her ballet injury is affecting her. She says her "life is ruined now" and "I will likely never dance again. I'll never be able to fulfill my dream of being a ballet dancer. I hate it. All of my dreams are crushed." She begins sobbing uncontrollably. You take a moment to de-escalate her intense emotional reaction. You explain that it is common to feel overwhelmed in the aftermath of a major injury, and there are strategies she can use to cope with her feelings. You discuss the importance of staying connected to friends, family, and supportive people during this difficult time. After completing your mental status examination of the client, you note suicidal ideation as an issue to discuss with her parents. Second session The client presents to her second counseling session in a defensive state. She is upset that you reported her suicidal ideation to her parents because she thought that everything she told you would remain confidential. She says, "Why should I tell you anything else? You'll just tell my parents." You tell the client that you understand her frustrations and empathize with her. You explain to her why confidentiality is not always absolute and that as a clinician, it is your responsibility to keep clients safe, even when they don't want you to. You further explain that in this case, you felt it was important for her parents to know about the suicidal ideation she has been experiencing. You emphasize that her parents care deeply about her, and they need to know what is going on with her in order for them to help. She responds by saying, "Okay, I get what you're saying, but telling them about it has only made things worse." She reports that her parents now treat her "differently" and do not allow her access to any "dangerous items like kitchen knives" without supervision. She feels restricted and watched. You nod your head in understanding and reflect that it can be difficult to feel like your parents don't trust you and have put restrictions on things they normally wouldn't. You also encourage her to try and see the situation from their perspective and agree that although the restrictions can be inconvenient, her safety is their top priority. She takes a deep breath and says, "I guess I can understand why they did it, but it still doesn't feel fair." You acknowledge her feelings of unfairness and validate that feeling. After your discussion, the client appears to have a better understanding of her parents' motivation for the restrictions and feels less resentful towards them. You ask her to tell you more about how she has been feeling lately and invite her to share any other issues she is having trouble managing. She tells you that her ballet teacher has invited her to help teach the younger ballet classes, but she is ambivalent about pursuing this opportunity. Though she still loves ballet, she thinks it will be painful to watch other children fulfill the dreams that she can no longer pursue. She says, "I'm afraid that if I agree to teach, I'll never get over my injury. It will just keep reminding me of what I could have been." You explain to her that it is natural for her to have these feelings and that it is okay to take time to make a decision. You ask her if she can see any benefits to teaching. She pauses and says, "I don't know...I've never really thought of myself as a teacher. I've always been the student." You acknowledge the difficulty of this transition and understand that it can feel risky to try something new. You suggest that teaching could be an opportunity for her to gain a sense of purpose, as well as an activity to help her stay connected to something she loves. You encourage her to try and explore her capacity for teaching and imagine what impact she could have on her students. Seventh session Almost two months have passed since you first met with the client. She has been meeting you for weekly therapy sessions. During previous sessions, you continued to work on developing a sense of trust with the client which has allowed her to open up to you about the myriad of feelings that she has regarding her injury. You explored and processed feelings of grief and sadness, as well as feelings of anger and resentment. Several sessions have been dedicated to identifying automatic thoughts that have been contributing to the client's negative attitude and replacing negative self-talk like "I'm broken" with more positive and realistic statements. You have also been using solution-focused techniques to help her to focus on what is within her power to change and take active steps toward making those changes. During today's session, the client agrees with you when you state that you believe she has achieved many of her goals in therapy. The client has worked through her ambivalence towards teaching the younger ballet classes and is now actively pursuing this opportunity. She reports that she finds a sense of purpose in helping the students learn and appreciate dance, as well as feel accomplished for their achievements. She says, "It's still strange not being the student anymore, but I'm glad that I decided to try it. The kids had a performance last week, and one of the girls gave me this really sweet clay ballet shoe that she made in her art class. She told me that I'm the reason she felt 'brave enough' to keep dancing even though she was scared. That meant a lot to me." You then ask her about her relationship with her parents. She reports that it has improved since they had the discussion about trust. They are now more willing to listen to her opinions and have loosened some of the restrictions, though there are still some limits in place. Although they still have expectations of her and restrict certain activities, they now talk to her more openly and engage with her in a positive manner. She tells you that she would like to get all A's this semester to make her parents proud. She is getting better grades in history but states that her other classes are "boring." She also mentions wanting to put some limits on the amount of time she spends with her friends and "get away from smoking as much." She says that she is trying to be a better role model for her ballet students. You acknowledge how hard she has worked to reach this point and congratulate her on taking initiative in improving her academic performance and setting new boundaries with her friends. | The client reports that she is doing "okay" in school. Her parents report that she used to make straight A's but is now making C's and D's. She is failing history because she did not complete a project. They share that her teachers have tried to reach out to her, but she has not responded to any of them. The client reports that she smokes cigarettes. She used to smoke once every couple of months while out with friends. Her use has become more frequent, and she is now smoking several times a week. She has tried alcohol (three beers) and smoked a joint at a friend's party, but she reports that she did not like how they made her feel. Pre-existing Conditions: The client fell in dance class two months ago and broke her ankle. There were complications during surgery to repair the break. The client is currently in intense rehabilitation planned for at least one year, but it may take longer. Doctors are unsure if she will ever regain full mobility of her ankle. | What would you consider the best way to begin the termination process with the client? | Review the progress that she has made on her stated treatment goals | Email the client before the session notifying her that you are starting the termination process | Outline how you will structure future sessions | Discuss unresolved treatment goals | (A): Review the progress that she has made on her stated treatment goals
(B): Email the client before the session notifying her that you are starting the termination process
(C): Outline how you will structure future sessions
(D): Discuss unresolved treatment goals | Review the progress that she has made on her stated treatment goals | A | This is probably the best way to start a conversation about termination. Discussion of the client's progress toward the completion of stated goals in therapy is important. Therefore, the correct answer is (C) | treatment planning |
840 | 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 approach for the counselor to take considering Molly's disposition is? | Tell Molly she knows how she feels because she lost her dad around the same age | Remind Molly that if she doesn't participate the car will be forfeited | Address questions only to Molly's mother | Ask more open-ended questions to allow Molly to expand on her answers | (A): Tell Molly she knows how she feels because she lost her dad around the same age
(B): Remind Molly that if she doesn't participate the car will be forfeited
(C): Address questions only to Molly's mother
(D): Ask more open-ended questions to allow Molly to expand on her answers | Ask more open-ended questions to allow Molly to expand on her answers | D | Asking open ended questions allows Molly to expand on her responses and leads to deeper conversations. Rapport building is key in an initial session. Although the car is what persuaded Molly to come in the first place, it would not wise for the counselor to bring this up as a way to force her to participate. It is best for the client to participate on their own terms especially as Molly seemed hesitant and possible distrustful of her counselor. If the counselor were to stop speaking to Molly altogether and only to her mother, this would hinder the engagement process as Molly was initially showing resistance. The counselor should acknowledge Molly and allow her opportunities to participate at her own pace. Finally, though self-disclosure can be beneficial, it is usually a purposeful intervention. This type of self-disclosure can be interpreted as minimizing the other person's feelings. Therefore, the correct answer is (B) | intake, assessment, and diagnosis |
841 | 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. | Which theoretical base would provide the most direct approach in helping the client identify underlying emotions and faulty thoughts contributing to her eating behavior? | Reality therapy | Emotion-Focused Therapy | Gestalt therapy | Solution-focused therapy | (A): Reality therapy
(B): Emotion-Focused Therapy
(C): Gestalt therapy
(D): Solution-focused therapy | Emotion-Focused Therapy | B | Emotion-focused therapy (EFT) emphasizes identifying, experiencing, and processing emotions. An EFT therapist would help the client connect with feelings like anxiety, sadness, etc, that may drive disordered eating patterns. Techniques like two-chair dialogues could be used to uncover the emotional roots of the eating behavior. erstanding. Therefore, the correct answer is (C) | treatment planning |
842 | 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. | To address your client's attachment style, which of the following steps should be taken as you work together? | All of the above | Develop social skills, including reading body language and responding to social cues | Build support networks for communication and trust | Address childhood trauma | (A): All of the above
(B): Develop social skills, including reading body language and responding to social cues
(C): Build support networks for communication and trust
(D): Address childhood trauma | All of the above | A | Each of these are important factors in building self-esteem, which is critical for resolving ambivalent attachment. Working through childhood trauma allows the individual to see how the parental figures' behavior influenced the client's insecurity. The counselor often acts as a model parental figure during this time to help the client form secure attachments. Individuals with ambivalent attachment are anxious and insecure so building supportive relationships that offer security and trust is helpful for building self-esteem and secure attachments. Finally, children with attachment issues may have poorly developed social skills as they did not feel safe forming attachments early on. In this case, helping the client learn to respond to social cues and read body language may assist him in choosing healthy individuals with whom to form relationships. Therefore, the correct answer is (D) | counseling skills and interventions |
843 | Name: Jeanne Clinical Issues: Fear and panic Diagnostic Category: Anxiety Disorders Provisional Diagnosis: F41.9 Unspecified Anxiety Disorder Age: 35 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: Latin American Marital Status: Married Modality: Individual Therapy Location of Therapy : Community Center | The client appears tearful and overwhelmed. Her affect is mood congruent with her reported symptoms of panic, stress, and guilt. The client has a poor sense of control over her current mental state, leading to ideas and fears of not being able to cope with her current circumstances. She reports having panic attacks and expresses feeling overwhelmed by the demands of motherhood and home life. The client has difficulty concentrating on tasks, as well as changes in her eating habits, sleeping patterns, and overall mood, leading to worries about managing her responsibilities as a mother. She expresses an understanding of her situation and an awareness that her current mental state is not sustainable in the long-term. She has also expressed a desire to seek counseling as a first step towards managing her anxiety. | First session You are a therapist at a community center. The client is a married, 35-year-old mother of two young children. She is a stay-at-home mother, and the family is financially dependent on her husband's income. He works long hours and is very tired when he finally gets home, leaving most of the household tasks and childrearing to the client. She tells you, "About eight months ago while driving my car, I began having hot flushes, sweating, and feeling like I was going to die. It has happened multiple times since then. What if my kids are with me, and it happens again while I'm driving? I can't stop thinking about it." She states that her husband drove her to the session today because she has been afraid to drive since her first panic attack. She describes another incident two weeks ago while getting her hair cut. She began feeling like she had a heart attack. She tells you, "I sat straight up in the middle of having my hair shampooed and just ran out the door. The room felt so small all of the sudden and I couldn't stand it. It's so embarrassing. It doesn't make any sense." As she wipes tears from her eyes, she shares, "I'm becoming more and more afraid to leave my house by myself. I'm not even going to church anymore. The idea of being in a closed room full of people freaks me out. I'm terrified I'm going to have another 'attack.' I can't tell when another one will come on, and I don't even know how long it will last. Please, help me. I'm no good to anyone right now - not me, my kids, or my husband." She tells you that she had a "bad experience" with medications in the past and wants to try counseling before considering medications again. She expresses feeling afraid that she will never "get better." She also states she feels like a "bad wife and mother" because she cannot control her anxiety. You discuss the principles of panic-focused CBT and mindfulness-based stress reduction to effectively treat her. Fourth session At the start of today's session, the client hands you a copy of a hospital discharge form. She went to the emergency room two days ago with severe dyspnea and fear of dying from a myocardial infarction. Upon arrival at the hospital, the client reported paresthesia, pounding heart, and chest pain. She appears "frazzled" and disheveled during today's session. She describes the circumstances leading up to her trip to the hospital. She reports that her husband has been emotionally distant and is becoming increasingly frustrated with her anxiety. Finally, he told her that "this has been going on long enough" and that she needed to "get her act together." After this conversation, the client experienced a panic attack and stated that she was "terrified" that she was dying. Her husband arranged for their neighbor to watch the kids and drive her to the hospital. You tell the client that she must stop thinking she will die or progress in therapy will be unlikely. You reassure her that the physical sensations she feels during a panic attack are not life-threatening, even though they may feel that way. You discuss the importance of her bringing compassion and attention to her body rather than jumping into "fight, flight, or freeze" mode. The client appears anxious and has poor eye contact with an averted gaze. She is continuously wringing her hands together and bouncing her legs. She has trouble concentrating, as evidenced by her asking you to repeat questions. The client tearfully states, "I'm ruining my family. What if I die? Who will take care of the kids?" You provide empathy and walk her through a relaxation technique. Ninth session You have seen the client weekly, and she is progressing. She arrives at today's session on time. She appears calm, alert and focused. She states that she has been actively journaling her thoughts and feelings. This has been helpful for her in identifying themes in her faulty cognitions. She tells you that she is surprised by how much she is learning about herself, including how much her past has influenced her current beliefs. She showed some psychomotor agitation by pulling on the strings of her blouse. The client expressed that she and her husband have been trying to implement a date night which has helped their relationship and for him to better understand what Panic Disorder is. She said that having meaningful conversations with him and having his support in times of panic has helped reduce the attack's length. However, the client did express that she cannot shake the fear of dying and leaving her children. You discuss with her the potential triggers of these panic attacks and discuss ways to manage them. As she leaves, you see that she has bruises on her arms as she is getting ready to leave and says she was "roughhousing" with her husband. You are unsure if she is telling the truth, making you wonder about everything she has been saying about her husband. You discuss with her the option of attending couples therapy to help them work through any issues they may face. She says she is open to it but worried about bringing up deeper issues surrounding their relationship. You reassure her that she and her husband will have a safe space to discuss any topics and remind her about the counseling. | The client has two young children, ages four and six, both of whom have been diagnosed with ADHD. She has been married for ten years. Her husband is 47, twelve years her senior. He works full-time, and she is a stay-at-home mom. For the past year, the client has reported feeling overwhelmed with the demands of motherhood and home life. She feels that her husband does not understand her struggles, nor does he contribute enough to their household responsibilities. This lack of support from her husband has caused her to feel a deep sense of resentment. She is also concerned that her children are not receiving the support they need from their father, as his involvement in their lives appears to be minimal. The client expresses frustration with her lack of motivation and has become increasingly more anxious and irritable over the past several months. She reports difficulty concentrating on tasks. She feels her stress levels are rising and she is having recurrent panic attacks. In addition, she has noticed changes in her eating habits, sleeping patterns, and overall mood. These changes have caused the client to worry about managing her responsibilities as a mother. The client has been a full-time stay-at-home mother since the birth of her older child. Before that, she was a salesperson and shift manager at a local women's clothing boutique for several years. Since becoming a stay-at-home mom, the client has felt increasingly isolated and disconnected from the outside world. She fears she has lost her ability to successfully manage conversations with strangers, her skills in sales and marketing have eroded, and she no longer feels as confident in herself. Previous Counseling: The client has been hospitalized as she feared she was having a heart attack which turned out to be a panic attack. According to he client, her husband (her designated emergency contact person) was responsible for creating the conditions that resulted in her being hospitalized. | Given the client's admission of her husband causing her bruises and your suspicions, what action should you take? | Acquaint the client about assistance and social services available. | Notify authorities only if you have the client's authorization. | Take the client at her word concerning her bruises. | Report to the authorities without the client's permission. | (A): Acquaint the client about assistance and social services available.
(B): Notify authorities only if you have the client's authorization.
(C): Take the client at her word concerning her bruises.
(D): Report to the authorities without the client's permission. | Acquaint the client about assistance and social services available. | A | In this situation, the client does not fall within the vulnerable population that requires mandated reporting. You should, however, help the client identify sources to help address abuse. It is important to assess the client's immediate needs and provide any necessary resources or referrals. You may also want to work with the client on developing strategies for safety and healing from the trauma of being in an abusive relationship. Additionally, if the client expresses a desire to reach out for help, you should provide information about local organizations that specialize in domestic violence. It is important to ensure that the client has a support system in place and knows how to access resources if needed. Therefore, the correct answer is (B) | professional practice and ethics |
844 | Client Age: 8 Sex: Female Gender: Female Grade: 3rd Ethnicity: African American Counseling Setting: School-based Type of Counseling: Individual and Family Presenting Problem: Defiance Diagnosis: Oppositional Defiant Disorder 313.81 (F91.3) | Mental Status Exam: The client displays an angry affect and sits with her arms crossed. She is well dressed and well groomed. The client’s PGM repeatedly prompts her to say, “yes ma’am” and “no ma’am” when answering questions. The client sits slumped in her chair. She agrees to color in a feelings thermometer that reflects increased anger, sadness, and fear. Her insight is poor. The client often refuses to eat school lunch, and the PGM reports that the client is a picky ea | You are a school-based mental health counselor conducting an initial intake with an 8-year-old African American female in the 3rd grade. The client presents today with her paternal grandmother (PGM), the client’s legal guardian. The PGM states that the client is argumentative, refuses to take responsibility for her actions, and has a tantrum when she receives a consequence for her behavior. She reports that the client is restricted from “every single privilege indefinitely.” The client has been told she can regain privileges once she “learns to act her age.” The client states she is treated unfairly and “blamed for everything” at home and school. The client’s teacher reports that she has difficulty following directions, is easily annoyed by her classmates, and frequently loses her temper. The client’s grades are poor, and she is below grade level in reading. However, she enjoys art and proudly reports that one of her pictures came in 1st place and is hanging in the library. | You are meeting with the client individually and providing parenting training with the client’s PGM. The client’s teacher has implemented a behavioral chart for the classroom, and you ensure the client is receiving appropriate reinforcement for targeted behaviors. The teacher believes the client’s behavior indicates ADHD, and you have agreed to conduct classroom observations. During the observation, you note that the client gets out of her seat multiple times to sharpen her pencil. While doing so, she glares at other students and is observed balling up her fists and threatening others. The teacher yells at the client to sit down and stop disrupting the classroom, which has little effect on the client’s behavior | Which one of the following accurately describes criterion-referenced measurements? | Measurements determine how a person’s knowledge or skills compare to someone with similar traits. | Measurements compare a person’s knowledge or skills against a predetermined standard. | Measurements compare a person’s knowledge or skills against a normed group. | Measurements are ranked on a bell curve. | (A): Measurements determine how a person’s knowledge or skills compare to someone with similar traits.
(B): Measurements compare a person’s knowledge or skills against a predetermined standard.
(C): Measurements compare a person’s knowledge or skills against a normed group.
(D): Measurements are ranked on a bell curve. | Measurements compare a person’s knowledge or skills against a predetermined standard. | B | Criterion-referenced measurements compare a person’s knowledge of skills against a predetermined standard. For example, goal attainment scaling is a criterion-referenced measure because it measures the client’s targeted behaviors, which is the predetermined standard or criterion. The client’s progress is compared with previous scores. Criterion-referenced tests often use cut scores to categorize predetermined standards. For example, the goal attainment scaling scores can be used to determine minimum, moderate, and significant improvement. Norm-referenced measurements compare a person’s knowledge or skills against a normed group, which can be ranked on a bell curve and compared with another person with similar traits. Examples of norm-referenced measures include pediatric growth charts or the SATs. Therefore, the correct answer is (C) | professional practice and ethics |
845 | Name: Dawn Clinical Issues: Maladaptive eating behaviors Diagnostic Category: Feeding and Eating Disorders Provisional Diagnosis: F50.01 Anorexia Nervosa, Restricting type Age: 17 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: White Marital Status: Single Modality: Individual Therapy Location of Therapy : University Counseling Center | The client presents as a female in her late teens who appears malnourished and underweight, dressed in loose, concealing clothing. She exhibits poor eye contact and a guarded, closed-off posture with arms protectively crossed. Her affect is tense and anxious. Speech is logical and goal-directed, with no evidence of hallucinations or delusions. She denies any suicidal or homicidal ideation. Cognition is grossly intact for person, place, and time. Her insight and judgment appear limited, as evidenced by unresolved conflict with her parents and changing college majors without considering long-term career goals. She reports a strained relationship with authoritarian parents who were often physically and emotionally absent, leaving her feelings of neglect. She exhibits low self-confidence and an inability to trust her thoughts and desires. She continues to seek parental approval but feels unable to assert her needs. Her mood is anxious and frustrated due to perceived external control and lack of autonomy. | First session You are a mental health counselor in a university counseling center. Dawn, a 17-year-old college student, is referred to you by her physician. The client's parents recently visited during their parents' weekend at the university campus and were very concerned when they saw their daughter, who appeared severely underweight. They had not seen her for several months and immediately contacted the family physician for guidance. After performing a complete physical exam, the physician could not determine any medical causes for the client's low weight. The physician noted, however, that the client expressed that she did not understand her parents' concern about her weight. During the physician's examination interview, she reported feeling intense anxiety about gaining weight and implied that she was unhappy with her appearance. Dawn reported feeling stressed and anxious about her schoolwork, friendships, and body image concerns. She explained that she often skips meals or severely restricts her food intake in an effort to maintain control. Dawn acknowledged that her eating habits have become more disordered over time and expressed openness to learning new coping strategies. While Dawn initially resisted her parents' efforts to intervene, their concern made an impression. She agreed to continue counseling to address the underlying issues driving her unhealthy behaviors. Dawn wants to improve her well-being despite lingering uncertainties. In today's initial counseling session, you focus on establishing trust and providing the client with a safe space to share her feelings without fear of judgment or reprisal. You begin by asking the client how she feels today and if there are any particular topics she would like to discuss. You also explore her feelings about her parents and brother and ask targeted questions to better understand the family dynamics and how they have impacted her self-esteem. You provide the client with psychoeducation regarding healthy eating habits, body image, and the consequences of not caring for oneself. Lastly, you discuss possible resources and referrals that may be helpful for the client during this time. Dawn seemed receptive to discussing her feelings and experiences in a judgment-free environment. She sometimes became emotional when describing her struggles but appeared relieved to openly share things she had kept private. Dawn stated the counseling session felt like a positive first step. After reviewing healthy coping tools and strategies, Dawn agreed to keep a daily food and feelings journal. She also committed to reaching out for support if feeling triggered or unable to care for herself. Dawn left the session with referrals for a nutritionist and an eating disorder support group. Fourth session You and the client have met twice weekly for therapy sessions on Monday and Thursday afternoons. This is your fourth session, and you begin to explore the client’s support network. She reports having a difficult time making friends at college and says that she feels very lonely. She shares a dorm room with two other female students who have been best friends since elementary school. The client says she feels like an “outsider” and struggles to share a living space with these two roommates. Dawn shared that she often spends time alone in her dorm room on weekends while her roommates go out together. She said this makes her feel even more isolated. Dawn explained that she has tried reaching out to her roommates to get to know them better, but they seem uninterested in including her in their plans. Dawn mentioned that her older brother is the only person she feels close with right now. However, since he lives so far away, they rarely see each other in person. Dawn said she misses having her brother around to talk to and confide in. One of her classmates invited her to have lunch on campus, but she was so anxious about eating in public that she declined the offer. Although she would like to have friends, she is worried that, eventually, she will end up in a social situation involving food; this idea creates intense anxiety for her. She believes that it is easier to avoid social situations altogether. The client begins to cry and says she often thinks about moving back home but does not feel like she belongs there anymore, especially since her parents repurposed her old bedroom. She continues crying and says, “I don’t have any friends at school, and I don’t even have a room at home. I feel like I don’t belong anywhere. I really miss my brother.” Dawn tearfully explained that she feels caught between missing her previous life and feeling unable to adjust to her new environment at college. She is longing for connection but finds it challenging to put herself out there socially. Crying, Dawn shared that she feels like she has no place where she truly belongs right now. She misses the security and familiarity of high school and being with her brother but also recognizes that things have changed there as well. Overall, Dawn conveyed profound feelings of loneliness and isolation. | The client has a 25-year-old brother who is a Navy Seal. The client's parents have government jobs and frequently travel to foreign countries for work. When the client moved away to live on campus, her parents immediately turned her old bedroom into a home gym, which the client found unsettling. The client says that while she knows her parents love her, they have never been very affectionate or spent much time with her. When she was younger, the client traveled with her family for a few weeks during the summer but was often left alone during their trips. She describes her relationship with her parents as "strained" but states that she does have a positive relationship with her brother. She plans to see him when he is on leave from the Navy. The client is a freshman at the university and has already changed her major from pre-med to music history. She is anxious about telling her parents that she switched majors and is worried they will be disappointed. She reports that she has always felt a lot of pressure from her parents to excel in school as her brother did. Since she was a child, her parents have expressed their desire to see her become a physician. Her parents have always set high expectations for her academic performance. Their authoritarian parenting style has left her doubting her confidence in her own capabilities. She is frustrated by this dynamic because she does not feel like she can think for herself or pursue her own goals without outside approval. | Which actions would be most ethical for the therapist to take regarding Dawn's feelings of isolation and lack of belonging? | Indicate to the client that she needs to reduce isolating herself and put herself out more socially. | Encourage the client to join campus groups aligned with her interests. | Refer the client to group therapy. | Contact the campus social life director to ask the client's roommates to include her in their plans. | (A): Indicate to the client that she needs to reduce isolating herself and put herself out more socially.
(B): Encourage the client to join campus groups aligned with her interests.
(C): Refer the client to group therapy.
