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Initial Intake: Age: 14 Gender: Female Sexual Orientation: Heterosexual Ethnicity: Hawaiian American Relationship Status: Single Counseling Setting: School-based mental health counseling Type of Counseling: Individual

Malik presents as well groomed, good hygiene and behavior within normal limits. She is highly anxious, evidenced by limited eye contact, tense expressions and fidgeting with her hands. Malik admits to having suicidal thoughts and has self-harmed by cutting herself in the past. She reluctantly shares that she had a traumatic event in Hawaii right before leaving but is unwilling to discuss it and begins crying. She then changes the subject and tells you moving out of Hawaii has been painful because “everything is different here, including how they do school and how people talk about each other.” She adds that she experiences at least one nightmare a week since moving.

Diagnosis: Major depressive disorder, single episode, unspecified (F32.9), Anxiety disorder, unspecified (F41.9) Malik, a 14-year-old girl entering High School is referred to you for mental health counseling by her school counselor for reports of her leaving the classroom in tears and because of calls received by her mother stating that she has crying spells at home. After speaking with Malik’s mother, you learn her mother, stepfather and sisters have recently moved with her to the mainland states from the Hawaiian Islands and that she has been missing her father, friends, school, and other family members left behind. Malik spends most of her time in her room, appears depressed often, gets upset easily and is constantly on her phone. Her mother asks that you meet with her during school hours and help her understand what is going on. She says Malik has been crying since just before leaving Hawaii.

Family History: Malik’s parents divorced while she was young but had always lived in Hawaii, making it easy for her to see both sides of her family at will. Malik has several siblings, cousins, and all her grandparents are still alive. Malik has a strained relationship with her father and stepmother and feels heavily influenced by her father’s opinion of her, stating “he just wants what is best for me, but he’s really harsh about it and it sometimes hurts my feelings and stresses me out.” She is struggling to connect with her mother now because she is working full-time, and she feels “doesn’t have time for her anymore.” Malik is also forced to do most of the household chores and care for her younger siblings on top of managing her schoolwork. All of this has made her feel overwhelmed.

As a culturally competent counselor, how should you respond to Malik's gift?

I appreciate the sentiment, but I am not allowed to accept gifts.

This is so sweet! But you should keep them, I'm on a diet!

I can't keep them, but let's open them now and share them together.

Mahalo! This is lovely. Thank you for thinking of me.

(A): I appreciate the sentiment, but I am not allowed to accept gifts. (B): This is so sweet! But you should keep them, I'm on a diet! (C): I can't keep them, but let's open them now and share them together. (D): Mahalo! This is lovely. Thank you for thinking of me.

Mahalo! This is lovely. Thank you for thinking of me.

D

It is of significance in Hawaiian and many other cultures to bring gifts from one's homeland, sending the message of affection or respect while showcasing and representing the beauty and history of one's culture. Knowing and understanding the meaning behind small gestures and further being able to communicate using common greetings from your client's ethnic culture are ways you can demonstrate cultural competency within clinical boundaries. Answer a may come across as disrespectful or as a rejection of one's heritage, and counselors may accept small, non-monetary gifts of appreciation without crossing ethical boundaries. Answer c would have the same effect, even if it came across as a well-meaning excuse for not accepting a gift. Even if you were on a diet, acceptance of the gift may be more important to your client than the reason why you cannot enjoy it. Answer d is irresponsible as it may convey that you feel like Malik may be infectious and sharing foods would be unsanitary. Therefore, the correct answer is (B)

professional practice and ethics

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.

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.

Taking into consideration what you have learned during the session, what is most important for you to consider when choosing an initial treatment modality for the client?

The client's preference regarding pharmacological intervention

The client's status as a stay-at-home mother

The client's relationship with her husband

The client's therapeutic expectations

(A): The client's preference regarding pharmacological intervention (B): The client's status as a stay-at-home mother (C): The client's relationship with her husband (D): The client's therapeutic expectations

The client's preference regarding pharmacological intervention

A

Of these options, the client's preference regarding pharmacological intervention is most important when choosing an initial treatment modality for the client. It is important to ensure that the client is comfortable with any medications prescribed and that the client has an understanding of possible side effects and is given the opportunity to make an informed decision about any medication prescribed. As indicated, the client has stated having a "bad" experience with medications in the past, and her preference is to first try counseling without medication. Therefore, the correct answer is (A)

treatment planning

Client Age: 25 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Counseling Clinic Type of Counseling: Individual Presenting Problem: Depression and Suicidal Ideation Diagnosis: Major Depressive Disorder, Recurrent, Mild (F33.0)

Mental Status Exam: The client appears to not have bathed recently because his hair is greasy and unkempt. The client has food stains on his clothing; however, he is dressed appropriately for the season. His motor movements are within normal limits. He is engaged in therapy, but he appears anxious as evidenced by hesitating before speaking and by his hand wringing. The client reports suicidal ideation with no plan or intent. The client reports a depressed mood more often than not and difficulty enjoying most activities. The client is oriented to person, place, time, and situation. The client reports that his appetite has increased lately and that he is experiencing hyperso

You are a resident in counseling practicing in a private practice agency. During the initial counseling session, the 25-year-old single male client reports feeling depressed and hopeless. He has difficulty enjoying activities that he has enjoyed in the past and feels unsatisfied with most areas of his life. The client identifies that he is not happy at work and wants to make a career change. The client verbalizes feeling sad more often than not, and that this has been going on for about 2 years. The client decided to start counseling when he began experiencing suicidal thoughts. The client reports no plan or intent to attempt suicide but is concerned about his own well-being.

The client contacted you to reschedule a session sooner than the one you had originally scheduled. The client reported that he continues to have difficulty getting to work on time and was told that he needs to meet with his supervisor on Friday. The client expresses anxiety surrounding this because he worries about getting fired. The client began to cry during the session when talking about worry regarding being unemployed. The client came to the session in clothes that had stains on them, and his hair was messy and appeared greasy. Due to increased anxiety and depressive symptoms, you choose to use CBT techniques

Due to increased anxiety and depressive symptoms, you choose to use CBT techniques. Which of the following would be an intervention used in CBT?

Cognitive restructuring or reframing

Assess for readiness for change

Operant conditioning

Reality acceptance

(A): Cognitive restructuring or reframing (B): Assess for readiness for change (C): Operant conditioning (D): Reality acceptance

Cognitive restructuring or reframing

A

CBT is based around cognitive restructuring and reframing, which can be a very effective intervention for anxiety or depression. Reality acceptance is part of dialectical behavior therapy and would not be as beneficial for this client because the anxiety is based around an unknown outcome. Assessing readiness for change is part of motivational interviewing, and it is not clear at this point whether the client is willing or able to change. Operant conditioning is a behavior therapy approach that involves positive/negative reinforcement and punishment. Therefore, the correct answer is (A)

counseling skills and interventions

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 instrument would you select to further assess the client’s social and emotional problems, including DSM-specific disorders such as ADHD, ODD, and other conduct problems?

The Brief Symptoms Inventory-18 (BSI-18)

The Woodcock-Johnson IV (WJ IV)

The Conners’ Third Edition (Conners 3)

The Achenbach Child Behavior Checklist (CBCL)

(A): The Brief Symptoms Inventory-18 (BSI-18) (B): The Woodcock-Johnson IV (WJ IV) (C): The Conners’ Third Edition (Conners 3) (D): The Achenbach Child Behavior Checklist (CBCL)

The Achenbach Child Behavior Checklist (CBCL)

D

The Achenbach Child Behavior Checklist (CBCL) helps detect social and emotional problems, including disorders such as ADHD, ODD, and other conduct problems. The CBCL detects DSM-specific symptoms in the following six categories: affective problems, anxiety problems, somatic problems, ADHD, oppositional defiant problems, and conduct problems. The CBCL also provides information on eight syndrome scales, including aggressive behavior, social issues, and rule-breaking behavior. The Brief Symptoms Inventory-18 (BSI-18) is an 18-item assessment that provides information on three subscales: somatization, depression, and anxiety. The Woodcock-Johnson IV (WJ IV) is an intelligence test that evaluates a wide range of cognitive functions with three batteries: the WJ IV Tests of Cognitive Abilities, the WJ IV Tests of Oral Language, and the WJ IV Tests of Achievement. Therefore, the correct answer is (A)

intake, assessment, and diagnosis

Initial Intake: Age: 28 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Married Counseling Setting: Private Practice Type of Counseling: Couple

The couple appear to be their stated ages with positive signs of self-care related to hygiene and dress. Both individuals appear overweight for height, and John appears to visually be categorizable as obese. Both individuals presented with congruent affect to their stated moods. Neither demonstrated retardation, spasticity, or hyperactivity of motor activity. The couple present as cooperative, open, and forthcoming, though each frequently looks at the other and confirms that the information they are presenting individually is accurate. Jane is noted to be caregiving of and highly empathetic to John. John is noted to respond appropriately to Jane’s statements. Neither presents with reports of suicidal ideations, thoughts of harm to self or others, or difficulties with memory, judgement, or concentration.

You are a counselor in a private practice setting. Your client, Jane, is 28 years old and presents with her spouse, John, a 24 year-old Hispanic male for “problems communicating.” The couple report that they have been married for one year after cohabitating for one year prior to marriage. Immediately after their marriage they began trying to become pregnant. They state they sought help from a specialist after several months and on learning that some degree of infertility existed, Jane began hormone therapy. Jane notes that it was soon after this time that the communication problems between them began. She tells you that it was at this point that she and John realized that they may not be able to have a biological child together. John acknowledges that Jane has tried many times over the last year to bring up this topic for discussion, but he chooses not to engage her. He tells you that he tends to believe that “if I don’t think about it, it will probably go away.” Jane agrees with John and reports that over time, the couple have talked less and spend much less time together. John agrees and says that sometimes “I may not say more than five words to Jane in a day.” Jane reports that they have not been intimate in over two months. When completing the intake paperwork, John endorsed no problems on any symptom criteria. Jane reported “serious” problems with “feeling sad, loss of interest in things she previously enjoyed, crying spells, and stress. She reported “moderate” problems with “feelings of worthlessness, anxiety, loss of appetite, and sleep disturbance. The couple states they were to sign divorce papers last week but made the decision to try counseling first. Neither has participated in counseling previously.

Family History: The couple currently live with Jane’s 10 year-old son from her previous marriage and Jane’s 75 year-old grandfather, for whom the couple provide care. Jane owns and operates a small shop, is completing her bachelor’s degree, cares for her grandfather, and parents her son, who is heavily involved in baseball. She describes a history of hypothyroid disease though is no longer taking medication as her disease is now controlled with diet and exercise. She reports taking an antidepressant for two years, approximately seven years ago. She currently is taking Provera and Clomid for infertility and states these have had a noticeable effect on her mood. John reports this is his first marriage and he has no children from prior relationships. He was laid off two years ago and has been working in his uncle’s business, but the family has no insurance. He is actively involved in caring for Jane’s son and grandfather. He reports a history of high blood pressure. Prior to their wedding, John states he experienced irritability, agitation, difficulty sleeping due to “thinking about things” and worry. He was prescribed an SSRI and took this for six months. He tells you it seemed to help but he discontinued it 8 to 9 months ago. He reports that his doctor said his anxiety might have been because of his high blood pressure.

Which of the following counseling skills or interventions should be used during this session?

Redirecting John's attention to Jane's distress

Exploring both families of origin patterns and themes

Psychoeducation on relaxation techniques for John and Jane

Summarizing John's fears about infertility and loss

(A): Redirecting John's attention to Jane's distress (B): Exploring both families of origin patterns and themes (C): Psychoeducation on relaxation techniques for John and Jane (D): Summarizing John's fears about infertility and loss

Summarizing John's fears about infertility and loss

D

During the individual interview, John openly discussed fears of his own infertility and the loss he would feel if he could not have a child. Because he has not been communicating with Jane, this would be important to summarize with John so that Jane can become more aware of his fears and emotional reaction to their infertility issues. This provides an opportunity for these issues to be discussed by the couple during sessions, while x John has not yet identified his feelings and actions to Jane so this intervention would not be appropriate at this time. Relaxation techniques are helpful when working through strong emotions, however, John is not showing strong emotional engagement at this time. Therefore, the correct answer is (A)

counseling skills and interventions

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 referrals will be most helpful in treating the client's hoarding disorder?

Refer client to psychiatry for medication evaluation

Refer client to local government services for evaluation of adequate housing

Refer client to behavioral health to determine client's competency to make decisions

Refer client to a professional organizer who can help organize the client's home

(A): Refer client to psychiatry for medication evaluation (B): Refer client to local government services for evaluation of adequate housing (C): Refer client to behavioral health to determine client's competency to make decisions (D): Refer client to a professional organizer who can help organize the client's home

Refer client to psychiatry for medication evaluation

A

Referring the client to psychiatry will be most helpful for treating the client's hoarding disorder due to the components of depression, OCD, and ADHD that are often co-occurring with hoarding disorder. Treatment with SSRIs is helpful in treating those with hoarding disorder. Referring to a professional organizer will not be adequate, although once the client has made gains through therapy, teaming a counselor with a professional organizer who is trained to work with hoarding disorders may be helpful. While hoarding disorders may include difficulty with decision-making, the client does not demonstrate incompetence and referral for evaluation or declaration of incompetence would be inappropriate. Counselors may provide information on local resources for housing but although the client's housing may not be adequate at this time, referring her to resources that may condemn and/or remove her from her home threatens the therapeutic relationship and dishonors the autonomy of the client to choose where she lives. Therefore, the correct answer is (B)

counseling skills and interventions

Initial Intake: Age: 23 Gender: Male Sexual Orientation: Heterosexual Ethnicity: Indian American Relationship Status: Single Counseling Setting: Private Practice Type of Counseling: Individual

Shawn is slightly unkempt, completes ADLs and has good hygiene. His motor movements are fidgety and tense, and he consistently averts eye contact and darts his eyes around the room and towards the door every time he hears a noise. He appears to be sensitive to the lighting in the office as evidenced by fluttering his eyes when he looks up and commenting about its brightness. Shawn speaks within normal rate and tone, however low volume and often mutters under his breath. He denies any past suicidal or homicidal ideation and denies hallucinations or delusions. Shawn also denies history of trauma.

Diagnosis: Social Phobia, unspecified (F40.10) provisional; Alcohol Use Disorder, moderate, in early remission (F10.10) Rishaan is a 23-year-old heterosexual male of Indian origin and is being referred to you by his parents for counseling in your private practice who are telling you Rishaan is at risk for going back to his drinking because he “never does anything constructive.” Further complaints by Rishaan’s parents include that “all he does is play video games and watch TV,” that he “never has money to pay for anything himself” and is constantly asking them for money. His parents offer to self-pay for Rishaan’s sessions. You welcome Rishaan to your office for an initial assessment. He respectfully requests that you refer to him as “Shawn,” which he explains is his preferred American name, and remarks that his parents really want him to talk to you. Shawn has agreed to counseling because he shares with you that he “has stuff to talk about anyway” and does not think he can go to his parents.

Substance Use History: Shawn entered treatment and rehabilitation five months ago after his ex-girlfriend’s family had an intervention with him about his abusive drinking and he has now been through all phases of treatment for Alcohol use disorder. Shawn tells you he is ashamed that his parents found out about his problem through his ex-girlfriend’s parents, because he had been lying to his own parents about his well-being for several years since he left home for college at 18 years old. Shawn is currently five months sober but is not engaged in any post-treatment recovery program nor has he continued counseling. Family History: Shawn has two older siblings, both of whom he shares are “successful and have families.” Shawn says, “my parents always want me to be like them and are constantly comparing me to them, it’s so annoying.” Shawn’s father is a dermatologist, and his mother is his father’s secretary in their medical practice. Both parents observe traditional Indian cultural practices in their social lives and with respect to Hinduism. Work History: Shawn has attempted part-time work following his graduation from his alcohol rehabilitation treatment program but was unable to make his shifts on time and was let go from his job. He tried another job selling products by cold calls but could not keep up with the volume required to make a viable salary. When asked what Shawn would like to do for a living, he says “I’d like to be a gaming coder or tester, something like that.”

You teach Shawn the cognitive strategy of labeling his negative thoughts while they are occurring in his mind in an emotionally detached manner and guide him in applying mindful observations without judging himself. This is an example of?

Thought Responding

Thought defusion

Oral Cognitive Restructuring

Paradoxical Repetition

(A): Thought Responding (B): Thought defusion (C): Oral Cognitive Restructuring (D): Paradoxical Repetition

Thought defusion

B

Thought defusion is applying mindful observation of your negative thoughts, then labeling your negative thoughts while they are occurring in your mind and reflecting on them unemotionally and without judgment ("For the moment, I'm having an anxious feeling, but it will pass eventually"). Then, instead of trying to restructure the negative thought, you redirect your attention to an activity or person in the moment as a "thought interruption" technique, avoiding self-criticism. This is a gentler approach to helping someone learn how to identify their thoughts and become used to managing them in an un-intimidating and passive way. A person who is constantly being told they must change may be resistant to the criticism. The other methods listed would be useful as brief cognitive strategies for change, but are not thought defusion as described in the question. Therefore, the correct answer is (C)

counseling skills and interventions

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 treatment objective would provide the client with long-term relief from her stress and anxiety?

Mastering deep breathing techniques during stressful situations

Identifying time-management skills and mindfulness techniques

Learning how to implement positive self-talk in times of stress

Increasing emotional resilience and problem-solving skills

(A): Mastering deep breathing techniques during stressful situations (B): Identifying time-management skills and mindfulness techniques (C): Learning how to implement positive self-talk in times of stress (D): Increasing emotional resilience and problem-solving skills

Increasing emotional resilience and problem-solving skills

D

Increasing emotional resilience and problem-solving skills would provide the client with long-term relief from her emotional symptoms. She struggles with anxiety and depression related to taking on the role of caregiver for her mother and having her mother live in the family home. Therefore, the correct answer is (A)

treatment planning

7 Initial Intake: Age: 18 Gender: Female Sexual Orientation: Bisexual Ethnicity: African American Relationship Status: Single Counseling Setting: Agency Type of Counseling: Individual

Millie was well groomed and presented as anxious with constricted affect as evidenced by shaking her leg and tapping her pen frequently. Millie made good eye contact and speech was coherent and rational, however tangential with increasingly rapid rate at times. Speech content is somewhat guarded, demonstrating preoccupation with social influences and deflection from discussion about losing her mother. Millie was surprisingly graphic with detail about self-starvation and purging food and did not show concern; presented with incongruent affect and smiling while she talked about it. Millie denied SI. Family History and Living Situation: Millie lived alone with her mother in a different state until last year when her mother died, and she moved to a new state to live with her father and his girlfriend. Their relationship had already been strained therefore Millie opted to live with her paternal grandparents who also lived locally, which is where she lives now. Millie comes and goes as she pleases and does not regard house rules. She reports most often staying in her room with the door locked while on the computer or phone

Diagnosis: Major Depressive Disorder, single episode, recurrent (F33), Anxiety disorder (F41.9) provisional You are a mental health counselor with a community agency and have been referred a new client named Millie, an 18-year-old African American girl, for problems adjusting to life without her mother who has passed away nearly one year ago from illness. Millie’s father brought her to your agency after convincing her to see a counselor. The referral form filled out by her father says she has never spoken about her mother’s death and does not talk about it with anyone he knows. Millie has had medical problems that have been best explained by disruptions in her eating and sleeping habits, which started after her mother died. You learn several reports were made during her senior year in high school of her fighting with other girls, which Millie tells you were erroneous and “not her fault”. Millie also demonstrates a highly active social life, but primarily online with strangers as she exhibits strong social phobic behavior in public and around others in person. You recommend in-person counseling rather than Telehealth virtual sessions to support her improvement.

llie was well groomed and presented as anxious with constricted affect as evidenced by shaking her leg and tapping her pen frequently. Millie made good eye contact and speech was coherent and rational, however tangential with increasingly rapid rate at times. Speech content is somewhat guarded, demonstrating preoccupation with social influences and deflection from discussion about losing her mother. Millie was surprisingly graphic with detail about self-starvation and purging food and did not show concern; presented with incongruent affect and smiling while she talked about it. Millie denied SI. Family History and Living Situation: Millie lived alone with her mother in a different state until last year when her mother died, and she moved to a new state to live with her father and his girlfriend. Their relationship had already been strained therefore Millie opted to live with her paternal grandparents who also lived locally, which is where she lives now. Millie comes and goes as she pleases and does not regard house rules. She reports most often staying in her room with the door locked while on the computer or phone.

Millie admits to abusing pain medication prescribed by her doctor for treating medical issues, as well as getting high on inhalants in her room at her grandparents' house. What is your next step?

Educate Millie on the harmful effects of substance abuse.

Inform her father and grandparents for her own safety.

Prepare Millie for a referral to a higher level of care.

Call 911 to have Millie expedited to detox.

(A): Educate Millie on the harmful effects of substance abuse. (B): Inform her father and grandparents for her own safety. (C): Prepare Millie for a referral to a higher level of care. (D): Call 911 to have Millie expedited to detox.

Prepare Millie for a referral to a higher level of care.

C

Unless Millie is experiencing an overdose, incapacitated, or in danger of harming herself or others, calling 911 is not necessary and you can work with Millie on understanding what the next steps would be for entering into a higher level of care should she choose to comply with your recommendations. Education, as in answer b, would present itself as an intervention used during this referral conversation, as well as throughout substance use treatment, but is not enough at this time to ethically address Millie's use. Millie would also be responsible for informing her parents of her plans, as HIPAA does not permit the counselor to report this to an adult's family on their behalf with special exceptions, such as if an individual has a previously indicated mental handicap and is under special guardianship as an adult for such purposes. Therefore, the correct answer is (D)

treatment planning

Name: Tabitha Clinical Issues: Family conflict and pregnancy Diagnostic Category: V-codes Provisional Diagnosis: Z71.9 Other Counseling or Consultation Age: 16 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: Latina Marital Status: Not Married Modality: Individual Therapy Location of Therapy : School

The client appears healthy but tired and distracted. She is dressed in loose-fitting clothing and sits with her hands between her knees. Eye contact is minimal. Speech volume is low. She is reluctant to talk at first and denies having a problem. Thought processes are logical, and her thoughts are appropriate to the discussion. The client's estimated level of intelligence is within average range. She appears to have difficulty maintaining concentration and occasionally asks you to repeat your questions. The client denies suicidal ideation but states that she has been considering abortion. She has not acted on anything but is feeling very overwhelmed and desperate.