(D): Contact the campus social life director to ask the client's roommates to include her in their plans. | Encourage the client to join campus groups aligned with her interests. | B | The therapist is ethically responsible for respecting Dawn's autonomy and empowering her to make connections. Joining campus groups would allow Dawn to take steps to build her social network in a way that aligns with her personal interests. This upholds Principle E of the APA Ethics Code. Therefore, the correct answer is (C) | treatment planning |
846 | Name: Michael Clinical Issues: Separation from primary care givers Diagnostic Category: Anxiety Disorders Provisional Diagnosis: F93.0 Separation Anxiety Disorder Age: 10 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Not Assessed Ethnicity: Guatemalan American Marital Status: Not Applicable Modality: Family Therapy Location of Therapy : Agency | Michael appears clean and dressed in appropriate clothing. He often fidgets with his hands and insists on sitting next to his father during the session. Speech volume is low, and pace is fast. He has a slightly flattened affect. He exhibits minimal insight consistent with his age. | First session You are a licensed mental health counselor at a pediatric behavioral health center. Michael, a 10-year-old male, presents along with his father. You conduct a thorough psychological exam, including a mental status examination. During the initial interview, you take note of Michael's behavior. He sits very close to his father and looks fearfully around the room. The father tells you Michael has been having trouble at school and home for the past few months and it has been getting worse. When you ask how Michael is doing in school, the father tells you there have been several incidents, including difficulty waking up for school, crying in the morning, and refusal to get dressed and ready. The father also tells you that Michael has been showing signs of frustration with his teachers and classmates. On the home front, the father mentions that his son has become "a nuisance for his babysitter, especially during bedtime." Both parents are paramedics on a 24-on/48-off shift rotation. Michael often calls his parents while at work, complaining that he feels sick and cannot fall asleep. He worries that someone might break into the house or that "something bad will happen" to his parents. The father reports that he and his wife have tried to reassure Michael, but their efforts have been unsuccessful. They are perplexed as to what is causing Michael's distress. The father tells you that Michael has always been a bright and energetic child, but now he seems overwhelmed and anxious. You conduct a more detailed interview with Michael alone, focusing on his current environment and daily routines. You ask him how he feels about school, and Michael denies having any issues. He tells you that he does not want to go because his new school is "boring." However, when you probe further, he admits to feeling scared and alone. He does not want to be away from his parents, and he imagines "all the ways they could be hurt" while they are not with him. You say, "I can understand why you might be feeling scared and anxious, Michael. It sounds like a lot has been going on recently. I'm here to help you and your parents understand what's causing your worries so you can start to feel better." You reconvene with Michael's father and provide a brief summary of your findings. You explain that you suspect Michael's anxiety is likely due to the family's recent relocation and having to adjust to a new school. His fears are also likely rooted in his parents' profession, which may lead him to worry about their safety while they are away from home. You have personal experience in dealing with pediatric anxiety and consider briefly sharing your story with Michael and his parents as you believe it may help them to feel supported and less alone in their struggles, while also providing a practical example of how to work through difficult times. You suggest developing an intervention plan to address Michael's distress and recommend meeting with Michael and his parents for weekly sessions. | Michael's parents have been married for nine years and both are dedicated to the well-being of their children. The father reports that he and his wife communicate openly with each other and make joint decisions about parenting issues. They also model healthy family dynamics, such as expressing affection and respect towards one another, being honest with one another, and sharing responsibilities. Michael has a five-year-old sister. His father characterizes the family as very close; they do everything together. The father says that he and his wife go to their children's sporting events and school meetings. Every weekend, the four of them are together doing family activities. Except when required to be away due to their work schedules as paramedics, the parents are home with the children at night. Prior to the family's move to a new state 6 months ago, Michael had been a successful student at school, typically performing at or above grade level. He was an active participant in the classroom, often volunteering to answer questions or participate in class discussions. Since the move, however, getting ready for school has been a struggle each day. He is struggling academically; while his grades haven't dropped drastically, he appears to be having trouble focusing and understanding the material. His parents have attended parent-teacher conferences and Michael's teachers have also reported that he seems distracted and uninterested in class. His parents also report that they are having difficulty getting him to stay on task when doing his homework at home. | The client claims that there are no issues at school, but the father's statements contradict the client's statement. How can you most effectively address this conflicting information? | Recognize that the client is using denial as a means of helping him cope with his anxiety and make a note for further exploration. | Ask the father to respond about the client's experience at school to reframe the client's experience. | Gently rephrase the question as a means to allow the client to provide a more factual answer. | Ask more detailed questions about the client's experience without directly contradicting the client. | (A): Recognize that the client is using denial as a means of helping him cope with his anxiety and make a note for further exploration.
(B): Ask the father to respond about the client's experience at school to reframe the client's experience.
(C): Gently rephrase the question as a means to allow the client to provide a more factual answer.
(D): Ask more detailed questions about the client's experience without directly contradicting the client. | Ask more detailed questions about the client's experience without directly contradicting the client. | D | Exploring the client's experiences while building rapport will help establish a viable therapeutic relationship. This is especially important when working with a child. Directly contradicting and "calling him out" risks harming the therapeutic relationship. Therefore, the correct answer is (D) | counseling skills and interventions |
847 | 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 counseling characteristics will be most effective when working with this or any client with a hoarding disorder? | Congruence | Empathic Responding | Sensitivity to multicultural issues | Positive Regard | (A): Congruence
(B): Empathic Responding
(C): Sensitivity to multicultural issues
(D): Positive Regard | Empathic Responding | B | Empathic responding will be the most important counseling characteristic when working with this or any client with a hoarding disorder. Even those with hoarding disorders have the autonomy to choose what they will keep and what they will discard. While the client's possessions may have no value to the counselor or others, they hold significant value for the client and the counselor's empathic response, as the client works through modifying thought, experiencing extreme emotions, and making choices, is critical. Congruence and positive regard are important counseling characteristics with all clients and facilitate the trust needed for the therapeutic relationship. While these are important for that relationship, without empathic responding during the hoarding client's exploration of possessions, change will not occur. Sensitivity to multicultural issues is also an important counseling characteristic with all clients and will help the counselor better understand the client's perceptions of the world and themselves; however, it is not as helpful in supporting the client's work on changes as is empathic responding. Therefore, the correct answer is (C) | counseling skills and interventions |
848 | 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 | How should the counselor respond to Li's description of her situation? | "That sounds like a tough job." | "You should not be treated this way." | "How was it like in your homeland?" | "This happens all the time." | (A): "That sounds like a tough job."
(B): "You should not be treated this way."
(C): "How was it like in your homeland?"
(D): "This happens all the time." | "You should not be treated this way." | B | Li is in an exploitive situation, and it must be addressed that this is not safe or appropriate. Choices a and b minimize what Li is experiencing and disregards her safety and well-being. Choice c is assuming that Li had a worse experience where she came from and also minimizes what she is currently going through. Therefore, the correct answer is (D) | professional practice and ethics |
849 | Client Age: 32 Sex: Female Gender: Female Sexual Orientation: Heterosexual Ethnicity: Latina; Mexican American Relationship Status: Married Counseling Setting: Community Mental Health Type of Counseling: Individual and Psychoeducation Presenting Problem: Depression Diagnosis: Major Depressive Disorder (MDD) with Psychotic Features 296.24 (F32.3) | Mental Status Exam: The client is well groomed and appropriately dressed. Her voice is soft and low, and she avoids eye contact, mainly when talking about her family. She states, “I’ve put them through so much. And I feel so ashamed when I’m unable to care for them.” She endorses feelings of hopelessness but denies suicidal and homicidal ideations. The client says that she hears voices and believes that they are the voices of her deceased ancestors trying to communicate with her. She explains that the “spirits” whisper her name in the middle of the night and come to her when she is alone. The client denies command hallucinations. Her appetite is poor, and she has difficulty sleeping “most nights.” She has experienced depressive symptoms most of her life, but, outside of the recent hospitalization, she has not sought treatment due to believing that mental illness is a sign of weakness. History of Conditio | You work in a community mental health setting. Your client is a 32-year-old Latina presenting with symptoms of depression and psychosis. She reports that she was hospitalized more than 6 months ago and did not attend follow-up appointments due to losing her health insurance coverage. The client currently reports anhedonia, sadness, feelings of worthlessness, and poor concentration. She explains that there are many days when she cannot get out of bed and is unable to fulfill her role as a wife and mother. The client also reports audio hallucinations and says this began when her grandmother died more than a year ago. She explains that her grandmother lived in her home and that her loss was “devastating” to the client. The client is fluent in Spanish and English. | n and Family History: You obtain a signed release of information before the client’s session today, which has enabled you to receive the client’s hospital records. The client was admitted due to hallucinations and suicidal ideation. The hospital psychiatrist provided a diagnosis of brief psychotic disorder and bipolar II disorder. The client was prescribed antipsychotic medication and an antidepressant. She reports that she discontinued the antipsychotic medication shortly after discharge because it caused excessive sleepiness. Regarding the antidepressant, the client states, “I just take it on the days when I’m really having a hard time.” The client has two teenage sons and lives near her extended family | How might you use motivational interviewing to elicit change talk from the client? | Evoke the client’s optimism for change by asking about a previous change she successfully made in her life. | Confront the client on how maintaining the status quo is detrimental to progress. | Persuade the client to attend a psychiatric evaluation for medication. | Help the client to reevaluate the nature of the relationship with her husband. | (A): Evoke the client’s optimism for change by asking about a previous change she successfully made in her life.
(B): Confront the client on how maintaining the status quo is detrimental to progress.
(C): Persuade the client to attend a psychiatric evaluation for medication.
(D): Help the client to reevaluate the nature of the relationship with her husband. | Evoke the client’s optimism for change by asking about a previous change she successfully made in her life. | A | Using motivational interviewing, you would elicit change talk by evoking the client’s optimism for change by asking about a previous change that she successfully made in her life. Motivational interviewing uses various techniques to reduce ambivalence and enhance motivation to change. The spirit of motivational interviewing focuses on collaborating with the client, evoking reasons for change, and honoring the client’s autonomy. Helping the client reevaluate her relationship with her husband would not be aligned with the spirit of motivational interviewing because the client did not establish this as an area in need of change. Using persuasion and confrontation is not in alignment with the spirit of motivational interviewing. Exploring disadvantages of the status quo is a component of motivational interviewing; however, the counselor must guide the client in this process rather than confront the client to take action. Therefore, the correct answer is (D) | counseling skills and interventions |
850 | Initial Intake: Age: 26 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Private Practice Type of Counseling: Individual | The client appears his stated age and is dressed appropriately for the circumstances in clean jeans and a t-shirt. He identifies his mood as “anxious but a little excited” because he “is hopeful that he can finally let his anger go.” He tells you he is tired because he has difficulty falling asleep and staying asleep most nights. His affect is pleasant with emotional lability evident. He demonstrates appropriate insight and judgment, memory, and orientation. He reports never “seriously” having considered suicide but acknowledges that there were times when he wondered “if dying would make this pain go away.” He has never attempted suicide and states he would never consider harming himself or anyone else. | You are a counselor in a private practice setting. Your client is a 26-year-old male who presents for counseling at the request of his family and his employer, with whom he is close and who knows his history. The client tells you that he has been angry for the past 15 years, beginning a year after the death of his father from a heart attack. He says that his anger is triggered very quickly when frustrated by people or situations and that his “fuse is very short these days.” He states that he has been in some “loud arguments” with his mother, and later his stepfather. He admits that there have been times in the past when he and his stepfather have “almost come to blows” but his mother stepped in and made them stop. He admits to having hit or kicked walls at times in his anger, but has never hit a person. He tells you that he doesn’t want to feel this way because it interferes with his relationships and his former girlfriends have never understood that when the anniversary of his dad’s death comes around, he just wants to be alone for a couple days and not have to talk to anyone. He tells you that he has never had a long-term relationship with a woman because either he gets “depressed” for a few days during certain times of the year (i.e., father’s birthdate and death date) or because he is too quick to get angry and then says things he doesn’t mean. He says that he has been in a relationship with a woman now for eight months and really wants to get himself together because he feels “she’s the one.” | Family History:
The client reports a family history of being the youngest of three siblings born to his mother and father. He reports a “great life” with his family and that they regularly spent time together playing, camping, traveling, and “just being a family.” He tells you that he is sure there were occasional arguments but that he doesn’t remember anything significant, except that he had been mad at his dad the night he died because his dad wouldn’t let him stay up late, but that before the client went to bed, he had come down, apologized to his dad, and they had both said “I love you.” He states his parents had been married for 15 years prior to his father’s death, which occurred when the client was 11 years old. He states his dad died of a heart attack while sleeping, so while he did not see it, he knew something had happened because his mother woke him and his siblings and rushed them over to the next door neighbors’ house. He said that his mother went to the hospital with his father in the ambulance and came home that night to tell him and his siblings that their father had died. He tells you that he and his siblings are still very close and that they now have three much younger siblings born after his mother married his stepfather. He says that he is very close to his mother and stepfather, although he lives three hours away from them. He tells you that he tries to get home for big family events, like birthdays. He states that his stepfather adopted him and his siblings after the wedding and the client loves him very much. He tells you that he and his stepfather have gotten in what the client thinks are “typical teenager/parent” conflicts but that they have often been made worse by the client’s anger that seems to always be inside and erupts quickly. | Which of the following treatments would be least helpful for treating this client? | Trauma-focused Cognitive Behavioral Therapy (TF-CBT) | Prolonged Exposure Therapy (PE) | Brain Spotting | Eye Movement Desensitization Reprocessing (EMDR) | (A): Trauma-focused Cognitive Behavioral Therapy (TF-CBT)
(B): Prolonged Exposure Therapy (PE)
(C): Brain Spotting
(D): Eye Movement Desensitization Reprocessing (EMDR) | Trauma-focused Cognitive Behavioral Therapy (TF-CBT) | A | TF-CBT is not appropriate treatment for this client because TF-CBT is engineered and modeled to be used with children and adolescents who have experienced trauma. EMDR, brain spotting, and PE are all appropriate treatments for adults with PTSD. Therefore, the correct answer is (A) | intake, assessment, and diagnosis |
851 | 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). | The client has been free of suicidal ideation for four weeks now. Psychoeducation has helped him gain insight into BDD. Distance counseling has been effective in decreasing ritualistic behaviors, and you provide face-to-face sessions every other week to help decrease avoidance behaviors. The client has benefited from cognitive-behavioral therapy (CBT). He attended two social events this month and has decreased ritualistic “safety behaviors” once used to prevent a feared consequence. He would like to take two college courses in the fall and is nearing the termination stage of therapy | As you near the termination phase with your client, you recommend which of the following to help assess progress, maintain learned skills, and prevent relapse? | Booster sessions | Psychoeducation | Value-based living | Mentorship | (A): Booster sessions
(B): Psychoeducation
(C): Value-based living
(D): Mentorship | Booster sessions | A | Booster sessions occur after treatment has ended and provide a way for clients to assess progress, maintain learned skills, and prevent relapse. Relapse prevention (RP) is an evidence-based practice for BDD. RP is a process in which skills are reviewed, potential challenges are addressed, and the idea of self-therapy is discussed. RP takes place prior to termination and during future pre-planned booster sessions. Value-based living is a component of acceptance and commitment therapy (ACT). Value-based living is an intervention that can help individuals with BDD de-emphasize the importance of attraction by focusing on other values in one’s life. Psychoeducation is generally used at the beginning of treatment for individuals with BDD to help improve insight. Mentorship is not a component of relapse prevention. Therefore, the correct answer is (C) | treatment planning |
852 | Name: Aghama Clinical Issues: Cultural adjustments and sexual identity confusion Diagnostic Category: V-codes Provisional Diagnosis: Z60.3 Acculturation Difficulty Age: 18 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Bisexual Ethnicity: Nigerian Marital Status: Never married Modality: Individual Therapy Location of Therapy : University Counseling Center | The client comes to your office and sits rigidly and makes little eye contact. She is dressed neatly and appropriately for the weather with overall good hygiene. She appears cooperative and open to the therapeutic process. She expresses a willingness to discuss her experiences, thoughts, and feelings, but show some hesitation due to her unfamiliarity with therapy. The client's mood is depressed. Her affect is congruent with her mood, displaying a flat or subdued demeanor, but shows some variability when discussing her family or life in Nigeria. Her speech is clear, fluent, and coherent. She has no difficulty expressing herself in English and seems to have a good command of the language. Her speech is slightly slow. The client's thought process appears linear and goal-directed. She is able to articulate her concerns and goals; her thoughts seem to be dominated by her feelings of sadness, loneliness, and homesickness. The client demonstrates some insight into her situation and the impact of her homesickness on her overall well-being. She appears to be motivated to seek help and improve her situation. There is no evidence of suicidal ideation or intent. The client does not express any thoughts of self-harm or harm to others. However, her ongoing feelings of sadness and loneliness warrant close monitoring and support during the therapeutic process. | First session You are a licensed mental health counselor working at a university counseling center and take a humanistic approach in your work with clients. Today you are meeting with an 18-year-old student who recently moved to the United States from Nigeria. She tells you that she moved to the United States one month ago after missionaries in Nigeria granted her a scholarship. She feels lonely, misses her family, and is questioning her decision to come to the United States. She indicates she has never been to therapy before but was told by her academic advisor that it might be helpful to make an appointment with a counselor. You continue the intake session by exploring the client's current psychological functioning. She expresses that she is homesick and is struggling to find her place in a new environment. She describes having difficulty making friends at college and feels isolated. She does not feel comfortable talking about her personal life with people she does not know well, which makes it even more difficult for her. Additionally, she is struggling with the pressure of living up to the expectations of the members of her church that gave her the scholarship to attend the university. She is currently pursuing a nursing degree at the university. You ask her to share some details about her family and cultural background in order to gain a better understanding of the context of her situation. She tells you that her parents are both teachers and she has two siblings. The family is very close-knit and they typically speak in their native language at home. You also ask about how she is managing her academic obligations, any specific challenges or barriers she might be facing, and how she is spending her free time. She says that her courses are challenging, but she is managing them well. In between classes, she spends most of her time in the library studying. You discuss the therapeutic process and what she hopes to gain from counseling. She expresses that she would like to learn how to better cope with her homesickness and loneliness. She says, "I'm worried that I'll be a disappointment. It took a lot of money and effort to get me here, and I don't want to let them down. I was so excited when I first got the scholarship, but maybe it would have been better if it went to someone else." You validate her feelings and explain that it is natural to feel overwhelmed when faced with a new culture and environment. You further explain the importance of focusing on her strengths, as she has already accomplished so much by making the decision to attend college abroad. You describe therapy as an opportunity for her to explore her feelings, develop coping strategies, and adjust to her new environment. At the end of the session, she tells you she is on a "tight schedule" and needs to know when she can see you for therapy so she can plan accordingly. You provide her with your availability and suggest that an ideal therapy schedule would involve weekly sessions. You also explain the importance of consistency in order to allow her to make meaningful progress during therapy. You schedule an appointment for the following week. | null | How would you explain your primary role as a humanistic-oriented therapist to this client? | "I'm here to provide a supportive and nonjudgmental space for you to explore your feelings and experiences to help you gain insight into your unique situation." | "My job is to help you focus on what you want to achieve in the future and use small steps to move towards those goals." | "During therapy, I will help you identify and challenge any unhelpful thoughts and biases that may be contributing to your current problems." | "My main objective as your therapist is to help you take ownership of your choices and develop the necessary skills to effectively handle your life circumstances." | (A): "I'm here to provide a supportive and nonjudgmental space for you to explore your feelings and experiences to help you gain insight into your unique situation."
(B): "My job is to help you focus on what you want to achieve in the future and use small steps to move towards those goals."
(C): "During therapy, I will help you identify and challenge any unhelpful thoughts and biases that may be contributing to your current problems."
(D): "My main objective as your therapist is to help you take ownership of your choices and develop the necessary skills to effectively handle your life circumstances." | "I'm here to provide a supportive and nonjudgmental space for you to explore your feelings and experiences to help you gain insight into your unique situation." | A | As a humanistic-oriented therapist, your primary role is to provide a safe and supportive environment in which the client can freely explore their feelings and experiences. This allows the client to gain insight and understanding into their unique situation. Your role is not to judge or make decisions for the client, but rather to provide guidance and support in order for them to come to their own conclusions about the best steps for moving forward. Therefore, the correct answer is (B) | professional practice and ethics |
853 | 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 | In a research study, which methodological feature considers ethnocultural variables when determining external validity? | Choice of outcome measures | Design of the study | Length of follow-up | Criteria for inclusion-exclusion | (A): Choice of outcome measures
(B): Design of the study
(C): Length of follow-up
(D): Criteria for inclusion-exclusion | Criteria for inclusion-exclusion | D | A research study’s inclusion-exclusion criteria are a methodological feature that considers ethnocultural variables (eg, race, ethnicity, gender, and age). Inclusion criteria are characteristics of the subjects participating in the study, whereas exclusion criteria disqualify individuals from being included. External validity, or how well the results can be generalized to other settings, is contingent upon the characteristics of the study’s participants. For example, a study concludes that certain foods and additives may impact symptoms of ADHD. However, if the study was only conducted with white adolescent females, it has limited value and thus cannot be generalized to the client, an African American 7-year-old male. The design of the study (whether it is quantitative or qualitative), outcome measures (ie, symptom reduction), and the length of follow-up (ie, the intervention effects over time) are crucial elements of a research study; however, only inclusion-exclusion criteria affect the study’s generalization to ethnocultural groups. Therefore, the correct answer is (D) | professional practice and ethics |
854 | 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. | You meet with the client, and she reports that she started dating someone. You and the client spend some time talking about the man who she is dating and agree that he sounds like a nice person that is not taking advantage of her personality. You and the client discuss her having an increased awareness of the behaviors that she has engaged in in the past that she did not like. The client identifies that she has engaged in behavior that worries her with this boyfriend. She went out for lunch and felt compelled to buy him lunch also, even though he was not there. After exploring why the client feels an obligation to buy her boyfriend lunch when he is not present with her, it becomes clear that it is motivated by the fear that he will be offended that she bought herself lunch without thinking of him. You support the client in identifying more helpful thoughts related to this and ask her to complete a behavioral experiment regarding this situation. The client becomes frustrated that she is still struggling with relationships and says, “I think I’ll just date who I want and how I want from here on out. It’s definitely the easiest choice instead of doing all of this.” You remind the client that therapy takes some time but can be really beneficial and you praise her for engaging fully so far | Which of the following statements demonstrates the use of paradox in response to the client’s statement that she should just date who she wants? | “Maybe you should date who you want and how you want, even though it can be frustrating for you. This process does seem like a really hard step for you.” | “You can continue to date who and how you want to; that is your own choice.” | “What if you decided to try things differently this time because you haven’t been happy in the past with dating.” | “Only you can decide if you want to continue counseling; you can always take a break or wait until you’re ready to work on your relationships.” | (A): “Maybe you should date who you want and how you want, even though it can be frustrating for you. This process does seem like a really hard step for you.”
(B): “You can continue to date who and how you want to; that is your own choice.”
(C): “What if you decided to try things differently this time because you haven’t been happy in the past with dating.”
(D): “Only you can decide if you want to continue counseling; you can always take a break or wait until you’re ready to work on your relationships.” | “Maybe you should date who you want and how you want, even though it can be frustrating for you. This process does seem like a really hard step for you.” | A | Paradox is a counseling technique in which the counselor goes along with the client’s statement even if they do not agree with it to demonstrate a deeper empathy for the client’s underlying feelings. It must be used with care in the counseling relationship. The purpose of using paradox is to investigate the roots of the client’s motivation to continue a negative behavior. For instance, this client is frustrated that counseling is taking time and rather than focusing on the client’s statement of continuing negative behavior, you are empathizing with this feeling of frustration by agreeing with her statement as an expression of frustration. This statement can also support the client in identifying reasons to change her behavior. The client has the right to start or stop therapy if she wants, but you would want to support her in finding the motivation to participate. Encouraging the client to try new behavior that may have more positive results is a helpful technique, but it does not demonstrate the use of paradox. Therefore, the correct answer is (C) | counseling skills and interventions |
855 | Initial Intake: Age: 32 Gender: Female Sexual Orientation: Bisexual Ethnicity: Caucasian Relationship Status: In a relationship Counseling Setting: Community mental health agency Type of Counseling: Individual via Telehealth | Melanie is unkempt, looks tired and is casually dressed. Motor movements are within normal limits, eye contact is appropriate. Melanie reported passive suicidal ideation intermittently throughout her depressive episode as a means for escaping her feelings but has no plan or intent. Melanie reluctantly admits to several instances of past trauma which include losing her son’s father to a tragic car accident four years ago where her son witnessed him die, as well as having three other older children, all with separate fathers, with whom she has no contact. Her only support system is her boyfriend who takes great care of her and her son’s school, which provides help with his Individualized Education Plan. | Diagnosis: Dysthymic disorder (F34.1), provisional, Anxiety disorder, unspecified (F41.9), Post-traumatic stress disorder (PTSD) (F43.1)
Melanie has been in mental health counseling for several years through your agency and was referred to you by her last counselor who obtained a position with a local University and was leaving your company. Melanie is a 32-year-old Caucasian female who lives in a house with her boyfriend and her 9-year-old son, Gus, who suffers from ADHD, anxiety, and PTSD. Melanie is receiving psychiatric medication from your agency’s Psychiatrist, another Psychiatric practice by a Nurse Practitioner in a different city and is being treated medically by a Gastroenterologist who has also prescribed medications. Melanie is complaining of ongoing depression caused by her chronic nausea and a cyclic vomiting syndrome and does not want to leave her bed out of helplessness and hopelessness that nothing will ever change. She also reports experiencing anxiety and panic-like attacks when she is around others which causes her to socially isolate for sometimes days at a time. She is upset she cannot care for her son the way she desires and wants to continue counseling to help her feel better. | Family History:
Melanie has what she states is a “complicated” relationship with her family, including her mother, whom she believes wants no involvement with her or her son, and has no contact with anyone else. Melanie states her falling out with her mother began when she was just a child. She comments that her father and her were “very close”, but his new wife makes it “challenging to communicate with him.” Melanie has lived on her own for much of her life and has not engaged in or sustained any relationship with her first three children. She adds that in each instance they were either unfairly taken away by the father or the state and that she has tried to initiate contact, but it has not been successful. Melanie continues to deflect from discussing family dynamics, causing gaps in your initial interviewing process.