First session You are a school counselor in an urban school setting. The client is a 16-year-old student who is reluctant to see you. The session begins with a discussion of the teacher's concerns and your role as a school therapist. After some gentle probing and reassurance, the client is able to open up more and discuss her difficult relationship with her father. She identifies feeling overwhelmed and frustrated by his expectations, which leads to frequent arguments between them. She appears tired and has trouble sleeping at home because her parents constantly argue. She suggests that her parents "are the ones who need therapy, not me." She briefly describes the arguments that she claims her parents get into regularly. "They are always going at it, unless thay are at church. Then they act like everything is perfect." When you ask about her friends and activities, she tells you she is involved in her church youth group and has an on-again/off-again boyfriend. You ask the client, "Can you tell me more about your relationship with your boyfriend? How long have you been together?" She says that they have been seeing each other for about a year, and she thought he was 'the one', but they had a "big fight" last week and have not talked since. You ask what she means by 'the one'. She looks down at the floor and starts to bite her fingernails. You see a tear fall down her cheek. She says, "I don't know what to do." You continue the session by providing a safe space for her to express and explore her feelings about her relationship with her boyfriend. She takes a deep breath and tells you that there is something she has not told anyone and she is scared that if she says it out loud that "it will make it too real." You tell her to take her time and that you are here to listen without judgment. She tells you that she missed her last menstrual period, and several "in-home" tests confirm that she is pregnant. She has not told her boyfriend and is scared to tell her parents because she is afraid they will disown her, so she has decided to keep the pregnancy a secret. While you are tempted to try to talk the client into telling her parents and boyfriend about her pregnancy, you recognize that it is important to respect her autonomy and allow her to make the best decision for herself. You provide her with accurate information about the options available to her and encourage her to explore the pros and cons of each option. You share that having a support system and someone to talk to during this time can be helpful. She nods her head and tells you that she knows that her parents will find out about the baby eventually, whether she tells them or not, but she is anxious about how they will react to the news. You listen and provide empathetic reflections to help her gain insight into her feelings. You then focus on helping the client develop effective coping strategies for managing her stress and anxiety about the situation. You let the client know that she can come back to see you at any time if she feels overwhelmed or needs additional support. The session concludes with an understanding of what to expect in future sessions, including exploring possible solutions for dealing with her parents and boyfriend, as well as developing healthy coping skills for managing her emotions.

The client has an older brother who is in college. The client lives at home with her parents. They are members of a Christian church and are all actively involved in their church group, and the client has a good relationship with her pastor. The client has never felt close with her father and says he has always had "high standards and expectations" for everyone in their family. The client says her parents "treat her like a child." She has not told her parents about her 16-year-old boyfriend as she knows they will disapprove. For the last year, she has been asserting her independence from her parents, which has caused conflict, friction, and discord within the family. The teacher who referred the client to you mentioned that the client has seemed distracted and anxious lately. She has not been completing homework assignments and failed a test last week. The client acknowledges these concerns and tells you she struggles to keep her grades up and has difficulty adjusting to hybrid learning. "One day, we're in school, and the next day we're virtual. It's just exhausting. I feel like giving up."

Given the nature of your relationship in the school setting, and the time you realistically can allot to the client, as well as her age and maturity level, which approach will you initially use to engage the client in the therapy process?

Person-centered therapy

Solution-focused brief therapy

Reality therapy

Cognitive-behavioral therapy

(A): Person-centered therapy (B): Solution-focused brief therapy (C): Reality therapy (D): Cognitive-behavioral therapy

Person-centered therapy

A

The client is in a vulnerable state right now. Using a person-centered approach and practicing unconditional positive regard, genuineness, and empathic understanding will help you establish trust with her. Therefore, the correct answer is (C)

counseling skills and interventions

Client Age: 25 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: In a Relationship Counseling Setting: Private Practice Clinic Type of Counseling: Individual Counseling Presenting Problem: Premature Ejaculation Diagnosis: Provisional

Mental Status Exam: The client is oriented to person, place, time, and situation. The client appears comfortable in the session as evidenced by his openness, congruent affect, and verbal express

You are a counseling resident at an outpatient clinic. Your 25-year-old male client reports he was in a bicycle accident a year ago and that, resultingly, he had reconstructive surgery to his penis. The client identifies that it takes approximately 30 seconds to a minute to ejaculate following vaginal penetration. The client reports that the symptoms occur every time he engages in sexual activities with his girlfriend. The client is a car salesman and also reports anxiety about performance at work and other areas of life. You suspect that the client may also have generalized anxiety disorder. The client reports that his girlfriend does not seem to mind that sex does not last long, but he feels bad because he also wants her to feel good during sex.

The client comes to the session reporting that he and his girlfriend attempted to have sex the past week, and he wrote down some thoughts he was having on his CBT thought log. The client and the clinician reviewed his thoughts and engaged in cognitive reframing to support him in creating new scripts to use when engaging in sex. The client also wrote down physical responses to anxiety that he was experiencing before and during sex that included muscle tension and increased heart rate. The client identified that one thought he had during sex was “I feel inadequate as a man; therefore, I must be inadequate because I can’t fully satisfy my girlfriend

The client identified that one thought he had during sex was “I feel inadequate as a man; therefore, I must be inadequate because I can’t fully satisfy my girlfriend.” Which of the following cognitive distortions best defines this thought?

Overgeneralization

Fortune-telling

All-or-nothing thinking

Emotional reasoning

(A): Overgeneralization (B): Fortune-telling (C): All-or-nothing thinking (D): Emotional reasoning

Emotional reasoning

D

Emotional reasoning is the cognitive distortion displayed here because the client is accepting his emotion as a reality even though just feeling something does not make it true. The client is not experiencing all-or-nothing thinking because he is not experiencing polarized thinking. The client is not fortune-telling because he is not predicting future experiences based on present feelings. The client is not overgeneralizing because he is not applying his current feelings to other situations. Therefore, the correct answer is (A)

counseling skills and interventions

Name: Jill Clinical Issues: Depression and recent death of a close friend Diagnostic Category: Depressive Disorders;Substance Use Disorders Provisional Diagnosis: F34.1 Persistent Depressive Disorder, with Anxious Distress, and F10.99 Unspecified Alcohol-Related Disorder Age: 26 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: Eastern European Marital Status: Never married Modality: Individual Therapy Location of Therapy : Agency

The client is a 26-year-old female who appears slightly disheveled and unkempt with bags under her eyes, suggesting recent lack of sleep. Her affect is flat and her behavior is withdrawn. She speaks in a quiet monotone and is tearful at times. Her speech is coherent, though her thoughts are sometimes diffuse. She exhibits difficulty in focusing on topics and has some difficulty in supplying relevant details. The client reports that she has difficulty concentrating and recalling information, as well as making decisions. No perceptual distortions are reported. The client has limited insight into the cause of her distress, but appears to understand that her drinking is a problem. Her judgment appears impaired due to her drinking, as evidenced by her blackout episodes. The client expresses feeling overwhelmed and states that if counseling does not help, she is not sure she wants to go on living. She has also had thoughts of death and dying.

First session You practice as a mental health therapist at an agency. A 26-year-old female presents for therapy following a recent incident involving the death of her close friend. The client elaborates on her friend's death by saying, "He was beaten to death because he was transgender." The attack occurred a week ago, but the client states she has felt depressed for as long as she can remember. She says, "He was the only person who could actually put up with me. Now that he's gone, I feel like I have no one." She tells you that during the past few years, she has been drinking as a way to cope with her feelings. She states that she is usually able to control her drinking, but admits that lately it has "gotten out of hand." After her friend was killed, she went to a party and blacked out after drinking. She states that she cannot seem to find joy in anything and cannot stop thinking about her friend. You continue your assessment by exploring the client's history and current symptoms. After gathering more information, you determine that the client is experiencing a major depressive episode which has been compounded by her friend's death. When asked what she is hoping to gain from therapy, she responds, "I just want to stop feeling so awful all the time." You validate her feelings and applaud her willingness to seek help. You share information about the counseling process and treatment options, including potential risks and benefits. You tell her that it is important to be open and honest during therapy and that she may need to talk about some difficult topics to make progress. After explaining the importance of developing a trusting relationship, you encourage her to ask questions and ask if she has any concerns. She asks if she can contact you outside of your counseling sessions. You review your agency's policies with her, including information about therapist availability. Third session You and the client have agreed to meet for biweekly therapy sessions as she feels she needs extra support right now. This is your third session with the client, and she presents looking exhausted and can barely speak. You consider alcohol use, but there is no smell of alcohol, and the client's eyes do not seem dilated. She is neither slurring her words nor stumbling. You can sense that she is exhausted, both mentally and physically. She shares that she has not slept in 48 hours and is struggling with nightmares about her deceased friend. She says, "Why did he have to die? I feel like it's my fault." Next, you ask her, "What do you think caused your friend's death?" but she looks away and shakes her head, unwilling to answer. You then try to explore the nightmares she has been experiencing, but she becomes irritable and angry. Finally, she breaks down and begins to cry. You allow her time to cry, knowing that it is a way for her to release some of the pain she is feeling. After a few minutes, you ask the client if she would like to talk about what is going on in her life. She agrees and starts talking about how overwhelmed she feels. She hates her job, her past, and her present. The client feels like everything is too much for her to handle. You listen patiently as she talks about her feelings.

The client grew up in a very chaotic household with five siblings. The client is a first-generation Eastern European whose family immigrated to the United States before her birth. Her parents never adapted to the culture. Her father committed suicide when she was in high school. She says, "It was like my dad leaving us just made everything worse." The client says she has no patience with her siblings when they call and has little desire to keep in touch with them. After completing her associate's degree, the client immediately started her job as a paralegal. She is a paralegal at a law firm where she has worked for two years. She describes her work as "okay, but not something I'm passionate about." She says that she has been feeling increasingly overwhelmed and stressed out. At work, she becomes easily annoyed, has trouble concentrating, and feels tense. She has difficulty getting along with her colleagues and tries to avoid them when she can.

Using a cognitive-behavioral approach, what technique could help your client through the thoughts she is dealing with by feeling she is responsible for her friend's death?

Exploration of family constellation

Reattribution

"Acting as if"

Psychodrama

(A): Exploration of family constellation (B): Reattribution (C): "Acting as if" (D): Psychodrama

Reattribution

B

Reattribution is a CBT technique which takes a situation and examines the automatic thought by considering alternatives for the events under consideration. Therefore, the correct answer is (C)

counseling skills and interventions

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.

Despite your possible feelings about Raul's mother's parenting skills, you smile with her as she shares information and offer her kindness and support. What is this practice called?

Fake it 'til you make it

Positive psychology

Emotional restraint

Unconditional positive regard

(A): Fake it 'til you make it (B): Positive psychology (C): Emotional restraint (D): Unconditional positive regard

Unconditional positive regard

D

This is a core competency of counselors and demands a non-judgmental stance. Therapy is intended to offer a client a different experience than they have ever had; offering compassion and positive regard makes it easier on the client to communicate their needs, feelings, fears, desires, and concerns. Answer b) is not a clinical term or practice. Answer c) is just suggestive of holding back emotions but does is not a core counseling attribute. Positive psychology is the scientific study of the strengths that enable clients to thrive and is founded on strengths-based interventions. Therefore, the correct answer is (A)

core counseling attributes

Name: Michael Clinical Issues: Separation from primary care givers Diagnostic Category: Anxiety Disorders Provisional Diagnosis: F93.0 Separation Anxiety Disorder Age: 10 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Not Assessed Ethnicity: Guatemalan American Marital Status: Not Applicable Modality: Family Therapy Location of Therapy : Agency

Michael appears clean and dressed in appropriate clothing. He often fidgets with his hands and insists on sitting next to his father during the session. Speech volume is low, and pace is fast. He has a slightly flattened affect. He exhibits minimal insight consistent with his age.

First session You are a licensed mental health counselor at a pediatric behavioral health center. Michael, a 10-year-old male, presents along with his father. You conduct a thorough psychological exam, including a mental status examination. During the initial interview, you take note of Michael's behavior. He sits very close to his father and looks fearfully around the room. The father tells you Michael has been having trouble at school and home for the past few months and it has been getting worse. When you ask how Michael is doing in school, the father tells you there have been several incidents, including difficulty waking up for school, crying in the morning, and refusal to get dressed and ready. The father also tells you that Michael has been showing signs of frustration with his teachers and classmates. On the home front, the father mentions that his son has become "a nuisance for his babysitter, especially during bedtime." Both parents are paramedics on a 24-on/48-off shift rotation. Michael often calls his parents while at work, complaining that he feels sick and cannot fall asleep. He worries that someone might break into the house or that "something bad will happen" to his parents. The father reports that he and his wife have tried to reassure Michael, but their efforts have been unsuccessful. They are perplexed as to what is causing Michael's distress. The father tells you that Michael has always been a bright and energetic child, but now he seems overwhelmed and anxious. You conduct a more detailed interview with Michael alone, focusing on his current environment and daily routines. You ask him how he feels about school, and Michael denies having any issues. He tells you that he does not want to go because his new school is "boring." However, when you probe further, he admits to feeling scared and alone. He does not want to be away from his parents, and he imagines "all the ways they could be hurt" while they are not with him. You say, "I can understand why you might be feeling scared and anxious, Michael. It sounds like a lot has been going on recently. I'm here to help you and your parents understand what's causing your worries so you can start to feel better." You reconvene with Michael's father and provide a brief summary of your findings. You explain that you suspect Michael's anxiety is likely due to the family's recent relocation and having to adjust to a new school. His fears are also likely rooted in his parents' profession, which may lead him to worry about their safety while they are away from home. You have personal experience in dealing with pediatric anxiety and consider briefly sharing your story with Michael and his parents as you believe it may help them to feel supported and less alone in their struggles, while also providing a practical example of how to work through difficult times. You suggest developing an intervention plan to address Michael's distress and recommend meeting with Michael and his parents for weekly sessions. Fourth session When you arrive at your office today, you realize that you inadvertently left therapy notes on your desk after work on Friday, which included information about Michael's case, and the notes are not where you left them. The weekend cleaning crew lets you know that the notes were discarded in the trash. You take the appropriate action in managing this breach of confidentiality, following your practice's guidelines and policies. You also take time to reflect on how this incident could have been prevented and use it as a learning opportunity for yourself. When you met with Michael and his parents during the previous two sessions, you gathered additional information about his symptoms, thoughts, and feelings. You provided psychoeducation about separation anxiety and recommended that Michael's parents make an appointment for him to see his pediatrician. You also began to formulate a treatment plan with the overall goal of tolerating separation from his parents without severe distress. Michael and his parents present for today's session on time. The parents begin by reporting that their son's symptoms continue to be a problem. School refusal is still an issue. His mother has had to come home from work three times this past week. His outbursts were so loud that the neighbors came by to check on him. The mother says, "My boss has been patient with me so far, but pretty soon, I'm going to be at risk of losing my job if we can't get a handle on our son's behavior. What are we doing wrong?" Your focus during this session is on helping the parents understand their role in the therapy process. You start by reviewing some of the psychoeducation you provided in prior sessions, focusing on the importance of consistency in parenting approaches and providing structure for Michael at home. You discuss different strategies they can use at home to help build their son's coping skills. You also provide some relaxation exercises that Michael can do when he feels anxious. At the end of the session, you thank Michael and his parents for coming in today and assure them that they are on the right track. You take time to summarize the key points of the session and emphasize the importance of follow-through with what was discussed in order for progress to be made. You provide them with resources to further support their efforts and suggest a follow-up appointment in one week. Tenth session You have been working with Michael to develop and practice effective coping skills appropriate to his age. You have been using behavioral modification techniques to decrease his anxiety about being away from his parents. During previous sessions, you suggested that his parents leave your office space for progressively more extended periods. Michael has complied with these requests, although he was initially anxious and agitated. After five weeks, he is now able to tolerate being away from his parents for up to an hour. In today's session, the parents reflect on their son's progress since he started therapy. They believe that he has made a significant improvement. To date, there have only been "little incidents." The parents report that two days ago, Michael was reluctant to go to bed without them and had a minor fit. Instead of escalating the situation, they calmly reminded him of the strategies he had learned in therapy such as taking deep breaths when feeling anxious. To their surprise, Michael began using his coping skills and went to bed peacefully. Michael's mother tells you, "It finally feels like we've turned a corner. I'm so proud of him!" The parents have also received positive updates from Michael's teachers who say that he is doing much better in school. They report that he has made a new friend and was invited to a sleepover. Michael seems excited about the idea. His parents are not sure how he will handle being away from home overnight, but they are willing to try. After providing you with an update, the parents leave the room to wait in the waiting room while you talk to Michael. He appears receptive and comfortable with this arrangement. He tells you, "I kind of feel dumb for being scared. I'm sorry for causing so much trouble." You respond affirmatively and validate his feelings. Next, you say, "I remember when you first came to my office with your mom and dad. You were having a lot of trouble being away from them. Do you think that's still a problem for you?" He shakes his head "No" and reports that he is now able to be away from his parents for longer periods of time without feeling scared or upset. You ask him what has been most helpful to him when he starts to feel anxious. He says, "The counting and breathing stuff you showed me how to do. Also, I think about something fun that I did with my mom and dad, like that time we went to the beach and built a giant sandcastle!" You tell him how proud you are of his progress and encourage him to keep using the coping strategies he has learned in therapy. Near the end of the session, you invite Michael's parents back into your office to check in with them about next steps. The parents agree that Michael has made significant progress in tolerating separation and they feel that the treatment has been successful. You offer additional resources for follow-up care and suggest a plan for transitioning out of therapy. Lastly, you thank Michael and his parents for their dedication throughout the course of therapy and let them know that you are available if they have any further questions or concerns.

Michael's parents have been married for nine years and both are dedicated to the well-being of their children. The father reports that he and his wife communicate openly with each other and make joint decisions about parenting issues. They also model healthy family dynamics, such as expressing affection and respect towards one another, being honest with one another, and sharing responsibilities. Michael has a five-year-old sister. His father characterizes the family as very close; they do everything together. The father says that he and his wife go to their children's sporting events and school meetings. Every weekend, the four of them are together doing family activities. Except when required to be away due to their work schedules as paramedics, the parents are home with the children at night. Prior to the family's move to a new state 6 months ago, Michael had been a successful student at school, typically performing at or above grade level. He was an active participant in the classroom, often volunteering to answer questions or participate in class discussions. Since the move, however, getting ready for school has been a struggle each day. He is struggling academically; while his grades haven't dropped drastically, he appears to be having trouble focusing and understanding the material. His parents have attended parent-teacher conferences and Michael's teachers have also reported that he seems distracted and uninterested in class. His parents also report that they are having difficulty getting him to stay on task when doing his homework at home.

What follow-up recommendation would be most beneficial for the client?

Periodic check-in sessions

Assign a case manager to call him when he is at home

Pediatrician checkup

Involvement in specialized group therapy

(A): Periodic check-in sessions (B): Assign a case manager to call him when he is at home (C): Pediatrician checkup (D): Involvement in specialized group therapy

Periodic check-in sessions

A

Although you believe the client is ready for termination, this process can be a difficult adjustment. Being available for periodic check-in sessions following the termination will increase the client's ability to maintain the progress he made in therapy. Therefore, the correct answer is (B)

treatment planning

Client Age: 30 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Pacific Islander Relationship Status: Single Counseling Setting: Private practice counseling clinic Type of Counseling: Individual counseling Presenting Problem: The client and her boyfriend recently broke up, and she is “tired of being with the wrong guys.” She admits that she will often stay in relationships even if she knows they are wrong for her. Diagnosis: Provisional diagnosis: Dependent personality disorder (F60.7), personal history (past history) of spouse or partner violence, physical (Z69.11), and personal history (past history) of spouse or partner psychological abuse (Z91.411)

Mental Status Exam: The client is oriented to person, place, time, and situation. No hallucinations, delusions, or paranoia are reported. The client was anxious at the start of the session, but she was able to calm herself down by easing into the counseling relation

You are a professional counselor working in a private practice clinic. The client comes in and sits quietly. The client appears nervous because she avoids eye contact and waits for you to initiate conversation. You ask why she is in counseling, and she responds that she is just tired. You ask more about this, and she says that she is not ready to talk about it yet. You decide to cover demographics and other less intimidating topics and then ask if she is comfortable talking yet. The client says that she feels a little more comfortable. She begins to state that she and her boyfriend broke up the previous week and that she was with him for 2 years. She explains that she has been “in this type of relationship before,” continually finds the “wrong guy,” and that she always goes “all in” with her relationships. Through processing, she identifies the following behaviors and beliefs: difficulty making daily decisions without the input of her partner, doing anything to gain support and affection even if she does not want to do the task or activity, quickly moving on to another relationship when a relationship ends, feeling that she cannot care for herself when she is not with someone else, and acknowledging that she needs others to take responsibility for major areas of her life. The client says that she has experienced physical and psychological abuse from partners, but that she is not ready to discuss this. The client identifies that her most important goal is to not end up in “the same relationship” again or rush into a relationship that is not right for her. Throughout the session, you provide empathetic and active listening. You suspect that the client has dependent personality disorder.

The client comes in, sits down, and immediately says that she has been thinking and decided that she is now ready to talk about the physical abuse that she has experienced. She recounts that from age 18 until age 20 she was with a boyfriend who would smack her if she said something he did not like. She believes this is why she is so preoccupied with pleasing others. The client’s second relationship was when she was 25 with a man who would get drunk nightly and punch her in the stomach or in the back when he was upset. You empathize with the client and reflect her emotions regarding these events. The client states, “I didn’t deserve it when the drunk guy hit me, but I do feel I wasn’t the best girlfriend with the first guy. I often didn’t do enough for him and often said the wrong thing.” Throughout the session, the client was tearful and started shaking slightly when speaking several times. The client paused for long periods before sharing more difficult parts of the story. You decide to assess for PTSD during this session, but she does not meet the criteria. When closing the session, the client states that she is not able to pay for today’s session until the end of the week. The client has no history of nonpayment with you thus far. Your informed consent includes fees for nonpayment and late cancellations of sessions

Your informed consent includes fees for nonpayment and late cancellations of sessions. Which of the following is the most therapeutic response to the client’s inability to pay for the session until the end of the week?

Allow the client until the end of the week to pay for the cost of the session with the added fee.

Waive the session fee and nonpayment fee because the client is experiencing financial hardship.

Allow the client until the end of the week to pay for the session and waive the nonpayment fee.

Consistency with fees is important in the client–counselor relationship. The fee should still be applied, and payment is still expected on time

(A): Allow the client until the end of the week to pay for the cost of the session with the added fee. (B): Waive the session fee and nonpayment fee because the client is experiencing financial hardship. (C): Allow the client until the end of the week to pay for the session and waive the nonpayment fee. (D): Consistency with fees is important in the client–counselor relationship. The fee should still be applied, and payment is still expected on time

Allow the client until the end of the week to pay for the session and waive the nonpayment fee.