Work History:
Melanie reports never having an “official” job but always being able to make money “somehow.” She has been on Medicaid for most of her life and continues to survive off government support and the charity of others. She tells you she has dreams of writing a book or even owning her own bakery but does not demonstrate willingness to take the steps at achieving those goals.
Legal History:
Melanie has incurred a criminal record for failing to pay child support several times over the past nine years and continues to receive notices and warnings to ensure she is making her payments on time. | You assess that EMDR (eye movement desensitization and reprocessing) therapy will be beneficial for Melanie's treatment of past trauma. However, this service is not covered by her Medicaid insurance provider. How do you bring this up with Melanie? | Provide EMDR services without payment as this is the ethical treatment option | Tell her she needs EMDR to heal regardless of how she pays for it | Explain the constraints on her resources will not afford her the opportunity to have EMDR | None of these approaches are appropriate in handling this situation | (A): Provide EMDR services without payment as this is the ethical treatment option
(B): Tell her she needs EMDR to heal regardless of how she pays for it
(C): Explain the constraints on her resources will not afford her the opportunity to have EMDR
(D): None of these approaches are appropriate in handling this situation | None of these approaches are appropriate in handling this situation | D | Your assessment of Melanie's need for EMDR to have effective counseling results is your initial clinical opinion to begin with and does not account for a "necessity" in her care despite how supportive it might be for her healing process. You may discuss the option of EMDR therapy with her throughout the course of counseling and educate her on the process while allowing her to make the final decision about receiving the services. Assuming she will not be able to afford EMDR because her specific Medicaid provider does not cover it, is not giving the client the chance to decide what is in her best interest. Providing any services without proper rendering of payment is not necessarily an ethical transaction, however, the transaction may be seen as a charitable one. It is best practice to present your assessment findings to Melanie while explaining how EMDR treatment could be beneficial, then inform her that her insurance does not cover it and collaborate with her on alternative options. Therefore, the correct answer is (D) | professional practice and ethics |
856 | 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. Ninth session Alexei appeared anxious during his weekly session today. He tells you that he constantly thinks about how good his life was in Germany and is afraid he will never feel comfortable in America. On a positive note, Alexei shares that he and his wife talked about their relationship and want to take steps to repair their marriage. He now admits to you that his drinking is a problem, but he struggles with the physical aspects of trying to quit. Whenever he tries to stop drinking, he gets sweaty and fears that he will have a seizure, so he begins drinking again. He explains that he cannot get past these symptoms. You discuss with Alexei the option of entering a rehabilitation center to assist him medically with the detox process. Alexei admits that he is unsure about the idea of going into treatment. He acknowledges that it might be beneficial but worries about leaving his family for a prolonged period. He expresses concern that his wife will not be able to handle everything on her own and wonders what will happen with their marriage while he is in treatment. You explore his concerns using motivational interviewing techniques and ask him to discuss this information with his wife. During the session, you commend Alexei for recognizing the impact of his drinking on his life and his willingness to discuss these concerns openly. You acknowledge the challenges he faces in trying to quit and the physical symptoms he experiences. You explain that seeking professional help at a rehabilitation center could provide the medical support he needs to manage withdrawal symptoms safely and effectively. You emphasize that by addressing his alcohol dependence, he will likely find it easier to adapt to his new life in America and repair his marriage. Regarding his concerns about his wife managing things while he is in treatment, you explore potential solutions and support systems that could be implemented during his absence. You encourage Alexei to discuss these concerns with his wife and involve her in decision-making. Together, they can identify family members, friends, or community resources that could offer assistance. Finally, you reassure Alexei that taking the time for treatment is an investment in his long-term well-being and that of his family. By addressing his alcohol dependence, he will be better equipped to support his wife and family emotionally and practically in the long run. | The client grew up in Germany and recently immigrated to America with his wife and mother. Both parents have a history of alcohol abuse and divorced when he was five. After his father left, his mother's enmeshment with her son intensified. She made him spend time with her rather than his school friends and used the threat of leaving him in an orphanage to control his behavior. Whenever he became upset or anxious, she would cuddle him and give him sips of whatever alcohol she consumed. The client was recently arrested for driving under the influence. The client's wife is contemplating separating because of her husband's continued drinking. He identifies a couple of bartenders as "friends" but cannot recall anyone he knows in an alcohol-free context. He has also been late or missed work due to hangovers and will likely lose his job. His co-workers have often complained that he smells of alcohol. Previous Counseling: The client has had suicidal thoughts thrice, all of which were recent. The initial occurrence was after a DUI incident, followed by a write-up at work, and the third after his wife proposed a separation. The client has shared that he has a specific plan in mind for ending his life, which involves either ingesting pills or cutting his wrists. | What secondary factor may be contributing to the client's substance use? | Codependency issues with his mother | Problems with his marriage | Difficulty in integrating culturally | Loneliness and lack of social interactions | (A): Codependency issues with his mother
(B): Problems with his marriage
(C): Difficulty in integrating culturally
(D): Loneliness and lack of social interactions | Difficulty in integrating culturally | C | The client is having difficulty with enculturation, as demonstrated by his missing home and his fear of not being able to adapt to being in America. Therefore, the correct answer is (C) | counseling skills and interventions |
857 | Initial Intake: Age: 18 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Community Residence Type of Counseling: Individual | Nadia was initially resistant to the interview. She stated that she had been seeing counselors her whole life and none of them ever helped. Nadia had limited insight regarding her risk-taking behaviors. The counselor assessed that Nadia’s cognitive functioning appeared low. She stated that although she had contemplated suicide in the past, she currently had no intention or plan.
| Nadia is an 18-year-old in a community residence for children in foster care. She was referred for counseling because she has been running away from the group home, often for days at a time. Currently she is not getting along with her peers and gets into fights when they make comments about her activities, which is starting to affect everyone in the house.
History:
Nadia is one of 10 children by her birth parents. She has an extensive history of abuse and sexual exploitation by her parents until the age of 14 when she was removed from her parent’s care. Her and her siblings were sent to various foster homes as they could not all stay together. This is a subject that Nadia does not like to talk about since she was the oldest and had the responsibility to care for the younger ones. She feels as if she let them down. Nadia is frequently truant from school. For the past 4 years Nadia was in and out of foster homes due to her risk-taking behaviors and disrespect for others. She does have a good relationship with two staff members in the group home. | null | Which of the following factors should be considered in an assessment in addition to a client's record? | Biases | All of the above | Influence of professional orientation | Trust and rapport | (A): Biases
(B): All of the above
(C): Influence of professional orientation
(D): Trust and rapport | All of the above | B | Although the client's record can provide a wealth of information, it should be reviewed in conjunction with interviews of client, family and collateral sources, as well as recent tests, evaluations or assessments. A counselor should also consider his/her professional orientation and how it may influence case conceptualization. It is also important to evaluate the trust and rapport in the relationship to understand whether there is possibly information that has been withheld. A counselor should also be aware of his/her biases in order to reflect upon those and how they may influence the assessment process. Therefore, the correct answer is (D) | treatment planning |
858 | 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. | The client comes to the session, sits down, and is quiet. The parents report that prior to the session he was playing an online game and became so upset that he threw his video game console. The parents express frustration that they do not know what to do when this happens. You provide psychoeducation to the client regarding coping skills to manage frustration. You find out that the parents respond by removing access to video games, and this usually results in yelling back and forth with the parents and the client. The parents do typically encourage the client to listen to music because this appears to be very effective in calming him down. The client expresses frustration with the people that he was playing with by saying that they “cheated and are lying about it.” You support the client with cognitive reframing. When the client becomes angry, the parents are unsure of what to do | When the client becomes angry, the parents are unsure of what to do. Which of the following would be considered positive reinforcement of the client’s behavior? | When the client resists becoming angry despite circumstances that usually generate his anger, the parents withhold a negative consequence (such as scolding) to encourage him to continue the appropriate behavior. | The client does not become angry when he loses, and the parents provide praise. | The parents remove the video game console and restrict his access to it over the next week. | The parents ignore the client when he throws his video game console. | (A): When the client resists becoming angry despite circumstances that usually generate his anger, the parents withhold a negative consequence (such as scolding) to encourage him to continue the appropriate behavior.
(B): The client does not become angry when he loses, and the parents provide praise.
(C): The parents remove the video game console and restrict his access to it over the next week.
(D): The parents ignore the client when he throws his video game console. | The client does not become angry when he loses, and the parents provide praise. | B | The parents are providing positive reinforcement when they provide praise when the client exhibits appropriate behavior. The parents removing a consequence (scolding) to increase appropriate behavior is negative reinforcement. The parents ignoring a behavior is considered extinction. The parents removing the console would be considered punishment for his behavior. Therefore, the correct answer is (A) | counseling skills and interventions |
859 | Client Age: 13 Sex Assigned at Birth: Male Gender: Transgender; Gender Nonconforming (TGNC) Ethnicity: Caucasian Counseling Setting: Child and Family Agency, School-Based Services Type of Counseling: Individual and Family Presenting Problem: Truancy; Gender Dysphoria Diagnosis: Gender Dysphoria, Provisional (F64.1); Social Exclusion or Rejection V62.4 (Z60.4) | Mental Status Exam: The client is dressed in age-appropriate clothing. They wear eye makeup and chipped black fingernail polish, and they have bitten most fingernails down to the quick. The client’s mood is irritable, and they are quick to show anger toward their mother when misgendered. Their thoughts are coherent, and they deny audio/visual hallucinations. The client acknowledges feeling sad and hopeless but denies suicidal ideation. They attribute increased levels of anxiety at school to bullying, particularly with select peers. They explain that a select group of students threaten the client and call them offensive and derogatory names. Family History and History of th | You are a school-based mental health counselor in a public middle school. Your client is a 13-year-old Caucasian 7th grader who presents for the initial intake with their mother. The mother says that the client has had several unexcused absences from school because “he is confused about his gender.” The client adamantly denies being confused and explains that they self-identify as transgender. The client’s preferred pronouns are “they/them.” The client further states that they have had a strong desire to be a different gender since early childhood, and this desire and their distress have recently intensified. The mother reports that the client is chronically irritable, spends a lot of time alone, and has “basically shut everyone out.”The client reports experiencingbullying—both verbal and physical—in school “nearly every day.” In addition to the bullying, the client says that certain teachers refuse to allow them to use the bathroom aligned with their identified gender. To prevent this conflict, the client does not eat breakfast or lunch at school. | Client Age/Gender: Sexuality: Both Heterosexual Ethnicity: Both Caucasian Relationship Status: Married Counseling Setting: Outpatient Behavioral Health Type of Counseling: Couples Counseling Marital Discord Diagnoses: You are a certified counselor providing couples therapy in an outpatient behavioral health setting. The wife serves as the primary client due to the complexity of her clinical and diagnostic presentation. She is a 34-year-old female seeking marital counseling with her 44-year-old husband of 18 months. The client explains that shortly after returning from the couple’s honeymoon, she began having chronic, debilitating migraines causing her to remain bedridden, sometimes for days on end. She reports that she no longer engages in activities that she once enjoyed and feels chronically tired and depressed. Despite being treated by several neurologists, her chronic migraines persist, and she is now on long-term leave from her job. The client’s husband is a chief financial officer for a large hospital system and works long hours. The couple has joint custody of the husband’s 12-year-old son from a previous marriage. The client thinks that there is an unfair amount of burden placed on her to parent her stepchild, which has caused conflict among the client, her husband, and the husband’s ex-wife. The husband admits to growing impatient with the chronic nature of his wife’s illness and says she is not the same person that she was when they met nearly 3 years ago. The client and the husband are both well dressed. The client is wearing sunglasses and explains that her migraines cause her to be light sensitive. It is the middle of the husband’s workday, and he is dressed in a suit and tie. The client reports daytime sleepiness, which she attributes to her migraine medication. Her appetite is fair. She denies current suicidal or homicidal ideations. However, the client does report that she has previously had thoughts of not wanting to live. Her mood is depressed, and her affect is congruent with her mood. The client is tearful when discussing how her illness has affected the marriage and states that she receives little support from her husband. When the client begins to cry, the husband responds by sitting silently, crossing his arms, shaking his head, and looking around the room. The client states, “See! This is what I’m talking about! Whenever I need his support, he checks out.” Family History and History of The client’s parents were never married. The client was placed in foster care at age 3 due to parental neglect. She remained in foster care until age 6, when the courts granted her paternal grandmother full custody. The client’s husband has two younger brothers and was raised by his biological mother and father. He describes his father as “hardworking” and his mother as a stay-at-home mom. Approximately 5 years ago, the husband was treated for alcohol use disorder. He states that he stopped drinking independently and “didn’t have to rely on a 12-step program to get sober.” The couple met when the husband was married, which contributed to a drawn-out and acrimonious divorce | What assessment tool should you use to better determine the couple’s relationship distress, cohesiveness, and affectional expression? | Maudsley Marital Questionnaire (MMQ) | Dyadic Adjustment Scale (DAS) | Measure of Attachment Qualities (MAQ) | Personal Assessment of Intimacy in Relationships (PAIR) | (A): Maudsley Marital Questionnaire (MMQ)
(B): Dyadic Adjustment Scale (DAS)
(C): Measure of Attachment Qualities (MAQ)
(D): Personal Assessment of Intimacy in Relationships (PAIR) | Dyadic Adjustment Scale (DAS) | B | The DAS measures a couple’s levels of relationship distress and includes the following four subscales: (1) dyadic consensus (ie, how well the couple agrees with one another), (2) dyadic satisfaction (ie, how content the couple is with the relationship), (3) dyadic cohesion (ie, how well the couple engages in activities with one another), and (4) affectual expression (ie, agreed-upon emotional and affectional expression). The DAS, which consists of a 32-item self-rated assessment instrument, is used to measure levels of perceived distress for couples in committed relationships. The MMQ is also a self-assessment. The MMQ uses two subscales to measure relational and sexual connectedness. The PAIR inventory identifies five forms of intimacy for a couple: emotional, recreational, sexual, social, and intellectual. The MAQ measures secure, avoidant, and anxious-ambivalent attachment styles. Therefore, the correct answer is (A) | intake, assessment, and diagnosis |
860 | Initial Intake: Age: 29 Gender: Female Sexual Orientation: Heterosexual Ethnicity: Caucasian Relationship Status: Engaged Counseling Setting: Agency - Telehealth Type of Counseling: Individual | Client presents as unkempt, hygiene unknown as it is unable to be assessed via telehealth. She is appropriately dressed. Motor movements are within normal limits. Her eye contact is intermittent as she appears to have difficulty focusing both eyes in the same direction (amblyopia or “lazy eye”). She is cooperative and engaged. She admits to having passive suicidal ideation when triggered with distressing emotions and has considered taking pills as a method that would be the most comfortable but declines having intent or plan to collect pills for this purpose. She states her anxiety increases when she takes her children to the grocery store and when she is around crowds, experiencing panic-like symptoms necessitating her to call a friend to calm her down. She reports experiencing flashbacks of sexual trauma and prefers to stay at home as often as possible. She is alert despite being distracted often by her children in the background and is oriented to person, place, time, and situation. She is fidgeting with her hands and speaking circumstantially, often changing topics and going on rants in different directions before returning to her main points. She reports low energy, sleeping too much and weight gain. She adds that she cries every night over losing her paternal grandfather over 10 years ago. | Diagnosis: Anxiety disorder, unspecified (F41.9), Reaction to severe stress, unspecified (F43.9)
You are a new counseling intern in a community agency conducting virtual individual counseling sessions using Telemedicine technology. You were referred a 29-year-old female client by your agency’s Psychiatrist who felt she needed to return to weekly psychotherapy as she had previously been doing two years ago. During your initial assessment session, you learn she has three young children under age 8, lives with her fiancé who is the father of the two youngest children, and that due to medical reasons she is on disability through Medicaid and is unable to work. She tells you she has been depressed and contemplating suicide because she cannot find relief from her anxious thoughts. She wants to be a better mom to her children than her mother was to her and wants help overcoming grief and loss, traumatic memories, panic attacks and irritability. | Family History:
Client has a strained relationship with her mother whom she reports is “always dating an alcoholic” and has been abusive to her growing up. She adds that her mother has “Bipolar depression and ADHD.” She complains often about both her mother and her fiance’s mother mistreating her, making her feel resentful and angry. Client has two sisters, one of which lives with her mother and is mentally challenged. Her other sister has little to no contact with her family. Her father, who has been divorced from her mother for over 20 years, was once accused of child sexual abuse which has alienated him from the rest of their family. The client is the only one who remains in contact with him. | Considering her family history and reported symptoms, which disorder can be ruled out before further assessing for an additional provisional diagnosis? | ADHD | panic disorder | Bipolar II | Bipolar I | (A): ADHD
(B): panic disorder
(C): Bipolar II
(D): Bipolar I | Bipolar I | D | The client demonstrates history, behavior and reported symptoms that are reasonable enough to screen and further assess for Panic Disorder, Bipolar II or ADHD. Since the client has not experienced a manic episode for a period of at least one week, she does not meet criteria for Bipolar I Disorder. Her panic symptoms, however, may be better explained by her existing diagnoses of either anxiety or post-traumatic stress. Family history of conditions (such as Bipolar or ADHD) may increase the likelihood but does not automatically implicate next of kin with a diagnosis. The sum of her specific symptoms could very well be side effects of her medication and may not necessarily indicate a co-occurring disorder. Answers a, c and d however, are conditions that have plausible reason to be considered upon further analysis. Therefore, the correct answer is (B) | intake, assessment, and diagnosis |
861 | Client Age: 8 Sex: Female Gender: Female Grade: 3rd Ethnicity: African American Counseling Setting: School-based Type of Counseling: Individual and Family Presenting Problem: Defiance Diagnosis: Oppositional Defiant Disorder 313.81 (F91.3) | Mental Status Exam: The client displays an angry affect and sits with her arms crossed. She is well dressed and well groomed. The client’s PGM repeatedly prompts her to say, “yes ma’am” and “no ma’am” when answering questions. The client sits slumped in her chair. She agrees to color in a feelings thermometer that reflects increased anger, sadness, and fear. Her insight is poor. The client often refuses to eat school lunch, and the PGM reports that the client is a picky ea | You are a school-based mental health counselor conducting an initial intake with an 8-year-old African American female in the 3rd grade. The client presents today with her paternal grandmother (PGM), the client’s legal guardian. The PGM states that the client is argumentative, refuses to take responsibility for her actions, and has a tantrum when she receives a consequence for her behavior. She reports that the client is restricted from “every single privilege indefinitely.” The client has been told she can regain privileges once she “learns to act her age.” The client states she is treated unfairly and “blamed for everything” at home and school. The client’s teacher reports that she has difficulty following directions, is easily annoyed by her classmates, and frequently loses her temper. The client’s grades are poor, and she is below grade level in reading. However, she enjoys art and proudly reports that one of her pictures came in 1st place and is hanging in the library. | You are meeting with the client individually and providing parenting training with the client’s PGM. The client’s teacher has implemented a behavioral chart for the classroom, and you ensure the client is receiving appropriate reinforcement for targeted behaviors. The teacher believes the client’s behavior indicates ADHD, and you have agreed to conduct classroom observations. During the observation, you note that the client gets out of her seat multiple times to sharpen her pencil. While doing so, she glares at other students and is observed balling up her fists and threatening others. The teacher yells at the client to sit down and stop disrupting the classroom, which has little effect on the client’s behavior. The client receives a sticker from her teacher to positively reinforce predetermined operant behaviors | The client receives a sticker from her teacher to positively reinforce predetermined operant behaviors. Which of the following is NOT a key principle of operant conditioning? | Stimulus control | Extinction | Reproduction | Punishment | (A): Stimulus control
(B): Extinction
(C): Reproduction
(D): Punishment | Reproduction | C | Reproduction is a social learning concept rather than a key principle of operant conditioning. There are four phases of social learning: (1) attention (ie, noticing a particular behavior; (2) retention (ie, remembering the information); (3) reproduction (ie, imitating the behavior); and (4) motivation (ie, the desire to imitate the behavior). Principles of operant conditioning include extinction, punishment, reinforcement, and stimulus control. For extinction to occur, there must first be a reinforced response. Extinction happens when the reinforcer for that response is stopped, which lessens the possibility of the behavior’s recurrence. In operant conditioning, punishment is the presentation or removal of a circumstance or stimulus, resulting in the decreased probability of that response occurring. Finally, stimulus control is the process in which behavioral responses differentially happen in the presence or absence of particular stimuli. Therefore, the correct answer is (D) | professional practice and ethics |
862 | 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 | Molly requested that the counselor not tell her mother about the consideration of cutting. The counselor should? | Call 911 to have Molly assessed for suicide risk | Immediately call mom in the room because it is a safety risk | Tell Molly not to worry, she will not tell her mom what is disclosed in session | Provide psychoeducation to Molly regarding self-harm | (A): Call 911 to have Molly assessed for suicide risk
(B): Immediately call mom in the room because it is a safety risk
(C): Tell Molly not to worry, she will not tell her mom what is disclosed in session
(D): Provide psychoeducation to Molly regarding self-harm | Provide psychoeducation to Molly regarding self-harm | D | Currently Molly is not at immediate risk of suicide. Self-harm is not necessarily an indication of suicide risk. Typically, cutting provides a release of built-up emotions and is not an indication of suicidal ideation. The best route is to provide Molly with facts about cutting. Telling her mom would also cause mistrust in the therapeutic relationship and Molly may not be honest in future sessions. During the informed consent process, confidentiality should be discussed. Although the therapist maintains confidentiality, there are exceptions to this. During the intake, the counselor must review confidentiality, the limits to confidentiality and the fact that they are a mandated reporter. Therefore, the correct answer is (C) | professional practice and ethics |
863 | Client Age: 22 Sex: Male Gender: Male Sexuality: Homosexual Ethnicity: Latino American Relationship Status: Single Counseling Setting: Community Mental Health Center Type of Counseling: Individual Presenting Problem: Depression Diagnosis: Major Depressive Disorder, Moderate | Mental Status Exam: The client is pleasant and dressed in age-appropriate attire. He is tearful when discussing his family and states this has been difficult for him. The client has had no previous suicide attempts. He is observed biting his nails. He describes feeling sad daily and states he sleeps during the day because he cannot sleep at night. He is slightly underweight but denied any difficulties with appetite. The client’s speech is coherent and clear. He denies suicidal ideation but often questions his worth and purpose. Fam | You are providing counseling services at a Community Mental Health Center. A 22-year-old Latino male, accompanied by his aunt, presents with symptoms of depression. The aunt is concerned about the client’s social isolation, feelings of hopelessness, and excessive daytime sleeping. Four months ago, the client’s parents kicked him out of their home after discovering a suggestive social media post of him with another male. He is close with his aunt and uncle, who have allowed him to stay in their basement. The client’s father refuses to speak to him and has told him he is “less than a man” and an embarrassment to the family. The client’s symptoms worsened last month when he was laid off from his job as a server. | ily and Work History: The client was recently laid off from his job as a server at an upscale restaurant in the downtown area. He misses the sense of family he had with his previous co-workers and feels “stuck” and “unable to move forward.” The client is a third-generation Cuban American whose paternal grandparents immigrated to the United States during Castro’s regime. His parents worked hard to put him and his siblings through Catholic school and instilled in him traditional heteronormative religious values and “familism” (i\. e., the belief that the family unit is more important than individual needs). The client also has a strong work ethic but states he is poorly motivated to seek another job because he doesn’t want to be “shot down.” History of Condition: The client reports that he has struggled with bouts of depression from a very early age. He explains that he never felt like he fit in. In middle school, he was bullied and harassed. He remembers locking himself in his room, crying, and asking God for help during this time. He continued to ask for forgiveness and bargain with God as he grew older. In his mid- to late-teens, he began drinking and vaping, “because I couldn’t keep my end of the bargain,” he explains. Despite finding acceptance in the community, he still feels guilty for disappointing his parents. The client reports feeling “defective” and carries a significant amount of shame related to his sexual orientation | Given the client’s background, all of the following factors may place him at higher risk for suicide EXCEPT: | Previous suicide attempt | Social isolation | Sexual orientation | Job loss | (A): Previous suicide attempt
(B): Social isolation
(C): Sexual orientation
(D): Job loss | Previous suicide attempt | A | Job loss, social isolation, sexual orientation, and previous suicide attempts all place individuals at higher risk for suicide. The client has experienced job loss and social isolation. His depressive symptoms were further complicated by his family’s response to his sexual orientation. However, the client denied suicidal ideation as well as previous suicide attempts in his mental status exam, so this factor would not place him at higher risk for suicide. Therefore, the correct answer is (D) | intake, assessment, and diagnosis |
864 | 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. | The client comes to the session, sits down, and is quiet. The parents report that prior to the session he was playing an online game and became so upset that he threw his video game console. The parents express frustration that they do not know what to do when this happens. You provide psychoeducation to the client regarding coping skills to manage frustration. You find out that the parents respond by removing access to video games, and this usually results in yelling back and forth with the parents and the client. The parents do typically encourage the client to listen to music because this appears to be very effective in calming him down. The client expresses frustration with the people that he was playing with by saying that they “cheated and are lying about it.” You support the client with cognitive reframing. You do not believe that the kids the client was playing video games with were cheating, and you do believe that it is more likely that the client was losing and was upset for that reason | You do not believe that the kids the client was playing video games with were cheating, and you do believe that it is more likely that the client was losing and was upset for that reason. Which one of the following actions would likely be the most helpful response to the client? | Process the situation with the client to help him understand his feelings. | Support the client in developing empathy skills to better understand the kids who he was playing games with. | Process the situation with the client to help him take responsibility for his feelings and actions. | Validate the client’s frustrations and support him in coping with his strong feelings. | (A): Process the situation with the client to help him understand his feelings.
(B): Support the client in developing empathy skills to better understand the kids who he was playing games with.