C

Because this client has no history of nonpayment, it would be the most therapeutic course of action to waive the nonpayment fee and allow the client extra time to pay for the session. Generally speaking, fees for the counseling sessions, for late cancellations, and for nonpayment are beneficial for the counselor and the client. The fees ensure that the counselor is paid, and they develop a level of buy-in and accountability for the client to have regular sessions. A blanket rule to apply the fee every time does not take into consideration special circumstances and can harm the counseling relationship. Waiving the fees for the session and nonpayment would not be a good course of action because you do not know at this point if the client will continue to have issues with payments and the client has already agreed to pay for your services. Therefore, the correct answer is (A)

professional practice and ethics

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.

What should you do at this stage of the session?

Align with her empathically and wait for her to be ready to engage undistracted

Inform her the session will be a waste of a Medicaid billing hour and she should reschedule

Explain how her children being present is inappropriate and a violation of HIPAA

Call Department of Family Services to report emotional abuse of children

(A): Align with her empathically and wait for her to be ready to engage undistracted (B): Inform her the session will be a waste of a Medicaid billing hour and she should reschedule (C): Explain how her children being present is inappropriate and a violation of HIPAA (D): Call Department of Family Services to report emotional abuse of children

Align with her empathically and wait for her to be ready to engage undistracted

A

In order to build rapport, safety, and trust with this client, especially through a telemedicine platform, it is important to demonstrate concern for her emotional wellbeing and to prioritize your therapeutic relationship. A parent yelling in frustration at her children is not enough evidence to support a claim of emotional abuse. While children in session may not seem appropriate, this is the parent's choice; in many cases clients may not have the ability to secure childcare for sessions. Emotional support for the client should be prioritized over the counselor's idea of how a session should be spent. In this case, the client requested the session to continue. Therefore, the correct answer is (C)

professional practice and ethics

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. You have provided support for your counseling intern, and he continues to be late for and miss client sessions

You have provided support for your counseling intern, and he continues to be late for and miss client sessions. Which of the following would meet ACA criteria for ethical considerations at this point?

You see this as an opportunity to support the intern in balancing his personal life and his professional life.

You seek consultation and document your decision to terminate your supervisory relationship with the intern.

You encourage the intern to seek counseling in order to work through what he is going through.

You provide a corrective action plan to the intern in order to prevent further issues with his clients.

(A): You see this as an opportunity to support the intern in balancing his personal life and his professional life. (B): You seek consultation and document your decision to terminate your supervisory relationship with the intern. (C): You encourage the intern to seek counseling in order to work through what he is going through. (D): You provide a corrective action plan to the intern in order to prevent further issues with his clients.

You seek consultation and document your decision to terminate your supervisory relationship with the intern.

B

At this point, documenting the consultation and terminating the relationship would be indicated because the intern is continuing to harm clients (ACA, 2014, p 13). You have already tried to support the intern, and it was not helpful in preventing client harm or changing his behavior. At this point, a corrective action plan may not be helpful because the intern has not shown that he is willing to change. It may be helpful to encourage the intern to seek counseling; however, this does not address the potential for further client harm. Therefore, the correct answer is (A)

professional practice and ethics

Name: Tony Clinical Issues: Feeling alone and disconnected from children Diagnostic Category: V-codes Provisional Diagnosis: Z60.0 Phase of Life Problem Age: 66 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: White Marital Status: Divorced Modality: Individual Therapy Location of Therapy : Private Practice

The client is well dressed and well-groomed. He appears healthy for his stated age. Speech flow is normal, and eye contact is appropriate. The client is cooperative with adequate rapport. His thought process is logical. He expresses feeling angry, "even though there is nothing to be angry about." You do not observe any physical evidence of anger. When asked to describe a time when he felt angry recently, he mentions a road rage incident. His affect is more sad than angry.

First session You are a licensed mental health professional working in a private practice setting. The client is a 66-year-old male who is returning to therapy with you. When he called to schedule the appointment, he asked if he could meet with you for dinner beforehand and offered to pay. He presents for his session today, reporting that he has been experiencing what he labels "anger," but he cannot figure out where these feelings are coming from. He says he often talks to himself and ruminates over problems to find solutions. He is seeking your help to improve his relationship with his children. He felt that working with you in the past was helpful, and now that his children are all adults and he is financially secure, he has the time and resources to spend with them. The client has a history of difficulty in forming and maintaining meaningful relationships, particularly with his children. He has a history of conflict with them and has difficulty with communication and boundaries. He has had difficulty constructively expressing his feelings and has frequently resorted to outbursts of anger and aggression. He has had difficulty positively expressing his needs and has often felt overwhelmed and frustrated by his inability to be heard or understood. The client also has difficulty with impulse control and self-regulation, contributing to his difficulty managing his anger. He has frequently engaged in self-destructive behaviors to manage these feelings and has had difficulty finding effective coping strategies to control his emotions. He has also reported a pattern of avoidance, in which he avoids or withdraws from difficult situations rather than confront them. At the end of today's session, the client asks if he can go ahead and schedule therapy appointments with you every Tuesday for the next month so that he is "guaranteed" a spot. You can accommodate his request and plan to see him again in one week. Fourth session The client has been seeing you every Tuesday and likes to schedule his weekly appointments a month in advance. Last week, you asked him to bring in a list of the triggers for his anger and the strategies he has tried in the past to manage it. You explained that this would help you create an individualized treatment plan with specific goals and objectives to work on throughout therapy. Furthermore, you suggested coming up with potential coping strategies to employ if/when he finds himself in a situation in which he feels the need to withdraw or avoid. You also stressed the importance of identifying and addressing any underlying issues contributing to this behavior. Today, you spend the session exploring his anger and constant road rage, and you help him identify his feelings. He recognizes that the rage comes from a sense of being disrespected and feeling taken advantage of. As you continue that discussion, the client has a revelation. He recognizes that he also feels insignificant, unappreciated, and taken advantage of by his adult children. He wonders aloud if they like him. You focus on providing a positive therapeutic empathic response to meet his need to connect in relationships.

After the client shares his revelation, you state, "It's impressive that you were able to make the connection between your road rage and feeling taken advantage of by your children." What are you attempting to do with this response?

Empower the client

Provide Unconditional Positive Regard

Demonstrate congruence

Engage the client in therapy

(A): Empower the client (B): Provide Unconditional Positive Regard (C): Demonstrate congruence (D): Engage the client in therapy

Empower the client

A

Affirmation is a form of encouragement that is used to affirm behaviors or life choices. Affirmation is important for empowering clients. A few common affirmations include affirming progress that a client has made toward a goal or encouraging a client to do what is important to him. Therefore, the correct answer is (C)

counseling skills and interventions

Initial Intake: Age: 35 Gender: Male Sexual Orientation: Heterosexual Ethnicity: African American Relationship Status: Divorced Counseling Setting: Community Mental Health Center Type of Counseling: Individual

Davone presents as well-groomed, of fair hygiene and motor movements are within normal limits. Davone makes decent eye contact throughout session. Speech tone and rate are normal. Thought process unremarkable. Denies SI/HI. Davone becomes tearful when he recalls past family information, sharing that his father was never around for him for the same reasons he is not around for his family. Davone frequently refers to his racial background and where he grew up, becomes angry as evidenced by tense expression, furrowed brow, and clenched fists, and then self-soothes without prompting by taking a deep breath and moving forward in conversation. When asked, Davone tells you he learned those skills in past anger management classes he was mandated to take years ago.

Diagnosis: Adjustment disorder with mixed disturbance of emotions and conduct (F43.25) Provisional, Problems related to other legal circumstances (Z65.3) Davone is referred to you by his probation officer after being mandated by the court to undergo weekly emotional and behavioral health counseling sessions for a minimum of 9 months or until his next court hearing is scheduled, whichever is sooner. Davone’s Medicaid insurance cover his sessions. The probation officer tells you Davone is undergoing sentencing for violating his probation and restraining orders put in place by his ex-wife, which render him unable to set foot on their property or visit with his children (twin boys, age 9, and girl, age 4). In the initial assessment, Davone shares that he has had run-ins with the criminal justice system for most of his life “just like his father” and that he fears a lifetime of being in prison and not being able to be there to watch his kids grow up. Davone tells you he will do anything to get out of his situation and return to having a life where he can continue going to work and providing for his children.

Legal and Work History: You learn from Davone’s referral paperwork that Davone’s legal record extends back to age 9 when he was first beginning to show signs of conduct at school. Davone was often sent to the “recovery room” in elementary school for aggressive outbursts and defiance towards teachers. He has a record with the Juvenile Justice System for breaking rules and truancy in middle and high school. After age 18, he was arrested several times for misdemeanors of vandalism, shoplifting and reckless driving. He then married and became employed full-time by age 25, where he did not get into trouble with the law again until age 31 when he got fired for stealing from his company. This caused marital discord and led to Davone’s divorce two years ago. Davone has had a continued string of misbehavior, arrests, and short-term jail stays ever since. Davone adds that his ex-wife accused him of consistently endangering her and the kids without caring, which is why she got the restraining order. He disagrees with her, saying “I would never harm my kids.”

You respond to Davone saying “You are clearly disappointed, and obviously hurt as well! I can't imagine not being able to see my children. It would be so hard.” This is an example of?

reflection

empathy

sympathy

direct correlation

(A): reflection (B): empathy (C): sympathy (D): direct correlation

empathy

B

Validating your client's presentation and feelings while attuning to their emotional condition can strengthen your therapeutic bond and help them to feel heard and understood. Offering sympathy shows pity for your client but does not accomplish the congruence that empathy does and maintains an emotional distance from your client, placing them in a position to feel the same sorrow and pity for themselves as opposed to connected. Reflection is part of the active listening process in which the therapist repeats back to the client what was heard. Direct correlation is a mathematical term. Therefore, the correct answer is (B)

counseling skills and interventions

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.

Which of the following would be the least appropriate response to the client's disclosure?

"It's understandable that you have a fear of dying and leaving your children. It's natural to think about the worst-case scenario. Can you tell me more about this fear?"

"Let's look at some of the pros and cons of your fear. On the one hand, this fear may be a way to protect your children and ensure they are taken care of. But, on the other hand, your fear paralyzes and prevents you from living your life to the fullest. What do you think?"

"It sounds like you have some substantial concerns about dying. Can you tell me more about why your fear around this subject is so strong?"

"I also had a fear of dying for a long time. I think my fear came from a combination of my childhood experiences and denying my mortality. Do any events from your childhood come to mind that might be related to your fears?"

(A): "It's understandable that you have a fear of dying and leaving your children. It's natural to think about the worst-case scenario. Can you tell me more about this fear?" (B): "Let's look at some of the pros and cons of your fear. On the one hand, this fear may be a way to protect your children and ensure they are taken care of. But, on the other hand, your fear paralyzes and prevents you from living your life to the fullest. What do you think?" (C): "It sounds like you have some substantial concerns about dying. Can you tell me more about why your fear around this subject is so strong?" (D): "I also had a fear of dying for a long time. I think my fear came from a combination of my childhood experiences and denying my mortality. Do any events from your childhood come to mind that might be related to your fears?"

"Let's look at some of the pros and cons of your fear. On the one hand, this fear may be a way to protect your children and ensure they are taken care of. But, on the other hand, your fear paralyzes and prevents you from living your life to the fullest. What do you think?"

B

This is not the best way to respond to a client's fear of dying as it does not provide any strategies to help the client cope with their fear. It also does not acknowledge the client's feelings or provide any support or reassurance. Therefore, the correct answer is (C)

professional practice and ethics

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.

Would it be appropriate for you to provide counseling for both Shania and Malia?

Yes, because you can always provide therapy for both parent and child.

No, because you need a child psychology degree to work with a child.

No, since you can never be the counselor for both a parent and child.

Yes, because this is the nature of your job at this company.

(A): Yes, because you can always provide therapy for both parent and child. (B): No, because you need a child psychology degree to work with a child. (C): No, since you can never be the counselor for both a parent and child. (D): Yes, because this is the nature of your job at this company.

Yes, because this is the nature of your job at this company.

D

In this scenario your counseling position is to provide services to individuals and their family members. General counseling ethics will guide your boundary making decisions with every case, however in this unique circumstance you are the case worker for the entire family which makes seeing them together appropriate. It is not advised that you are the same provider for more than one family member in other circumstances, but the agency you work for, job description, and case specifics will help inform your boundaries and guide your decision. For reasons of confidentiality, appropriateness, or clinical considerations, you may have difficulty being the advocate of a child while also providing individual services for a parent. While there are specialists in child therapy training and child psychologists, you do not need a child psychology degree or specialized training with children to provide mental health counseling support to them and their families (unless it is against your agency rules or your job description. Therefore, the correct answer is (C)

professional practice and ethics

Name: Tina Clinical Issues: Maladaptive eating behaviors Diagnostic Category: Feeding and Eating Disorders Provisional Diagnosis: F50.01 Anorexia Nervosa, Restricting Type Age: 21 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: Italian American Marital Status: Not Married Modality: Individual Therapy Location of Therapy : University counseling center

The client presented with a slender physique and was observed wearing conservative, dark-colored attire. Her overall demeanor was reserved, displaying noticeable nervousness and a tendency to withdraw from interactions. Upon conversing with her, it became evident that her train of thought often deviated from the topic at hand, hinting at a tangential pattern. This difficulty in maintaining concentration appears to be a consequence of her heightened anxiety levels. Delving deeper into her thought content, a recurring theme of obsessions surrounding food and body weight emerged. Additionally, a palpable fear of judgment from her peers and the broader society was evident. In terms of her cognitive functioning, she was found to be alert and fully oriented to her personal details, as well as her current location and time. However, a significant concern is her limited insight into her present circumstances and the implications of her behaviors. Throughout the assessment, there were no indications of any memory impairments.

First session You are a mental health therapist working in a university counseling center. The client, a 21-year-old female, presents issues related to anxiety, poor body image, and eating. You begin the session by introducing yourself and explaining your role as a therapist. You also explain how confidentiality is handled and make sure that she understands her rights as a client. After the initial introductions, you ask her to tell you about her current situation and what led her to seek out therapy. She reports that she has been feeling anxious for a while, but it has gotten worse since a basketball game when someone in the audience yelled to the referee "thunder thighs over there needs to get her act together!" Even though the comment was not directed at her, she internalized it. She explains that she was already feeling uneasy due to her stepfather's comments about her weight from a few years ago, and the recent insult at the game made it "all come crashing down" for her. Now, she cannot stop ruminating about her appearance. She saw a poster in her dorm room promoting counseling services and decided to make an appointment. You continue your interview by asking about her current eating behaviors. She explains that she avoids carbohydrates, sugar, and most dairy "since that stuff makes you fat." When you ask her to describe what she eats during a typical day, she says, "I usually have a fruit smoothie with almond milk for breakfast, an apple and 12 nuts for lunch, and then some steamed vegetables or a salad for dinner." When asked about exercise or other physical activity besides basketball, she reports that she runs at least seven miles on a nearby trail every morning and spends two hours swimming laps at the indoor gymnasium pool every evening before bed. She says, "The pool is pretty quiet at night. I don't like to be around a lot of people when I'm exercising." As you continue your dialogue, you ask the client open-ended questions to explore her relationship with her parents, especially her stepfather. She reports that her stepfather has always had negative remarks about her size and shape. She states that she feels like he views her as "less-than" because of her weight, which has led to feelings of shame and worthlessness. You explore the dynamic further by inquiring about how these comments have impacted her self-esteem. She reports feeling anxious, embarrassed, and inadequate when her stepfather is critical. You validate her feelings and explain that comments like these can be very damaging to a person's self-image. You ask the client what she hopes to accomplish in therapy. After some thought, the client says that she wants to learn how to manage her anxiety. She looks at your shyly and says, "I also want to be able to eat a piece of chocolate. I know that sounds crazy, but I just want to be able to enjoy it, without feeling guilty or like I'm going to get fat." You affirm her desires and explain that a key part of the therapeutic process will be to help her build self-confidence and develop healthier relationships with food. Sixth session You have been working with the client in intensive outpatient therapy and have been meeting with her two times per week. She is under medical care at the university's health center and has started taking an anti-anxiety medication that was prescribed by her physician. You have also referred her to a nutritionist for specialized guidance on developing a healthier relationship with food. You have established a strong, trusting relationship, and she has told you that she feels comfortable talking to you. Today, the client brings up an issue that has been bothering her for a while: anxiety about eating around other people. She tells you that she usually gets her food "to go" from the cafeteria and eats at a bench outside or alone in her dorm room. She avoids eating in front of others when possible. However, at least once or twice a week, her teammates all go out to lunch after practice. This usually requires her to order food in front of them and she feels very anxious about it. She has been ordering the same salad with dressing "on the side" for several months because that is what makes her feel the most comfortable. One of her teammates commented on her "same old salad" and asked why she never got anything else to eat. Everyone at the table got quiet and turned to look at her. The client reports that the comment made her feel embarrassed and ashamed, like everyone was laughing at her. You ask her how she responded in the moment and she shares that she just laughed it off, but internally, she felt very embarrassed and anxious. You explore this further by asking her what emotions arise when she is around food, particularly in social settings. She reports feeling ashamed for wanting to eat "fattening food" because of her father's comments about her size. She skipped the last team lunch because she was so anxious about someone drawing attention to her food choices again. She closes her eyes and takes a breath. When she opens her eyes, you can see that she is struggling to hold back tears. She says, "Everyone eats their food like it's no big deal. But it's a huge deal for me. It's all I can think about. I just want to be able to eat a meal without feeling guilty or like I'm going to get fat. I'm so tired of worrying about food all the time!" You consider using exposure and response prevention techniques to address her fear and anxiety related to eating. You continue the session by identifying a list of foods and situations that trigger her anxiety and negative feelings about her body. You ask the client if she would like to meet with you for her next session right after practice and bring a lunch to eat in your office. She appears relieved and grateful to have a break from eating in front of her teammates. 10th session During your last session with the client, she discussed the anxiety that she was feeling about going home for winter break in a few weeks. She told you that her mom and stepdad always prepare a large meal for the holidays, and the extended family members get together to eat. She expressed a desire to participate in the family festivities but concern about her mom and stepdad's lack of understanding about her illness. She told you, "I don't want to make anyone feel bad, but I just can't eat like everyone else. It's not only the food - it's the conversations and comments about my body that really bother me." You listened as she expressed her fear of disappointing her family and reassured her that is was okay to set boundaries and have conversations about food. Together, you brainstormed coping strategies to manage her anxiety. You also suggested that she bring a dish of food that she would be comfortable eating to the winter break gathering. At the end of the session, she asked if she could bring her parents to the next session in an effort to gain their support and to help them understand what she is going through. You agreed to her request and scheduled an appointment to meet with the client and her parents. At the start of today's session, you introduce yourself to her parents and explain your role in helping their daughter. The client's mother tearfully shares that she had no idea her daughter was struggling so much and that she wishes she had picked up on the signs sooner. The stepfather appears quiet and reserved. You help guide a conversation between the client and her parents about her eating disorder and symptoms that she is experiencing. The client shares her fears, triggers, and struggles around food. Her stepfather speaks up and says, "I've heard enough. This is just ridiculous. You should just be able to eat, like everyone else. Your generation has gone 'soft' and started making up problems. There are people out there who don't have any food. When I was growing up, we had nothing. Your behavior is disrespectful." As he is talking, the client's mother is quiet and visibly uncomfortable. The client interjects, "Are you kidding? I'm the one who's being disrespectful?" She looks toward you and says, "When I'm home, he cooks these extravagant meals and refuses to let me leave the table until I've eaten what he's served me because it's 'wasteful to throw away food.' It's abuse! I feel like a captive when I'm at home." She looks back at her stepfather and says, "All I'm asking is that you understand what I'm going through and try to be a little more supportive." The stepfather's face turns red with anger, and he gets up to leave the room. You intervene and ask him to stay, offering a suggestion that you all take a few moments to reflect on what each person has shared before continuing the conversation. While the stepfather takes a break, you encourage the mother to open up and express her feelings. She reveals that she is scared of not being able to help her daughter and feels helpless in understanding how to come together as a family. You discuss ways that she can be supportive and provide an empathetic environment for her daughter.

The client's parents divorced when she was six years old. Her mother remarried 12 years ago. The client has a younger half-brother who lives with her mother and stepfather. She is close to her mother, but "my stepfather is a different story." She reports that he is critical of her and often remarks on how she looks or what she is eating. She states that he has commented on her weight and body shape since middle school. Her mother tries to intervene, but her stepfather continues to be critical. She tells you she couldn't wait to graduate high school and move out of the house. She tells you, "I remember that when I went home for a visit during winter break during my freshman year, my stepdad had this shocked look on his face when he saw me. He told me I had gained so much weight that I didn't even look like myself anymore. I've never forgotten that. And it's not like he's the picture of health." Previous Counseling: The client has a history of anxiety. She saw a therapist for a few sessions in high school after being referred by her school counselor, but she did not feel comfortable with the therapist and refused to continue attending sessions. She did not receive a clinical diagnosis related to her anxiety. The client reports that she has been feeling more anxious lately and is struggling to cope with her anxiety. She says that she feels "on edge," and that makes it difficult for her to concentrate. She is interested in exploring therapy to manage her anxiety. Additional Characteristics: The client is currently on the school's basketball team. She was voted most valuable player two years in a row.

Based on best practices for family therapy, how would you recommend structuring future sessions with the client and her parents?

Propose bringing in a co-therapist to take the stepfather for individual work while you continue with the client and mother.

Decline any further joint sessions to avoid exposing the client to further harm and conflict. Only meet with her individually.

Hold joint sessions to resolve conflicts and teach communication skills together.

Suggest individual sessions for each, then small joint sessions with the client and mother before full family sessions.

(A): Propose bringing in a co-therapist to take the stepfather for individual work while you continue with the client and mother. (B): Decline any further joint sessions to avoid exposing the client to further harm and conflict. Only meet with her individually. (C): Hold joint sessions to resolve conflicts and teach communication skills together. (D): Suggest individual sessions for each, then small joint sessions with the client and mother before full family sessions.

Suggest individual sessions for each, then small joint sessions with the client and mother before full family sessions.