(C): Process the situation with the client to help him take responsibility for his feelings and actions.
(D): Validate the client’s frustrations and support him in coping with his strong feelings. | Validate the client’s frustrations and support him in coping with his strong feelings. | D | Focusing on helping him cope with his strong feelings would be most helpful to the client at this stage of the therapeutic relationship. Supporting the client in taking responsibility might make the client think that you are accusing him of being wrong about his interpretation of the situation. Supporting the client in understanding his feelings might be helpful; however, it does not encourage the client to manage his strong emotions, which are often the root of his negative behavior. Empathy can be a difficult skill for someone diagnosed with ASD to conquer and therefore may not best support the client in managing his strong emotions regarding the situation. Therefore, the correct answer is (D) | counseling skills and interventions |
865 | 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. Ninth session Alexei appeared anxious during his weekly session today. He tells you that he constantly thinks about how good his life was in Germany and is afraid he will never feel comfortable in America. On a positive note, Alexei shares that he and his wife talked about their relationship and want to take steps to repair their marriage. He now admits to you that his drinking is a problem, but he struggles with the physical aspects of trying to quit. Whenever he tries to stop drinking, he gets sweaty and fears that he will have a seizure, so he begins drinking again. He explains that he cannot get past these symptoms. You discuss with Alexei the option of entering a rehabilitation center to assist him medically with the detox process. Alexei admits that he is unsure about the idea of going into treatment. He acknowledges that it might be beneficial but worries about leaving his family for a prolonged period. He expresses concern that his wife will not be able to handle everything on her own and wonders what will happen with their marriage while he is in treatment. You explore his concerns using motivational interviewing techniques and ask him to discuss this information with his wife. During the session, you commend Alexei for recognizing the impact of his drinking on his life and his willingness to discuss these concerns openly. You acknowledge the challenges he faces in trying to quit and the physical symptoms he experiences. You explain that seeking professional help at a rehabilitation center could provide the medical support he needs to manage withdrawal symptoms safely and effectively. You emphasize that by addressing his alcohol dependence, he will likely find it easier to adapt to his new life in America and repair his marriage. Regarding his concerns about his wife managing things while he is in treatment, you explore potential solutions and support systems that could be implemented during his absence. You encourage Alexei to discuss these concerns with his wife and involve her in decision-making. Together, they can identify family members, friends, or community resources that could offer assistance. Finally, you reassure Alexei that taking the time for treatment is an investment in his long-term well-being and that of his family. By addressing his alcohol dependence, he will be better equipped to support his wife and family emotionally and practically in the long run. | 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. | Using motivational interviewing, how would you evoke change talk with Alexei? | "I think you should recognize that your negative ideations are manifestations of catastrophizing, and your recognition of that will help you make progress." | "The fear and physical symptoms you are experiencing when trying to stop drinking are completely normal. With the help of a rehabilitation center, you can learn how to manage this fear without resorting to drinking." | "I understand your concerns, but I think your wife will understand if you go into treatment. I believe that making a commitment to become sober is a positive step in achieving your goal of repairing your marriage." | "You have identified a variety of potential solutions to this problem and I'm wondering what potential advantages or disadvantages you may see from each option." | (A): "I think you should recognize that your negative ideations are manifestations of catastrophizing, and your recognition of that will help you make progress."
(B): "The fear and physical symptoms you are experiencing when trying to stop drinking are completely normal. With the help of a rehabilitation center, you can learn how to manage this fear without resorting to drinking."
(C): "I understand your concerns, but I think your wife will understand if you go into treatment. I believe that making a commitment to become sober is a positive step in achieving your goal of repairing your marriage."
(D): "You have identified a variety of potential solutions to this problem and I'm wondering what potential advantages or disadvantages you may see from each option." | "You have identified a variety of potential solutions to this problem and I'm wondering what potential advantages or disadvantages you may see from each option." | D | This question allows the client to explore their thoughts and feelings about the situation, which is an important part of motivational interviewing. It encourages open dialogue and helps Alexei to better identify potential pros and cons to each option. This type of questioning can help Alexei gain insight into his own behavior, preferences, and decisions, which is a key component of motivational enhancement therapy. Additionally, this question does not push him to choose a particular option; rather it encourages him to reflect on his own circumstances and make an informed decision about how he wants to move forward. This can help Alexei feel more empowered in the process and ultimately increase motivation for change. Therefore, the correct answer is (B) | counseling skills and interventions |
866 | Age: 9 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Private practice Type of Counseling: Individual counseling Presenting Problem: The client has been engaging in behavior that has gotten him suspended from school several times over the past year, which also causes significant distress for the client’s family at home. Diagnosis: Conduct disorder, childhood-onset type, with limited prosocial emotions, severe (F91.1) | Mental Status Exam: The client was minimally engaged in the session. The client’s behavior was withdrawn, argumentative, and la | You are a professional counselor, and you specialize in working with children and adolescents. The client comes to this session with his parents. You review informed consent with the client and his parents and begin to ask the client about what brings him to counseling. The client responds by saying “shut the hell up” and leaves the room to go to the lobby. The client’s father gets up and follows him out, and after a few minutes they return. The client sits down and faces away from you. The client does not engage in the intake session aside from cursing at his parents when they report specific behavioral incidents and he disagrees with them about the facts of the events. The client’s parents say that he has had “bad behavior” over the past 2 years and that his behavior has “gotten worse” over the past 5 months. The parents outline the following behavioral problems that the client engages in, in all settings: bullying, physical fighting, kicking and throwing items at his dog, intentionally breaking others’ property, lying to others to get items or have access to activities, stealing items from others, truancy, and leaving the house at night without permission or supervision. | bile. Family History: The client has two younger brothers who are 6 and 7 years old. The client often engages in physical fights and arguments with his younger siblings and often will break or steal their toys. The client takes advantage of his 6-year-old sibling by conning him out of items and activities by convincing him that a certain trade or decision is better for him, when it is usually better for the client. The client’s parents report that these behaviors occur at school and that the client does not have any friends as far as they are aware. The client’s parents state that the client is adopted and that he was in foster care from when he was 2 until he was 4 years old. The client’s parents state that his basic needs were neglected because his birth mother was heavily using drugs | All of the following treatment modalities and services would be appropriate based on the client’s presentation, EXCEPT: | Medication management | DBT | Family therapy | CBT | (A): Medication management
(B): DBT
(C): Family therapy
(D): CBT | DBT | B | DBT is not considered effective for treatment of conduct disorder. DBT is a modified version of CBT that was created for treatment of personality disorders, and it has also been proven effective with depression and bipolar disorder. CBT would be helpful in supporting the client in processing his thoughts more effectively in order to improve his behavior; it also has a focus on emotional regulation, which the client would benefit from. Family therapy would be appropriate to consider because the client and his family system are not functioning well as a whole and could use support in reestablishing relationships to become a more effective family system. The client could benefit from medication management for support in managing strong emotions. Therefore, the correct answer is (A) | treatment planning |
867 | Client Age: 8 Sex: Female Gender: Female Grade: 3rd Ethnicity: African American Counseling Setting: School-based Type of Counseling: Individual and Family Presenting Problem: Defiance Diagnosis: Oppositional Defiant Disorder 313.81 (F91.3) | Mental Status Exam: The client displays an angry affect and sits with her arms crossed. She is well dressed and well groomed. The client’s PGM repeatedly prompts her to say, “yes ma’am” and “no ma’am” when answering questions. The client sits slumped in her chair. She agrees to color in a feelings thermometer that reflects increased anger, sadness, and fear. Her insight is poor. The client often refuses to eat school lunch, and the PGM reports that the client is a picky ea | You are a school-based mental health counselor conducting an initial intake with an 8-year-old African American female in the 3rd grade. The client presents today with her paternal grandmother (PGM), the client’s legal guardian. The PGM states that the client is argumentative, refuses to take responsibility for her actions, and has a tantrum when she receives a consequence for her behavior. She reports that the client is restricted from “every single privilege indefinitely.” The client has been told she can regain privileges once she “learns to act her age.” The client states she is treated unfairly and “blamed for everything” at home and school. The client’s teacher reports that she has difficulty following directions, is easily annoyed by her classmates, and frequently loses her temper. The client’s grades are poor, and she is below grade level in reading. However, she enjoys art and proudly reports that one of her pictures came in 1st place and is hanging in the library. | ter. F amily History: The client’s paternal grandmother received legal guardianship when the client was in 1st grade due to parental neglect. The client’s mother and father have had ongoing issues with substance abuse. The client’s father is currently incarcerated for drug-related offenses. The PGM reports that the client’s mother continues to “run the streets” and shows up periodically asking for money. The PGM states that the client’s mother abused drugs while pregnant and that the client was born prematurely. In addition, the client’s father had similar school difficulties and dropped out of high school in the 10th grade. History of Condition: The client’s disruptive behavior began in early childhood. When the client was four years old, her tantrums were so severe that she disrupted two daycare placements and was not allowed to return. In kindergarten, the client was given a stimulant by her primary care provider to assist with symptoms of ADHD. The PGM says she is no longer on the medication and believes the client chooses to misbehave, explaining, “she is strong-willed, just like her father.” The client’s school records show she has an individualized education plan (IEP) and receives limited services for developmental delays in reading and written expression | Which alternative behavior best targets the PGM’s needs based on her current parenting approach? | Give directives in a calm, matter-of-fact manner. | Ignore negative behavior. | Provide clear expectations. | Use consistent follow through. | (A): Give directives in a calm, matter-of-fact manner.
(B): Ignore negative behavior.
(C): Provide clear expectations.
(D): Use consistent follow through. | Provide clear expectations. | C | Providing clear expectations is reflective of the PGM’s current learning needs. We gather from the intake session that the PGM has restricted the client from every single privilege indefinitely. The PGM has told the client that she can regain privileges once she learns to act her age. The best response targets the vague expectation for the client to act her age. You can provide effective parenting training by helping the PGM operationally define what it means for the client to act her age and how to state expectations in the affirmative (ie, instruct the client on what she should do rather than what she shouldn’t do). An example of a clear and positive directive is, “It’s time for you to brush your teeth” rather than, “Stop playing. You know it’s your bedtime” Further, by taking away privileges indefinitely, the PGM has no additional recourse for correcting subsequent misbehavior. While all other answer options are invaluable parenting strategies, insufficient information matches the alternative behaviors to the PGMs’ needs. For example, we do not know if she is ignoring negative behavior, which appropriate behaviors she chooses to ignore, and when. We also do not know if there is consistent follow through, nor do we know the manner in which she provides directives. Therefore, the correct answer is (B) | intake, assessment, and diagnosis |
868 | 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. | What cognitive distortion is the client exhibiting during his initial session? | Personalization | Catastrophizing | All-or-nothing thinking | Overgeneralization | (A): Personalization
(B): Catastrophizing
(C): All-or-nothing thinking
(D): Overgeneralization | All-or-nothing thinking | C | All-or-nothing thinking is a cognitive distortion wherein a person views a situation in extremes, such as seeing themselves as an utter failure or believing that their thoughts are permanent. In this case, the client believes he is a "total failure", no one can help him, and no one cares about him. Therefore, the correct answer is (C) | intake, assessment, and diagnosis |
869 | Name: Robin Clinical Issues: Substance use/addiction issues Diagnostic Category: Substance Use Disorders Provisional Diagnosis: F10.20 Alcohol Use Disorder, Moderate Age: 28 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: Black Marital Status: Not Married Modality: Individual Therapy Location of Therapy : Private Practice | The client is well-groomed. She reports her mood as depressed due to her relationship breakup and feeling that she is unable to talk to family members about her life. Her affect is characterized by anxiousness and difficulties in answering questions. Her overall speech is slow and soft, with little eye contact as she speaks. The client's insight is fair. She recognizes that alcohol has been a major factor in her life, and she is aware of the negative effects it has had on her relationships and work performance. She states that she is at a point where she feels like she needs help to make changes in her life. Though she presents as sober at the time of the interview, her judgment appears impaired due to her continued heavy drinking despite the negative consequences. | First session You are a clinical mental health counselor at a community mental health center. You see many clients who struggle with substance use issues. A 28-year-old female presents for outpatient services today. She is an attorney who works long hours, specializing in family law. She and her boyfriend of ten years recently ended their relationship due to the client's excessive drinking. She says, "I can't live with the pain of our separation much longer, and I don't know how to cope with it." She tells you she is devastated and does not know what to do next. The breakup has triggered her to drink even more lately, and she is currently facing a DUI charge. Her attorney recommended that she seek an assessment for substance use disorder treatment in an effort to avoid a criminal conviction. You administer an assessment to determine the severity of the client's alcohol use and further evaluate her statement about being unable to live with the pain of her breakup. She reports an urge to drink daily, and acknowledges she has lost control of her drinking on many occasions. She also states that she has increased her alcohol intake because "it helps numb the pain and I can forget about everything for a little while." The client discusses her father's death when she was 17 and how this affected her life. She states that his death hit her hard, and only made matters worse because of her family's lack of emotional support in the wake of his passing. Even though she was still in High School, she began drinking heavily to cope with the grief, a pattern which has been present ever since. She drinks alone, typically at home or in bars after work. When asked about the effects of alcohol on other areas of her life like her finances, she says, "One of the perks of my job is that I get paid pretty well, so at least I'm not in debt like my brother." She pauses for a moment, then says, "Well, not yet anyway. I've got some court costs coming up." You explain to the client that substance use disorder is treatable and that it is important to take an honest look at her relationship with alcohol, in order to make positive changes to her lifestyle. You discuss the effects of excessive drinking on physical health, mental health, and personal relationships. You review the various options for treatment available and encourage her to be proactive in seeking help. The client acknowledges your advice but expresses hesitancy about beginning treatment due to fear of the stigma associated with addiction. You empathize with her feelings while emphasizing the importance of taking action now rather than waiting until her issues become worse. You present evidence-based treatment modalities that have been shown effective in managing substance use disorders. You let the client know you are here for her to help develop healthy coping skills, explore the underlying causes of her drinking, and create a plan to avoid future drinking and driving offenses. Then, you both discuss a treatment plan with the goal of helping the client resolve her current crisis and developing a strategy to maintain sobriety and avoid future legal issues. She provides you with releases to speak with her mother and her attorney. You set up a follow-up appointment one week from now. | The client has a younger brother. Her father died when she was 17, and her mother never remarried. The client's family has a history of problematic alcohol use, with family members utilizing alcohol to mask underlying emotions and distress. This pattern can be seen in her mother and brother, as well as extended family. Her mother is particularly reliant on alcohol and uses it as a way to cope with negative feelings. This has been an ongoing issue for many years. The client was raised in an environment where emotions were not discussed openly. The client expresses she learned early that it was best not to bring attention to any discomfort or upset she may have felt because it would only be met with more criticism and judgments. She states, "My mother and brother 'don't believe in depression.' When I told my mom that my boyfriend broke up with me and I was feeling depressed, she told me to that I needed to 'get over it and move on.' It's like I'm talking to a wall when I try to tell her anything about how I'm feeling." Although the client does not feel that her family understands her problems, she does communicate with her mother weekly. The client has been using alcohol as a way to cope with stress for many years. She expresses she has "been through a lot" in her life and that going to bars after work is an escape. Alcohol has maintained a significant presence during various phases of her life. | The client seems to be forthcoming in relation to the frequency and severity of her use of alcohol, but she maintains a reticence in coming to terms with the overall effect of her alcohol use on her life. As part of the initial intake process, which question will help you further evaluate the client’s level of functioning? | "Has your drinking caused you to overlook any obligations at work?" | "What support do you have now that you and your boyfriend are separated?" | "What is your current living situation?" | "Did your episode of driving intoxicated cause harm to anyone?" | (A): "Has your drinking caused you to overlook any obligations at work?"
(B): "What support do you have now that you and your boyfriend are separated?"
(C): "What is your current living situation?"
(D): "Did your episode of driving intoxicated cause harm to anyone?" | "Has your drinking caused you to overlook any obligations at work?" | A | Asking whether the client's drinking has affected her ability to fulfill responsibilities at her job will help you assess her level of functioning. Therefore, the correct answer is (C) | intake, assessment, and diagnosis |
870 | 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. | What happened during this session that leads you to consider adjusting the client's treatment plan? | The client's sarcastic attitude | The client's shift in emotional response | The client leaving the session early | The client's reported improvement in academic functioning | (A): The client's sarcastic attitude
(B): The client's shift in emotional response
(C): The client leaving the session early
(D): The client's reported improvement in academic functioning | The client's shift in emotional response | B | The client's emotional response in this session is very different than what you have seen before. Crying, along with a subdued and almost respectful response is a new behavior he has not demonstrated. This indicates the need for further assessment and/or another diagnosis. Therefore, the correct answer is (C) | treatment planning |
871 | Initial Intake: Age: 65 Gender: Male Sexual Orientation: Heterosexual Race/Ethnicity: Caucasian Relationship Status: Married Counseling Setting: Inpatient detox facility Type of Counseling: Individual | William presents as irritable and quite anxious with congruent strained affect. William is casually dressed and with good hygiene. William’s rate and tone of speech are normal with motor movements appearing tense and agitated as evidenced by shifting of position and frequent crossing of arms. William avoids eye contact the entire visit. William denies any depression however his chart indicates that he reported having a history of depression with suicidal thoughts. He says, “Only God can judge me, and I know where I’m goin’ so I don’t have any worries about whether I go now or later.” You then notice in his intake he identified as Christian with active faith-based beliefs. He repeats several times that he plans to leave as soon as he meets with the doctor later today and receives “medical clearance” saying “I can’t stay the whole three weeks it’s just not possible, not going to happen.” | Diagnosis: Alcohol dependence (F10.20), Major depressive disorder, single episode, unspecified (F32.9)
You are a mental health counseling intern providing brief crisis intervention and counseling support for patients admitted to a substance use rehabilitation facility at the detox-level of care. Your clinical director schedules William to meet with you on his first Monday morning after being admitted the Friday night before for alcohol dependency. William tells you he had a “medical issue” last week that “freaked his wife out” and she said she would “kick him out of the house” if he did not come to your program. He notes that he has been drinking their entire marriage and does not understand why it is suddenly such an issue for her, but that he would have “nowhere to go” otherwise so he conceded to coming in. You learn from the overnight staff nurse that William had several bouts of delirium and vomiting with tremors over the weekend, and one instance of a seizure which required emergency interventions to have him stabilized. You ask what “medical issue” he was referring to and she tells you that his chart indicates he had a heart attack. William interjects, saying “She thought I had a stroke, but it wasn’t that big a deal I just had some bad indigestion.” He is now on a benzodiazepine regimen to help regulate his symptoms and stabilize his mood throughout his detox process until he can report a reduction in anxiety and be seen by the weekday psychiatrist. | Work History:
William has worked has a construction company manager for almost 30 years until just before reaching retirement he was let go due to COVID-related company downsizing. He attempted to file a legal case against his company for wrongful actions that would in William’s words “rob him of his hard-earned retirement” however they cited his daily alcohol use on the job as an additional reason he was fired. He was informed due to his longevity with the company that they would offer him a generous severance package and not pursue administrative actions against him for breaking company policies. He adds that he was not planning on stopping working when retiring from his company, saying “I’m too young to just stop. I was going to start my own business.” He also retorts that no one calls him William but his wife and insists that you call him “Bob.” | You determine Bob has poor emotional coping skills. Which objective most effectively addresses this? | Bob will identify ineffective coping methods and learn 3 new coping skills within 3 weeks. | Bob will effectively use new coping strategies to deal with his emotions. | Bob will identify 3 ways his emotional coping is ineffective and verbalize them. | Bob will learn and apply 5 new coping skills within 3 weeks. | (A): Bob will identify ineffective coping methods and learn 3 new coping skills within 3 weeks.
(B): Bob will effectively use new coping strategies to deal with his emotions.
(C): Bob will identify 3 ways his emotional coping is ineffective and verbalize them.
(D): Bob will learn and apply 5 new coping skills within 3 weeks. | Bob will identify ineffective coping methods and learn 3 new coping skills within 3 weeks. | A | With this objective, Bob is challenged to both recognize what he has been doing that has not been working and learn new ways of coping in their place. This objective satisfies the timeliness factor of a SMART goal by giving an adequate deadline and it is realistic to learn a new coping skill each week he is in rehab. Answer a) does not challenge Bob to learn new skills, only identify ineffective ones, which can be a great start to the learning process but in a short-term program it would be more advantageous to spend his time improving on what he already knows. Answer b) is unrealistic as it mandates that he applies all his learning within just three weeks, and it realistically takes six months for any adult to effectively apply just one coping skill routinely. Answer c) encourages Bob to apply new coping strategies, but it is not specific or timely. Therefore, the correct answer is (D) | counseling skills and interventions |
872 | 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. Your client is worried about how panic attacks are affecting her academic life | Your client is worried about how panic attacks are affecting her academic life. With appropriate releases of information signed by the client, which of the following would be the most effective way to advocate on behalf of the client with the college based on her presenting needs? | Meet with her teachers to discuss what the client is going through. | Meet with teachers of the classes that the client has in the morning to discuss extending deadlines for her assignments. | Meet with the college’s department of disabilities to discuss extending deadlines for her assignments. | Meet with the college’s department of disabilities to discuss leniency with attendance. | (A): Meet with her teachers to discuss what the client is going through.
(B): Meet with teachers of the classes that the client has in the morning to discuss extending deadlines for her assignments.
(C): Meet with the college’s department of disabilities to discuss extending deadlines for her assignments.
(D): Meet with the college’s department of disabilities to discuss leniency with attendance. | Meet with the college’s department of disabilities to discuss leniency with attendance. | D | Each university has a department that advocates and provides accommodations for individuals who have disabilities, including mental health conditions. Because the client is experiencing panic attacks that are affecting her academic performance, this might be an appropriate opportunity to advocate for the client’s needs. The client is having trouble with attendance and attending class on time, and this would be the most important area to advocate for leniency. The client does not need to have deadlines extended because as far as you know, she is meeting the deadlines for her assignments. The department of disabilities will coordinate with her teachers; therefore, you do not need to meet with each one. Therefore, the correct answer is (B) | professional practice and ethics |
873 | Initial Intake: Age: 58 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Married Counseling Setting: Private Practice Type of Counseling: Individual | The client reports that in the past six months she has lost 40 pounds, which leaves her looking thinner than seems appropriate for her 5’8” frame. Her hair is combed and neat, but looks thin and lacks a healthy shine. Her clothes, while clean, appear rumpled as if they have been slept in. She is cooperative and engaged, but moves slowly and pauses in her speech, causing you to wonder if she is lost in thought or if speaking is too painful. She reports she has difficulty falling asleep at night and never feels like she has any energy, though she does go to work each day. She denies any suicidal thoughts but states she feels sad all the time and “can’t wait to see him again.” She admits she blames herself for not keeping him home that evening, which would have prevented his death. | You are a counselor in a private practice setting. You receive a telephone call from an attorney that would like to refer their client, who is engaged in a civil suit, to you for counseling treatment. The attorney provides you with a detailed description of a traumatic event, death of her son, and expresses concerns about the client’s well-being. The attorney requests that you work with their client and be prepared to testify in court when the case goes to trial. | Family History:
During the intake session, the client reports that her youngest son was killed in a car accident eighteen months ago, which was caused by an impaired driver. Her son was the youngest of her five children and while she said she loves them all equally, she reported that her children have always said their youngest brother was her favorite. | What is the best explanation for how the counselor distinguishes between clients with suicidal ideations related to depression and clients who have thoughts of death and dying due to grief? | Clients with depression and suicidal ideations will often have history of suicide attempts in their past; whereas clients who have thoughts of death or dying have no history of previous suicidal attempts. | Clients with depression and suicidal ideations very rarely tell anyone about their thoughts of suicide; whereas clients who think about death due to bereavement very often feel comfortable talking to others about wishing that their life was over. | Clients with depression and suicidal ideations isolate themselves from others; whereas clients who have thoughts of death and dying due to grief seek the company of others even though they are sad. | Clients with depression and suicidal ideation focus on their own feelings of worthlessness, guilt, or inability to cope; whereas clients with thoughts of death and dying due to grief usually focus on the deceased person. | (A): Clients with depression and suicidal ideations will often have history of suicide attempts in their past; whereas clients who have thoughts of death or dying have no history of previous suicidal attempts.
(B): Clients with depression and suicidal ideations very rarely tell anyone about their thoughts of suicide; whereas clients who think about death due to bereavement very often feel comfortable talking to others about wishing that their life was over.
(C): Clients with depression and suicidal ideations isolate themselves from others; whereas clients who have thoughts of death and dying due to grief seek the company of others even though they are sad.