D

Starting with individual sessions allows each family member to work on their concerns separately, optimizing progress. Small joint sessions for the client and mother can nurture their relationship before engaging the stepfather. This staged approach minimizes the risks of re-traumatization. Therefore, the correct answer is (C)

professional practice and ethics

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 arrives with his wife for his scheduled individual session today. You have yet to meet his wife in person. Before you can obtain an accurate appraisal of the situation, you find yourself mediating a conflict that has quickly intensified. The wife has given the client an ultimatum—to either stop the “endless manipulation, control, and sharp criticism” or she will take their daughter and go live with her mother, who resides in another state. The wife states that she has shown up today in a last-ditch effort to save their marriage. The client expresses a desire to remain with his wife and daughter. The client discloses that he has recently taken up boxing to release pent-up energy

The client discloses that he has recently taken up boxing to release pent-up energy. This is an example of which one of the following?

Sublimation

Regression

Rationalization

Reaction formation

(A): Sublimation (B): Regression (C): Rationalization (D): Reaction formation

Sublimation

A

Taking up boxing to release pent-up energy is an example of sublimation. Sublimation, rationalization, reaction formation, and regression are all defense mechanisms. Defense mechanisms are unconscious means for protecting a person from overwhelming feelings of anxiety. Sublimation occurs when a person redirects unacceptable urges in a socially acceptable way (eg, boxing). Rationalization is when a person provides a logical reason for behaving or thinking instead of the actual reason or motive. Reaction formation occurs when a person expresses the opposite opinion, feeling, or action because their true belief causes great anxiety. Regression is the process of returning to an earlier stage of development when encountering overwhelming feelings of fear, anger, anxiety, or resentment. Therefore, the correct answer is (D)

counseling skills and interventions

Name: Jack and Diane Clinical Issues: Marital/partner communication problems Diagnostic Category: V-codes Provisional Diagnosis: Z63.0 Relationship Distress with Spouse Age: 35 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: White Marital Status: Married Modality: Couples Therapy Location of Therapy : Community-based mental health facility

The clients are a couple in their mid-30s. The husband is tall and healthy. The wife is petite and well-groomed. As they enter, you make note that though they came in the same vehicle, they enter with no contact between them. They sit far away from one another and do not look at each other but maintain excellent eye contact with you. The husband's movements seem to be more agitated; the wife appears subdued. He speaks quickly and loudly and often fidgets in his chair, rarely sitting still; in contrast, her speech is low and soft, and she remains still and moves very little. They both seem guarded. They both identify their son's diagnosis of Autism Spectrum as being a significant strssor.

First session Your clients are in their mid-30s and present to the community agency where you are employed as both a licensed mental health therapist and a marriage and family therapist. You begin by introducing yourself and telling the couple about your professional experience and explain the types of therapies that you provide for couples. When asked why the couple made an appointment to meet with you, the husband takes the lead and tells you that he and his wife have been "serious problems" with their relationship for a few years. The husband shares that his wife does not trust him since his alcohol use "got out of control." Although he has been able to maintain sobriety for two years, he says that his wife is "paranoid" that he is using again and insists on knowing where he is "every minute of the day." He further reports that his wife is "too dependent" on him, and he feels "suffocated." He says, "I just can't keep doing this" and puts his head in his hands. You thank him for sharing his perspective of the problem and encourage the wife to share her thoughts about what is going on with their relationship. She tells you, "Truthfully? I'm scared to death that he's going to start drinking again and leave me alone with our children. I don't know what I would do if I lost him." She wipes a tear away from her face. After taking a deep breath, she says that when she tries to approach him to talk about how she feels, "he just gets mad and leaves the room." Using open-ended questions, you ask about each person's expectations for the counseling process and inquire about past experiences in therapy that may inform the current situation. Both partners look at each other, then back at you and share that they would like to re-establish trust and respect in their marriage. This is their first time seeking counseling. You also invite them to share the story of how they first met each other, memories of their relationship prior to getting married, and how they felt when they became parents. The husband shares that they first met when they were teenagers and have been together ever since. He talks about how their relationship was full of passion, respect, and trust. Even during the difficult times, they felt like nothing could tear them apart. He also shares that when their son was diagnosed with Autism Spectrum Disorder, they felt like the world had come to a standstill, but they were determined to get him the best care possible. He pauses. The husband and wife look at each other before the wife speaks. She explains that after their son's diagnosis, her husband began to drink more heavily as a way of dealing with his own stress and anxiety. He denied it for a long time, but eventually admitted he needed help and sought treatment. Although she was relieved that he got help, she is still struggling to trust him again. Fourth session Today, the couple arrives for their afternoon appointment ten minutes late. The wife appears to have been crying. Her husband smells like mouthwash, and his movements are slightly slower than normal. You ask if he has been drinking today. He states that he has not had any alcohol today, but his wife says, "That's not true!" and proceeds to tell you that she "caught" him holding a bottle of liquor in their garage this morning. The husband replies, "I didn't do anything wrong. This is just another example of you looking for problems where there are none. Why can't you believe me when I tell you that I'm not drinking?" She replies, "I really want to believe you, but you make it really hard to do that." He shakes his head and throws his hands up in the air in frustration. You ask the husband to step out of the room for a few minutes. He agrees and says, "Fine. You know where to find me." The wife shares that she feels like her husband is not taking the process seriously, and she questions whether or not counseling will work for them. You thank her for expressing her thoughts and explain that it is very common for couples to have doubts about therapy, especially when there has been a history of substance abuse. You discuss the potential treatment barriers and emphasize that it is important to have insight into these problems in order to create positive outcomes. The wife appears to understand and is reassured by your words. You invite the husband back into the room and ask him to share his thoughts about the counseling process. He takes a deep breath and says that he still wants to make their marriage work, but he is afraid of failing. He admits that he does not know how to "make things right" and this makes him feel helpless. You explain to him that counseling can help them gain insight into their communication patterns, learn new ways to interact with each other, and develop healthier coping strategies. You also discuss a plan for handling escalations in future sessions. You explain to the couple that it is important to have a plan in place whenever they are feeling overwhelmed or angry. Next, you discuss conflict resolution skills, emphasizing the importance of communicating their feelings and needs in an honest, respectful, and non-judgmental way. You also stress the importance of each partner taking responsibility for their own actions. You encourage them to practice these strategies outside of the session in order to improve their communication and relationship. After the session, you discover that the community-based mental health facility where you work will be closing in six months due to a lack of funding. You view this as a potential barrier that will inhibit mental health treatment access for many clients as this is the only mental health treatment facility in the city. Sixth session The wife presents for today's session without her husband. She reports that two nights ago, he was taken to the emergency room for pain. He had been drinking, and test results at the hospital liver indicated that his liver functioning was impaired. He continues to deny that he is drinking, but she knows this is untrue as she has been finding half-full liquor containers hidden around the house. She starts to cry, "I don't know what I will do without him. I had to call a babysitter and get a cab to come here. I'm worried about how I'll pay for the mortgage if my husband can't work. We'll end up losing the house and our health insurance! I'm going to have to sell off everything to make ends meet!" You respond to her fears with empathy and understanding. You are respectful of the client's thoughts and feelings and seek to understand her experience. You also explore the cognitive error that your client has made and how this is affecting her emotions. You continue the session by asking her what her most immediate concerns are at the moment and what she needs help with. She pauses for a moment and then starts to explain how she is feeling overwhelmed by the situation and feeling helpless in being able to help her husband. She expresses a lot of fear and anxiety about her family's financial security and the potential loss of the house and health insurance if her husband's drinking continues. She expresses a need for support and understanding and worries about how she will cope without her husband. She feels isolated and alone, stating, "I feel like my worst nightmare has come true. I've been worrying about my husband's drinking for a long time. I've heard horror stories about how addiction can ruin people's marriages, and I don't want that for us. I know it's hard for him, but it's hard for me, too." You offer her some resources that could help her with her financial situation and ask her to put together a list of a few people she feels she can talk to for emotional support.

The husband used to have severe issues with alcohol. He went to rehab three years ago and has maintained sobriety for two years. He continues to attend weekly meetings. As a result of his alcohol misuse, he has some medical issues with his liver, but they are not currently life-threatening as long as he continues to abstain from alcohol. The husband has worked hard to rebuild his relationships with his family and friends. He is actively trying to repair the damage that was done due to his alcohol misuse. He has been attending AA meetings and is focusing on rebuilding trust and communication. He has also been making an effort to be more present in his family life and to be a better husband and father.

The wife's reaction to the loss of her husband's income is an example of which cognitive error?

Catastrophizing

Mental Filtering

Overgeneralization

Polarization

(A): Catastrophizing (B): Mental Filtering (C): Overgeneralization (D): Polarization

Catastrophizing

A

Catastrophizing is the cognitive error of automatically expecting the worst-case scenario to occur. In this case, the client is jumping to the conclusion that she will lose her mortgage and health insurance and have to sell everything without considering other potential solutions or outcomes. Therefore, the correct answer is (A)

intake, assessment, and diagnosis

Name: Aghama Clinical Issues: Cultural adjustments and sexual identity confusion Diagnostic Category: V-codes Provisional Diagnosis: Z60.3 Acculturation Difficulty Age: 18 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Bisexual Ethnicity: Nigerian Marital Status: Never married Modality: Individual Therapy Location of Therapy : University Counseling Center

The client comes to your office and sits rigidly and makes little eye contact. She is dressed neatly and appropriately for the weather with overall good hygiene. She appears cooperative and open to the therapeutic process. She expresses a willingness to discuss her experiences, thoughts, and feelings, but show some hesitation due to her unfamiliarity with therapy. The client's mood is depressed. Her affect is congruent with her mood, displaying a flat or subdued demeanor, but shows some variability when discussing her family or life in Nigeria. Her speech is clear, fluent, and coherent. She has no difficulty expressing herself in English and seems to have a good command of the language. Her speech is slightly slow. The client's thought process appears linear and goal-directed. She is able to articulate her concerns and goals; her thoughts seem to be dominated by her feelings of sadness, loneliness, and homesickness. The client demonstrates some insight into her situation and the impact of her homesickness on her overall well-being. She appears to be motivated to seek help and improve her situation. There is no evidence of suicidal ideation or intent. The client does not express any thoughts of self-harm or harm to others. However, her ongoing feelings of sadness and loneliness warrant close monitoring and support during the therapeutic process.

First session You are a licensed mental health counselor working at a university counseling center and take a humanistic approach in your work with clients. Today you are meeting with an 18-year-old student who recently moved to the United States from Nigeria. She tells you that she moved to the United States one month ago after missionaries in Nigeria granted her a scholarship. She feels lonely, misses her family, and is questioning her decision to come to the United States. She indicates she has never been to therapy before but was told by her academic advisor that it might be helpful to make an appointment with a counselor. You continue the intake session by exploring the client's current psychological functioning. She expresses that she is homesick and is struggling to find her place in a new environment. She describes having difficulty making friends at college and feels isolated. She does not feel comfortable talking about her personal life with people she does not know well, which makes it even more difficult for her. Additionally, she is struggling with the pressure of living up to the expectations of the members of her church that gave her the scholarship to attend the university. She is currently pursuing a nursing degree at the university. You ask her to share some details about her family and cultural background in order to gain a better understanding of the context of her situation. She tells you that her parents are both teachers and she has two siblings. The family is very close-knit and they typically speak in their native language at home. You also ask about how she is managing her academic obligations, any specific challenges or barriers she might be facing, and how she is spending her free time. She says that her courses are challenging, but she is managing them well. In between classes, she spends most of her time in the library studying. You discuss the therapeutic process and what she hopes to gain from counseling. She expresses that she would like to learn how to better cope with her homesickness and loneliness. She says, "I'm worried that I'll be a disappointment. It took a lot of money and effort to get me here, and I don't want to let them down. I was so excited when I first got the scholarship, but maybe it would have been better if it went to someone else." You validate her feelings and explain that it is natural to feel overwhelmed when faced with a new culture and environment. You further explain the importance of focusing on her strengths, as she has already accomplished so much by making the decision to attend college abroad. You describe therapy as an opportunity for her to explore her feelings, develop coping strategies, and adjust to her new environment. At the end of the session, she tells you she is on a "tight schedule" and needs to know when she can see you for therapy so she can plan accordingly. You provide her with your availability and suggest that an ideal therapy schedule would involve weekly sessions. You also explain the importance of consistency in order to allow her to make meaningful progress during therapy. You schedule an appointment for the following week. Fifth session This is your fifth weekly session with the client, and she states that she likes the "structure" of seeing you on Wednesday afternoons. The client appears to be doing better since she last saw you. She begins today's session by telling you that she still feels isolated and is having difficulty making friends. You ask her to elaborate on the challenges she has been facing in connecting with students at the university. She tells you that most of the other international students are from countries closer to America like the Caribbean islands, and it is difficult for her to relate to them. She pauses for a moment and asks if she can tell you about something that happened a few days ago that she is feeling nervous about. You respond affirmatively, and she tells you that her roommate invited her to a party and she ended up drinking which is not something she would normally do. When she and her roommate got back to their dorm room later that night, they kissed. She goes on to say that she thinks she has developed romantic feelings for her female roommate. This experience made her feel confused and anxious, and her family's expectations weigh heavily on her mind. You ask her to elaborate on her feelings in order to gain a better understanding of the situation. The client shares that she is unsure what this could mean for her future and worries if her family will be disappointed in her if they find out. She says, "I am actually engaged to a man in Nigeria. We decided to postpone the wedding until I finished my degree, but now I don't know what to do. My parents were so excited when we announced our engagement, and the thought of breaking it off feels like a betrayal." You explain that it is natural to feel confused when faced with new experiences and remind her that she is in control of the decisions she makes about her life. You suggest exploring what a relationship with her roommate might look like, as well as considering the consequences of breaking off her engagement. She says, "I know I need to stay true to myself. I just don't want anyone hurt in the process. I can't even imagine what it would mean if I told my parents or church family about my roommate. They are not as conservative as other people in the town where I grew up, but I don't think they know many, if any, people who are in same-sex relationships." You discuss with the client how her religious and cultural beliefs may affect her sexual identity and contribute to feelings of guilt and fear of disappointing her family. During the next few weeks following today's session, the client cancels twice without proper notice and later tells you that she "had other stuff going on." Seventh session During today's session, the client tells you that she read a few of the chapters in the book you recommended on human sexuality, and she is starting to feel more comfortable with herself. At your suggestion, she started keeping a journal to organize her thoughts and feelings about her sexuality. She says that she has "pretty much decided to end my engagement and take some time to explore who I am and what it means to be in a relationship with another woman." She relates that she still feels homesick at times, but her roommate has been supportive and understanding. She smiles and says, "My roommate surprised me the other day by cooking a traditional dish that I told her about that my mom used to cook for us growing up. It was so comforting to have a reminder of home like that." You continue to explore the client's thoughts on telling her parents about her newfound identity, and she says that although the idea of coming out to them and breaking off her engagement is frightening, she knows it is "the right thing to do." You provide guidance on how to approach this sensitive subject in a way that may be best received by her family. You also provide additional resources that may help her learn more about navigating conversations around sexuality and sexual orientation with family and friends. The client notes that if all goes well, she'd like to take her roommate back home with her for a visit during a school break so they can spend time together away from school.

What is the best way to demonstrate empathic attunement in response to the client's fear of her family's disapproval?

"What would you advise another person in your situation to do?"

"It's understandable that you are worried about how your family will react. It can be very difficult to balance the expectations of your family with your own needs."

"How would you feel about role playing a conversation with your family about your relationship? This might help alleviate some of the anxiety that you're feeling."

"You're not alone in this experience and what you're feeling is valid."

(A): "What would you advise another person in your situation to do?" (B): "It's understandable that you are worried about how your family will react. It can be very difficult to balance the expectations of your family with your own needs." (C): "How would you feel about role playing a conversation with your family about your relationship? This might help alleviate some of the anxiety that you're feeling." (D): "You're not alone in this experience and what you're feeling is valid."

"It's understandable that you are worried about how your family will react. It can be very difficult to balance the expectations of your family with your own needs."

B

This is an example of empathic understanding because it acknowledges the client's feelings and validates her concerns without passing judgment. It shows that the therapist understands the difficulty of navigating family expectations, while also affirming the client's autonomy to make decisions about her own life. This response allows the client to feel heard and understood in a non-judgmental environment. Therefore, the correct answer is (C)

core counseling attributes

Client Age: 41 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Divorced Counseling Setting: Behavioral Health Type of Counseling: Outpatient Presenting Problem: Fear and Panic Diagnosis: Agoraphobia 300.22 (F40.00)

Mental Status Exam: The client appears her stated age, and she is dressed in casual attire. Her affect and mood are anxious. She is tearful and seems extremely distressed when recounting her panic attacks. The client denies suicidal or homicidal ideations but does endorse feeling hopeless about her condition. She is unsure if she will benefit from counseling and expresses mixed feelings about seeking help. The client denies audio and visual hallucinations. Fam

You work in a behavioral health outpatient center. Your client is a 41-year-old Caucasian female presenting with symptoms of fear and panic. The client has a history of anxiety and depression but explains that her anxiety has worsened within the last year and that she has begun to experience panic attacks. She states that she has an “overwhelming fear” of elevators and stairwells. When exposed to these situations, she has trouble breathing, begins to feel dizzy, and hyperventilates. The client remembers having her first panic attack while staying at a hotel one weekend. She was taking the stairs and suddenly felt intense fear and panic. On the same trip, she had a similar experience when taking the elevator. The client quit her last job due to travel requirements, and she is currently unemployed. She stays away from stairwells and elevators as much as she possibly can. When unable to do so, she asks her son to accompany her.

ily and Work History: The client was married for 15 years before she divorced. She and her ex-husband share custody of their 16-year-old son. The client is an only child and reports that her parents were strict and overbearing when she was growing up. She works as a travel photographer and, until recently, worked for a large national publication. She enjoyed her job but cannot envision a time when she would feel comfortable staying in hotels again. This fear has prevented her from exploring other travel accommodations while on assignment. She states, “There are too many unknowns with travel, and I just don’t think I can do it any longer.” You use a biopsychosocial assessment during the client’s initial intake appointment

You use a biopsychosocial assessment during the client’s initial intake appointment. Which one of the following uses a holistic approach to address a client’s biopsychosocial and spiritual dimensions?

Humanistic

Behavioral

Cognitive-behavioral

Psychoanalytic

(A): Humanistic (B): Behavioral (C): Cognitive-behavioral (D): Psychoanalytic

Humanistic

A

A humanistic style uses a holistic approach to address a client’s biopsychosocial and spiritual dimensions. Humanistic theories include person-centered therapy, gestalt therapy, and existential therapy. CBT’s primary focus is to help clients change thought patterns characterized by erroneous, irrational, or negative beliefs. There are several examples of CBT, including REBT, dialectic behavior therapy, and cognitive therapy. Psychoanalytic theory addresses the effects of early childhood experiences on the unconscious mind. Behavioral therapy is based on the assumption that a person’s behaviors can be changed through rewards, punishments, reinforcement, and desensitization. Therefore, the correct answer is (B)

counseling skills and interventions

Initial Intake: Age: 82 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Widowed Counseling Setting: Community Clinic Type of Counseling: Individual

Theodore is tearful most days and has dropped a significant amount of weight. He has not been sleeping and stays up watching videos of his deceased wife.

Theodore is an 82-year-old who was referred for grief counseling by his son, Nate. Theodore’s wife, Nancy died one month ago after a 4-year battle with cancer. History: Theodore was the primary caretaker for Nancy and has not paid attention to his own health in years. Nate would like his father to move in with him and his family and sell the house his parents lived in to pay off their debt. However, Theodore refuses to sell the house and stated that he will not give away or sell anything that they owned. Nate drove Theodore to the initial session and sat in for the intake, with Theodore’s consent. Once everyone sat down, Theodore looked at the counselor and stated, “I am only here so my son stops bugging me about selling the house. I am not getting rid of anything in that house- and especially not the house itself!” Nate explained that his father cannot maintain the house on his own and is worried about him being lonely. Theodore insists that he has other options and thinks that living with Nate would put a burden on him.

Theodore decides that he would like to tell Nate about his decision to not move in with him. A Gestalt technique in which Theodore can practice, by playing both sides of the conversation, would be?

Role playing

Empty chair technique

Rehearsal technique

Drama therapy

(A): Role playing (B): Empty chair technique (C): Rehearsal technique (D): Drama therapy

Empty chair technique

B

The empty chair technique is a Gestalt technique in which Theodore practices the conversation between him and Nate. This can show the counselor the expectations that Theodore has of Nate. This technique is also used in counseling for internal conflicts where an individual may have a conversation with a part of themselves, or a younger self. Role playing would be the client playing himself or Nate and the counselor playing the other. Drama therapy describes many techniques, not specific to Gestalt. The rehearsal technique is used to enhance memory and is a way to practice a speech or dialogue. It is not a two-way conversation. Therefore, the correct answer is (B)

counseling skills and interventions

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." Eighth session The client has been coming to therapy consistently for seven weeks. During today's session, he states that he has been able to have sex once to full term and has been practicing his relaxation skills before initiating sexual activity with his wife. The client tells you, "My wife just doesn't do it for me anymore. With the other two women I am currently seeing, I can go two, even three times. I don't feel guilty, and it feels great to feel like a man now." This is the first time your client has admitted his infidelity to you. The client expresses feelings of relief to speak honestly about his infidelities and the dual benefit of "feeling like a man again" and being able to perform sexually. He reports that he feels more confident and his anxiety levels have decreased since engaging in extra sexual activity with the other two women and his wife.

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.

Using an Adlerian approach, what technique might be most appropriate for this client in light of the client's most recent revelations regarding his extra affairs?

Push button technique

Guided imagery

"Spitting in the client's soup"

Empty chair

(A): Push button technique (B): Guided imagery (C): "Spitting in the client's soup" (D): Empty chair

"Spitting in the client's soup"

C

The Adlerian technique "spitting in the client's soup" can be used to bring awareness to a persistent pattern of negative behavior (ex. the client having affairs while saying he wants to enjoy a sexual relationship with his wife). Therefore, the correct answer is (B)

counseling skills and interventions

Name: Ethan & Cindy Clinical Issues: Sexual functioning concerns Diagnostic Category: V-codes Provisional Diagnosis: Z63.0 Relationship Distress with Spouse Age: 69 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: White Marital Status: Married Modality: Couples Therapy Location of Therapy : Private Practice

The husband appears to be of average build. His dress is appropriate for the occasion, but his facial expression is blank and he keeps staring off into space. He has difficulty maintaining eye contact and speaks in an aimless monotone. His affect is blunted, and he appears to be emotionally detached from the situation. He reports feelings of worthlessness and emptiness that have been ongoing for many years. He has had recurrent suicidal ideations but is not currently making any plans to act on them. His thought process is disorganized, concrete and circumstantial in nature. The wife is slightly overweight and dressed in loose clothing. She appears agitated and tense but is able to maintain good eye contact throughout the conversation. She speaks in a clear, consistent manner and expresses her thoughts in an organized fashion. Her thought content is focused on her current difficulties with her husband, and she expresses feelings of disappointment, rejection, and anger. She acknowledges feeling a sense of hopelessness in the situation and shares concerns about her future. Her mood reflects her thoughts and is generally pessimistic. Insight is intact as she is able to recognize the impact of her own actions on the current state of affairs. Her judgment is also intact as she recognizes that her current behavior and attitude are not helping the situation.

First session You are a mental health therapist in a private practice setting. A couple, a 69-year-old male and a 65-year-old female, enters your office together. The couple has been married for over 40 years and have two grown children. Their second child age 31 is currently living at home. When you ask what brings them to therapy, the wife immediately states that her husband is not attracted to her anymore. She tells you that he never wants to be in a situation where they are romantic together. She is feeling unwanted, unattractive, and as if they are "roommates" who just cohabitate together. When you ask the husband how feels, he says that he has a sense of disgust toward his wife when he thinks of having an intimate encounter with her. The wife believes that her husband is repulsed by her physical appearance as she is overweight. The husband confesses to feeling guilty for his lack of interest in his wife, but he is unable to pinpoint why he feels this way or understand why it has become an issue now after 40 years of marriage. Exploring further, you ask the couple about their family of origin. The wife states that her parents were highly critical and demanding, while the husband's parents were more passive and removed when it came to expressing affection or showing disapproval. She also expresses concern over possible sexual abuse in the husband's past, though he is not sure if anything happened or simply cannot remember due to its traumatic nature. With these additional pieces of information, you begin to develop a comprehensive picture of their situation and focus on working with the couple towards a positive outcome. Fourth session You have seen the couple for three therapy sessions so far. Today is your fourth session with the couple. The wife tells you that she is "officially sleeping in the spare bedroom" and is considering a trial separation. Last week she bought lingerie to entice her husband, and he responded by ridiculing her, then turning away from her and going to sleep. The wife begins to cry as she says, "We don't talk anymore. He just berates me all the time, and that hurts a lot." As the wife tells you about the incident, the husband sighs audibly and shakes his head. He looks at you and states, "She's a mess. I don't know what to say." You empathize with the couple's emotional struggles, and you acknowledge their pain. You explain to them that it can be helpful for couples to explore personal issues in an individual therapy setting before coming together as a couple to make progress on their relationship challenges. You let them know that they may find it easier to express themselves when one partner is not present, and that individual counseling can give them each the space to address their own personal issues in a safe environment. You encourage them to take some time to reflect further on whether they believe individual therapy would be useful for them at this time, and you offer to provide further information about the process if needed. Finally, you let them know that you are here to support them as they make decisions about how best to move forward. You assure them that while their relationship may be in a difficult place right now, it is possible to heal and strengthen their connection with one another. You remind them that relationship issues are often complex and that it is important to be patient with each other as they work together to find solutions. You encourage them to stay committed to the process, even when things feel difficult, and you offer your ongoing support in helping them build a more fulfilling relationship. Seventh session You met previously with each partner separately. They shared their perspectives with you about their relationship. The husband told you that he was reluctant to stay with his wife. The wife described feelings of worthlessness and loneliness. Today, the husband arrives for their couples session ten minutes after the wife, as they are driving in separate cars. The husband states that he is bored at home and is tired of his wife "nagging" him. The wife rolls her eyes and expresses that she will never be a priority, and the husband blames her for everything that goes wrong. The wife is now staying at her friend's house, and the husband is relieved that she is gone. You talk to the couple about their perceived outcomes in therapy and what they hope to accomplish going forward.

The wife states that she had an emotionally distant relationship with her parents growing up and never felt truly accepted by them. She also reveals that her father was often angry and verbally abusive, which left her feeling anxious and fearful in his presence. When asked about his family of origin, the husband speaks of his parents as being cold and unapproachable; they showed acceptance or rejection based on whether he met their expectations. He expresses difficulty in determining how he is supposed to act around them. Stressors & Trauma: When asked about how the family of origin showed acceptance or rejection, the husband states, “My parents ignored me when they were displeased. I got to sleep in their bed when they were pleased with the way I acted.” When asked about sexual abuse, the client states, “I'm not sure. It seems like something bad happened with my mother and uncle. There might be something more than that, too. I can't really remember.” Previous Counseling: The husband has been struggling with depression for the past few months after he lost his job in an economic downturn. He has been struggling with feelings of worthlessness and emptiness for many years, even when he was employed. He has had multiple periods of suicidal ideation, but never acted on them. The client also states that it is difficult for him to focus and stay motivated. He is currently taking Wellbutrin that was prescribed by his primary care physician and states that it helps "take the edge off." The client states he would rather deal with the pain than be emotionally blunted.

When talking to the wife, you tell her that sometimes you take a break from your own marriage by taking a "mini-vacation" for a weekend. What are you doing here?

Using self-disclosure

Summarizing the client's statements

Empowering the client

Demonstrating respect for the client's autonomy

(A): Using self-disclosure (B): Summarizing the client's statements (C): Empowering the client (D): Demonstrating respect for the client's autonomy

Using self-disclosure

A

You are disclosing personal information to the client. As a therapist, you can self-disclose as long as you do not take away from the client and as long as your self-disclosure is appropriate to the client's situation. Therefore, the correct answer is (A)

professional practice and ethics

Client Age: 30 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Married Counseling Setting: Counseling clinic Type of Counseling: Individual counseling Presenting Problem: The client is engaging in restrictive eating daily. The client engages in bingeing when her husband is away for business trips and engages in exercise as compensatory behavior. Diagnosis: Anorexia nervosa, binge eating/purging type, moderate (F50.02)

Mental Status Exam: The client is oriented to person, place, time, and situation. She reports no hallucinations or paranoia. The client was engaged in the session, but she had trouble accepting that her weight and self-talk were problem

You are a licensed counselor working in your own private practice, and you specialize in eating disorders. The client comes to counseling after her primary care physician (PCP) provided a referral to counseling due to restrictive eating that has led to a low body mass index of 16.5. The client says that she has lost about 30 pounds over the past 6 months and that she still feels that she is overweight. The client says that she usually consumes about 500 calories each day and that she fears that if she eats more, she will gain weight. The client’s mother, who was overweight, passed away at age 46 due to an aneurysm, which has contributed to the client’s perception that her mother’s death was weight related. The client expresses that she also has a fear that if she gains weight, then her husband will not love her. She describes experiencing anxiety resulting from the belief that she is currently overweight and is therefore already at risk of both her husband not loving her and of dying. The client says that she generally restricts eating when her husband is home, but when he is on business trips she binges and then forces herself to throw up.

You meet with the client, and she comes and sits down and appears happy because she is smiling and sitting with an open posture. The client’s food log shows improvement in engaging in healthier eating habits and minimal restriction. You and the client review her progress in treatment and agree that she has met all of the treatment goals. The client reports several situations in which she wanted to restrict, purge, and binge, but instead she engaged in cognitive reframing and was able to manage her reaction to the trigger. You praise the client and express that she should be proud of herself for her management of her symptoms. The client reports that she has gained weight and is in a healthy weight range at this point. She continues that her husband has made comments of concern about her weight gain and that the frequency of sex has decreased recently. The client says that she and her husband have been arguing about her eating recently and that she does not feel that he supports her in recovering from her eating disorder. You empathize with the client

Which of the following indicates that this client is ready for termination?

The client reports that no symptoms of the eating disorder or trauma are present, and you also observe no symptoms.

The client states that she is not restricting, bingeing, or purging and that she and her husband are going to start couples counseling.

The client has nothing to talk about in sessions and reports that she does not have anything she needs to work on.

Minimal symptoms of the eating disorder and trauma are present, and the client manages them when they occur.

(A): The client reports that no symptoms of the eating disorder or trauma are present, and you also observe no symptoms. (B): The client states that she is not restricting, bingeing, or purging and that she and her husband are going to start couples counseling. (C): The client has nothing to talk about in sessions and reports that she does not have anything she needs to work on. (D): Minimal symptoms of the eating disorder and trauma are present, and the client manages them when they occur.

Minimal symptoms of the eating disorder and trauma are present, and the client manages them when they occur.

D

It is not always realistic to expect all symptoms to be abated. When minimal symptoms are present and the client is able to manage them and maintain progress, termination is appropriate. Although no symptoms being present is the ideal, this may never be attainable in some clients; therefore, it is appropriate to terminate when the client is able to be autonomous and manage her symptoms by herself. The client having nothing to talk about is not ideal for termination because this may indicate that she is not reporting or not being forthcoming with what she is experiencing. The client’s report regarding eating habits and a plan for couples counseling is good progress, but it does not focus on the client’s autonomy regarding her ability to manage symptoms on her own. Symptoms may be present long after therapy, but one of the most important aspects of counseling is that the client is able to self-regulate and manage what life sends to her. Therefore, the correct answer is (B)

professional practice and ethics

Initial Intake: Age: 37 Gender: Female Sexual Orientation: Heterosexual Race/Ethnicity: Caucasian/non-Hispanic Relationship Status: Married Counseling Setting: Mental health counseling agency Type of Counseling: Individual telemedicine

Leah is casually dressed, presenting with anxious mood and affect. Speech is of fast rate but with normal tone. Breathing is shallow from speaking fast, you note she stops to take deep breaths before continuing. Leah denies SI/HI, reports many protective factors, and admits that nothing in her life is “really that wrong.” Leah demonstrates good insight and judgment into the nature of her concerns.

Diagnosis: Generalized Anxiety Disorder (F41.1), Adjustment disorder with mixed anxiety and depressed mood (F43.23) Leah is referred to your counseling agency by the U.S. Department of Veterans Affairs (VA) mental health program due to their inability to accommodate her because of their high caseloads. Leah is a 37-year-old married woman with a 2-year-old child and is a disabled combat veteran who served 8 years in active-duty Air Force service. Both you and Leah work full-time as mental health counseling interns in your respective practices. Leah struggles to manage her own anxiety which causes both interpersonal and professional problems for her. Leah reports experiencing trauma related to deployments, past divorce, death of a pet and birth trauma with her daughter. Leah tells you she needs someone to process everything with regularly as she does not want to exhaust members of her family with her stress. Leah’s biggest problem, she shares, is that she knows how to resolve her negative thoughts that lead her to act impulsively but cannot apply her skills when she feels overwhelmed.

Education and Work History: Prior to military life Leah worked several different jobs since the age of 13. Leah joined the Air Force at age 21, worked overseas as well as in the states, and had several deployments including one year in Kabul, Afghanistan as a Staff Sergeant during her fifth year of service. Leah obtained her bachelor’s degree right after separation, and then returned to Afghanistan as a contractor. Following this experience, she completed her master’s degree in counseling. She admits she is “skeptical” working with someone who has the same amount of experience as herself. Family History: Leah grew up with two younger siblings, and her parents divorced when she was 11. Due to joint custody, her and her siblings moved back and forth weekly every Friday until she originally left home for college at 18. Both of Leah’s parents remarried; her father having three more children with her stepmother, and Leah inheriting a stepsister when her mother married her stepfather. Leah was also previously married to an Army Sergeant while active duty, but her husband had an affair and left her prior to her military separation.

Which response would help Leah regulate her emotions while accepting her situation?

Explain that feeling anxious is unhelpful if she cannot change anything.

Remind her of her counseling skills and challenge her to use them.

Validate her feelings and acknowledge her virtues as a mother.

Deliver a list of possible solutions to her problems.

(A): Explain that feeling anxious is unhelpful if she cannot change anything. (B): Remind her of her counseling skills and challenge her to use them. (C): Validate her feelings and acknowledge her virtues as a mother. (D): Deliver a list of possible solutions to her problems.

Validate her feelings and acknowledge her virtues as a mother.

C

Regardless of Leah's knowledge and competency as a clinician, she is in the vulnerable position of needing to feel supported just like any other clients in your caseload. Therefore, using the same strategies as you would with a client who does not already possess prior knowledge of anxiety reduction skills will offer the most effective delivery of emotional comfort. Normalizing or validating her distressing thoughts has been proven in behavioral therapy techniques to actively reduce a person's momentary suffering because it allows them to feel the way they do without challenging them to fight against it which can often be more anxiety-provoking. Using strengths-based and positive psychology strategies of reflecting her virtues as a mother who prioritizes her child is a way of motivating her out of her own value system and hopefully leading her into a discussion about accepting her temporary, unchangeable position. Reminding her of coping skills, offering her solutions, or even attempting to have her rationalize, are all secondary supportive techniques to helping Leah feel heard, understood, valued, and accepted. If she were momentarily able to use her coping skills, she would have. Reviewing them and challenging her at this moment could increase her feelings of shame she has already expressed that she is not able to put into practice things she knows she should do. Trying to solve her problems for her will not help her as much as regulating her disposition in session for her to be able to find solutions to her own problems. Therefore, the correct answer is (D)

counseling skills and interventions

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.

At the start of the session, the foster parents ask the client if she would mind meeting alone with you; she agrees and asks to have access to the toy bin in your office. You and the client begin to play together, and you ask her if she talked to her birth parents. The client says “yeah, Mommy talked about coming home in a few years.” You ask how she feels about living with her mother again, and she says she does not want to be with her because her mother does not want to be with her. You try to process this with the client, and she says that she likes her house and her school and does not want to leave. You meet with the foster parents and the client at the end of the session, and they report that spending quality time with the client on a daily basis has been helpful in improving their relationship. They state that they think they had been too afraid to overwhelm her and that at times they were trying to give her space, but they realize that the intentional time together has been helpful. You empathize with the foster parents and encourage them to continue to spend quality family time with her. The court provides a subpoena for an update on the counseling process

The court provides a subpoena for an update on the counseling process. All of the following are appropriate considerations EXCEPT:

Providing all progress notes and assessments

Only sending information in an encrypted and secure manner

Providing only relevant material

Obtaining legal counsel

(A): Providing all progress notes and assessments (B): Only sending information in an encrypted and secure manner (C): Providing only relevant material (D): Obtaining legal counsel

Providing all progress notes and assessments

A

Even when information is subpoenaed, it is important to only provide relevant information, which means that you may not provide the client’s entire file. The ACA Code of Ethics encourages only sharing information that is relevant to the entity receiving the information (ACA Governing Council, 2014). It may be helpful to obtain legal counsel to navigate this situation because you want to ensure that you are providing what is legally appropriate. It is always important that information is sent in a manner that is compliant with HIPAA standards. Therefore, the correct answer is (B)

professional practice and ethics

Clients Age: Husband: 45 Wife: 43 Sex: Husband: Male Wife: Female Gender: Husband: Male Wife: Female Sexuality: Heterosexual Ethnicity: Both Individuals Are Caucasian Relationship Status: Married Counseling Setting: Private Practice Counseling Clinic Type of Counseling: Couples Counseling Presenting Problem: Marital Distress Diagnoses: Couple Diagnosis: Adjustment Disorder with Anxiety (F43.22) and Relationship Distress with Spouse or Intimate Partner (Z62.898) Individual Diagnosis (Wife): Generalized Anxiety Disorder (F41.1)

Mental Status Exam: The husband and wife were both oriented to person, place, time, and situation. Both individuals were dressed appropriately for the season and appeared clean. The husband presented as angry, and the wife presented as remors

You are a licensed therapist working at a private practice. The couple comes to counseling in order to work on their relationship following an infidelity. The wife has difficulty expressing what happened, and the husband interrupts her and expresses that his wife had an affair with a coworker 3 weeks ago. The couple states that they are currently talking very little aside from conversations that involve their children. The wife states that she is regretful of what she did and that she does want her marriage “to be saved.” The husband explains that he is very hurt by her infidelity and that he is unsure if he can forgive her and continue being married to her. The couple has been married for 25 years and report that they both are in counseling to see if they can continue to be married following the affair. The husband expresses strong anxiety following the revelation of the affair and questions how he can be in a relationship with his wife following the infidelity. The wife is experiencing anxiety regarding her husband leaving her because she reports regretting the sexual interaction with her coworker and does not want to get divorced.

The husband and wife come into the session and sit as far as they can from each other on the couch, and their individual body positions are oriented away from each other. You ask for any updates in the couple’s relationship, and the husband states that they have not been talking about the affair and continue to only communicate regarding the kids. You attempt to process with the couple what the affair means for their relationship and what events led up to the affair. During the session, the husband stops talking and looks away from his wife when she talks about how she became frustrated that her husband did not spend quality time with her prior to the affair. She thinks that this led to her seeking attention from a man outside of the couple’s relationship

Based on John and Julie Gottman’s concept of the four horsemen of the apocalypse, which include criticism, defensiveness, contempt, and stonewalling, which one of the following terms describes the husband’s communication style when he disengages from the session?

Criticism

Contempt

Defensiveness

Stonewalling

(A): Criticism (B): Contempt (C): Defensiveness (D): Stonewalling

Stonewalling

D

The husband’s response is an example of stonewalling. Stonewalling occurs when a partner stops engaging in communication. Criticism involves attacking the partner for who they are and what they do. Contempt involves treating the partner with disrespect and ridicule. Finally, defensiveness involves making excuses for behavior and often deflects from addressing the partner’s feelings. These often are sequential, going from criticism to contempt and subsequently from defensiveness to stonewalling (Lisitsa, 2021). Therefore, the correct answer is (C)

counseling skills and interventions

Client Age: 48 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Separated Counseling Setting: Private practice Type of Counseling: Individual Presenting Problem: Alcohol use Diagnosis: Alcohol Use Disorder, Moderate, Provisional (F10.20)

Mental Status Exam: The client’s hands tremble, and she becomes tearful on several occasions. There is mild perspiration on her forehead. She endorses feeling hopeless about the future but denies suicidal ideation. The client shows no signs of intoxication or impairment. She presents as well-dressed with good hygiene. Both affect and mood are dysphoric. She apologizes several times for crying and states she has been “a mess” lately due to not sleeping for the last several days. Her demeanor becomes somewhat defensive when asked about her drinking, and she appears to minimize the impact this has had on her life. Fam

You are a counselor working in private practice evaluating a 48-year-old female with a history of alcohol misuse. Three weeks ago, the client was hospitalized due to alcohol poisoning. She explains that she was in a blackout before waking up in the hospital and was told her BAC was 0.26, just over three times the legal limit. This occurred on the evening she discovered that her husband was having an affair. The client briefly attended a drug and alcohol intensive outpatient program (IOP) but felt she was not improving with group therapy and would like to try individual therapy instead. She admits that there are times in her life when she has abused alcohol but does not believe she is an alcoholic. The client experiences frequent anxiety and admits to using alcohol “just to take the edge off” and to help her fall asleep. Her alcohol intake increased nearly six months ago when her youngest child left for college. During this time, her husband of 25 years announced he was leaving and filing for divorce. She struggles with being an “empty nester” and is mourning the loss of the life she and her husband built together.

During the previous session, the client committed to controlled drinking and agreed on a limit of two drinks per night. She admits to having limited success with this goal and concedes to over-indulging when feeling “stressed out.” You learn she ran into a woman from her church who she discovered was a recovering alcoholic. She agreed to meet the woman at an AA meeting, and the client was surprised she could relate to other alcoholics. The client’s affect brightened as she reported that she has had seven days of continuous sobriety. She continues to have a strained relationship with her now ex-husband. Her youngest child is home on spring break, which has helped improve her mood and kept her accountable for staying sober. She is able to use relaxation and mindfulness techniques for insomnia, which have been effective at times at improving her sleep pattern

According to the Transtheoretical Stages of Change model, in which stage would you classify this client?

Precontemplation

Action

Preparation

Contemplation

(A): Precontemplation (B): Action (C): Preparation (D): Contemplation

Preparation

C

The Transtheoretical Stages of Change (SOC) Model, developed by Miller & Rollnick (2013), outlines the following SOC: precontemplation, contemplation, preparation, action, and maintenance. This client has just entered the preparation stage. Individuals in the preparation stage consider making a change but are unsure exactly how to do so. Like others in this stage, this client has taken significant steps towards sobriety, but there is still unresolved ambivalenceShe has explored AA and is in early sobriety but will need specific behavioral goals and a more solid commitment to reach the action stage. Individuals in the precontemplation stage are not considering a change, while those in the contemplation stage are beginning to consider making a change. Those in the contemplation stage are still drinking but are weighing the pros and cons of cutting back or abstaining. This client was in the contemplation stage when she attempted to cut back to two drinks per night. Individuals in the action stage have a specific behavioral plan and are committed to the process of change. When individuals become more stable in their sobriety, they have reached the maintenance stage. Therefore, the correct answer is (B)

intake, assessment, and diagnosis

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 approach should you recommend Shania use with Malia for discipline?

Use preventative, supportive, and corrective discipline.

Set strict boundaries with consequences.

Use positive parenting approach.

You should learn more about and meet Malia prior to making suggestions.

(A): Use preventative, supportive, and corrective discipline. (B): Set strict boundaries with consequences. (C): Use positive parenting approach. (D): You should learn more about and meet Malia prior to making suggestions.

You should learn more about and meet Malia prior to making suggestions.

D

It is best practice whenever possible to obtain as much information about a client's parenting experience and their children before offering suggestions of methods to apply. Conducting skills tests, hearing family history, understanding the child's medical or psychological conditions, observing the parent-child interaction are some of the many ways to obtain information prior to making recommendations. A well-informed evaluation could lead to different interventions that could be more directly targeted towards the problem rather than attempting to treat the patient, using basic parenting skills, such as possible psychiatric medications for the child, distress tolerance training for the parent, or even clinical assessments that discover autism spectrum disorder. Therefore, the correct answer is (C)

intake, assessment, and diagnosis

Client Age: 32 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Counseling Setting: Community Mental Health Agency Type of Counseling: Individual Presenting Problem: Depressed Mood Diagnosis: Bipolar II 296.89 (F31.81), current episode depressed

Mental Status Exam: The client is dressed casually and is somewhat disheveled. She avoids eye contact and displays a flat affect. The client admits to having suicidal thoughts in the past but currently denies both suicidal and homicidal ideations. Her speech is soft in volume and tone. She tends to provide one-word responses but is cooperative when asked to elaborate. The client denies audio-visual hallucinations, and her thought content is coherent. The client’s mood is depressed, and her affect is flat. She appears tired and reports she has insomnia at night and is sleeping most of the day. The client has experienced depression off-and-on, beginning in late adolesc

You work at a community mental health agency providing outpatient services to adults. Today, you are meeting with a 32-year-old female who presents with her husband for an initial intake session. The client’s husband is concerned about his wife’s depressive symptoms. She is experiencing sadness, decreased appetite, and hypersomnolence. The client also expresses hopelessness and has lost interest in doing the things she once enjoyed. Until recently, the client worked at an art gallery. When employed, she reports that she, “just couldn’t get out of bed” and was eventually let go due to excessive absences. After her employment ended, her depressive symptoms worsened. The client was able to recall a time nearly one year ago when she felt “almost the opposite” of how she feels now. During this time, she experienced increased energy and felt more inspired and creative. The client explains that she and her husband used to travel selling their art at juried art exhibitions most weekends, but it has been awhile since she has joined him.