(D): Clients with depression and suicidal ideation focus on their own feelings of worthlessness, guilt, or inability to cope; whereas clients with thoughts of death and dying due to grief usually focus on the deceased person. | Clients with depression and suicidal ideation focus on their own feelings of worthlessness, guilt, or inability to cope; whereas clients with thoughts of death and dying due to grief usually focus on the deceased person. | D | Focusing on one's thoughts of death or dying is the best indicator of depression versus bereavement or grief. Alternatively, both clients with depression and clients who are grieving may talk to others about their active or passive suicidal thoughts, may or may not have a history of suicide attempt, or may or may not isolate themselves from others. Therefore, the correct answer is (A) | counseling skills and interventions |
874 | Name: Rick Clinical Issues: Referred for emotional and behavior issues Diagnostic Category: No Diagnosis Provisional Diagnosis: No Diagnosis Age: 18 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: Korean Marital Status: Single Modality: Group Therapy Location of Therapy : Community Center | The client is slouched over in his seat and appears withdrawn with a flat affect. He keeps his head down. The client plays with his shirt sleeve, twisting the material and pulling at it. You cannot see any cuts on his arms as reported by the mother. He does not appear to be angry at this time, which was also a symptom reported by his mother. He responds to your questions with one-word answers. He seems uninterested. The client denies any suicidal and homicidal ideation. The client mumbles, "I don't want to talk about anything here." | First session You work as both an individual and group therapist at a community center that primarily sees adolescents with emotional and behavioral issues. Rick is a senior in high school and lives with his mother and two sisters. Rick does not want to participate in individual or group therapy, but his mother insists that he get help. During the intake, you work to establish rapport with Rick. You also gather information to determine if he is an appropriate candidate for one of the groups you are preparing to start, along with a co-facilitator. You suspect he may have trouble trusting females as he expresses anger when talking about his mother, sister, and ex-girlfriend. Since his father left, Rick says that his mother has been "in his business" all the time, and he does not feel like he has any real privacy. You remain patient with Rick, listening to his story and validating his feelings. You empathize with him, letting him know it is understandable to feel frustrated about not having much privacy. You explain that you are here to help him, not to control him and that you are interested in learning more about him. You explain to Rick that you are planning to start a group therapy session with a co-facilitator and that you would like to see if it would be a good fit for him. You explain that the group will provide an opportunity for him to talk about his experiences in a safe space with others who may have gone through similar situations In addition, you share that it could be an excellent way for him to practice expressing himself and developing trust in others. You also explain to Rick that individual therapy sessions could be beneficial in addition to group therapy. You discuss the possibility of one-on-one sessions that would give him a chance to talk more deeply about his experiences in a safe, private setting You emphasize that this could be an excellent way for him to explore his feelings and learn how to cope with them in a healthy way. Sixth session Rick has been attending group therapy weekly. He continues to wear long sleeves to the session but appears engaged and involved in the group process. The group exhibits high cohesion, and all members participate in group activities. The focus is on continued productivity and problem-solving. You ask the members to reflect on the skills they have been practicing in the group and share an experience in which they have applied those skills outside the session. Rick's experience in the group has further helped him to identify and understand his feelings. He has been able to recognize his anger and express it in a healthier way. He has also been able to recognize his need for connection. He says he recently called his ex-girlfriend to apologize for being angry about his parents and "taking it out on her" by withdrawing from her. This has enabled him to develop a more constructive approach to conflict. The group members have provided Rick with a safe space to practice his new skills, giving him the confidence to try them in his real-life relationships. The other members have shown Rick support and encouraged him to take risks and to be open to opportunities for growth. Rick's active engagement in the group has been instrumental in his progress. He has become more aware of his emotions, and he can express himself in a way that is respectful and appropriate. His newfound ability to communicate effectively has been a significant step towards strengthening his relationships both inside and outside of the group. 11th session The group as a whole has made progress, and members have found healthy outlets for expressing their thoughts and feelings. Rick has become more open with the women in the group and seems more receptive to what they have to say. Rick says that his grades have improved, his mother is proud, and he is encouraged by other group members who nod their heads and smile. The group has met its goals. The members have learned strategies to take with them as they prepare for termination. You remind the group that there are only a few more weeks left to meet. You begin to discuss the group members' feelings regarding the end of therapy. Rick starts to cry and says, "Why does every woman in my life cause problems for me?" The other group members offer Rick reassurance and empathy, but he continues expressing his frustration and sadness. You encourage the group to reflect on each person's progress and to be mindful of the emotions that this ending brings out. You explain to the group that endings can be difficult and that giving them permission to feel the emotions that arise during this transition is important. Rick is still struggling with the idea of ending the therapy and expresses his fear of being left alone. He continues to express his feeling that every woman in his life has caused him pain and suffering, and this group's ending has triggered his worst fears. You recognize his fear and attempt to validate his experience by emphasizing his progress in the group and the positive changes he has seen in himself. You explain that the group can support him through the transition and the other members offer encouraging words of encouragement. Rick is still anxious and overwhelmed. He talks about the difficulty of coping with the loss of the group and how he worries that he won't be able to manage his feelings without the support of the group. You explain to the group that it is natural to feel sadness and loss as well as gratefulness and pride in the progress they have all made. You encourage the group to identify the strategies they have learned in the group that they can use to manage their emotions. Finally, you assure Rick that he can use the skills he has learned in the group to cope with the emotions associated with the end of therapy. | The client is a first-generation American whose parents immigrated from Korea. He has an old sister who, based on Korean culture, is his superior whom he must obey and be subservient to. His parents have high expectations for him and are very controlling, expecting him to study every night and attend tutoring sessions on the weekend. They have arranged for him to marry a daughter of a prestigious family in Korea after he completes medical school eight years from now, with the intention that he and his wife will live with them and provide financial support. However, this plan has drastically changed. Seven months ago, the client's father moved out after his mother had an affair. The client became sullen, angry, and withdrawn after this event. Four months ago, while doing laundry, the client's mother saw dried blood on his shirt sleeve. She also noticed that he was wearing long-sleeved shirts all the time. She waited until he was getting dressed, walked in on him, and found he had cuts up and down his arms. The client does not speak to his father much since his parents separated. The client expresses a lot of anger toward the women in his life, specifically his mother, sister and ex-girlfriend. The client is a senior in high school. His grades have been suffering lately, and he is currently failing his math and science classes. Personal/Social Relationships: The client had been concealing his romantic relationship with a girl from his Saturday tutoring class, but following his father's abrupt departure from the family, he chose to discontinue the relationship and cease attending the class. He has since refrained from any communication or contact with her. His mother's affair has caused him to feel overwhelmed with anger, leading him to develop a dislike of all women. | A group therapist has been recording group therapy sessions for teaching purposes but has not told the members. What should be done when this is discovered? | The recorded material must be destroyed, and the therapist's license should be suspended. | The group therapist should get a signed release from group members and continue. | As long as the faces are blurred and identities disguised, there is no breach of protocol. | The recorded material must be destroyed, and it is the group members' responsibility to file a complaint. | (A): The recorded material must be destroyed, and the therapist's license should be suspended.
(B): The group therapist should get a signed release from group members and continue.
(C): As long as the faces are blurred and identities disguised, there is no breach of protocol.
(D): The recorded material must be destroyed, and it is the group members' responsibility to file a complaint. | The recorded material must be destroyed, and it is the group members' responsibility to file a complaint. | D | Recording sessions should have been discussed during informed consent where the therapist would discuss with members that sessions would be taped, and the members could choose to partake or withdraw from the group. Taping sessions without group members' consent involves multiple breaches of confidentiality, ethics, and the law. As such, the recorded material should be destroyed and a complaint should be filed by group members. The results of an investigation will determine the penalties. Therefore, the correct answer is (A) | professional practice and ethics |
875 | 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. | Prior to ending the intake, which would be the most helpful intervention for this client based on the information gathered? | Provide contact information so client can reach counselor anytime stressors occur | Teach grounding techniques to help client deal with stressors | Identify ways the client has successfully dealt with stressors in the past | Complete a family genogram to determine familial patterns related to stressors | (A): Provide contact information so client can reach counselor anytime stressors occur
(B): Teach grounding techniques to help client deal with stressors
(C): Identify ways the client has successfully dealt with stressors in the past
(D): Complete a family genogram to determine familial patterns related to stressors | Identify ways the client has successfully dealt with stressors in the past | C | The best answer is to help the client identify ways he has successfully dealt with stressors in the past. These are techniques that he is familiar with, can be activated as needed, and which he already knows work for him. Completing a genogram will provide insight into why the client responds to stressors in certain ways, but will not provide him with a tool to deal with stressors. Grounding techniques are helpful during times of anxiety but this will be a new skill that the client will need to learn, practice, and become habitual in using, whereas it will be easier to rely on a known skill that has proven to work. Counselors provide emergency contact information but generally do not guarantee that the client can reach their counselor at any time of the day or night. Therefore, the correct answer is (B) | counseling skills and interventions |
876 | Name: Rick Clinical Issues: Referred for emotional and behavior issues Diagnostic Category: No Diagnosis Provisional Diagnosis: No Diagnosis Age: 18 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: Korean Marital Status: Single Modality: Group Therapy Location of Therapy : Community Center | The client is slouched over in his seat and appears withdrawn with a flat affect. He keeps his head down. The client plays with his shirt sleeve, twisting the material and pulling at it. You cannot see any cuts on his arms as reported by the mother. He does not appear to be angry at this time, which was also a symptom reported by his mother. He responds to your questions with one-word answers. He seems uninterested. The client denies any suicidal and homicidal ideation. The client mumbles, "I don't want to talk about anything here." | First session You work as both an individual and group therapist at a community center that primarily sees adolescents with emotional and behavioral issues. Rick is a senior in high school and lives with his mother and two sisters. Rick does not want to participate in individual or group therapy, but his mother insists that he get help. During the intake, you work to establish rapport with Rick. You also gather information to determine if he is an appropriate candidate for one of the groups you are preparing to start, along with a co-facilitator. You suspect he may have trouble trusting females as he expresses anger when talking about his mother, sister, and ex-girlfriend. Since his father left, Rick says that his mother has been "in his business" all the time, and he does not feel like he has any real privacy. You remain patient with Rick, listening to his story and validating his feelings. You empathize with him, letting him know it is understandable to feel frustrated about not having much privacy. You explain that you are here to help him, not to control him and that you are interested in learning more about him. You explain to Rick that you are planning to start a group therapy session with a co-facilitator and that you would like to see if it would be a good fit for him. You explain that the group will provide an opportunity for him to talk about his experiences in a safe space with others who may have gone through similar situations In addition, you share that it could be an excellent way for him to practice expressing himself and developing trust in others. You also explain to Rick that individual therapy sessions could be beneficial in addition to group therapy. You discuss the possibility of one-on-one sessions that would give him a chance to talk more deeply about his experiences in a safe, private setting You emphasize that this could be an excellent way for him to explore his feelings and learn how to cope with them in a healthy way. Sixth session Rick has been attending group therapy weekly. He continues to wear long sleeves to the session but appears engaged and involved in the group process. The group exhibits high cohesion, and all members participate in group activities. The focus is on continued productivity and problem-solving. You ask the members to reflect on the skills they have been practicing in the group and share an experience in which they have applied those skills outside the session. Rick's experience in the group has further helped him to identify and understand his feelings. He has been able to recognize his anger and express it in a healthier way. He has also been able to recognize his need for connection. He says he recently called his ex-girlfriend to apologize for being angry about his parents and "taking it out on her" by withdrawing from her. This has enabled him to develop a more constructive approach to conflict. The group members have provided Rick with a safe space to practice his new skills, giving him the confidence to try them in his real-life relationships. The other members have shown Rick support and encouraged him to take risks and to be open to opportunities for growth. Rick's active engagement in the group has been instrumental in his progress. He has become more aware of his emotions, and he can express himself in a way that is respectful and appropriate. His newfound ability to communicate effectively has been a significant step towards strengthening his relationships both inside and outside of the group. 11th session The group as a whole has made progress, and members have found healthy outlets for expressing their thoughts and feelings. Rick has become more open with the women in the group and seems more receptive to what they have to say. Rick says that his grades have improved, his mother is proud, and he is encouraged by other group members who nod their heads and smile. The group has met its goals. The members have learned strategies to take with them as they prepare for termination. You remind the group that there are only a few more weeks left to meet. You begin to discuss the group members' feelings regarding the end of therapy. Rick starts to cry and says, "Why does every woman in my life cause problems for me?" The other group members offer Rick reassurance and empathy, but he continues expressing his frustration and sadness. You encourage the group to reflect on each person's progress and to be mindful of the emotions that this ending brings out. You explain to the group that endings can be difficult and that giving them permission to feel the emotions that arise during this transition is important. Rick is still struggling with the idea of ending the therapy and expresses his fear of being left alone. He continues to express his feeling that every woman in his life has caused him pain and suffering, and this group's ending has triggered his worst fears. You recognize his fear and attempt to validate his experience by emphasizing his progress in the group and the positive changes he has seen in himself. You explain that the group can support him through the transition and the other members offer encouraging words of encouragement. Rick is still anxious and overwhelmed. He talks about the difficulty of coping with the loss of the group and how he worries that he won't be able to manage his feelings without the support of the group. You explain to the group that it is natural to feel sadness and loss as well as gratefulness and pride in the progress they have all made. You encourage the group to identify the strategies they have learned in the group that they can use to manage their emotions. Finally, you assure Rick that he can use the skills he has learned in the group to cope with the emotions associated with the end of therapy. | The client is a first-generation American whose parents immigrated from Korea. He has an old sister who, based on Korean culture, is his superior whom he must obey and be subservient to. His parents have high expectations for him and are very controlling, expecting him to study every night and attend tutoring sessions on the weekend. They have arranged for him to marry a daughter of a prestigious family in Korea after he completes medical school eight years from now, with the intention that he and his wife will live with them and provide financial support. However, this plan has drastically changed. Seven months ago, the client's father moved out after his mother had an affair. The client became sullen, angry, and withdrawn after this event. Four months ago, while doing laundry, the client's mother saw dried blood on his shirt sleeve. She also noticed that he was wearing long-sleeved shirts all the time. She waited until he was getting dressed, walked in on him, and found he had cuts up and down his arms. The client does not speak to his father much since his parents separated. The client expresses a lot of anger toward the women in his life, specifically his mother, sister and ex-girlfriend. The client is a senior in high school. His grades have been suffering lately, and he is currently failing his math and science classes. Personal/Social Relationships: The client had been concealing his romantic relationship with a girl from his Saturday tutoring class, but following his father's abrupt departure from the family, he chose to discontinue the relationship and cease attending the class. He has since refrained from any communication or contact with her. His mother's affair has caused him to feel overwhelmed with anger, leading him to develop a dislike of all women. | Rick appears distressed about the group ending soon, and you realize that there may be some unfinished business that he needs to work on. What would be the most appropriate way to handle this situation as the group leader? | Ask the client to explicitly share his feelings with the group. | Use active listening and reflection of the meaning | Promote positive interactions by allowing another member to share | Self-disclose by stating that you have difficulty when groups end | (A): Ask the client to explicitly share his feelings with the group.
(B): Use active listening and reflection of the meaning
(C): Promote positive interactions by allowing another member to share
(D): Self-disclose by stating that you have difficulty when groups end | Use active listening and reflection of the meaning | B | Active listening and reflection on the meaning would benefit the client. Listening to the client and reflecting on meaning, such as, "You said every woman in your life causes issues. Does this include any of the group members?. Please tell me, what does that mean to you?". Therefore, the correct answer is (A) | counseling skills and interventions |
877 | Name: Candy Clinical Issues: Anxiety and relationship distress Diagnostic Category: Personality Disorders Provisional Diagnosis: F60.03 Borderline Personality Disorder Age: 29 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: Black Marital Status: Married Modality: Individual Therapy Location of Therapy : Private Practice | The client presented as a well-groomed female who appeared her stated age. She was appropriately dressed in casual attire. Her speech was marked by a slow rate and low volume overall, though, at times, her rate and loudness increased spontaneously. Her tone was muffled and difficult to hear clearly at times. The client's mood appeared depressed and confused. She displayed emotional lability during the evaluation, with shifts between expressing elation, fear, and distrust of this clinician and the treatment environment. Despite her affective instability, she was oriented to person, place, and time. Her attention and concentration waxed and waned throughout the session, with some difficulty tracking questions and sustaining focus on topics. She denied current homicidal ideation or intent. However, the client endorsed chronic passive suicidal ideation that intensifies during times of high personal stress. She also reported a remote history of hospitalization due to engaging in self-injurious cutting behaviors when feeling extremely distressed. | First session You are a clinical mental health counselor working in a private practice setting. The client, a 29-year-old female, presents to the intake session expressing that she has trouble controlling impulsive acts and is constantly worried. She speaks about her marriage, describing it as up and down. She looks down tearfully and says, "I keep hurting him. One day I love him, and the next day I can't look at him." She pauses and asks, "What if he leaves me? I can't deal with that." She further reveals that after she fights with her husband, she goes into their bedroom and cuts her thighs. At first, she feels relief, but this is followed by profound sadness and a feeling of worthlessness. The client's lack of a stable parental figure resulted in her having difficulty forming healthy attachments with others. She feels isolated and disconnected from the world around her and has difficulty appropriately expressing her emotions. Her relationships are often strained, and she finds it difficult to trust others or herself. She has difficulty setting healthy boundaries and repeatedly emotionally abuses herself and others. She reports feeling overwhelmed by her emotions and finds it difficult to regulate them. She states that she experiences intense guilt and shame following her impulsive acts and is often worried that her husband may leave her due to her behaviors. The client has struggled to control her emotions, which has been a source of significant distress in her life. The client's self-destructive behavior has become increasingly frequent and intense. She has been unable to find a way to cope with her emotions and has resorted to self-harm as a way to manage her distress. She has become increasingly isolated and withdrawn, and her relationships have suffered as a result. She has become increasingly dependent on her husband, and her fear of abandonment has become a source of significant distress. Third session You are in your office waiting for the client to arrive for her weekly session when suddenly you hear screaming. You run out into the hallway and see the client crying hysterically. After guiding her into your office, she lies on the couch, crying. She begins to punch the pillows on the sofa. You indicate you are here to listen when she is ready to talk. The client is in a heightened emotional state and says, "He. Left. Me." You maintain a calm demeanor and encourage the client to tell you what happened. She said she arrived home after work and noticed her husband's car was gone. He had left her a note indicating he was leaving and wanted a divorce. The client expresses feelings of shock and betrayal as she discusses how she had been blindsided by her husband's sudden decision to end the marriage. She reports feeling overwhelmed by a range of emotions, including fear, anger, sadness, and confusion. The client expresses hopelessness and despair, believing her situation is beyond repair. She ruminates on the idea that her marriage is irrevocably broken and that her life will never be the same. She expresses feelings of helplessness and fear of the unknown, feeling overwhelmed by the magnitude of the situation. The client struggles to make sense of her husband's decision and appears overwhelmed by the potential consequences. She is particularly concerned about how her husband's decision will affect their children and their family's future. The client stares at you with a blank expression and states, "I might as well give up. There's no point anymore." You further assess her current mental health state and determine that she is suffering from an acute stress reaction. You provide empathy and validation while creating a safe space for the client to process her thoughts and feelings. You encourage her to talk openly and honestly about her experience, allowing her to express her emotions without judgment. Fourth session Last week you misjudged the client, and she ended up in the hospital for mood stabilization. She was released after 7 days and arrives to today's session with an older gentleman who remains seated in the waiting room. You notice her mood is elevated, and she exhibits childlike behaviors in the session. The client is giggling and fidgeting in her chair. You ask her about her feelings and her goals for therapy. She describes feeling happy and having a "new chance at living." She further discloses that she recently met a "wonderful man." They have had dinner together every night since she was released from the hospital. The client continues to describe her newfound relationship with this man and explains that they met on a dating app. She shares that "he is the answer to all of my prayers to be in a healthy relationship with someone who truly loves and understands me." She also shares that her soon-to-be ex-husband never truly loved her and that this new relationship feels different. From her description, this new relationship appears to provide her with a sense of safety and security, but you remain cautious. You explore the client's thoughts and feelings about this newfound relationship in more detail. You ask the client to describe how the relationship has changed her outlook on life. The client explains that she now feels hopeful and optimistic about the future, as this new partner makes her feel loved and accepted for who she is. She also reports feeling more confident in herself and her decisions. You ask the client how she knows that this man cares about her. The client discloses that he has been very supportive and understanding, even when she was hospitalized for her mood stabilization. She explains that he has gone out of his way to make sure she feels safe and secure in their relationship. "He's always around when I need him," she explains, "And he listens to me and takes what I say seriously." The client acknowledges that the man is older, and they come from different cultural backgrounds. She shares that she does not know much about his past relationships, but he has been very honest with her about his intentions for their relationship. She tells you, "If I'm honest, I'm a little bit anxious about the future, but I'm more excited than scared." You recognize that the client is in an emotionally vulnerable state, and you want to ensure she is making healthy decisions. You proceed by exploring the potential risks of this relationship in more detail. You ask the client questions about her comfort level with entering into a relationship with someone from a different cultural background, and how she believes these differences may affect their relationship. You also explore the potential benefits and risks of entering into a new romantic relationship. You remind her that healthy relationships are built on trust, communication, and respect - all components that take time to develop. You further explain the importance of setting boundaries and expectations early in a relationship in order to ensure that both parties’ needs are met. Finally, you encourage the client to take any necessary steps to ensure her safety, such as getting to know her partner better and introducing him to friends or family members she trusts. | The client's father died when she was very young. She describes her mother as having a "difficult time raising me and my brother as a single mother." The client's mother worked three jobs and could not spend much time with her children. The client remembers having several babysitters as a child, but they never lasted long. Currently, the only relative the client speaks with is her mother. She lists her husband and mother as her emergency contacts on the intake form. The client reports feeling isolated and alone, especially since her father's death. Personal/Social Relationships: The client has a long history of attempting suicide. She has been in and out of emergency rooms nearly every week. She is persistently angry, needs attention and recognition, and has difficulty trusting others. She has had numerous affairs in an attempt to feel worthy. The client compensates for her guilt by buying her husband expensive gifts. She grapples with maintaining healthy relationships and controlling her rage and violent behaviors when she feels threatened. She has struggled to form meaningful relationships with her peers and has few friends. Although she does not lack socialization skills, the client finds it difficult to get close to people. Previous Counseling: The client is currently taking Paxil for her underlying depressive symptoms. She has expressed concern about her ability to manage her mental health with her current treatment. She worries that her erratic adherence to her medication regimen and lack of follow-up with her psychiatrist could lead to a termination of services. She has reported increased anxiety and stress as a result of this fear. She reports that her mood swings are more extreme, and she is having difficulty concentrating and staying focused. She reports that her friends and family have noticed her behavior change and expressed concern. | The client wants to add her boyfriend to the list of people who can have access to her therapy records. What is the best way to proceed? | Provide the client with a release of information to sign | Share the ethical pitfalls of sharing her records with her new partner | Encourage the client to avoid discussing any of her therapy sessions with her boyfriend | Discuss the client's request with her to gain an understanding of why she feels sharing her records is necessary | (A): Provide the client with a release of information to sign
(B): Share the ethical pitfalls of sharing her records with her new partner
(C): Encourage the client to avoid discussing any of her therapy sessions with her boyfriend
(D): Discuss the client's request with her to gain an understanding of why she feels sharing her records is necessary | Discuss the client's request with her to gain an understanding of why she feels sharing her records is necessary | D | It is important to discuss the client's request with her in order to gain an understanding of why she feels sharing her records with her boyfriend is necessary. This will help ensure that the decision is made in line with the client's wishes and that it is respectful of her privacy and autonomy. This can help protect against any potential risks associated with sharing sensitive information. Therefore, the correct answer is (D) | counseling skills and interventions |
878 | Name: Denise Clinical Issues: Hopelessness/depression Diagnostic Category: Bipolar and Related Disorders Provisional Diagnosis: F34.0 Cyclothymic Disorder Age: 38 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: White Marital Status: Divorced Modality: Individual Therapy Location of Therapy : Private Practice | The client is appropriately dressed. She is overweight and appears edgy and irritable. Her attention wanders during the intake. She is articulate and able to communicate her thoughts logically. The client focuses on the negative aspects of life and appears to have a strong external locus of control. Insight is low, and judgment is strong. | First session You are a mental health counselor in a community agency. The client is a 38-year-old White female teacher referred to you by her principal. The client is experiencing difficulty with her school colleagues. She wants to keep her job and is motivated to improve her social skills. Since she was a young adult, she has had tumultuous relationships with co-workers, friends, and family. She tells you she has periods of highs and lows. During the high periods, she is overly talkative, impulsive, and insensitive to others. However, during the low periods, she withdraws from social contact, feels hopeless and helpless, and has trouble concentrating. She expresses a desire to be liked, but people see her as an "emotional roller coaster" and avoid her. She is very talkative throughout the session and changes the topic frequently. You raise your hand periodically to summarize what she is telling you. Early on during the session, the client says, "Please help me. I know something is wrong, but I don't know what to do. Can you fix me?" You discuss the scope of your practice and explore options for treatment with her. You explain that one of your responsibilities as a therapist is to provide a safe space where she can express her thoughts and feelings without fear of judgement or criticism. You explain that through understanding and integrating different aspects of herself, she has the potential to develop healthier relationships both in and outside of work. You emphasize the importance of building self-awareness and developing effective coping skills as part of her journey towards healing. Ultimately, you focus on empowering the client by providing support, guidance, and skills that will enable her to make positive changes in herself so she can function more effectively in life moving forward. You discuss the importance of the client taking an active role in her treatment process and explore methods she can use to become more mindful of her thoughts, feelings, and behavior. You suggest that this will help her gain better insight into the sources of her distress, which will enable her to take more control over how she copes with difficult situations in the future. The client appears relieved that there is something constructive she can do. You end the session by scheduling another appointment for next week and encourage the client to focus on self-care in between sessions. You also reassure her that you will be there as a supportive resource throughout the therapeutic journey ahead. The client leaves feeling empowered and energized to take the first steps towards change. Fourth session During the previous two sessions, you spent the majority of the time listening to the client describing her conflicted relationships. You asked her to start keeping a mood diary, and while you review it together today, you notice that entries involving her father always precipitate a depressive mood. While you try to bring her attention to this trigger, she says, "I bet my dad enjoys watching this from the grave," and laughs. She tells you that she never felt like her father really loved her, and she believes that he blamed her for her mother's death. You demonstrate empathy and unconditional positive regard in response to her feelings. You begin to explore the client's thoughts about her father's suicide. Her demeanor changes, and she begins to talk about finding his body and the pain he must have gone through. She has "an epiphany" as she describes how she feels and realizes that he must have suffered a lot. Following the client's disclosure, you take the time to normalize her feelings and process her experience. You acknowledge the immense amount of pain and suffering she has endured, both from her father's death, as well as his emotionally distant behavior during life. Through your therapeutic dialogue, you emphasize that it is natural for a person to feel overwhelmed and disconnected in such circumstances, and that these feelings are not a source of shame or weakness. You prompt her to think of new ways in which she can build healthier relationships with others, including developing more meaningful connections through open and honest communication. Finally, you ask her to brainstorm different activities and interests that she finds joy in doing so she can incorporate them into daily life as a way for her to find balance amidst the chaos. At the end of the session, the client mentions that she is going to be visiting a friend who lives on the other side of the country. They are planning to explore one of the national parks for a few days and spend the remainder of the time "just chilling" at her friend's house. She tells you that she is looking forward to spending some time in nature. The client does not want to miss her weekly appointment with you and asks if you can meet with her for a virtual session next week instead of your usual in-person counseling session. | The client's mother was diagnosed with Bipolar I Disorder. The client's mother passed away ten years ago in a car accident. The client reported constant criticism from her father when she was growing up. When the client's mother was not depressed, she acted as a buffer between the client and her father. The client reports getting married immediately after graduating high school to an abusive man who was similar to her father in many ways. The couple divorced two years ago after the client wound up in the emergency room after reporting that she "slipped on the last step of the staircase and fell into a door jam." She got full custody of their son and went to live with her father until he passed away a year ago from suicide. He was chronically ill with cancer. The client is currently a science teacher. For the past three years, every school she has worked at has declined to renew her contract. The client's father left his house and all of his financial assets to her, so she does not have to make a mortgage payment. She has savings, but she is burning through it quickly. Previous Counseling: The client sought grief counseling at the time of her mother's death. She felt the therapist was "not spiritual enough" to deal with the client's beliefs. The client knew she needed help, and her pastor recommended a group. She attended four group sessions before leaving the group due to interpersonal conflicts with some of the group members. She tells you that she is not interested in participating in any group therapy. | What adjunct service might you recommend for this client? | Case manager | Group therapy | Nutritionist | Psychiatrist | (A): Case manager
(B): Group therapy
(C): Nutritionist
(D): Psychiatrist | Psychiatrist | D | A medication review is essential in this case to ensure proper mood stabilization as soon as possible. The proper course of treatment for anyone exhibiting mood dysregulation patterns is to ensure that they are able to stabilize their mood first and foremost while at the same time ensuring their personal safety. Therefore, the correct answer is (B) | treatment planning |
879 | Name: Marta Clinical Issues: Caregiving concerns Diagnostic Category: Trauma and Stressor Related Disorders Provisional Diagnosis: F43.23 Adjustment Disorder, with Mixed Anxiety and Depressed Mood Age: 55 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: Colombian American Marital Status: Married Modality: Individual Therapy Location of Therapy : Agency | The client appears older than her stated age. She is disheveled, poorly groomed, and has a strong body odor. She is cooperative but demonstrates a high level of distress manifested as restlessness, being easily distracted, and consistently rubbing her hands. Her speech is initially slow and halted but later becomes elevated and loud. She is oriented X3. Her affect is characterized by anxiety and depression, as she is having difficulty answering your questions. The client indicates that she has thoughts about putting a pillow over her mother's face or taking an overdose of sleeping pills so that she does not have to deal with her family or her mother's demands anymore. | First session You are a counseling intern for a mental health agency. A 55-year-old Colombian American female presents to therapy with tears in her eyes. She appears distraught, anxious, and despondent. She describes feeling guilty about wanting to put her mother in an assisted living facility. Although the client knows that putting her mother in an assisted living facility is probably the best decision, she feels guilty because it goes against the values of her culture. She explains that in traditional Colombian culture, elders are revered, and it is the responsibility of the oldest child to take care of them. The client's siblings have been "critical of me even talking about moving her into an assisted living facility" and are pressuring her to keep their mother at home. The client starts to cry and covers her face. Finally, she looks up and says, "I feel torn. There are these cultural expectations that I look after my mother, but she never even liked me and made my life miserable when I was growing up." The client does not have any nearby family who can help support her or assist in the care of her elderly mother. Her brothers live in different states, and her husband is an only child whose parents both passed away a few years ago. The client has expressed feeling overwhelmed by the responsibility of taking care of her mother and running her own household. She says, "I feel like I just can't keep up with everything. My kids need me, my husband needs me, and now I have to take care of my mother, too. And as for having any time to myself, that's a dream that's never going to happen." She further explains that her current circumstances remind her of what it felt like growing up in a chaotic household and feeling the pressure of having to take care of her younger siblings. She states, "It's like history is just repeating itself." She reports feeling "like a failure at being a wife, mother, sister, and daughter." As you listen to the client's story, you sense her feelings of guilt, frustration, and overwhelm about not being able to meet all the demands placed on her. You empathize with the client and validate her feelings. You compliment her on the strength it took for her to take on an additional responsibility despite the hardships that come with it. When asked what she hopes to gain from therapy, the client tells you that she wants to figure out how to balance her responsibilities. She expresses wanting to find a way to care for her family members without "losing myself and my sanity in the process." You suggest meeting with the client for weekly sessions as a place to begin, and you walk the client through what she can expect from therapy. Fourth session During a previous session, the client expressed an interest in bringing her husband to a therapy session to discuss her feelings and how to best manage their respective responsibilities. The client arrives to today's session with her husband, but he appears disengaged as you begin the session. You notice that the client is on edge, and she avoids looking at her husband. You start out by addressing both of them and asking how they are doing. The client responds first, saying that things have been difficult for her lately due to all the pressure she has been under from taking care of her mother in addition to managing her own household. She expresses feeling overwhelmed and anxious about not being able to meet everyone's needs perfectly. The husband remains silent, so you ask him specifically what he thinks about his wife's concerns. He replies that he feels frustrated because he believes that she is being "too sensitive" and should focus on fulfilling her obligations as a wife and mother instead of worrying about how others think she should do things. Feeling defensive, the client interjects and tells her husband that he does not understand what it feels like to be in her position. He replies, "You're right. I don't get it. Look, I don't want to be the 'bad guy' here, but you're obsessed with what your brothers think. They don't have to live with your mother. We do. We should be thinking about what's best for our family, not your siblings." The client says, "I'm trying my best, but I feel like I'm alone in this. When you get home from work, instead of helping around the house, you just binge watch cartoons and ignore everything. It's like I don't have a husband - I have an extra child!" The husband appears angry and tenses up, and you notice that the client is equally upset. You acknowledge their feelings of frustration, disappointment, and overwhelm and reiterate that it is understandable to feel this way given the amount of pressure they are both under. You take this moment to help both the client and her husband understand each other's perspectives in a supportive way. As you discuss their different points of view, it becomes clear that both the client and her husband are feeling overwhelmed by having to balance the demands of caring for an elderly family member. You explain the importance of being able to express their feelings and work together when making decisions about how to manage the family's needs. Next, you suggest that the client and her husband take some time to reflect on their feelings and experiences. You educate them about strategies they can use at home to express their feelings in a supportive way. | The client is the oldest child in her family. She has 3 younger brothers, all of whom are separated in age by one year. She was born and raised in Colombia. When she was in middle school, her family immigrated to the United States in search of better opportunities. Her father worked long hours as a taxi driver while her mother worked as a nanny taking care of other people's children. The client stated that she often felt like she had no parents because they were always working. The client stated that when they moved, her mother asked her to help out more at home with the cooking, cleaning, and taking care of her siblings. She often felt overwhelmed and guilty because she wanted to spend time with friends or focus on her studies rather than watching her brothers. The client revealed that she often feel a deep sense of resentment knowing that while other girls were able to go outside and play, she had responsibilities to take care of. Personal/Social Relationships: The client's father passed away four months ago and her 76-year-old mother has been living with the client since then. The mother does not speak English and requires assistance with medical appointments, financial dealings, and daily care. She constantly "nags" the client about how she is raising her children and often complains about her cooking. The client's husband, who is second-generation Irish American and grew up in Boston, is becoming increasingly irritated with his mother-in-law. He complains to his wife about her mother, which puts a "massive strain" on the couple's relationship. | Which defense mechanism best describes the husband's behavior at home as described by his wife? | Regression | Denial | Displacement | Reaction formation | (A): Regression
(B): Denial
(C): Displacement
(D): Reaction formation | Regression | A | The husband's behavior at home as described by his wife is an example of regression. Regression is a defense mechanism in which an individual reverts to behavior from an earlier stage of development in order to cope with stressful situations. In this case, the husband is engaging in behaviors that are more typical of someone younger (eg, watching cartoons instead of helping around the house) as a way to avoid dealing with the stress and pressure he feels due to his family's situation. Therefore, the correct answer is (D) | intake, assessment, and diagnosis |
880 | Name: Sierra Clinical Issues: Adjustment related to physical loss/injury/medical condition Diagnostic Category: Trauma and Stressor Related Disorders Provisional Diagnosis: F43.23 Adjustment Disorder with Mixed Anxiety and Depressed Mood Age: 16 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: Native American (Cherokee) Marital Status: Not Applicable Modality: Individual Therapy Location of Therapy : Private Practice | The client's appearance is slightly disheveled. Her behavior is withdrawn. She has her arms crossed throughout the session. The client's affect is congruent. Her mood is depressed during the initial intake. She reports that she sometimes "doesn't feel like existing" when thinking about her injury. She shares that the thought of not being able to dance ever again is "too much to bear." Exploration of thought content reveals that she has considered how she might harm herself. She reports that her father has guns locked in a safe, but she knows the passcode. The client denies she would ever act on this impulse and identifies three friends she could contact for support. | First session You are a mental health therapist in a rural private practice setting. A 16-year-old female is referred to you by her pediatrician for concerns about her mood, behavior, and low appetite. She is accompanied by her mother and father. You begin by speaking with all three family members, reviewing the informed consent process and how confidentiality will be handled with the daughter. They all acknowledge and sign the appropriate paperwork. Next you meet one-on-one with the parents to understand their concerns. They are extremely concerned about their daughter's mental health and wellbeing. They share that their daughter has been crying more often lately and she has become incredibly sensitive to criticism. She is often irritable and "snaps" at them over minor issues. She withdraws from social interaction with friends, which is out of character for her. She appears increasingly withdrawn from activities she used to enjoy like drawing and playing the piano. She is also sleeping more and eating less than usual, resulting in weight loss. The parents confirm that they have limited insight into their daughter's actual feelings, as she often refuses to discuss them. The mother tells you, "She had a ballet injury a couple of months ago, and she seems to be struggling with it. We've been trying to stay positive and supportive, but she's just not getting better. Her physical therapist said that keeping up a positive attitude is really important in the recovery process, but our daughter doesn't seem to care." After you feel you have obtained a thorough understanding of the parents' concerns, you ask the parents to wait in your waiting room and invite the daughter back into your office. You begin by expressing your understanding of the situation that lead her parents to bring her in for therapy. You state, “From what your parents have told me, I understand you have been going through a difficult time lately with your physical injury and the changes that it has caused in your life.” After establishing this understanding, you ask her to tell you about her experience with the injury, how it has impacted her life, and how she has been feeling since it occurred. She tells you she has a hard time concentrating at school because she is unable to dance. She becomes tearful when you attempt to find out about how her ballet injury is affecting her. She says her "life is ruined now" and "I will likely never dance again. I'll never be able to fulfill my dream of being a ballet dancer. I hate it. All of my dreams are crushed." She begins sobbing uncontrollably. You take a moment to de-escalate her intense emotional reaction. You explain that it is common to feel overwhelmed in the aftermath of a major injury, and there are strategies she can use to cope with her feelings. You discuss the importance of staying connected to friends, family, and supportive people during this difficult time. After completing your mental status examination of the client, you note suicidal ideation as an issue to discuss with her parents. Second session The client presents to her second counseling session in a defensive state. She is upset that you reported her suicidal ideation to her parents because she thought that everything she told you would remain confidential. She says, "Why should I tell you anything else? You'll just tell my parents." You tell the client that you understand her frustrations and empathize with her. You explain to her why confidentiality is not always absolute and that as a clinician, it is your responsibility to keep clients safe, even when they don't want you to. You further explain that in this case, you felt it was important for her parents to know about the suicidal ideation she has been experiencing. You emphasize that her parents care deeply about her, and they need to know what is going on with her in order for them to help. She responds by saying, "Okay, I get what you're saying, but telling them about it has only made things worse." She reports that her parents now treat her "differently" and do not allow her access to any "dangerous items like kitchen knives" without supervision. She feels restricted and watched. You nod your head in understanding and reflect that it can be difficult to feel like your parents don't trust you and have put restrictions on things they normally wouldn't. You also encourage her to try and see the situation from their perspective and agree that although the restrictions can be inconvenient, her safety is their top priority. She takes a deep breath and says, "I guess I can understand why they did it, but it still doesn't feel fair." You acknowledge her feelings of unfairness and validate that feeling. After your discussion, the client appears to have a better understanding of her parents' motivation for the restrictions and feels less resentful towards them. You ask her to tell you more about how she has been feeling lately and invite her to share any other issues she is having trouble managing. She tells you that her ballet teacher has invited her to help teach the younger ballet classes, but she is ambivalent about pursuing this opportunity. Though she still loves ballet, she thinks it will be painful to watch other children fulfill the dreams that she can no longer pursue. She says, "I'm afraid that if I agree to teach, I'll never get over my injury. It will just keep reminding me of what I could have been." You explain to her that it is natural for her to have these feelings and that it is okay to take time to make a decision. You ask her if she can see any benefits to teaching. She pauses and says, "I don't know...I've never really thought of myself as a teacher. I've always been the student." You acknowledge the difficulty of this transition and understand that it can feel risky to try something new. You suggest that teaching could be an opportunity for her to gain a sense of purpose, as well as an activity to help her stay connected to something she loves. You encourage her to try and explore her capacity for teaching and imagine what impact she could have on her students. | The client reports that she is doing "okay" in school. Her parents report that she used to make straight A's but is now making C's and D's. She is failing history because she did not complete a project. They share that her teachers have tried to reach out to her, but she has not responded to any of them. The client reports that she smokes cigarettes. She used to smoke once every couple of months while out with friends. Her use has become more frequent, and she is now smoking several times a week. She has tried alcohol (three beers) and smoked a joint at a friend's party, but she reports that she did not like how they made her feel. Pre-existing Conditions: The client fell in dance class two months ago and broke her ankle. There were complications during surgery to repair the break. The client is currently in intense rehabilitation planned for at least one year, but it may take longer. Doctors are unsure if she will ever regain full mobility of her ankle. | Toward the end of the session, you reflect back the main points that you and the client have discussed. Which statement provides the more accurate summarization of today's session? | "We talked about your ballet injury and how it's affecting your mental health. From what you've told me, it doesn't seem like you're interested in teaching younger ballet students right now." | "We talked about your suicidal ideation and how your parents reacted to it, which seems to have made things worse. I can understand why you're upset about me telling your parents, but it was necessary for your safety." | "We talked about your recent experiences with your parents, your thoughts about helping teach ballet classes, and your overall mental health. While we explored some difficult feelings and situations, we also talked about potential opportunities for you to find purpose and enjoyment." | "We talked about how your parents have been restricting you and making you feel watched, which has made things worse for you." | (A): "We talked about your ballet injury and how it's affecting your mental health. From what you've told me, it doesn't seem like you're interested in teaching younger ballet students right now."
(B): "We talked about your suicidal ideation and how your parents reacted to it, which seems to have made things worse. I can understand why you're upset about me telling your parents, but it was necessary for your safety."
(C): "We talked about your recent experiences with your parents, your thoughts about helping teach ballet classes, and your overall mental health. While we explored some difficult feelings and situations, we also talked about potential opportunities for you to find purpose and enjoyment."
(D): "We talked about how your parents have been restricting you and making you feel watched, which has made things worse for you." | "We talked about your recent experiences with your parents, your thoughts about helping teach ballet classes, and your overall mental health. While we explored some difficult feelings and situations, we also talked about potential opportunities for you to find purpose and enjoyment." | C | This is a good summarization statement because it accurately reflects the key points that were discussed during the session. It demonstrates that the therapist was listening and engaged with the client and is able to understand and reflect back the important issues that were raised. The statement acknowledges the client's feelings and ambivalence about teaching ballet, while also recognizing the importance of safety and the concerns the client has about her parents' restrictions. By summarizing these points, the therapist can help the client to gain a clearer understanding of what was discussed, and provide a foundation for further exploration and progress in future sessions. Therefore, the correct answer is (D) | counseling skills and interventions |
881 | 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. Fifth session The client missed last week's appointment and rescheduled to see you today. Before she sits down in the chair, she hands you a file with her medical records and blood work. She explains that she made copies for you to review. You discuss how she has felt since meeting with you. She uses various clinical terminology when describing her feelings and reports "battling anhedonia." It is difficult for her to enjoy going anywhere as she is constantly worried that she will contract a disease. She states that her anxiety has caused her to make some mistakes at work which she is very upset about. You notice that the client is wringing her hands together and biting her lips. You state to the client, "It sounds like you're really struggling with your anxiety. I noticed that you were talking about some of the mistakes you feel like you make at work because of your anxiety. Can you tell me more about that?" The client replies, "Yeah, it's so embarrassing and frustrating. Whenever I go out, and especially when I'm at work, I feel like everyone is judging me for my weight. It's like they think I'm not good enough because of it. I start to question myself and mess something up." You ask the client, "Have people actually said anything to you about your weight?" She responds, "No, but I can tell they're thinking it." As the therapist, you are able to observe how the client's cognitive biases may be contributing to her distress. You acknowledge her emotions, while also highlighting that she is facing challenges associated with being in a demanding role at work. You utilize cognitive-behavioral strategies with an emphasis on mindfulness practices to help her manage her feelings. You also discuss possible coping mechanisms that could help her manage the stress of her job. At the end of the session, you summarize what you have worked on and schedule her next appointment. | 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 would you include in the treatment plan for this client, based on her disclosures during today's session? | Taking an art class, meal planning, and increasing activity level. | Hypnosis, reading articles on anxiety, and recommended homework to reduce anxiety symptoms. | Sleep hygiene, meal planning, increase in activity level, and deep breathing. | Psychoeducation about anxiety, relaxation methods, deep breathing, and visualization. | (A): Taking an art class, meal planning, and increasing activity level.
(B): Hypnosis, reading articles on anxiety, and recommended homework to reduce anxiety symptoms.
(C): Sleep hygiene, meal planning, increase in activity level, and deep breathing.
(D): Psychoeducation about anxiety, relaxation methods, deep breathing, and visualization. | Psychoeducation about anxiety, relaxation methods, deep breathing, and visualization. | D | These methods are evidence-based to reduce anxiety symptoms. You could use articles or reading for your client, but these methods are a good starting point to lower anxiety symptoms. Therefore, the correct answer is (D) | treatment planning |
882 | Initial Intake: Age: 31 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Widowed Counseling Setting: Private Practice Type of Counseling: Individual | The client appears her stated age, dressed appropriately for the circumstances. Her mood is identified as sad and frustrated and her affect is restricted and flat. Her primary emotion in the session is anger, though it is expressed in a tempered manner. She demonstrates limited insight, and appropriate judgment, memory, and orientation. She reports having considered suicide when she was in high school but made no attempt and would now never consider harming herself or anyone else. | You are a counselor in a private practice setting. Your client is a 31 year-old female who reports that she is very impatient and feels angry all the time, and is taking it out on her children and others with angry outbursts. She says that her children are good but they don’t pick up when she tells them to and often, they put their toys away in the wrong places. The client states that her husband died while the family was on a vacation. She tells you that they had stopped for a break and her husband was hit by a car. She says that it happened in front of her and the children, who are now 6 and 7 years old. She endorses feeling angry, restless, and having trouble making decisions. She tells you that she is having trouble falling asleep, is anxious and overwhelmed. The client tells you that her husband was a good man and “very much my opposite.” She has high expectations for neatness and being on time, he was often messy and ran late. She tells you that sometimes she felt like the whole activity they were doing was “ruined” because he made them late or the kids didn’t follow the rules. She states that she was the “controller” in their relationship, which worked well for both of them, except when she got angry with him for not doing what she wanted, when she wanted, or how she wanted it. She acknowledges that she was often angry and frustrated with his casual way of going through life but now regrets it because he’s gone. She states that her goals for counseling are to be more patient and decrease her anger. | Family History:
The client reports a significant family history with her mother diagnosed with schizophrenia, with catatonia and was not medicated. She describes her mother as a “zombie” who loved her children but never told them because she was “absent.” The client describes her father as verbally abusive and involved with drugs and alcohol, often yelling, screaming, and throwing things. She states he often told the client that any mistakes she made were the reason that their life was so bad. She has no siblings but her husband has two sisters, with whom the client does not engage. She states one of his sisters is living with her boyfriend and the other asked to borrow money from her and her husband, which made the client angry. She identifies her support system as her church and a group of couples whom she and her husband were friends with prior to his death, most of whom attended the client and her husband’s high school and college. The client says she tends to be drawn to overly controlling people and her church, though fundamentalist and legalistic, became like family to her in high school. She tells you that the couple’s closest friends are her husband’s best friend, whom the client dated in high school, and his wife. She says that while dating, her then boyfriend was very attentive, “almost smothering,” but also very demanding by leaving her notes with things or work he wanted her to do for him. She states they dated for several years and then she met and married his best friend, who was her husband. She tells you that their best friend’s wife is her best friend, although “she irritates me all the time, and I don’t really like her that much.” She says her friend has a strong personality, is controlling, and wants to make all the decisions and plans in their relationship. | Using the information you have learned, which of the following should be addressed first in this session? | How can the client know when she feels better | Process progress with children and setting boundaries with her friend | Review circumstances around her arrival to the party and why she was angry | Discuss plans for helping the client work on not being angry at herself | (A): How can the client know when she feels better
(B): Process progress with children and setting boundaries with her friend
(C): Review circumstances around her arrival to the party and why she was angry
(D): Discuss plans for helping the client work on not being angry at herself | Process progress with children and setting boundaries with her friend | B | The client has made progress in two areas and while these are first steps, the counselor and client should process the client's emotions about having made these choices and acknowledge her hard work and success. Celebrating her success will increase the client's motivation to continue making positive changes. Following this, the counselor and client can address the other responses. Helping the client know when she feels better will be made easier by first processing her emotions about the positive steps she has already taken. Reviewing the circumstances around that party and instilling new skills to help her not become so angry at herself are important parts of the session, but new tasks should not be embarked upon without acknowledging and processing what she has already accomplished. Therefore, the correct answer is (B) | counseling skills and interventions |
883 | Client Age: 25 Sex: Male Gender: Male Sexuality: Bisexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Telehealth Type of Counseling: Individual counseling Presenting Problem: The client is experiencing difficulty focusing on work due to a childhood diagnosis of attention-deficit/hyperactivity disorder (ADHD) and thinks that if he cannot keep up with work, he is going to get fired. Diagnosis: Attention-deficit/hyperactivity disorder (ADHD), predominantly inattentive presentation (F90.0) | Mental Status Exam: The client is oriented to person, place, time and situation. The client is engaged and participates fully in the intake session. The client does not appear anxious. The client has a flat af | You are a licensed counselor working in your own private practice and providing telehealth sessions to clients. The client states that he is having trouble keeping up with tasks at work. The client reports that he wakes up and does not want to go to work because he knows he will not get much done. The client is often late to work, and although he is typically the only one in the office, his employer comes to work every now and then, and he worries that he will get caught arriving late. He says that he procrastinates on tasks but, often near the end of the day, finds motivation to complete the tasks and stays late to do so. In addition to his trouble at work, the client says he thinks that he does not do much that makes him happy. He expresses the desire to write stories and play guitar more because these activities used to make him happy, but he has trouble finding motivation to engage in them at the present. | fect. Family History: The client reports a strained relationship with his parents, but he says that he does not want to talk about them because they are not the reason that he is in therapy. The client says that he has a younger sister (age 23) and that they are not close. The client reports that he currently has a girlfriend | Which of the following would be the most appropriate short-term goal to focus on first in therapy for this client? | Identify the current ADHD behaviors that cause the most difficulty for the client. | Encourage the client to invite his girlfriend to a session so they can work through how ADHD affects their relationship. | Learn and implement planning and organization skills. | Identify, challenge, and reframe self-talk that reinforces behaviors associated with ADHD. | (A): Identify the current ADHD behaviors that cause the most difficulty for the client.
(B): Encourage the client to invite his girlfriend to a session so they can work through how ADHD affects their relationship.
(C): Learn and implement planning and organization skills.