The client reports that she has been feeling less depressed. Her affect is full-range and appropriate to the situation. She continues to have sleeping difficulties that seem to worsen when experiencing unexpected stressors. The client explains that she has been arguing with her daughter’s father about financial matters, which developed after the client lost her job. The client believes her depressive symptoms are exacerbated after spending significant periods of time on social media. The client remarks, “My husband’s patience with me is growing thin. I don’t think I can ever live up to his expectations.” After your discussion with the client about her social media use, she sends you a Facebook friend request

After your discussion with the client about her social media use, she sends you a Facebook friend request. What is your ethical obligation regarding the use of social media, distance counseling, and other related technology?

To have written procedures in place and reviewed before or during the client’s initial session

To recognize the potential harm and benefits of developing an informal virtual relationship with clients, former clients, and their families and personal friends

To disclose that you maintain a professional and personal online presence, and it may be difficult for the client to distinguish between the two

To include in the client’s record all electronic communication, except clerical information (e.g., appointment scheduling)

(A): To have written procedures in place and reviewed before or during the client’s initial session (B): To recognize the potential harm and benefits of developing an informal virtual relationship with clients, former clients, and their families and personal friends (C): To disclose that you maintain a professional and personal online presence, and it may be difficult for the client to distinguish between the two (D): To include in the client’s record all electronic communication, except clerical information (e.g., appointment scheduling)

To have written procedures in place and reviewed before or during the client’s initial session

A

Your ethical obligation is to have written procedures in place and reviewed before or during the client’s initial session. Answer B is incorrect. According to the NBCC Code of Ethics (2016), “NCCs shall include all electronic communications exchanged with clients and supervisees, including those through digital technology and social media methods, as a part of the record, even when strictly related to clerical issues such as change of contact information or scheduling appointments” Answer C is incorrect because it includes benefits and harms rather than only specifying harms. The NBCC Code of Ethics states, “NCCs shall recognize the potential harm of informal uses of social media and other related technology with clients, former clients and their families and personal friends” Lastly, the ethical guideline for an online virtual presence included in the ACA Code of Ethics (2014) states, “separate professional and personal web pages and profiles are created to clearly distinguish between the two kinds of virtual presence (ACA, 2014)”. Therefore, the correct answer is (A)

professional practice and ethics

Initial Intake: Age: 40 Sex: Female Gender: Female Sexuality: Lesbian Ethnicity: African American Relationship Status: Partnered Counseling Setting: Community Agency Type of Counseling: Individual

The client appears to be slightly older than stated and demonstrates positive signs of self-care in her hygiene and dress. She states her mood fluctuates between “sad and okay.” Her affect is labile and mirrors topics discussed in session. She smiles when describing her children and her relationship with her former oncology team. She cries easily when discussing cancer, moving, instability, and fears. The client is cooperative and forthcoming, with easily understood speech. She offers insight into her thoughts and behaviors, is attentive, and shows no difficulties with memory or judgement. She acknowledges one episode of suicidal ideation, without plan, during her adolescence when she desperately missed her mother while on a custodial visit with her father. She has had no thoughts of harming herself since then and has no thoughts of harming others.

You are a counselor in a community agency. Your client presents with concerns about her lifelong history of being “anxious and emotional” since her parent’s divorce when she was 12. She tells you her feelings of “anxiety and feeling badly about myself” intensified when she was diagnosed with breast cancer four years ago and then again when her family moved to the area last year. She tells you that she thinks she managed her emotions well during her treatment because her focus was on getting through the crisis. She also was taking Klonopin twice a day for anxiety. She says she feels that she has let her family down by having cancer because it costs them monetarily and emotionally; she wonders sometimes if her cancer is a punishment for something she’s done. She reports that she does not discuss these concerns and emotional fears with her partner because “she has become the breadwinner and I feel like I need to protect her from my negativity.” On intake forms, she endorses crying daily, trouble sleeping, concentrating on things, has been losing weight without trying, and constantly worrying about her health and the family’s finances. She tells you that her partner says she “runs around like a chicken with my head cut off because I start stuff like cleaning or cooking and then stop right in the middle of it. I just get restless and sometimes I just can’t stop fidgeting when I should be paying attention.” She notes that she is in menopause due to her cancer treatments, which included a removal of her ovaries three years ago and a hysterectomy one year ago. She tells you people often refer to her as a “cancer survivor” but she doesn’t feel like she has survived it because every surgery makes her feel like she “is losing another piece of me.” Additionally, she says that having to have body scans every six months and not being able to look in the mirror and see a “complete woman” makes her feel that she is still trying to survive, rather than putting it in the past.

Family History: Your client reports a four-year history of treatment for breast cancer. She has had 16 months of chemotherapy and 27 rounds of radiation, as well as a double mastectomy three years ago. She has completed reconstructive surgery for her breasts but has not yet added nipple tattooing for a more realistic image. She reports that she has three close female relatives with breast cancer, but no relapses after treatment. She states that she has been in a relationship with her partner for 17 years and they share two children, ages 12 and 8. She describes her partner as a “good person” and the relationship as “good.” She tells you that they moved to the area one year ago when her partner had an unexpected promotion. She reports this has been good but that their oldest child is “anxious, emotional, and just angry sometimes.”

When assessing this client's cultural identity, which of the following will provide the most information?

Influence of client's cancer on her mental health

Influence of client's race, ethnicity, and sexuality on her mental health

All of the above

Influence of parent's divorce on her mental health

(A): Influence of client's cancer on her mental health (B): Influence of client's race, ethnicity, and sexuality on her mental health (C): All of the above (D): Influence of parent's divorce on her mental health

All of the above

C

Culture encompasses all groups which an individual has membership in, including race, ethnicity, socioeconomics, sexuality, religion, biological disease or emotional disorder, and family of origin. For example, research shows that people who grow up in divorced households have different experiences than those in non-divorced households. Just as people from different ethnic cultures have differing experiences based on their cultural norms, so do people who have experienced chronic disease, such as cancer. Cultural identity is not restricted to race and includes assessing for all influences on a client's identity. Therefore, the correct answer is (D)

intake, assessment, and diagnosis

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.

You discuss with Shania how trauma is a psychological injury that continues to harm one's cognitive and emotional state, often rendering them helpless to recurrent patterns of maladaptive behaviors. She agrees to begin trauma work. In what order would you attempt the following interventions?

coping skills, TF-cognitive therapy, order for EMDR and/or neurofeedback

cognitive therapy, teach coping skills, EMDR

neurofeedback, prolonged exposure therapy, cognitive therapy, teach coping skills

EMDR, teach self-soothing techniques, TF-cognitive therapy

(A): coping skills, TF-cognitive therapy, order for EMDR and/or neurofeedback (B): cognitive therapy, teach coping skills, EMDR (C): neurofeedback, prolonged exposure therapy, cognitive therapy, teach coping skills (D): EMDR, teach self-soothing techniques, TF-cognitive therapy

coping skills, TF-cognitive therapy, order for EMDR and/or neurofeedback

A

It is crucial that prior to having a client address their trauma they learn to master coping skills, both during exercises in session as well as at home in real life situations. Concurrent to teaching coping (self-soothing techniques included) you should engage your client in cognitive interventions, such as Cognitive Processing Therapy approach and trauma-focused Cognitive Behavioral therapy. Once they have thoroughly discussed their traumas and become comfortable managing their reactions and emotions in counseling sessions, they should continue interventions such as neurofeedback operations or EMDR (eye-movement desensitization reprocessing) techniques. Neurofeedback machines are not commonly found on most agency sites and technicians must be specialty trained to administer the resource; but they have been found to drastically reduce emotional complications from trauma, anxiety, and depression often in a single session. EMDR is a specialty intervention requiring licensure and/or certification and training. As a counseling intern in a state-run facility, you would have to order a referral for this service. EMDR interventions may seem like the first line of defense in treating trauma, however without first feeling comfortable with approaching traumatic content in therapy and having confidence in one's ability to self-soothe resultant anxiety, it is possible for EMDR to be too challenging. Prolonged exposure therapy is effective if relatable to certain traumas where one can control the reduction of fear response associated with the trauma (ie, driving over the bridge where they had a car accident, or taking a shower after being attacked in water). It would not be appropriate for Shania who has a history of physical and verbal abuse by her parents. Therefore, the correct answer is (D)

treatment planning

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.

You learn that the client withheld information during the intake interview because of a negative experience with psychiatric treatment. Two years previously, the client presented at the emergency room with symptoms of depression and suicidal ideation. The emergency department clinician recommended hospitalization, and the client complied. During his hospital stay, he was placed on an antipsychotic medication for paranoia and was diagnosed with schizoaffective disorder. Although the client admits to suicidal ideation, he denies ever experiencing paranoia. He reports having side effects from the medication and immediately discontinued it after discharge. The client states that he has been very depressed since the breakup with his girlfriend and was willing to give counseling another try before his depression “hit rock bottom.” After disclosing his experience with hospitalization, the client asks questions about your credentials, counseling approach, and experience

After disclosing his experience with hospitalization, the client asks questions about your credentials, counseling approach, and experience. What would be your first response?

Understand and validate the client’s experience with hospitalization and consider contextualized factors.

Shift the focus back to the client and emphasize the importance of honest communication regarding suicidality.

Obtain a signed release of information to communicate with the hospital and request the client’s records.

Provide a written copy of informed consent, which includes your credentials and related information.

(A): Understand and validate the client’s experience with hospitalization and consider contextualized factors. (B): Shift the focus back to the client and emphasize the importance of honest communication regarding suicidality. (C): Obtain a signed release of information to communicate with the hospital and request the client’s records. (D): Provide a written copy of informed consent, which includes your credentials and related information.

Understand and validate the client’s experience with hospitalization and consider contextualized factors.

A

You would first seek to better understand and validate the client’s experiences with psychiatric care and consider contextualized factors (eg, race, gender, ethnicity). For example, researchers suggest that African Americans are more likely to be diagnosed with schizophrenia or psychosis than non-Hispanic whites presenting with the same symptoms. Your client’s misdiagnosis likely contributes to medical mistrust and influences his help-seeking behaviors. Establishing a therapeutic alliance at this juncture is critical. Empathetic listening and validation communicate warmth, positive regard, and affirmation. Emphasizing the importance of honest communication regarding suicidality is more likely to occur within the context of a trusting counselor-client relationship. Providing the client with a written copy of informed consent is appropriate but should not be the first consideration. Lastly, obtaining a signed release of information to communicate with the hospital may be helpful. However, using this as an initial response may communicate to the client that you doubt his experiences. Therefore, the correct answer is (C)

counseling skills and interventions

Initial Intake: Age: 23 Gender: Male Sexual Orientation: Heterosexual Ethnicity: Indian American Relationship Status: Single Counseling Setting: Private Practice Type of Counseling: Individual

Shawn is slightly unkempt, completes ADLs and has good hygiene. His motor movements are fidgety and tense, and he consistently averts eye contact and darts his eyes around the room and towards the door every time he hears a noise. He appears to be sensitive to the lighting in the office as evidenced by fluttering his eyes when he looks up and commenting about its brightness. Shawn speaks within normal rate and tone, however low volume and often mutters under his breath. He denies any past suicidal or homicidal ideation and denies hallucinations or delusions. Shawn also denies history of trauma.

Diagnosis: Social Phobia, unspecified (F40.10) provisional; Alcohol Use Disorder, moderate, in early remission (F10.10) Rishaan is a 23-year-old heterosexual male of Indian origin and is being referred to you by his parents for counseling in your private practice who are telling you Rishaan is at risk for going back to his drinking because he “never does anything constructive.” Further complaints by Rishaan’s parents include that “all he does is play video games and watch TV,” that he “never has money to pay for anything himself” and is constantly asking them for money. His parents offer to self-pay for Rishaan’s sessions. You welcome Rishaan to your office for an initial assessment. He respectfully requests that you refer to him as “Shawn,” which he explains is his preferred American name, and remarks that his parents really want him to talk to you. Shawn has agreed to counseling because he shares with you that he “has stuff to talk about anyway” and does not think he can go to his parents.

Substance Use History: Shawn entered treatment and rehabilitation five months ago after his ex-girlfriend’s family had an intervention with him about his abusive drinking and he has now been through all phases of treatment for Alcohol use disorder. Shawn tells you he is ashamed that his parents found out about his problem through his ex-girlfriend’s parents, because he had been lying to his own parents about his well-being for several years since he left home for college at 18 years old. Shawn is currently five months sober but is not engaged in any post-treatment recovery program nor has he continued counseling. Family History: Shawn has two older siblings, both of whom he shares are “successful and have families.” Shawn says, “my parents always want me to be like them and are constantly comparing me to them, it’s so annoying.” Shawn’s father is a dermatologist, and his mother is his father’s secretary in their medical practice. Both parents observe traditional Indian cultural practices in their social lives and with respect to Hinduism. Work History: Shawn has attempted part-time work following his graduation from his alcohol rehabilitation treatment program but was unable to make his shifts on time and was let go from his job. He tried another job selling products by cold calls but could not keep up with the volume required to make a viable salary. When asked what Shawn would like to do for a living, he says “I’d like to be a gaming coder or tester, something like that.”

Shawn expresses his frustrations over his parents' pressure on him to do something with his life. Which response is the most effective use of motivational interviewing?

"I think their pressure is what is causing your social anxiety. Does that make sense?"

"I would be frustrated, too! What do you think is the best way to get them to stop?"

"You have quite the inner strength to manage that and still stay sober. How are you doing it?"

"Tell me about how your family's strong Indian culture affects you and your stress."

(A): "I think their pressure is what is causing your social anxiety. Does that make sense?" (B): "I would be frustrated, too! What do you think is the best way to get them to stop?" (C): "You have quite the inner strength to manage that and still stay sober. How are you doing it?" (D): "Tell me about how your family's strong Indian culture affects you and your stress."

"You have quite the inner strength to manage that and still stay sober. How are you doing it?"

C

Bringing up culture when the client did not address his culture as a stressor is not culturally sensitive, so it does not yet apply here unless Shawn chooses to discuss it. If Shawn knew the best way to "get his parents to stop pressuring him" he would not be in counseling asking you about it, nor would he feel frustrated. Diagnosing his anxiety with your own theories about where it comes from is not helpful to your client in developing his own insight into his problems. Only answer d utilizes core MI skills of affirming your client's strengths and asking open-ended questions to increase or review your client's motivation. Therefore, the correct answer is (D)

counseling skills and interventions

Name: Tony Clinical Issues: Feeling alone and disconnected from children Diagnostic Category: V-codes Provisional Diagnosis: Z60.0 Phase of Life Problem Age: 66 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: White Marital Status: Divorced Modality: Individual Therapy Location of Therapy : Private Practice

The client is well dressed and well-groomed. He appears healthy for his stated age. Speech flow is normal, and eye contact is appropriate. The client is cooperative with adequate rapport. His thought process is logical. He expresses feeling angry, "even though there is nothing to be angry about." You do not observe any physical evidence of anger. When asked to describe a time when he felt angry recently, he mentions a road rage incident. His affect is more sad than angry.

First session You are a licensed mental health professional working in a private practice setting. The client is a 66-year-old male who is returning to therapy with you. When he called to schedule the appointment, he asked if he could meet with you for dinner beforehand and offered to pay. He presents for his session today, reporting that he has been experiencing what he labels "anger," but he cannot figure out where these feelings are coming from. He says he often talks to himself and ruminates over problems to find solutions. He is seeking your help to improve his relationship with his children. He felt that working with you in the past was helpful, and now that his children are all adults and he is financially secure, he has the time and resources to spend with them. The client has a history of difficulty in forming and maintaining meaningful relationships, particularly with his children. He has a history of conflict with them and has difficulty with communication and boundaries. He has had difficulty constructively expressing his feelings and has frequently resorted to outbursts of anger and aggression. He has had difficulty positively expressing his needs and has often felt overwhelmed and frustrated by his inability to be heard or understood. The client also has difficulty with impulse control and self-regulation, contributing to his difficulty managing his anger. He has frequently engaged in self-destructive behaviors to manage these feelings and has had difficulty finding effective coping strategies to control his emotions. He has also reported a pattern of avoidance, in which he avoids or withdraws from difficult situations rather than confront them. At the end of today's session, the client asks if he can go ahead and schedule therapy appointments with you every Tuesday for the next month so that he is "guaranteed" a spot. You can accommodate his request and plan to see him again in one week.

What therapeutic approach would be most beneficial for this client at this time?

Adlerian therapy

Cognitive-behavioral therapy

Person-centered therapy

Emotion-focused therapy

(A): Adlerian therapy (B): Cognitive-behavioral therapy (C): Person-centered therapy (D): Emotion-focused therapy

Emotion-focused therapy

D

Emotion-focused therapy (EFT) is a therapeutic approach based on the premise that emotions are key to identity. According to EFT, emotions are also a guide for individual choice and decision making. This type of therapy assumes that lacking emotional awareness or avoiding unpleasant emotions can cause harm. Therefore, the correct answer is (A)

counseling skills and interventions

Name: Roger Clinical Issues: Physical/emotional issues related to trauma Diagnostic Category: Neurocognitive Disorders Provisional Diagnosis: F02.81 Major Neurocognitive Disorder Due to Traumatic Brain Injury, with Behavioral Disturbance Age: 36 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: White Marital Status: Married Modality: Individual Therapy Location of Therapy : Outpatient clinic

The client presents as tired. He reports a mild headache at the intake appointment, which he says is likely due to coming in from the bright day outside. Memory is slightly impaired. Mood is depressed, though he says this is impermanent, and his mood changes within a day, though the depressed mood is more prevalent and longer-lasting.

First session The client returned home from Afghanistan last month after separating from the Navy after 12 years of service. He states he is tired of trying to get an appointment at the VA Hospital, so he Googled locations that treat brain injuries, and your office was on the results page. He called to arrange a consultation with you. You have been practicing as a licensed mental health therapist at the outpatient clinic for over a decade, and you have worked with many clients diagnosed with traumatic brain injury. The client complains about difficulty sleeping, bad headaches, and feeling like he is on a roller coaster - feeling happy one minute and then down in the dumps the next. He states that the happy times don't last long, and he is "down in the dumps" most of the time. When asked why he left the Navy, he replies: "Toward the end of my last deployment, I just got sick and tired of everything and couldn't deal with it anymore. I couldn't sleep, was jumpy all the time, and didn't even want to go outside during the day." Now, I'm finally back home, but things only seem worse. My wife keeps nagging me to get a job, my kids look at me like I'm a monster, and nobody understands how I feel. I want to lay in bed all day and drink a couple of beers. I think something isn't right, and I can't take it anymore." Near the end of the session, the client asked what he could expect if a medical professional recommended medication management to treat NCD. The client discloses experiencing a highly distressing and psychologically damaging event during his military service in Afghanistan. While on patrol with his unit, their convoy was ambushed, and a fellow soldier directly next to the client was seized by insurgents. The client painfully witnessed his peer and friend being brutally beheaded, describing the horrific sight and sounds as permanently seared into his memory. Helplessly observing the brutal murder firsthand left him stunned and overwhelmed with grief and terror at the moment. The grotesque violence and knowing that could have just as quickly been his fate continues haunting him years later. The constant stress of combat and imminent danger already had the client in a perpetual state of hypervigilance and anxiety during his deployment. He shares that coming to terms with the abrupt, unfair loss of life was a daily reality there. While transporting supplies between bases in a standard jeep convoy, his vehicle triggered an IED explosion or was directly hit by artillery fire. The client was violently jolted and knocked completely unconscious as the blast disabled their jeep. He remained in and out of consciousness for over 24 distressing hours, being evacuated while critically injured to a military hospital. Once stabilized, he was thoroughly examined and diagnosed with a traumatic brain injury concussion along with other shrapnel wounds.

The client drinks three beers every night before bed to help him fall asleep. He started this pattern a few years ago after struggling with insomnia and finding it challenging to relax his mind. Though effective at first in inducing drowsiness, he has built up a growing tolerance and now needs to drink three beers minimum to feel any sedative effects. He discloses that he knows consuming alcohol regularly can be unhealthy, but he feels dependent on having those beers to wind down from the stresses of his day and quiet his anxious thoughts enough to get adequate rest. During his time serving in the military, the client reported smoking cannabis on occasion when it was available. However, he did not enjoy the experience or feel compelled to use it. He mainly partook when offered by peers to be social. Since his discharge five years ago, he states he has not had any cannabis. The client currently smokes approximately one pack of cigarettes per week, a habit he picked up during his military service as a way to cope with boredom and nerves. He expresses some interest in trying to cut back for health reasons but also shares smoking provides a sense of relief and routine.

Knowing this client's history and symptomology, it would be important to assess for which disorder in the intake session?

Substance/medication-induced Obsessive-Compulsive Disorder

Attention-Deficit/Hyperactive Disorder

Somatic Symptom Disorder

Post-traumatic stress disorder (PTSD)

(A): Substance/medication-induced Obsessive-Compulsive Disorder (B): Attention-Deficit/Hyperactive Disorder (C): Somatic Symptom Disorder (D): Post-traumatic stress disorder (PTSD)

Post-traumatic stress disorder (PTSD)

D

This client's combat experience and symptomology would require a PTSD rule-out to ensure that this diagnosis is not warranted. Therefore, the correct answer is (A)

intake, assessment, and diagnosis

Client Age: 32 Gender: Female Sexuality: Bisexual Ethnicity: Caucasian Counseling Setting: Agency Type of Counseling: Individual Presenting Problem: Binge-eating Diagnosis: Binge-Eating Disorder 307.51 (F50.8), Moderate

Mental Status Exam: The client presents as polite and cooperative. She was well-groomed and dressed appropriately for the situation. Her affect is blunted, and she is tearful when discussing episodes of binge eating. The client has poor eye contact and periodically bites her fingernails. Her thought content is clear. She does not endorse audiovisual hallucinations, and she is oriented to person, place, time, and situation. The client denies suicidal and homicidal ideations. She denies previous suicidal attempts but states that she used to engage in cutting when she was an adolescent

You are working at an agency serving clients from the metropolitan area. Your client is a 32-year-old bisexual female presenting with feelings of sadness, frustration, and shame due to increased episodes of binge eating. The client explains that she has tried unsuccessfully to manage her weight and control her eating. She states she is secretive when bingeing and feels “disgusted” afterward but “completely unable” to stop the compulsion. The client reports binge eating six times per week, with episodes worsening in the last two years. She identifies as bisexual and reports her binge eating increased after coming out to her family. She continues to struggle with depressive symptoms, including feelings of hopelessness, depressed mood, and anhedonia. The client’s weight places her in the category of obese, and she has recently been diagnosed with borderline diabetes. Towards the end of the session, the client states, “This is starting to affect my health. If I could change anything in my life, it would be to stop binge eating.”