(D): Identify, challenge, and reframe self-talk that reinforces behaviors associated with ADHD. | Identify the current ADHD behaviors that cause the most difficulty for the client. | A | Identifying the current ADHD behaviors that cause the most difficulty for the client is the most important first step in this client’s therapy, followed by determining the impact of symptoms on functioning. Encouraging the participation of the client’s girlfriend may provide insight into the client’s functioning and may also provide a social support for the client; however, relationship issues were not indicated in the first sessionOrganization skills and cognitive reframing are important parts of therapy for treatment of ADHD; however, they are not the first step. Psychoeducation on reframing and organization must be prioritized as well, but you need to identify the behaviors that cause the most difficulty to begin working on these skills. Therefore, the correct answer is (B) | treatment planning |
884 | Name: Barry Allen Clinical Issues: Behavioral problems Diagnostic Category: V-codes Provisional Diagnosis: Z62.898 Child Affected by Parental Relationship Distress Age: 13 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Not Assessed Ethnicity: White Marital Status: Not Applicable Modality: Individual Therapy Location of Therapy : Agency | The client is dressed in DC Comic attire and lives for cosplay. He is well groomed and sensitive to his appearance. Eye contact is minimal. His behavior is tense and purposeful. He demonstrates a limited affect and is minimally responsive. The client denies any current suicidal or homicidal ideation. | First session The client and his father present at the community counseling center where you practice as a marriage and family therapist. The father reports that his son has not been doing his homework or contributing to family chores. The client's mother is "at her wit's end" and told her ex-husband to get their son help. The school has called several times out of concern for the client's withdrawn behavior. He is not paying attention, is sleeping in class, and appears sad and irritable. You notice that he is disinterested, withdrawn, and does not want to be involved in therapy. The father minimizes his son's behavior and does not want any responsibility related to therapy. At the same time, he wants you to improve his son's attitude. Through open-ended questions and careful exploration, it is revealed that the client has been having difficulty establishing relationships with peers and adults. He has been feeling overwhelmed by his parents' relationship distress and his mother's new family dynamics. Furthermore, he has been struggling to manage the transition of living in two different homes between his parents. His father reports that his son appears to be increasingly isolated and has difficulty regulating his emotions. The client reveals that he is feeling lonely, depressed, and anxious due to the stress and uncertainty of his parents' relationship issues. He feels as though he is caught in the middle of his parents’ conflict and unable to meet their expectations. It appears that the distress caused by his parents’ relationship is affecting the client's overall wellbeing. You explain to the client and his father that therapy can help him process his feelings, build healthy coping strategies, and develop better communication skills with both of his parents. | The client's parents have been divorced for five years. The client's father shares parenting responsibilities of his only son, age 13, with the client's mother. The father, who is not currently in a relationship, "tries to get along" with his ex-wife but finds this challenging. The client's mother is living with her new fiancé. The fiancé is twice divorced and has three children from previous marriages. Both sets of the client's maternal and paternal grandparents have passed away. | Which assessment tools would you select to better understand the client's problem? | Adlerian Family Constellation Assessment | Family Map Inventory (FMI) and Beck Anxiety Inventory (BAI) | Parenting Stress Index | Family Environment Scale (FES) and the Beck Depression Inventory (BDI) | (A): Adlerian Family Constellation Assessment
(B): Family Map Inventory (FMI) and Beck Anxiety Inventory (BAI)
(C): Parenting Stress Index
(D): Family Environment Scale (FES) and the Beck Depression Inventory (BDI) | Family Environment Scale (FES) and the Beck Depression Inventory (BDI) | D | This covers both the family system issues and the possible depressive symptoms appearing in the case. The FES gives you an overview of how the client perceives the family and how each member's behavior affects the family. The BDI assists in determining a baseline for possible clinical depression. Therefore, the correct answer is (D) | intake, assessment, and diagnosis |
885 | Client Age: 24 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: African American Relationship Status: Single Counseling Setting: Private practice counseling clinic Type of Counseling: Individual counseling Presenting Problem: The client comes to counseling for help in managing anxiety, workplace dissatisfaction, and a pornography addiction. Diagnosis: Generalized anxiety disorder (F41.1), other problem related to employment (Z56.9), religious or spiritual problems (Z65.8) | Mental Status Exam: The client is oriented to person, place, time, and situation. The client appeared hesitant when talking about pornography | You are a professional counselor, and the client comes to counseling to work on anxiety, work dissatisfaction, and a pornography addiction. You and the client discuss his anxiety, and he identifies that he experiences anxiety at work, regarding daily tasks, and in social settings. The anxiety is characterized by restlessness, difficulty concentrating, muscle tension, and insomnia. The client states that at work he is often treated poorly by his supervisors, who often point out what he does wrong and do not acknowledge what he does right. He does not feel that he does as much wrong as they claim, and he often finds that their accusations do not accurately reflect his actions, which is frustrating. The client states that he has had many meetings with his supervisors and that they do not appear to try to understand his point of view. The client appears uncomfortable and begins to speak but stops for about a minute before saying that he also has a pornography addiction. The client says that he is a Christian and that he does not feel he should view any pornography, but also that he uses pornography a lot and does not feel like he has control over himself or the frequency at which he uses it. The client asks if you are a Christian, and you decide to disclose with him that you are, knowing this is an important part of the client’s life and perspective. The client states that his work problems and pornography use are his most pressing issues. | use. Family History: The client has a close relationship with his parents and his older sister. The client has close friends | Which of the following would be an appropriate short-term goal for this client that could be completed in the next month? | Decrease the client’s urges to masturbate. | Learn and implement coping skills for anxiety. | Explore what the client has liked and disliked about his current and past jobs. | Identify and implement assertiveness skills in the workplace. | (A): Decrease the client’s urges to masturbate.
(B): Learn and implement coping skills for anxiety.
(C): Explore what the client has liked and disliked about his current and past jobs.
(D): Identify and implement assertiveness skills in the workplace. | Explore what the client has liked and disliked about his current and past jobs. | C | The client wants to focus initially on cessation of pornography use and his unhappiness in the workplace. Exploring what the client has liked and disliked about his current and past employment is an appropriate short-term goal that can open up conversations about possibly changing the employment and identifying what matters to the client when at work. Although decreasing the frequency of masturbation may happen in the first month, you likely will only have a few sessions in this time period, and the skills necessary to manage urges to masturbate will not likely be developed at this point. Assertiveness skills training can be helpful in improving work situations; however, the client has already had several conversations with his supervisors and it does not appear that they have been open to his input thus far. The client does have a generalized anxiety diagnosis; however, he has more immediately pressing issues that he wants to work on, so you likely will not master coping skills for anxiety within the first month. Therefore, the correct answer is (B) | counseling skills and interventions |
886 | Name: Timmy Clinical Issues: Developmental processes/tasks/issues Diagnostic Category: Neurodevelopmental Disorders Provisional Diagnosis: F84.0 Autism Spectrum Disorder, Level 2 Age: 13 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: Black Marital Status: Not Applicable Modality: Family Therapy Location of Therapy : School | The client speaks using only a few words. There is no report of echolalia or other repetitive or overly formal use of language. You ask him to say "hi," and he opens his mouth wide, smiles, and laughs. He sustains direct eye contact with you for about two seconds. When you ask him to show you where his mother is, he points to her, looks back at you, and begins to laugh again. There are no reported or observed preoccupations and no reported or observed sensory symptoms to date. | First session You are a mental health therapist in a school setting. The client is referred to you by your school district to complete an evaluation. The client and his mother enter the session. The mother is prompting the client in a "toddler-like" voice to sit in the seat. The mother tells you that the client is becoming increasingly "violent" in the home setting, and she and her husband are not equipped to teach their son the skills he needs to regulate his emotions. In addition, she states that he needs some social exposure to others. He is nonresponsive to subtle social cues and has difficulty when others cannot understand his needs. She states that they need professional help and requests assistance in getting him "the education he deserves". You listen carefully to the mother's concerns and ask additional questions about her son's behavior, both at home and in school, as well as any history of mental health treatment or diagnoses. You explain to the client’s mother that you will provide an assessment of her son’s social and emotional needs and use evidence-based interventions to help him develop effective strategies for regulating his emotions and interacting with others. You review your therapy procedures in detail, including your expectations regarding how often the client and family should come for sessions and what to expect in terms of treatment outcomes. You also discuss any potential risks associated with therapy and the importance of open communication between family members, the client, and yourself during treatment. The mother expresses her understanding of your expectations and agrees to follow through with treatment. You encourage her to ask questions if she has any concerns or needs clarification about any part of the therapy process. Fourth session You have arranged for the client to have a one-on-one aid at school. You review his progress with his team of teachers and give them necklaces with visual cues to help communicate with him. The aid brings the client in for his weekly session with you today. The client sits and stares. At times he will rock and make loud noises. You hand him a stress ball and model for him how to squeeze it. The client starts to giggle as he squeezes the stress ball. You show the client the picture of a person laughing. You clap for the client and tell him "good job." The client mimics you and starts to clap. You ask the client if he would like to try playing a game with you. He nods his head in agreement and looks at you with anticipation. You choose a simple matching game with different shapes, colors, and sizes. Through this game, you encourage him to take turns and practice communication skills. As the session progresses, you provide verbal praise for his efforts and watch as he slowly builds a sense of trust in you. You create opportunities for him to share small stories about himself and encourage him to express his feelings through drawings or writing exercises. Through these activities, you provide a safe and comfortable environment for him to explore his emotions and interact with others. Following your session with the client, you contact his mother with an update on his progress. You discuss the importance of continuing therapy on a regular basis and explain what kinds of progress she can expect to see as time goes on. You also provide her with resources such as books, websites, and support groups that she can use to help reinforce the skills her son is learning in therapy. Finally, you outline a plan for continuing treatment and develop a timeline for when the family should check back in for sessions. The client's mother expresses her appreciation for your assistance and her agreement to follow through with the treatment plan. Ninth session The client's one-on-one aide presents to this session with the client. The client is crying and having difficulties following the aid's directives in the hallway. You walk into the hall and show the client a picture with "a quiet sign." You open your door, and he reluctantly walks in and begins to kick the toy bins. You show him the "no" visual sign and shake your head no. You sit on the floor quietly until he joins you on the floor. You pull out a deck of visual cue cards and place them in front of him. He points to a picture of a boy being mean to another classmate, then starts to cry harder. You allow some extra time for the client to process his emotions. You then explain to him that it is not okay to kick the toy bin, and that he can use his words or draw pictures of what he feels instead. You provide reassurance that you are there to help him learn how to control his feelings in a better way. You then select some calming activities such as squeezing the stress ball and playing a matching game. As he begins to gain control of his emotions, you reinforce positive behaviors with verbal praise and approval. Throughout the session, you actively listen and provide opportunities for him to express himself in whatever manner is comfortable to him. You end the session by drawing a picture of yourself and your client, with both of you smiling together. You explain that this is what happens when you work together to find positive ways to cope with emotions. | The client has a close-knit family, and his parents strive to support their son in any way they can. They have little outside support, however, and have been overwhelmed by their child's needs. The client has been home-schooled and lacks social skill development. Parents report that lately he refuses to do school work; as he gets older they will not have the skills to teach him what he needs to know academically. They feel it is now best for him to learn how to thrive socially and emotionally in a public school setting. | Using a filial therapy approach, what might you employ with the parents to increase interactional dynamics? | Assist the parents as a combination of trainer, supervisor, and coach in learning how to conduct "special playtime" sessions with the child. | Employ empathy, unconditional positive regard, and congruence as well as provide a nonjudgmental, understanding venue for the client's parents to explore what they need to explore. | Employ brief therapeutic procedures often in the form of paradox designed to change undesired patterns. | Educate the parents about a combination of biological, psychological, and social factors which drive how humans come to feel and act as they do. | (A): Assist the parents as a combination of trainer, supervisor, and coach in learning how to conduct "special playtime" sessions with the child.
(B): Employ empathy, unconditional positive regard, and congruence as well as provide a nonjudgmental, understanding venue for the client's parents to explore what they need to explore.
(C): Employ brief therapeutic procedures often in the form of paradox designed to change undesired patterns.
(D): Educate the parents about a combination of biological, psychological, and social factors which drive how humans come to feel and act as they do. | Assist the parents as a combination of trainer, supervisor, and coach in learning how to conduct "special playtime" sessions with the child. | A | This describes the primary concepts behind filial therapy. Therefore, the correct answer is (C) | counseling skills and interventions |
887 | 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. Fourth session All seven members have been coming to your group for three weeks. The group is made up of married, single, and divorced females. Some have children and some do not. Ages range from 25 to 33 years old. It is multiculturally diverse. As group sessions progress, you note that some group members are starting to take risks, while others are still not fully trusting you and the group's co-facilitator. Most of the clients generally worry about their family and loved ones. Some are more afraid of getting ill and dying because of COVID-19. You lead the group in a guided meditation before you start making the rounds to calm everyone down and have them feel centered. Sixth session You and your intern, who has never facilitated a group, meet five weeks after intake with the group members. One of the members shows up late to the group despite knowing the norms and rules. This member is from a Hispanic background. One of the other members, an African-American woman, says angrily, "You're wasting our time when you arrive late to every session. We have to pause for you. I have anxiety and need help. If you do not need help from the group, why don't you leave!" The Hispanic woman starts to cry and says, "Mind your business. I'm taking care of my dying mother and also have anxiety, so shut up!" You have to intervene as other members are getting frazzled and upset. You ask the intern to carry on with the group as you ask the two members to step outside. | null | Once the two members have calmed down and returned, you have the other group members tell how the altercation made them feel. You, as the therapist, listen without interrupting and avoid giving advice. Which technique are you demonstrating? | Free association | Congruence | Positive regard | Storytelling | (A): Free association
(B): Congruence
(C): Positive regard
(D): Storytelling | Positive regard | C | When using positive regard, the therapist listens without interrupting and avoids giving advice. There is no judgment, and the therapist listens actively. Therefore, the correct answer is (A) | counseling skills and interventions |
888 | Client Age: 20 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Asian Relationship Status: Single Counseling Setting: College counseling clinic Type of Counseling: Individual counseling Presenting Problem: Panic attacks Diagnosis: Provisional diagnosis: panic disorder (F41.0) | Mental Status Exam: The client is oriented to person, place, time, and situation. The client does not appear anxious or depressed and was friendly and eng | You are a counselor working in a college counseling department. The client comes in after being late to class several times over the last month due to reported “freak-outs” in the morning. The client experiences the following panic symptoms: accelerated heart rate, sweating, shaking, shortness of breath, and a feeling of impending doom. The client reports a feeling of impending doom when she wakes up on days when she has classes, and this anxiety tends to escalate into fear of having a panic attack on a daily basis, often making her late to her first class. The client is worried that she will have panic attacks every day for the rest of her life. She says that her parents have put a lot of pressure on her to get a high grade point average at college. The client is worried about how this pressure and the panic attacks are going to affect her doing well at college and engaging socially. | The client enters the room and appears distracted when she sits down because she has a furrowed brow and is looking off to the side of the room. You ask her what is on her mind, and she reports that this morning she had a panic attack that led to her throwing up. You ask her to talk through the moments when she noticed it starting and how the panic attack progressed. She says that she woke up and was worried that she might have a panic attack because she typically has one on school days, and this turned into worry that she might be late for class, which compounded into worry about how it might affect her grades and eventually into certainty that she would fail. The client then experienced an increased heart rate, chest tightness, difficulty breathing, a feeling of impending doom, shaking, and finally vomiting. You empathize with the client and provide psychoeducation on the management of panic attacks. You had an argument with your roommate prior to the session and are distracted | You had an argument with your roommate prior to the session and are distracted. Which of the following would be the most appropriate decision with regard to your client’s well-being as it is impacted by your distraction? | Start the session a little late so you can resolve the argument in order to be more focused. | Reschedule the session with the client. | Talk with the client about how you might impact the session and get refocused. | Be aware of how your personal life is impacting the session and refocus as needed. | (A): Start the session a little late so you can resolve the argument in order to be more focused.
(B): Reschedule the session with the client.
(C): Talk with the client about how you might impact the session and get refocused.
(D): Be aware of how your personal life is impacting the session and refocus as needed. | Be aware of how your personal life is impacting the session and refocus as needed. | D | It is most ethical and appropriate to continue your session as scheduled, while maintaining awareness of how your personal life is affecting the counseling session because you want to support the client and prevent as much personal impact as possible. Rescheduling may be appropriate if the impact of your personal life is unavoidable; however, it is your responsibility as a therapist to ensure that you are minimizing your own personal life’s impact on the client. Occasionally, you may need to directly address emotions or thoughts that you are having during sessions; however, this topic may distract from the client and reduce their confidence in your focus this session. You want to be consistent and be on time to respect your client’s time and to show your investment in the client. Therefore, the correct answer is (B) | professional practice and ethics |
889 | Client Age: 4 Sex: Female Gender: Female Sexuality: Unknown Ethnicity: Caucasian Relationship Status: Not applicable Counseling Setting: Private Practice Clinic Type of Counseling: Family Therapy Presenting Problem: Foster Care; Disengaged Child; Behavioral Problems Diagnosis: Provisional Diagnosis of Reactive Attachment Disorder (F94.1) | Mental Status Exam: The client is disengaged, and when the foster parents prompt her to answer questions, she ignores them and continues playing. The client appears oriented to person, place, time, and situation because she answered questions about these topics. The client appeared more responsive to your questions than her foster par | You are a private practice counselor specializing in working with children with developmental disorders. The 4-year-old female client is referred to you by her PCP and arrives with her foster parents, who join her in the first session. The client has been with her foster parents for the last 13 months after being removed from the care of her biological parents due to their incarceration for drug trafficking and attempted armed robbery. The foster parents are worried because the client exhibits minimal positive mood, irritability without an obvious trigger, and behaviors that appear to be clearly connected to attachment with caregivers. She experienced emotional and physical neglect from the birth parents and changes in primary caregivers. The foster parents also report that the client does not seek comfort when something happens that upsets her. The client did not engage very much in the intake session and was instead playing with the toys provided by the counselor. During the session, the client becomes upset with her foster parents when they prompt her to answer some questions. She hits the foster father, runs out to the lobby, and sits down with the toys. You leave the office and meet her in the lobby. | You meet with the client 2 weeks after the initial intake because she refused to come for the session scheduled the past week. Because of the cancellation, you decide to change the focus of your session to meet the client’s needs for comfort and security over the foster parents’ need for guidance and skills. The client engages a little more in interacting with you, and you praise her for her involvement. At one point in the session, the client hits you and goes and sits down to continue playing. At the end of the session, you provide the foster parents with ways that they can increase attachment and positive interactions with your client. You empathize with the foster parents regarding their desire to help the client feel loved and cared for. The foster parents state, “we know that we are going to mess up, and she will be worse off | The foster parents state, “we know that we are going to mess up, and she will be worse off.” What kind of cognitive distortion is this? | Blaming | “Should” statements | Overgeneralization | All-or-nothing thinking | (A): Blaming
(B): “Should” statements
(C): Overgeneralization
(D): All-or-nothing thinking | Blaming | A | This kind of thinking places blame on the couple, and it may be helpful to focus on what the couple is doing well for the client in order to increase their confidence. “Should” statements focus on what the individual should do. The parents aren’t focusing on what they should do; rather, they feel guilty for the client’s potential future situation. This is not all-or-nothing thinking because the parents are not focusing on their actions as either extremely good or bad. Instead, they are blaming themselves for the client’s situation. Overgeneralization focuses on creating an expectation based on an experience. The client’s foster parents are not creating an expectation based on an experience because she is rather blaming them for the future outcome. Therefore, the correct answer is (A) | counseling skills and interventions |
890 | Name: Gordon Clinical Issues: Mood instability and substance use leading to occupational impairment Diagnostic Category: Bipolar and Related Disorders;Substance Use Disorders Provisional Diagnosis: F31.0 Bipolar I Disorder with Rapid Cycling; F10.20 Alcohol Use Disorder, Severe Age: 33 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: White Marital Status: Never married Modality: Individual Therapy Location of Therapy : Agency | The client appears to the intake session disheveled and displaying a strong presence of body odor. He is inconsistently cooperative within the session. His mood and affect are anxious and labile. His attention and concentration are impaired, and he is easily distracted in the session. He admits to his recent suicidal ideations and hospitalization but minimizes the impact stating, "Everyone overreacts these days." He mentions that when he was in his 20s, he was prescribed Lithium. He denies any homicidal ideations and displays no acts of delusion or hallucination. The client's ability to abstract and generalize is slightly lower than average. The client grapples with his impulse control regarding alcohol. He has insight into the level of the illness with which he is struggling but lacks judgment when making healthy choices. | First session You are a mental health therapist in an agency. The client, a 33-year-old former cab driver, comes to see you per his hospitalization discharge. The client's speech is characterized by an increased rate of speech, tangentially, and circumstantiality. He reports feeling overwhelmed and out of control, often losing his temper and having difficulty regulating his emotions. He reports a history of alcohol abuse, as well as self-medicating to cope with his emotional distress. He states that he has lost his job due to his difficulty controlling his emotions, and he is hopeful that therapy can help him regain his job. He also reports a history of legal trouble and has been incarcerated multiple times in the past. His legal record shows a history of violent offenses and domestic abuse. After the initial interview, you review the paperwork from the client. You recognize his last name and realize he is a distant cousin by marriage, although this is your first time meeting him. You consider the ethical implications of continuing to see him for therapy along with the possibility of transferring him to one of your colleagues. Third session After determining that you would be able to remain objective with the client, you met with him for a session and continued your assessment. You recommended seeing him once a week for therapy sessions and asked him to check in with you between sessions. You also provided him with a referral for a psychiatric evaluation to determine if medication was warranted for mood stabilization. Today is your third counseling session, and the client arrives 10 minutes late. The client's behavior during the session was increasingly concerning. He appeared disheveled, and his speech was slurred and jumbled, indicating that his level of intoxication was likely high. The client exhibited bizarre behaviors and laughed inappropriately, indicating a potential manic or hypomanic episode. His attention span during the session was limited, and he could not focus on the topics at hand. When asked, the client admits to drinking before the session and is unable to provide an accurate account of how much he has consumed. He reports going to the local bar down the street from his house to have "one drink." He is also unable to provide any information on the location of his emergency contact. This lack of insight and awareness of his current intoxication, combined with the inappropriate behaviors he is exhibiting, prompts you to assess for the next level of intervention that is needed. | The client had a history of alcohol abuse and had been warned multiple times by his employer to stop drinking while on the job. The client's boss tried to counsel him, but he refused to accept help or advice. Instead, he continued driving while under the influence, and his reckless behavior eventually led to an accident. As a result, the client was dismissed from his job and has struggled ever since. The client has been unsuccessful in finding other employment due to his record of drinking on the job. He has been trying to seek help with his drinking but without any success. He believes that therapy may be his last hope for getting his job back, and he is desperate to change his life. The client tells you, "I started drinking years ago. I've tried to quit, but I can't do it." He further states, "It used to be a couple of beers, but that doesn't do it for me anymore. So now, I drink almost half a bottle of whiskey a day. I usually start in the morning because if I don't, I feel terrible; my hands shake, I feel clammy, and I get an upset stomach. For years, I used just to let the mood pass, but in the last year or so, the alcohol has helped." | What is most important to consider when developing this client's treatment plan? | The client's level of motivation to change | The client's support network | The client's ability to maintain employment | The client's genetic predisposition to addiction | (A): The client's level of motivation to change
(B): The client's support network
(C): The client's ability to maintain employment
(D): The client's genetic predisposition to addiction | The client's level of motivation to change | A | Assessing the stage of change which he is currently in will help guide your treatment plan. If the client is not motivated to make any changes, therapy will not be effective. Therefore, the correct answer is (B) | treatment planning |
891 | Client Age: 25 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Counseling Clinic Type of Counseling: Individual Presenting Problem: Depression and Suicidal Ideation Diagnosis: Major Depressive Disorder, Recurrent, Mild (F33.0) | Mental Status Exam: The client appears to not have bathed recently because his hair is greasy and unkempt. The client has food stains on his clothing; however, he is dressed appropriately for the season. His motor movements are within normal limits. He is engaged in therapy, but he appears anxious as evidenced by hesitating before speaking and by his hand wringing. The client reports suicidal ideation with no plan or intent. The client reports a depressed mood more often than not and difficulty enjoying most activities. The client is oriented to person, place, time, and situation. The client reports that his appetite has increased lately and that he is experiencing hyperso | You are a resident in counseling practicing in a private practice agency. During the initial counseling session, the 25-year-old single male client reports feeling depressed and hopeless. He has difficulty enjoying activities that he has enjoyed in the past and feels unsatisfied with most areas of his life. The client identifies that he is not happy at work and wants to make a career change. The client verbalizes feeling sad more often than not, and that this has been going on for about 2 years. The client decided to start counseling when he began experiencing suicidal thoughts. The client reports no plan or intent to attempt suicide but is concerned about his own well-being. | mnia. Family History: The client reports that he has two younger brothers who are 19 and 22 years old. His parents divorced when he was 10 years old, and he grew up living with his mother but maintained a strong consistent relationship with his father. The client reports no history of trauma, neglect, physical abuse, sexual abuse, or emotional abuse. The client denies drug or alcohol use, although he reports that his father previously was an active alcoholic. Due to your observation of anxious behavior, you prompt the client to identify and rate his feelings at the start and end of the session | Due to your observation of anxious behavior, you prompt the client to identify and rate his feelings at the start and end of the session. What would be the main purpose of this therapeutic intervention in the first session? | To facilitate the client’s awareness of his anxious behavior | To determine the client’s level of comfort | To determine if the counselor can meet the needs of the client | To facilitate discussion regarding goals for anxiety management | (A): To facilitate the client’s awareness of his anxious behavior
(B): To determine the client’s level of comfort
(C): To determine if the counselor can meet the needs of the client
(D): To facilitate discussion regarding goals for anxiety management | To determine the client’s level of comfort | B | The client’s level of comfort is assessed using this therapeutic intervention. This intervention involves the use of the counseling skill called “immediacy” Immediacy addresses emotional responses that are present in the counseling session and can facilitate deeper processing of emotions and building therapeutic rapport. Although the client’s hesitation before speaking and him wringing his hands may indicate anxiety, it is common for clients to be nervous during their first therapy session. Creating awareness of anxious behavior alone may make the client feel judgment, which may make him more uncomfortable. This intervention will not, on its own, determine if the counselor is a good fit for the client. Therefore, the correct answer is (B) | professional practice and ethics |