The client reports that she started her week doing well but had a setback a few days ago, causing her to lose confidence in her ability to change. Despite her progress in reducing binge-eating episodes, the client remarks, “I’ll never control my eating.” She says she is frustrated and feels hopeless and unmotivated. You address her ambivalence to change, as well as obstacles she has experienced in the past. When discussing exercise, the client states, “You don’t understand! I’ve tried exercise, and it never works.” You provide the client with self-monitoring sheets to record the following in real-time: daily food intake, maladaptive eating patterns, and thoughts and feelings that accompany binge eating. She is hesitant but agrees to give it a try for one week. You are using self-monitoring to obtain baseline data and wish to use the SMART framework for constructing treatment plan goals and objectives

You are using self-monitoring to obtain baseline data and wish to use the SMART framework for constructing treatment plan goals and objectives. Which of the following accurately depicts the five SMART criteria?

Strengths-based, measurable, appropriate, rational, timeless

Strengths-based, measurable, appropriate, rational, and timely

Specific, measurable, achievable, realistic, and timeless

Specific, measurable, achievable, realistic, and timely

(A): Strengths-based, measurable, appropriate, rational, timeless (B): Strengths-based, measurable, appropriate, rational, and timely (C): Specific, measurable, achievable, realistic, and timeless (D): Specific, measurable, achievable, realistic, and timely

Specific, measurable, achievable, realistic, and timely

D

SMART goals and objectives are specific, measurable, achievable, realistic, and timely. The counselor and the client construct specific goals and objectives by determining, in detail, what they would like to accomplish. Measurable goals consist of changes that are observable or quantifiable in terms of progress made within a pre-selected timeframe. Goals and objectives must be achievable. The client and counselor set achievable goals by examining the client’s internal and external resources, such as personal characteristics and social support. Goals must be realistic or relevant to the client’s diagnosis and overall plan for overcoming the presenting problem. Timely goals and objectives are an accurate reflection of the timeframe in which they can realistically be accomplished. Therefore, the correct answer is (B)

treatment planning

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.

What cognitive error is the client making when she talks about being judged at work?

Catastrophizing

Mind reading

All-or-nothing thinking

Magnification of negative thoughts/minimizing positive ones

(A): Catastrophizing (B): Mind reading (C): All-or-nothing thinking (D): Magnification of negative thoughts/minimizing positive ones

Mind reading

B

The client is demonstrating the cognitive distortion of mind reading in this session, where she assumes that others are judging her and thinking negatively about her weight without any evidence or confirmation from them. Therefore, the correct answer is (A)

counseling skills and interventions

Name: Denise Clinical Issues: Hopelessness/depression Diagnostic Category: Bipolar and Related Disorders Provisional Diagnosis: F34.0 Cyclothymic Disorder Age: 38 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: White Marital Status: Divorced Modality: Individual Therapy Location of Therapy : Private Practice

The client is appropriately dressed. She is overweight and appears edgy and irritable. Her attention wanders during the intake. She is articulate and able to communicate her thoughts logically. The client focuses on the negative aspects of life and appears to have a strong external locus of control. Insight is low, and judgment is strong.

First session You are a mental health counselor in a community agency. The client is a 38-year-old White female teacher referred to you by her principal. The client is experiencing difficulty with her school colleagues. She wants to keep her job and is motivated to improve her social skills. Since she was a young adult, she has had tumultuous relationships with co-workers, friends, and family. She tells you she has periods of highs and lows. During the high periods, she is overly talkative, impulsive, and insensitive to others. However, during the low periods, she withdraws from social contact, feels hopeless and helpless, and has trouble concentrating. She expresses a desire to be liked, but people see her as an "emotional roller coaster" and avoid her. She is very talkative throughout the session and changes the topic frequently. You raise your hand periodically to summarize what she is telling you. Early on during the session, the client says, "Please help me. I know something is wrong, but I don't know what to do. Can you fix me?" You discuss the scope of your practice and explore options for treatment with her. You explain that one of your responsibilities as a therapist is to provide a safe space where she can express her thoughts and feelings without fear of judgement or criticism. You explain that through understanding and integrating different aspects of herself, she has the potential to develop healthier relationships both in and outside of work. You emphasize the importance of building self-awareness and developing effective coping skills as part of her journey towards healing. Ultimately, you focus on empowering the client by providing support, guidance, and skills that will enable her to make positive changes in herself so she can function more effectively in life moving forward. You discuss the importance of the client taking an active role in her treatment process and explore methods she can use to become more mindful of her thoughts, feelings, and behavior. You suggest that this will help her gain better insight into the sources of her distress, which will enable her to take more control over how she copes with difficult situations in the future. The client appears relieved that there is something constructive she can do. You end the session by scheduling another appointment for next week and encourage the client to focus on self-care in between sessions. You also reassure her that you will be there as a supportive resource throughout the therapeutic journey ahead. The client leaves feeling empowered and energized to take the first steps towards change.

The client's mother was diagnosed with Bipolar I Disorder. The client's mother passed away ten years ago in a car accident. The client reported constant criticism from her father when she was growing up. When the client's mother was not depressed, she acted as a buffer between the client and her father. The client reports getting married immediately after graduating high school to an abusive man who was similar to her father in many ways. The couple divorced two years ago after the client wound up in the emergency room after reporting that she "slipped on the last step of the staircase and fell into a door jam." She got full custody of their son and went to live with her father until he passed away a year ago from suicide. He was chronically ill with cancer. The client is currently a science teacher. For the past three years, every school she has worked at has declined to renew her contract. The client's father left his house and all of his financial assets to her, so she does not have to make a mortgage payment. She has savings, but she is burning through it quickly. Previous Counseling: The client sought grief counseling at the time of her mother's death. She felt the therapist was "not spiritual enough" to deal with the client's beliefs. The client knew she needed help, and her pastor recommended a group. She attended four group sessions before leaving the group due to interpersonal conflicts with some of the group members. She tells you that she is not interested in participating in any group therapy.

The client asks you if you can "fix" her. What is the best response to this statement?

Acknowledge her comment, then redirect her concern

Explain the benefits of psychotherapy

Explain your role as a therapist

Convey that it may take some time, but you will work on fixing her

(A): Acknowledge her comment, then redirect her concern (B): Explain the benefits of psychotherapy (C): Explain your role as a therapist (D): Convey that it may take some time, but you will work on fixing her

Explain your role as a therapist

C

Therapists, or psychotherapists, are licensed mental health professionals who specialize in helping clients develop better cognitive and emotional skills, reduce symptoms of mental illness, and cope with various challenges to improve their lives. Therefore, the correct answer is (A)

professional practice and ethics

Initial Intake: Age: 16 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Biracial Relationship Status: Single Counseling Setting: High School Social Worker Type of Counseling: Individual

Autumn came to intake session, during her lunch period. She appeared younger than her stated age because she was so underweight. The counselor greeted Autumn and told her that she was welcome to eat during their session if she wanted to. Autumn looked down and responded, “It’s okay- I don’t like to eat in front of anyone- I can just eat later.” Erin seemed tired during the interview but was cooperative and friendly.

History: Autumn is a junior in high school. Her parents divorced about a month ago. Recently, the teacher noticed a change in Autumn’s mood. Autumn’s teacher also noticed that she was taking her lunch and eating it outside by herself. Oftentimes, she didn’t seem to eat much of it at all. When asked about it, Autumn seemed embarrassed and stated that she was fine.

Later in the day, the counselor realized what had occurred in his office and went to find Autumn in class. The counselor explained that the other school counselor had left some of her files on her desk of graduated students college essays. The counselor stated that regardless of this, all files should have been put away and she made a serious mistake. Autumn considers this for a few moments and agreed to return. The counselor demonstrated?

Non-judgement

Genuineness

Congruence

Positive regard

(A): Non-judgement (B): Genuineness (C): Congruence (D): Positive regard

Genuineness

B

In this situation, the counselor is displaying the attribute of genuineness as she is speaking honestly and apologizing for her mistake without being defensive or pretentious. Congruence is when a counselor gives feedback on the client's progress in a genuine manner. Positive regard describes when a counselor can focus on the positive and demonstrated the belief that everyone can make positive changes in their lives. Non-judgement is the acceptance of the client and their actions. Therefore, the correct answer is (B)

intake, assessment, and diagnosis

Client Age: 42 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Divorced Counseling Setting: Agency Type of Counseling: Individual and Group Presenting Problem: Social Anxiety Diagnosis: Social Anxiety Disorder (Social Phobia), Provisional 300.23 (F 40.10)

Mental Status: The client is meticulously dressed and well groomed. She is cooperative and periodically exhibits a nervous smile. The client is fidgety and frequently repositions herself when seated. Her mood is anxious, and she becomes tearful when discussing feeling “stupid” during job interviews. She exhibits cohesive thinking, and her insight and judgment are intact. The client is oriented to person, place, situation, and time. Her affect is reserved. She denies suicidal and homicidal ideation as well as audio/visual hallucinations.

You are a certified mental health counselor working in a community mental health center. Your client is a 42-year-old white female who presents today with symptoms of social anxiety disorder. The client reports debilitating anxiety when interacting with others, particularly when meeting unfamiliar people or going somewhere for the first time. She states that she cannot sleep and has a poor appetite on the days leading up to social events. When encountering anxiety-provoking situations, she says that her hands shake, she sweats excessively, and her voice trembles. The client is recently divorced and, after more than 15 years of being out of the workforce, she is seeking employment. She explains that job interviews have been “humiliating” because of what she perceives as an “inherent lack of knowledge and a substantially impaired skill set.”

History of Condition: The client first noticed symptoms of social anxiety when her family moved north during the summer of her 8th-grade school year. When she began high school, she received unwanted attention for being the “new girl.” She explains that she was often teased because of her Southern accent and was labeled “country” and “ignorant.” Before meeting her husband, the client remembers drinking before going on a date stating, “It just helped settle my nerves.” Her social anxiety lessened after becoming a stay-at-home mom to her two now-teenage children. However, she noticed a sharp increase in social anxiety after her divorce, particularly when attempting to reenter the job force and trying to find new social circles. She denies current drug use and states that she is a social drinker. Family History: The client’s parents both live out of town and run a business together. The client’s father has been treated for alcohol use disorder and is now in recovery. Her mother takes medication for anxiety and depression. The client has two teenage girls. Both girls have had a difficult time with the divorce. Her youngest child is seeing a therapist for depression. The client’s ex-husband is a prominent attorney in their town. This is the client’s first experience with counseling, and she asks many questions when filling out the intake paperwork

To accurately diagnose social anxiety disorder, individuals must experience marked fear or anxiety in social situations and which of the following?

Fear of acting in ways that other people will scrutinize

Fear of social situations because of perceived appearance-related flaws

Fear of not being able to escape certain situations in the presence of profound anxiety

Fear of being incapacitated by an unforeseen panic attack in public

(A): Fear of acting in ways that other people will scrutinize (B): Fear of social situations because of perceived appearance-related flaws (C): Fear of not being able to escape certain situations in the presence of profound anxiety (D): Fear of being incapacitated by an unforeseen panic attack in public

Fear of acting in ways that other people will scrutinize

A

According to the DSM-5-TR, social anxiety disorder is characterized by a marked and persistent fear of social situations or occasions in which the individual may be called upon to perform. Typically, the individual fears criticism and evaluation by others. This aspect of social anxiety disorder differentiates it from other anxiety disorders. Fear of being incapacitated by an unforeseen panic attack in public is a manifestation of panic disorder. The fear or avoidance of social situations because of perceived appearance-related flaws characterizes body dysmorphic disorder. Individuals with agoraphobia fear not being able to escape certain conditions in the presence of profound anxiety. Therefore, the correct answer is (C)

counseling skills and interventions

Name: Roger Clinical Issues: Physical/emotional issues related to trauma Diagnostic Category: Neurocognitive Disorders Provisional Diagnosis: F02.81 Major Neurocognitive Disorder Due to Traumatic Brain Injury, with Behavioral Disturbance Age: 36 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: White Marital Status: Married Modality: Individual Therapy Location of Therapy : Outpatient clinic

The client presents as tired. He reports a mild headache at the intake appointment, which he says is likely due to coming in from the bright day outside. Memory is slightly impaired. Mood is depressed, though he says this is impermanent, and his mood changes within a day, though the depressed mood is more prevalent and longer-lasting.

First session The client returned home from Afghanistan last month after separating from the Navy after 12 years of service. He states he is tired of trying to get an appointment at the VA Hospital, so he Googled locations that treat brain injuries, and your office was on the results page. He called to arrange a consultation with you. You have been practicing as a licensed mental health therapist at the outpatient clinic for over a decade, and you have worked with many clients diagnosed with traumatic brain injury. The client complains about difficulty sleeping, bad headaches, and feeling like he is on a roller coaster - feeling happy one minute and then down in the dumps the next. He states that the happy times don't last long, and he is "down in the dumps" most of the time. When asked why he left the Navy, he replies: "Toward the end of my last deployment, I just got sick and tired of everything and couldn't deal with it anymore. I couldn't sleep, was jumpy all the time, and didn't even want to go outside during the day." Now, I'm finally back home, but things only seem worse. My wife keeps nagging me to get a job, my kids look at me like I'm a monster, and nobody understands how I feel. I want to lay in bed all day and drink a couple of beers. I think something isn't right, and I can't take it anymore." Near the end of the session, the client asked what he could expect if a medical professional recommended medication management to treat NCD. The client discloses experiencing a highly distressing and psychologically damaging event during his military service in Afghanistan. While on patrol with his unit, their convoy was ambushed, and a fellow soldier directly next to the client was seized by insurgents. The client painfully witnessed his peer and friend being brutally beheaded, describing the horrific sight and sounds as permanently seared into his memory. Helplessly observing the brutal murder firsthand left him stunned and overwhelmed with grief and terror at the moment. The grotesque violence and knowing that could have just as quickly been his fate continues haunting him years later. The constant stress of combat and imminent danger already had the client in a perpetual state of hypervigilance and anxiety during his deployment. He shares that coming to terms with the abrupt, unfair loss of life was a daily reality there. While transporting supplies between bases in a standard jeep convoy, his vehicle triggered an IED explosion or was directly hit by artillery fire. The client was violently jolted and knocked completely unconscious as the blast disabled their jeep. He remained in and out of consciousness for over 24 distressing hours, being evacuated while critically injured to a military hospital. Once stabilized, he was thoroughly examined and diagnosed with a traumatic brain injury concussion along with other shrapnel wounds. Fourth session You and the client decided to meet for weekly sessions based on his current needs. You have established a trusting relationship with him, and he feels more comfortable knowing that you have experience in working with military populations. You provided psychoeducation regarding the effects of traumatic brain injuries and what he can expect from the counseling process. You were able to instill hope that he could recover emotionally following his injury and learn new skills along with coping mechanisms. He presents for today's session in a depressed mood which he states began the previous night. He reports that his family appears to now better understand what he is going through and they are getting along better. He is still drinking three beers at night to help him fall asleep, and his headaches have decreased in intensity due to finally getting a medication consult from the VA. However, he is still sensitive to light. He shares that he is ready to look for work but is concerned about finding a job and performing due to his ongoing symptoms.

The client drinks three beers every night before bed to help him fall asleep. He started this pattern a few years ago after struggling with insomnia and finding it challenging to relax his mind. Though effective at first in inducing drowsiness, he has built up a growing tolerance and now needs to drink three beers minimum to feel any sedative effects. He discloses that he knows consuming alcohol regularly can be unhealthy, but he feels dependent on having those beers to wind down from the stresses of his day and quiet his anxious thoughts enough to get adequate rest. During his time serving in the military, the client reported smoking cannabis on occasion when it was available. However, he did not enjoy the experience or feel compelled to use it. He mainly partook when offered by peers to be social. Since his discharge five years ago, he states he has not had any cannabis. The client currently smokes approximately one pack of cigarettes per week, a habit he picked up during his military service as a way to cope with boredom and nerves. He expresses some interest in trying to cut back for health reasons but also shares smoking provides a sense of relief and routine.

The client expresses concern about his daughter's difficulties at school and inquires about the possibility of you becoming her therapist. Which of the following responses would be most appropriate to the client's request?

Explain the potential for a conflict of interest and offer to provide a referral for his daughter.

Clarify that offering therapy to adolescents falls outside the scope of your clinical practice.

Consent to become the therapist for his daughter and elucidate that she will receive exceptional care.

Explain that you cannot work with both of them in your practice as it would be a violation of ethical principles.

(A): Explain the potential for a conflict of interest and offer to provide a referral for his daughter. (B): Clarify that offering therapy to adolescents falls outside the scope of your clinical practice. (C): Consent to become the therapist for his daughter and elucidate that she will receive exceptional care. (D): Explain that you cannot work with both of them in your practice as it would be a violation of ethical principles.

Explain the potential for a conflict of interest and offer to provide a referral for his daughter.

A

This response acknowledges the potential conflicts of interest and suggests that it would be best for the client's daughter to receive treatment from another counselor. Therefore, the correct answer is (C)

counseling skills and interventions

Initial Intake: Age: 22 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: African American Relationship Status: In a long-term relationship Counseling Setting: Adult inpatient psychiatric Type of Counseling: Individual

Mark was unable to complete a mental status exam as he was not speaking coherently and was displaying violent behavior towards hospital staff. The ER nurse interviewed Mark’s girlfriend, Erin.

Mark came into ER after his girlfriend Erin called 911 when Mark attacked someone on the bus. History: Erin told the ER nurse that Mark has been displaying increasingly irrational behaviors. Erin shared that Mark recently took a trip to Africa. Since then, Mark told Erin that he was hearing the voice of God, telling him that it was his responsibility to rid the world of evil. At first Erin noticed Mark staying up late at night, writing all his thoughts in a journal. When Erin read the journal, the content was incoherent. Erin also shared that Mark was recently put on probation at work for going into the women’s restroom. Mark told his boss that God told him to keep an eye on one of his coworkers.

The severity of Mark's symptoms can be assessed by administering all of the following, except?

Calgary Depression Scale for Schizophrenia

Brief Psychiatric Rating Scale (BPRS)

The scale of assessment for Positive symptoms (SAPS)

The scale for the assessment of Negative symptoms (SANS)

(A): Calgary Depression Scale for Schizophrenia (B): Brief Psychiatric Rating Scale (BPRS) (C): The scale of assessment for Positive symptoms (SAPS) (D): The scale for the assessment of Negative symptoms (SANS)

Calgary Depression Scale for Schizophrenia

A

The Calgary depression scale for schizophrenia should not be used as Mark did not mention any symptoms of depression. The SANS measures 25 negative symptoms of schizophrenia including lack of facial expressions, social inattentiveness, lack of interests and relationships. SAPS checks for 34 positive symptoms including hallucinations and delusions. The SANS and SAPS can be administered together. The BPRS is the most common test that psychiatrists use when they want to check how severe someone's symptoms of schizophrenia are. Therefore, the correct answer is (D)

intake, assessment, and diagnosis

Client Age: 22 Sex: Male Gender: Male Sexuality: Homosexual Ethnicity: Latino American Relationship Status: Single Counseling Setting: Community Mental Health Center Type of Counseling: Individual Presenting Problem: Depression Diagnosis: Major Depressive Disorder, Moderate

Mental Status Exam: The client is pleasant and dressed in age-appropriate attire. He is tearful when discussing his family and states this has been difficult for him. The client has had no previous suicide attempts. He is observed biting his nails. He describes feeling sad daily and states he sleeps during the day because he cannot sleep at night. He is slightly underweight but denied any difficulties with appetite. The client’s speech is coherent and clear. He denies suicidal ideation but often questions his worth and purpose. Fam

You are providing counseling services at a Community Mental Health Center. A 22-year-old Latino male, accompanied by his aunt, presents with symptoms of depression. The aunt is concerned about the client’s social isolation, feelings of hopelessness, and excessive daytime sleeping. Four months ago, the client’s parents kicked him out of their home after discovering a suggestive social media post of him with another male. He is close with his aunt and uncle, who have allowed him to stay in their basement. The client’s father refuses to speak to him and has told him he is “less than a man” and an embarrassment to the family. The client’s symptoms worsened last month when he was laid off from his job as a server.

The client reports fewer symptoms of hopelessness and depression. He discloses that he has been seeing a guy he met at his previous job. He is happy with this new relationship but says he’s still “fighting against” feelings of guilt and shame surrounding his sexual orientation and his parents continued rejection of him. The client says he has attended Metropolitan Community Church (MCC) with his boyfriend and was surprised to hear their messages of acceptance and inclusion. He has stopped going to bars and nightclubs since dating and reports less substance and alcohol misuse. The client states it has been quite some time since he felt like he had no purpose in life

You have selected acceptance and commitment therapy (ACT) and mindfulness to best address which of the following?

Shame and guilt

Sexual desire

Social isolation

Negative self-talk

(A): Shame and guilt (B): Sexual desire (C): Social isolation (D): Negative self-talk

Shame and guilt

A

Acceptance and commitment therapy and mindfulness are evidence-based mental health interventions for various mental health disorders, including depression. The premise of ACT is that moving individuals toward acknowledging and accepting (rather than fighting) their thoughts and feelings in the present moment influence behavioral changes. The fact that the client is fighting against feelings of guilt and shame makes ACT and mindfulness an effective means for helping the client learn to gradually accept these feelings, as well as the thoughts that accompany them. Although some consider ACT a form of cognitive-behavioral therapy (CBT), ACT seeks to accept (rather than change) thoughts and feelings, whereas CBT aims to change thoughts so one’s feelings can change. Sexual desire is a physiological concept rather than a thought or feeling. When appropriate, behavioral therapy best addresses sexual desire. Social isolation is a behavior. There are thoughts and feelings underlying social isolation, but social isolation as a behavior is better addressed through behavioral modification or other behavioral therapy techniques. Therefore, the correct answer is (C)

counseling skills and interventions

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.