892 | Name: Jeff Clinical Issues: Referral following hospitalization for suicidal ideation Diagnostic Category: Bipolar and Related Disorders Provisional Diagnosis: F31.32 Bipolar I Disorder, Moderate, Most Recent Episode Depressed Age: 33 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: White Marital Status: Never married Modality: Individual Therapy Location of Therapy : Private Practice | The client's overall presentation during the examination is disheveled. He is thin, taller than average, and hunches over in his chair. He appears tired and exhibits low energy. Several times during the examination, he massages his neck and shoulders. He has inconsistent eye contact and often looks down at the floor. Speech is quiet and slow. You have to wait several seconds for him to answer questions. Thought content reveals negative themes. At various times he appears numb and indifferent but then shifts to tearfulness. Memory is slightly impaired, and he has difficulty staying focused. He denies homicidal ideations but states having past suicidal ideations. | First session You are a clinical mental health therapist working in a private practice setting. The client is a 33-year-old male referred to you by an ER physician as a follow-up after being hospitalized due to suicidal ideation. This is not the first time the client has been hospitalized. During the initial counseling session, the client discloses, "I don't know why I'm here. No one can help me. My sister made this appointment for me because I got this referral when I left the hospital. She drove me here and is sitting out in the waiting room." He continues with a tearful eye, "I'm a total failure. No one cares about. My sister looks after me, but I think it's because she feels sorry for me." You continue with your assessment to gain a more thorough understanding of his current situation. He tells you that there are times when he feels "really low" and his mind tells him that he would be better off dead. Other times, he feels "pretty good" with a lot of energy, a positive self-image, and motivation to complete various projects. You ask about his relationships with friends and family, and the client reveals that he has lost contact with most of his close friends due to a "series of negative events" in his life. He further discloses that he has difficulty maintaining relationships. He expresses feelings of loneliness and disconnection from the world. He is worried that his sister will eventually "give up" on him. When asked about his parents, he softly laughs and says, "They took the easy way out and died. Mom in a car crash and Dad from cancer. They are the ones who deserve to suffer and instead, they've got it easy." You discuss your role as a therapist and what the client can expect from the counseling process. You also review the parameters of confidentiality involved in therapy. He tells you that he would like to "give counseling a try" and see you for another session. You schedule an appointment to see him the following week. Fourth session The client appears energetic during this session. He presents as much more carefully groomed and in an elevated mood. He states, "It sure has been a journey these past few days." He reports that he met a woman at a local bar, and after spending the night together at a local hotel, they ended up taking a spontaneous road trip to Florida. He talks about the weekend as "mind-blowing", and states that this adventure has helped him design his new goal, which will be "life-changing." He goes on to say that his boss "didn't appreciate my free spirit because I had a bunch of voicemails from her waiting for me when I got home." He laughs when he relates that he had turned his phone off, so he didn't have to be "brought down." He recognizes that he had made commitments to work over the weekend, but he states, "If you met this girl, you'd know why I did it." Then laughs. You listen to the client's story intently and encourage him to talk more about his experience. Then you explore his feelings around the situation and his decision to leave work without making prior arrangements to cover his absence. You also discuss with the client the potential consequences of his actions and help him consider how to move forward in a way that is not harmful or dangerous. You ask him to think about his goals and create an action plan to help him reach those goals. Together, you and the client come up with strategies for the client to move forward in a healthy way. 10th session As you have been working with the client over the past two and a half months, he has made significant progress with treatment goals, including mood stabilization and behavioral control. In the last session, as you reviewed the progress that the client had made over the course of treatment, you both agreed that the client was ready for termination as he felt he had gotten what he needed from therapy. The client was especially pleased when considering his progress in mood regulation and mindfulness, as well as addressing his thrill-seeking behaviors during his manic phases. For this final session, the client arrived ten minutes late. He appears out of breath as he runs into the room. The client states that he got a call from the hospital where his sister was just admitted. As he describes the phone call, he pauses and looks out the window with tears in his eyes. You ask him how he feels. The client responds quietly, "I don't know, my sister has been in a serious accident, and I don't know how I'll continue without her support," prompting you to recognize that unresolved issues may require additional therapy. You state, "It sounds like your sister's accident has brought up a lot of emotions for you. You are feeling overwhelmed and unsure about how to cope without her support. It must be difficult to process all of this at once." The client nods his head. You continue by telling him that it is natural to feel overwhelmed and uncertain in a situation like this. You engage him in a discussion about coping strategies or support systems that have helped him in the past when facing difficult challenges. You also ask him if it would be helpful to have additional therapy sessions during this time to which he replies, "Yes, I don't want to undo all the progress I've made." | The client's parents divorced when he was ten years old. He has an older sister who he currently lives with. He recalls his childhood memories as traumatic and reports experiencing verbal and physical abuse by both parents. The client states that he lived with his dad after his mom died when he was 14 years old. He explains that living with his dad was difficult, saying, "Being around my dad was like being around a ticking time bomb. There were times when he was calm and seemed interested in what I was doing, but there were other times when he would become very angry and I was never sure what might set him off." The client works in a local pizza shop. He says he is written up weekly for being late to work. He reports verbal altercations with his coworkers because they will not listen to him. In his teen years, the client used alcohol to cope with his family situation. Since that time, he only drinks socially. | What cognitive-behavioral technique might best facilitate mood stabilization for this client? | Mood charting | Cognitive restructuring | Mindfulness meditation | Progressive muscle relaxation | (A): Mood charting
(B): Cognitive restructuring
(C): Mindfulness meditation
(D): Progressive muscle relaxation | Cognitive restructuring | B | Cognitive restructuring is a CBT technique that instructs clients to examine their thoughts by looking for distortions to achieve more balanced thinking. Individuals' thoughts influence their emotions which then affect their mood and behavior. Therefore, the correct answer is (B) | treatment planning |
893 | 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 focus area(s) would be most helpful for Bob throughout the remainder of his treatment? | relationship skill building | family systems and codependency | stages of addiction | communication and forgiveness | (A): relationship skill building
(B): family systems and codependency
(C): stages of addiction
(D): communication and forgiveness | communication and forgiveness | D | Teaching communication skills such as assertiveness can help Bob learn how to share his feelings, attempt getting his needs met, and set boundaries for himself and within his marriage. Addressing forgiveness using evidence-based approaches has been clinically proven to reduce anger, anxiety and helplessness while raising self-esteem and independence. Answer a) is not going to be possible without his wife engaged in the process, and Bob is not yet in a willing place. Answer b) would also be a useful area to engage both parties of the marriage together, with specific focus of codependency for his wife. Answer c) is crucial to his education in recovery and would likely have been covered in his first week of treatment but does not prepare Bob to face the challenges of his triggers ahead when he arrives home. Therefore, the correct answer is (D) | counseling skills and interventions |
894 | 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. Fourth session You have been meeting with Becky for 30-minute sessions once a week for the past three weeks. You have been collaborating with her parents and sharing strategies for how they can support their daughter at home. You have also been communicating with Becky's teacher to monitor Becky's behavior in the classroom. Today is your fourth session with Becky, and she is accompanied by her mother. The mother reveals that her daughter has stolen money from her purse. The mother has also received a call from Becky's teacher informing the parent that Becky was seen removing items from the teacher's desk. When confronted with this information during the session, Becky loudly denies stealing anything, calls her mother a liar, grabs a coffee cup from your desk, and throws it on the floor. You respond to the situation by remaining calm and utilizing a nonjudgmental approach. You remind Becky and her mother that it was a safe space to discuss their feelings and that it was important to express them appropriately. You then explored Becky's feelings about her mother's accusation to understand her perspective and encourage Becky to take ownership of her behavior. Finally, before Becky and her mother leave, you provide them with tools to practice at home to manage their emotions, suggesting they focus on communication, problem-solving, and finding healthy ways to express their feelings. | 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. | You are currently dealing with some difficult unresolved childhood issues, and your client's explosive outburst in session has made you feel uncomfortable and threatened. Given the client's intense reaction, how should you proceed? | Contact a supervisor to discuss your issues and provide insight on possible next steps | Contact a supervisor to help you compartmentalize your personal and professional issues | Contact a supervisor to refer the client to another therapist | Contact a supervisor to help manage transference issues related to your childhood trauma | (A): Contact a supervisor to discuss your issues and provide insight on possible next steps
(B): Contact a supervisor to help you compartmentalize your personal and professional issues
(C): Contact a supervisor to refer the client to another therapist
(D): Contact a supervisor to help manage transference issues related to your childhood trauma | Contact a supervisor to discuss your issues and provide insight on possible next steps | A | Therapists should always be aware of their own issues and how they affect the therapeutic process. If personal issues are affecting the therapeutic relationship, the therapist should seek supervision. Therefore, the correct answer is (D) | professional practice and ethics |
895 | Initial Intake: Age: 31 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Widowed Counseling Setting: Private Practice Type of Counseling: Individual | The client appears her stated age, dressed appropriately for the circumstances. Her mood is identified as sad and frustrated and her affect is restricted and flat. Her primary emotion in the session is anger, though it is expressed in a tempered manner. She demonstrates limited insight, and appropriate judgment, memory, and orientation. She reports having considered suicide when she was in high school but made no attempt and would now never consider harming herself or anyone else. | You are a counselor in a private practice setting. Your client is a 31 year-old female who reports that she is very impatient and feels angry all the time, and is taking it out on her children and others with angry outbursts. She says that her children are good but they don’t pick up when she tells them to and often, they put their toys away in the wrong places. The client states that her husband died while the family was on a vacation. She tells you that they had stopped for a break and her husband was hit by a car. She says that it happened in front of her and the children, who are now 6 and 7 years old. She endorses feeling angry, restless, and having trouble making decisions. She tells you that she is having trouble falling asleep, is anxious and overwhelmed. The client tells you that her husband was a good man and “very much my opposite.” She has high expectations for neatness and being on time, he was often messy and ran late. She tells you that sometimes she felt like the whole activity they were doing was “ruined” because he made them late or the kids didn’t follow the rules. She states that she was the “controller” in their relationship, which worked well for both of them, except when she got angry with him for not doing what she wanted, when she wanted, or how she wanted it. She acknowledges that she was often angry and frustrated with his casual way of going through life but now regrets it because he’s gone. She states that her goals for counseling are to be more patient and decrease her anger. | Family History:
The client reports a significant family history with her mother diagnosed with schizophrenia, with catatonia and was not medicated. She describes her mother as a “zombie” who loved her children but never told them because she was “absent.” The client describes her father as verbally abusive and involved with drugs and alcohol, often yelling, screaming, and throwing things. She states he often told the client that any mistakes she made were the reason that their life was so bad. She has no siblings but her husband has two sisters, with whom the client does not engage. She states one of his sisters is living with her boyfriend and the other asked to borrow money from her and her husband, which made the client angry. She identifies her support system as her church and a group of couples whom she and her husband were friends with prior to his death, most of whom attended the client and her husband’s high school and college. The client says she tends to be drawn to overly controlling people and her church, though fundamentalist and legalistic, became like family to her in high school. She tells you that the couple’s closest friends are her husband’s best friend, whom the client dated in high school, and his wife. She says that while dating, her then boyfriend was very attentive, “almost smothering,” but also very demanding by leaving her notes with things or work he wanted her to do for him. She states they dated for several years and then she met and married his best friend, who was her husband. She tells you that their best friend’s wife is her best friend, although “she irritates me all the time, and I don’t really like her that much.” She says her friend has a strong personality, is controlling, and wants to make all the decisions and plans in their relationship. | Based on the information provided, which of the following is not a cultural factor to explore with this client? | Client growing up in a family with a verbally abusive parent | Client becoming a widow and single parent before age 30 | Client growing up in a family with a parent diagnosed with schizophrenia | Client marrying her former boyfriend's best friend | (A): Client growing up in a family with a verbally abusive parent
(B): Client becoming a widow and single parent before age 30
(C): Client growing up in a family with a parent diagnosed with schizophrenia
(D): Client marrying her former boyfriend's best friend | Client marrying her former boyfriend's best friend | D | Culture includes a client's race, ethnicity, socioeconomic style, family structure, and any group membership that the client is or becomes a part of that influences her identity and personality formation. Marrying her husband, who was the best friend of her former boyfriend, is not a cultural factor and may be explored in relation to the client's history, but not as part of the section of the intake that explores the client's cultural formation. Living with a parent who has schizophrenia and another parent who is verbally abusive will shape how the client perceives herself and the world around her. It is unexpected to lose a spouse prior to age 30 and places the client in a cultural category with other young women who have been widowed early in life and will shape the way the client views herself and the world around her. Therefore, the correct answer is (A) | intake, assessment, and diagnosis |
896 | 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 | Which is of the following is an ethical expectation for certified counselors providing distance counseling and maintaining a social media presence? | Refrain from viewing a client’s personal or public social media profile without permission; however, counselors must discuss professional limitations with maintaining confidential electronic communication. | Ensure that professional social media accounts are merged with personal accounts to avoid ambiguity and confusion. | Refrain from entering personal virtual relationships with clients for a period of 5 years following the last professional contact. | Develop informed consent procedures covering issues such as the possibility of technology failure, emergencies, and the increased risk for harmful boundary violations. | (A): Refrain from viewing a client’s personal or public social media profile without permission; however, counselors must discuss professional limitations with maintaining confidential electronic communication.
(B): Ensure that professional social media accounts are merged with personal accounts to avoid ambiguity and confusion.
(C): Refrain from entering personal virtual relationships with clients for a period of 5 years following the last professional contact.
(D): Develop informed consent procedures covering issues such as the possibility of technology failure, emergencies, and the increased risk for harmful boundary violations. | Refrain from viewing a client’s personal or public social media profile without permission; however, counselors must discuss professional limitations with maintaining confidential electronic communication. | A | Distance counseling, technology, and social media use is covered in section H of the ACA Code of Ethics (2014). Concerning social media, counselors must refrain from viewing a client’s personal or public social media profile without permission. Confidentiality and its limitations must be addressed in terms of potential unauthorized and authorized electronic records and their transmissions. Answer B is incorrect because counselors are encouraged to keep their personal and professional accounts separate. For answer C, developing informed consent procedures covering issues such as the possibility of technology failure and emergency policies is correct, but addressing the increased risk for harmful boundary violations (eg, sexual relationships, exploitation) is incorrect because counselors are solely responsible for protecting clients from harm and eliminating risks. Boundary violations are not only unethical but may also have legal implications. Lastly, according to the ACA Code of Ethics, “counselors are prohibited from engaging in a personal virtual relationship with individuals with whom they have a current counseling relationship (eg, through social and other media) (ACA, 2014)” The 5-year timeframe refers to sexual relationships. Specifically, “client interactions or relationships with former clients, their romantic partners, or their family members are prohibited for a period of 5 years following the last professional contact (ACA, 2014)”. Therefore, the correct answer is (A) | professional practice and ethics |
897 | 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. Fourth session All seven members have been coming to your group for three weeks. The group is made up of married, single, and divorced females. Some have children and some do not. Ages range from 25 to 33 years old. It is multiculturally diverse. As group sessions progress, you note that some group members are starting to take risks, while others are still not fully trusting you and the group's co-facilitator. Most of the clients generally worry about their family and loved ones. Some are more afraid of getting ill and dying because of COVID-19. You lead the group in a guided meditation before you start making the rounds to calm everyone down and have them feel centered. Sixth session You and your intern, who has never facilitated a group, meet five weeks after intake with the group members. One of the members shows up late to the group despite knowing the norms and rules. This member is from a Hispanic background. One of the other members, an African-American woman, says angrily, "You're wasting our time when you arrive late to every session. We have to pause for you. I have anxiety and need help. If you do not need help from the group, why don't you leave!" The Hispanic woman starts to cry and says, "Mind your business. I'm taking care of my dying mother and also have anxiety, so shut up!" You have to intervene as other members are getting frazzled and upset. You ask the intern to carry on with the group as you ask the two members to step outside. | null | Two group members are talking over each other and getting louder to prove their points. What method would be effective in handling this situation? | Blocking | Prompt the intern to intervene under your supervision | Providing self-disclosure | Linking | (A): Blocking
(B): Prompt the intern to intervene under your supervision
(C): Providing self-disclosure
(D): Linking | Blocking | A | Blocking is a term which is used to cut off members from talking too much or, in certain cases, to cut off members who may be getting out of control. As the leader, you need to intervene in such cases. Therefore, the correct answer is (B) | counseling skills and interventions |
898 | 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. You are concerned about the client’s online activity. You search and find her social media account, view the content, and find evidence of cyberbullying | You are concerned about the client’s online activity. You search and find her social media account, view the content, and find evidence of cyberbullying. You and your supervisor use an ethical decision-making model to appropriately determine which of the following? | You must respect the client’s privacy unless she permits you to view her social media account. | You must breach confidentiality and inform the client’s parents. | You must respect the client’s privacy but report the cyberbullying peers. | You must disclose the findings to the client and assess for safety. | (A): You must respect the client’s privacy unless she permits you to view her social media account.
(B): You must breach confidentiality and inform the client’s parents.
(C): You must respect the client’s privacy but report the cyberbullying peers.
(D): You must disclose the findings to the client and assess for safety. | You must respect the client’s privacy unless she permits you to view her social media account. | A | You and your supervisor appropriately determine that you must respect the client’s privacy unless she permits you to view her social media account. The ACA Code of Ethics addresses this issue in Section H6c, entitled “Client Virtual Presence” In this scenario, you searched for the client’s social media account without prior permission. You appropriately discuss the ethical dilemma with your supervisor. Per the ACA Code of Ethics, counselors “are expected to engage in a carefully considered ethical decision-making process” This process generally involves determining the scope of the problem, applying the code of ethics, consulting supervisors and other appropriate professionals, and determining the best course of action. You not only viewed a private account without permission but did not have grounds for suspicion. The client stated that she felt like she didn’t fit in with her peers and equated her number of likes with her worth as a person; this did not include allegations of cyberbullying or other safety-related concerns. Therefore, the correct answer is (C) | professional practice and ethics |
899 | Initial Intake: Age: 48 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Private Practice Type of Counseling: Individual | The client appears to be his stated age and overweight for his height. He is dressed professionally and appropriately to the circumstances as he tells you he will see clients after your appointment. The client lays on the office couch with his hands behind his head and his feet on a cushion. He answers questions without pauses and often replies very casually with “sure” or “I don’t know,” demonstrating little insight into his thoughts, behaviors, and emotions. He estimates his mood as dissatisfied and unhappy though his affect suggests ambivalence. He presents with some complaints of forgetfulness but is oriented to time and place, and endorses no delusions or hallucinations. He acknowledges frequently feeling suspicious, especially when he’s feeling really stressed. He says he questions other people’s motives and what they are doing or saying when he’s not present. The client acknowledges using alcohol on weekends, and has used marijuana and cocaine regularly over the past ten years but admits it has increased over the last two years. He assures you he only drinks and uses drugs when not seeing clients. He has a prescription for pain medicine and states he uses it appropriately. | You are a counselor in a private practice setting. Your client presents with complaints of not meeting his own expectations in his licensed, health care profession, and dealing with the business aspect of his work, difficulty meeting financial obligations, difficulty getting along with others, and problems with his ability to concentrate. He says his business partner used to be his best friend but now he can’t stand him because he sees the clients more often and leaves your client to do all the work. He tells you his concentration issues have always been present but have become progressively worse over the past eighteen months, as have his feelings of irritability, failure, fatigue, and lately he has pains in his chest and shoulder. He tells you that he thinks sometimes about what would happen if he died, but only as far as wondering how others would react. Later in the session, he says he is not suicidal and does not have a plan, but occasionally he just “gets tired of it all.” He tells you that sometimes he feels like “ending it” and has said that to women when the relationship isn’t going well and once or twice during breakups. He asserts that he has not actually tried to kill himself. He summarizes his relationships with others as “if they like me, they lose interest” and says that he finds himself “almost being manipulative” in how he chooses his words in his relationships with women and sometimes takes them on spontaneous “wildly expensive vacations” so they will not lose interest in him. The client tells you he has been in several relationships with women over the years, beginning with his high school sweetheart, then with his college sweetheart, but none of them have “worked out.” He states he was engaged to his college sweetheart at 24 for 6 months and then she married someone else. He tells you that another girlfriend was married and didn’t tell him, one “went crazy and threatened him with a gun,” and one broke up with him saying that he was “too needy” and “almost obsessive” in wanting to see her every day. He tells you that “all in all, I’m unhappy with how things are going and I need to make changes, but I just have no motivation to do it and I don’t know why I should have to.” | Family History:
He states he is close to his sister who has never married but “always likes the deadbeat guys.” He tells you his father and mother never showed affection to him while growing up, were always bickering, and his mother was always obsessive about saving money and always complaining. He acknowledges loving his parents but sometimes getting so angry at them that he wishes he could just ignore them forever. He tells you both his maternal and paternal grandfathers were “mean as snakes,” while his paternal grandmother was a “saint.” He reports that one of his uncles committed suicide several years ago and that his cousin, whom he was very close to, committed suicide last year. He also says his best friend died five years ago due to a drug overdose. | In addition to a potential substance use disorder, which of the following mental health disorders should be viewed as potential diagnoses based on the information provided? | Narcissistic Personality Disorder (NPD) | Borderline Personality Disorder (BPD) | Post Traumatic Stress Disorder (PTSD) | General Anxiety Disorder (GAD) | (A): Narcissistic Personality Disorder (NPD)
(B): Borderline Personality Disorder (BPD)
(C): Post Traumatic Stress Disorder (PTSD)
(D): General Anxiety Disorder (GAD) | Borderline Personality Disorder (BPD) | B | While BPD is diagnosed primarily in females, males can also meet criteria for this disorder. The client admits to being manipulative in his words to keep women from leaving him (Criterion 1); his relationship patterns are unstable and often intense (C2. ); he demonstrates impulsivity in spending and substance use, which are self-damaging as he has trouble meeting financial obligations and has increased his substance use in the past eighteen months (C4); he has made recurrent suicidal threats (C5); he exhibits transient, stress-related paranoid ideation (C9). The client does not demonstrate excessive or irrational worry about the future as seen in GAD, and does not present with a history of trauma as needed for a PTSD diagnosis. The client's lack of insight, ambivalence, and feeling that he should not have to make changes can indicate some traits of NPD, but he does not demonstrate the grandiose sense of self-importance or preoccupation with himself as special, and powerful that would be expected with that diagnosis. It is very possible for the client to possess traits of NPD without meeting the full diagnosis. Therefore, the correct answer is (C) | intake, assessment, and diagnosis |
900 | Client Age: 13 Sex Assigned at Birth: Male Gender: Transgender; Gender Nonconforming (TGNC) Ethnicity: Caucasian Counseling Setting: Child and Family Agency, School-Based Services Type of Counseling: Individual and Family Presenting Problem: Truancy; Gender Dysphoria Diagnosis: Gender Dysphoria, Provisional (F64.1); Social Exclusion or Rejection V62.4 (Z60.4) | Mental Status Exam: The client is dressed in age-appropriate clothing. They wear eye makeup and chipped black fingernail polish, and they have bitten most fingernails down to the quick. The client’s mood is irritable, and they are quick to show anger toward their mother when misgendered. Their thoughts are coherent, and they deny audio/visual hallucinations. The client acknowledges feeling sad and hopeless but denies suicidal ideation. They attribute increased levels of anxiety at school to bullying, particularly with select peers. They explain that a select group of students threaten the client and call them offensive and derogatory names. Family History and History of th | You are a school-based mental health counselor in a public middle school. Your client is a 13-year-old Caucasian 7th grader who presents for the initial intake with their mother. The mother says that the client has had several unexcused absences from school because “he is confused about his gender.” The client adamantly denies being confused and explains that they self-identify as transgender. The client’s preferred pronouns are “they/them.” The client further states that they have had a strong desire to be a different gender since early childhood, and this desire and their distress have recently intensified. The mother reports that the client is chronically irritable, spends a lot of time alone, and has “basically shut everyone out.”The client reports experiencingbullying—both verbal and physical—in school “nearly every day.” In addition to the bullying, the client says that certain teachers refuse to allow them to use the bathroom aligned with their identified gender. To prevent this conflict, the client does not eat breakfast or lunch at school. | You work with the client and their parents to help the parents understand how the client conceptualizes their gender identity. You use the client’s self-identified, gender-affirming pronouns and praise the client for taking a brave first step. The client’s mother is fearful and anxious, particularly when thinking about the client’s safety. The client’s father expresses an overall lack of understanding and thinks it could be a phase. You recognize the father’s efforts to understand and help the client explain the distressing emotions associated with coming to terms with their gender identity, including an increase in severity since the onset of adolescence. The father states that he is unsure if he can accept the client’s transgender identity but says that he is committed to the counseling process. Your goal is to deliberately disrupt the family’s homeostasis through unbalancing, blocking transactional patterns, and shifting boundaries | Your goal is to deliberately disrupt the family’s homeostasis through unbalancing, blocking transactional patterns, and shifting boundaries. These techniques are associated with which one of the following? | Contextual family therapy | Structural family therapy | Strategic family therapy | Multigenerational family therapy | (A): Contextual family therapy
(B): Structural family therapy
(C): Strategic family therapy
(D): Multigenerational family therapy | Structural family therapy | B | Structural family therapy’s primary purpose is to strengthen the boundaries within family systems. Counselors accomplish this by deliberately disrupting the family’s homeostasis through techniques that include unbalancing, blocking transactional patterns, and shifting boundaries. Additional structural family therapy techniques include assigning tasks, reframing, escalating stress, psychoeducation, and developing implicit conflict. Contextual family therapy emphasizes the ethical elements of each family, including loyalty, trust, and relational principles. Murray Bowen developed multigenerational (extended) family systems theory, which focuses on families with high levels of emotional fusion and low levels of differentiation. Bowenian therapists use multigenerational transmission process to assess how a family’s dysfunctional interactions can be handed down from generation to generation. Strategic family therapy places much less emphasis on boundaries; instead, it focuses on patterns of communication and interactions. Some techniques of strategic family therapy include paradoxical intervention, pretend techniques, and hypothesizing. Therefore, the correct answer is (B) | counseling skills and interventions |
Subsets and Splits