How would you use dialectical behavior therapy to validate the client's positive experiences in this relationship and help her manage any potential risks?

Acknowledge her feelings and encourage the client to continue her current treatment plan and discuss her new relationship during her next session.

Acknowledge her feelings, and challenge the client's perception of her new relationship, focusing on the potential negative consequences of her impulsive actions.

Acknowledge her feelings and encourage her to take the relationship slowly while continuing to get to know her partner.

Acknowledge her feelings and encourage her to recognize and act on the positive effects of the relationship.

(A): Acknowledge her feelings and encourage the client to continue her current treatment plan and discuss her new relationship during her next session. (B): Acknowledge her feelings, and challenge the client's perception of her new relationship, focusing on the potential negative consequences of her impulsive actions. (C): Acknowledge her feelings and encourage her to take the relationship slowly while continuing to get to know her partner. (D): Acknowledge her feelings and encourage her to recognize and act on the positive effects of the relationship.

Acknowledge her feelings and encourage her to take the relationship slowly while continuing to get to know her partner.

C

Validation is an important part of creating a supportive and safe therapeutic environment. By validating her positive experiences in this relationship, it can help to reinforce and build the client's feelings of self worth and trust in herself. Additionally, by encouraging her to take things slowly while continuing to get to know her partner better, it allows her to make informed decisions and reduces any potential risks. Therefore, the correct answer is (A)

counseling skills and interventions

Name: Jack and Diane Clinical Issues: Marital/partner communication problems Diagnostic Category: V-codes Provisional Diagnosis: Z63.0 Relationship Distress with Spouse Age: 35 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: White Marital Status: Married Modality: Couples Therapy Location of Therapy : Community-based mental health facility

The clients are a couple in their mid-30s. The husband is tall and healthy. The wife is petite and well-groomed. As they enter, you make note that though they came in the same vehicle, they enter with no contact between them. They sit far away from one another and do not look at each other but maintain excellent eye contact with you. The husband's movements seem to be more agitated; the wife appears subdued. He speaks quickly and loudly and often fidgets in his chair, rarely sitting still; in contrast, her speech is low and soft, and she remains still and moves very little. They both seem guarded. They both identify their son's diagnosis of Autism Spectrum as being a significant strssor.

First session Your clients are in their mid-30s and present to the community agency where you are employed as both a licensed mental health therapist and a marriage and family therapist. You begin by introducing yourself and telling the couple about your professional experience and explain the types of therapies that you provide for couples. When asked why the couple made an appointment to meet with you, the husband takes the lead and tells you that he and his wife have been "serious problems" with their relationship for a few years. The husband shares that his wife does not trust him since his alcohol use "got out of control." Although he has been able to maintain sobriety for two years, he says that his wife is "paranoid" that he is using again and insists on knowing where he is "every minute of the day." He further reports that his wife is "too dependent" on him, and he feels "suffocated." He says, "I just can't keep doing this" and puts his head in his hands. You thank him for sharing his perspective of the problem and encourage the wife to share her thoughts about what is going on with their relationship. She tells you, "Truthfully? I'm scared to death that he's going to start drinking again and leave me alone with our children. I don't know what I would do if I lost him." She wipes a tear away from her face. After taking a deep breath, she says that when she tries to approach him to talk about how she feels, "he just gets mad and leaves the room." Using open-ended questions, you ask about each person's expectations for the counseling process and inquire about past experiences in therapy that may inform the current situation. Both partners look at each other, then back at you and share that they would like to re-establish trust and respect in their marriage. This is their first time seeking counseling. You also invite them to share the story of how they first met each other, memories of their relationship prior to getting married, and how they felt when they became parents. The husband shares that they first met when they were teenagers and have been together ever since. He talks about how their relationship was full of passion, respect, and trust. Even during the difficult times, they felt like nothing could tear them apart. He also shares that when their son was diagnosed with Autism Spectrum Disorder, they felt like the world had come to a standstill, but they were determined to get him the best care possible. He pauses. The husband and wife look at each other before the wife speaks. She explains that after their son's diagnosis, her husband began to drink more heavily as a way of dealing with his own stress and anxiety. He denied it for a long time, but eventually admitted he needed help and sought treatment. Although she was relieved that he got help, she is still struggling to trust him again. Fourth session Today, the couple arrives for their afternoon appointment ten minutes late. The wife appears to have been crying. Her husband smells like mouthwash, and his movements are slightly slower than normal. You ask if he has been drinking today. He states that he has not had any alcohol today, but his wife says, "That's not true!" and proceeds to tell you that she "caught" him holding a bottle of liquor in their garage this morning. The husband replies, "I didn't do anything wrong. This is just another example of you looking for problems where there are none. Why can't you believe me when I tell you that I'm not drinking?" She replies, "I really want to believe you, but you make it really hard to do that." He shakes his head and throws his hands up in the air in frustration. You ask the husband to step out of the room for a few minutes. He agrees and says, "Fine. You know where to find me." The wife shares that she feels like her husband is not taking the process seriously, and she questions whether or not counseling will work for them. You thank her for expressing her thoughts and explain that it is very common for couples to have doubts about therapy, especially when there has been a history of substance abuse. You discuss the potential treatment barriers and emphasize that it is important to have insight into these problems in order to create positive outcomes. The wife appears to understand and is reassured by your words. You invite the husband back into the room and ask him to share his thoughts about the counseling process. He takes a deep breath and says that he still wants to make their marriage work, but he is afraid of failing. He admits that he does not know how to "make things right" and this makes him feel helpless. You explain to him that counseling can help them gain insight into their communication patterns, learn new ways to interact with each other, and develop healthier coping strategies. You also discuss a plan for handling escalations in future sessions. You explain to the couple that it is important to have a plan in place whenever they are feeling overwhelmed or angry. Next, you discuss conflict resolution skills, emphasizing the importance of communicating their feelings and needs in an honest, respectful, and non-judgmental way. You also stress the importance of each partner taking responsibility for their own actions. You encourage them to practice these strategies outside of the session in order to improve their communication and relationship. After the session, you discover that the community-based mental health facility where you work will be closing in six months due to a lack of funding. You view this as a potential barrier that will inhibit mental health treatment access for many clients as this is the only mental health treatment facility in the city.

The husband used to have severe issues with alcohol. He went to rehab three years ago and has maintained sobriety for two years. He continues to attend weekly meetings. As a result of his alcohol misuse, he has some medical issues with his liver, but they are not currently life-threatening as long as he continues to abstain from alcohol. The husband has worked hard to rebuild his relationships with his family and friends. He is actively trying to repair the damage that was done due to his alcohol misuse. He has been attending AA meetings and is focusing on rebuilding trust and communication. He has also been making an effort to be more present in his family life and to be a better husband and father.

What is a common reason that couples therapy fails?

Couples' communication styles are overtly ambiguous.

The couple lacks the willingness to deal with uncomfortable feelings.

The couple lacks the ability to see their relationship and themselves objectively.

The couple does not seek therapy until problems are severe.

(A): Couples' communication styles are overtly ambiguous. (B): The couple lacks the willingness to deal with uncomfortable feelings. (C): The couple lacks the ability to see their relationship and themselves objectively. (D): The couple does not seek therapy until problems are severe.

The couple does not seek therapy until problems are severe.

D

Most couples do not go to therapy until their problems have escalated out of control, which often results in unsuccessful therapy. Therefore, the correct answer is (C)

counseling skills and interventions

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.

Before wrapping up your latest session, you suggest John attend a support group. Which of the following is not the best recommendation?

Celebrate Recovery

Emotions Anonymous

A support group for single professionals

A men's divorce support group

(A): Celebrate Recovery (B): Emotions Anonymous (C): A support group for single professionals (D): A men's divorce support group

A support group for single professionals

C

This type of group may trigger John and not adequately address his emotional needs. Emotions Anonymous is a 12-step group for dealing with any emotional condition. Celebrate Recovery is also a 12-step group that is faith-based and addresses recovery from any addiction, "hurt, habit or hang-up" and can be a new outlet for John to reconnect with his spirituality as he mentioned in the family history portion of the initial assessment. Men's groups that focus on divorce are also great for divorcees to find common ground among others in the same situations and can learn from one another in a safe environment. Therefore, the correct answer is (A)

counseling skills and interventions

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

What information gathered during the assessment is most indicative of the diagnosis of Major Depressive Disorder (MDD)?

Poor coping skills

Strained relationships with family members

Emotional dysregulation

Excessive guilt

(A): Poor coping skills (B): Strained relationships with family members (C): Emotional dysregulation (D): Excessive guilt

Excessive guilt

D

The client’s diagnosis of Major Depressive disorder is confirmed by the following symptoms: excessive guilt, suicidal ideation, insomnia, persistent negative mood, and feelings of worthlessness. These symptoms must be present during a sustained period of 2 weeks, which is also confirmed in the assessment. Strained relationships with family members have exacerbated the client’s symptoms, but this is not a clinical manifestation of MDD. Poor copings skills are not required for a diagnosis of MDD. Emotional dysregulation occurs when individuals exhibit emotional reactions that are disproportional to the actual event. Individuals diagnosed with Disruptive Mood Dysregulation Disorder, PTSD, and bipolar disorder, rather than MDD, tend to exhibit emotional dysregulation. Therefore, the correct answer is (B)

intake, assessment, and diagnosis

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.

Which instrument would allow you to screen for Autism Spectrum Disorder?

Behavior Assessment Rating Scale

The Behaviors and Experiences Inventory

The Behavior Assessment System for Children

The Behavioral Summarized Evaluation

(A): Behavior Assessment Rating Scale (B): The Behaviors and Experiences Inventory (C): The Behavior Assessment System for Children (D): The Behavioral Summarized Evaluation

The Behavioral Summarized Evaluation

D

The Behavioral Summarized Evaluation assesses Autism Spectrum Disorders. Therefore, the correct answer is (A)

intake, assessment, and diagnosis

Initial Intake: Age: 23 Gender: Male Sexual Orientation: Heterosexual Ethnicity: Indian American Relationship Status: Single Counseling Setting: Private Practice Type of Counseling: Individual

Shawn is slightly unkempt, completes ADLs and has good hygiene. His motor movements are fidgety and tense, and he consistently averts eye contact and darts his eyes around the room and towards the door every time he hears a noise. He appears to be sensitive to the lighting in the office as evidenced by fluttering his eyes when he looks up and commenting about its brightness. Shawn speaks within normal rate and tone, however low volume and often mutters under his breath. He denies any past suicidal or homicidal ideation and denies hallucinations or delusions. Shawn also denies history of trauma.

Diagnosis: Social Phobia, unspecified (F40.10) provisional; Alcohol Use Disorder, moderate, in early remission (F10.10) Rishaan is a 23-year-old heterosexual male of Indian origin and is being referred to you by his parents for counseling in your private practice who are telling you Rishaan is at risk for going back to his drinking because he “never does anything constructive.” Further complaints by Rishaan’s parents include that “all he does is play video games and watch TV,” that he “never has money to pay for anything himself” and is constantly asking them for money. His parents offer to self-pay for Rishaan’s sessions. You welcome Rishaan to your office for an initial assessment. He respectfully requests that you refer to him as “Shawn,” which he explains is his preferred American name, and remarks that his parents really want him to talk to you. Shawn has agreed to counseling because he shares with you that he “has stuff to talk about anyway” and does not think he can go to his parents.

Substance Use History: Shawn entered treatment and rehabilitation five months ago after his ex-girlfriend’s family had an intervention with him about his abusive drinking and he has now been through all phases of treatment for Alcohol use disorder. Shawn tells you he is ashamed that his parents found out about his problem through his ex-girlfriend’s parents, because he had been lying to his own parents about his well-being for several years since he left home for college at 18 years old. Shawn is currently five months sober but is not engaged in any post-treatment recovery program nor has he continued counseling. Family History: Shawn has two older siblings, both of whom he shares are “successful and have families.” Shawn says, “my parents always want me to be like them and are constantly comparing me to them, it’s so annoying.” Shawn’s father is a dermatologist, and his mother is his father’s secretary in their medical practice. Both parents observe traditional Indian cultural practices in their social lives and with respect to Hinduism. Work History: Shawn has attempted part-time work following his graduation from his alcohol rehabilitation treatment program but was unable to make his shifts on time and was let go from his job. He tried another job selling products by cold calls but could not keep up with the volume required to make a viable salary. When asked what Shawn would like to do for a living, he says “I’d like to be a gaming coder or tester, something like that.”

Before hanging up with Shawn's parents over the phone, you tell them "I am very impressed with and grateful for your concern and involvement in Shawn's healing process, so I thank you for understanding that he is not yet ready to share in front of his parents!" This statement best demonstrates which attribute?

Sensitivity to multicultural issues

Respect for client confidentiality

Awareness of self and impact on clients

Empathic attunement

(A): Sensitivity to multicultural issues (B): Respect for client confidentiality (C): Awareness of self and impact on clients (D): Empathic attunement

Respect for client confidentiality

B

Using this positive voice in an uncomfortable situation where the payors of your client's counseling are demanding to sit in your sessions is an effective method for demonstrating respect of your client's HIPAA rights. Answers a, c and d do not seem to apply here; although it is important to be aware of self and the impact you have on your clients, as well as to be sensitive to multicultural issues. Empathic attunement is when one tries to respond to the client's perception of reality at that moment as opposed to their objective view of reality. Therefore, the correct answer is (B)

counseling skills and interventions

Initial Intake: Age: 20 Gender: Male Sexual Orientation: Homosexual Race/Ethnicity: African American Relationship Status: Single Counseling Setting: University counseling center Type of Counseling: Individual

Jonathan presents as anxious with congruent affect, evidenced by client self-report and therapist observations of fidgeting, inability to sit still, tearfulness and shallow breathing with rapid paced speech. Jonathan occasionally closes his eyes and takes deep breaths when he begins to cry in attempt to slow himself down and prevent what he calls “another emotional breakdown.” He has prior inpatient treatment history of a one-week episode where he was involuntarily committed at 17 for making comments about planning to kill himself in response to his stress over finishing high school. He admits to passive suicidal ideations in the past few weeks while studying for exams but does not report considering a method or plan. He reports that he has been losing sleep because of long study hours and feeling too keyed up to calm down. You assess him as having distress primarily associated with anxiety, which at times of abundant stress turns to episodes of depression and hopelessness.

Diagnosis: Anxiety disorder, unspecified (F41.9), Major depressive disorder, single episode, unspecified (F32.9) You are a brand-new counseling intern in the counseling resource center of a local university. Jonathan is a junior in college and comes to speak with you, as you are his newly assigned college university counselor. Jonathan is concerned about finals that he feels unprepared for, stating he is “overwhelmed” and “under too much pressure” from his family to “allow himself” to fail. He is making disparaging, negative remarks about himself and his abilities, often repeating himself and talking in circles using emotional reasoning. He asks you for help in getting his teachers to modify his deadlines so that he can have enough time to accomplish all his assignments, mentioning that his last counselor did that and called it “playing the mental health card”. There are no previous records on file for this student, but when you ask him who he met with he just changes the subject and continues to express his worry that he will “never amount to anything or graduate” if he fails these exams.

Education and Work History: Jonathan has a high academic performance history, despite short periods of time where he experiences heightened stress. Jonathan has never gotten in trouble in school or had any infractions at part-time jobs later as a teenager. He has worked after-school jobs at the grocery store, bowling alley, and local town library. Jonathan had only one work-related incident where he broke down emotionally when feeling overwhelmed and left work in the middle of his shift, but his supervisor was supportive and helped him. Current Living Situation: Jonathan lives in the college dormitory with a peer and is supported by his mother. His mother is a single mom who works full-time in Jonathan’s hometown, which is almost a full day’s worth of driving from where Jonathan goes to college. Jonathan mentions that his friends call him “Jonny.” He adds that the food available to him is not very healthy and he has poor eating habits due to prioritizing studying and his involvement in extra-curricular activities.

Jonny responds to your outburst by grabbing his books and leaving your office. You feel powerfully obliged to run after him and apologize. What should you do?

Go apologize right away and ask him if he will come back in and talk.

Let the dust settle and process with Jonny at your next scheduled session.

Call his cell phone and leave a voicemail asking about his safety.

Allow him to go and then consult with a supervisor prior to engaging Jonny again.

(A): Go apologize right away and ask him if he will come back in and talk. (B): Let the dust settle and process with Jonny at your next scheduled session. (C): Call his cell phone and leave a voicemail asking about his safety. (D): Allow him to go and then consult with a supervisor prior to engaging Jonny again.

Allow him to go and then consult with a supervisor prior to engaging Jonny again.

D

There has clearly been a breach of trust in your therapeutic relationship with Jonny considering his reaction. Seeking supervision to process your thoughts and feelings, choices you have made, and underlying reasons why is the best choice for you. It is vital that counselors have good self-awareness and understand how to avoid future instances of countertransference, unhealthy projection, or lack of restraint. This session with your supervisor will protect you professionally as well as Jonny clinically in the future if you are afforded another opportunity to counsel with him again. Antagonizing him while he is upset before you have had the chance to process the event is not advised, as in answers a) or b); however, neglecting to address this issue with supervision could result in repeat mistakes. Therefore, the correct answer is (C)

counseling skills and interventions

Client Age: 42 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Divorced Counseling Setting: Agency Type of Counseling: Individual and Group Presenting Problem: Social Anxiety Diagnosis: Social Anxiety Disorder (Social Phobia), Provisional 300.23 (F 40.10)

Mental Status: The client is meticulously dressed and well groomed. She is cooperative and periodically exhibits a nervous smile. The client is fidgety and frequently repositions herself when seated. Her mood is anxious, and she becomes tearful when discussing feeling “stupid” during job interviews. She exhibits cohesive thinking, and her insight and judgment are intact. The client is oriented to person, place, situation, and time. Her affect is reserved. She denies suicidal and homicidal ideation as well as audio/visual hallucinations.

You are a certified mental health counselor working in a community mental health center. Your client is a 42-year-old white female who presents today with symptoms of social anxiety disorder. The client reports debilitating anxiety when interacting with others, particularly when meeting unfamiliar people or going somewhere for the first time. She states that she cannot sleep and has a poor appetite on the days leading up to social events. When encountering anxiety-provoking situations, she says that her hands shake, she sweats excessively, and her voice trembles. The client is recently divorced and, after more than 15 years of being out of the workforce, she is seeking employment. She explains that job interviews have been “humiliating” because of what she perceives as an “inherent lack of knowledge and a substantially impaired skill set.”

The client participates in her last group therapy session today. You and the client review her treatment plan goals, and she reports an overall decrease in anxiety and says that she possesses a greater awareness of social anxiety disorder and the associated interventions. She has recently completed a job interview after previously scheduling and canceling two interviews. She plans to stay in touch with two group members. The client is ready to begin termination but is anxious about ending counseling. You and the client review the psychoeducation material reviewed in the group, including factors associated with social anxiety disorder and learned coping strategies. The client recognizes gains that she has made but fears that she will fail after discharge

The client recognizes gains that she has made but fears that she will fail after discharge. Which humanistic technique would you use to best respond to this discrepancy?

Self-disclosure

Constructive confrontation

Amplified reflection

Attending

(A): Self-disclosure (B): Constructive confrontation (C): Amplified reflection (D): Attending

Constructive confrontation

B

Constructive confrontation is designed to help clients achieve congruence. Humanistic therapists assert that incongruence occurs when there is a discrepancy between clients’ perceptions of themselves and reality. Therapists use constructive confrontation when pointing out discrepancies among the client’s actions, thoughts, behaviors, perception, or nonverbal communication. An amplified reflection is a motivational interviewing skill used to state the client’s original statement and overemphasize their point or intent. Amplified reflections address ambivalence to change, making this answer option incorrect. Attending is the counselor’s way of showing interest. The interest can be verbal (eg, by saying “Go on”) or nonverbal (eg, nodding the head). Finally, counselors use self-disclosure when sharing personal aspects of themselves. Self-disclosure can take many forms and may be appropriate or inappropriate, depending on the counselor’s motives (ie, self-serving versus benefiting the client and/or the therapeutic relationship). Therefore, the correct answer is (A)

counseling skills and interventions

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.

The client is in the early stages of recovery and has stated that he and his wife want to work on their relationship. How would you incorporate this request into his treatment plan?

Consider allowing the rehab center to manage couples therapy work at a more clinically appropriate time.

Provide the client the option to start couples therapy now or after his recovery.

Recognize that couples' therapy is appropriate only after his rehabilitation is complete, and advise against it.

Let the client determine what he wants to do about the couples therapy.

(A): Consider allowing the rehab center to manage couples therapy work at a more clinically appropriate time. (B): Provide the client the option to start couples therapy now or after his recovery. (C): Recognize that couples' therapy is appropriate only after his rehabilitation is complete, and advise against it. (D): Let the client determine what he wants to do about the couples therapy.

Consider allowing the rehab center to manage couples therapy work at a more clinically appropriate time.

A

As early on as the client's recovery appears to be, beginning couples therapy at this time would be premature. Allowing him to get stabilized initially will be essential before diving into the relationship dynamics. It would be okay to convey that you could be available for follow-up couples work if necessary when the time comes after he returns from rehab. Therefore, the correct answer is (B)

treatment planning

Name: Denise Clinical Issues: Hopelessness/depression Diagnostic Category: Bipolar and Related Disorders Provisional Diagnosis: F34.0 Cyclothymic Disorder Age: 38 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: White Marital Status: Divorced Modality: Individual Therapy Location of Therapy : Private Practice

The client is appropriately dressed. She is overweight and appears edgy and irritable. Her attention wanders during the intake. She is articulate and able to communicate her thoughts logically. The client focuses on the negative aspects of life and appears to have a strong external locus of control. Insight is low, and judgment is strong.

First session You are a mental health counselor in a community agency. The client is a 38-year-old White female teacher referred to you by her principal. The client is experiencing difficulty with her school colleagues. She wants to keep her job and is motivated to improve her social skills. Since she was a young adult, she has had tumultuous relationships with co-workers, friends, and family. She tells you she has periods of highs and lows. During the high periods, she is overly talkative, impulsive, and insensitive to others. However, during the low periods, she withdraws from social contact, feels hopeless and helpless, and has trouble concentrating. She expresses a desire to be liked, but people see her as an "emotional roller coaster" and avoid her. She is very talkative throughout the session and changes the topic frequently. You raise your hand periodically to summarize what she is telling you. Early on during the session, the client says, "Please help me. I know something is wrong, but I don't know what to do. Can you fix me?" You discuss the scope of your practice and explore options for treatment with her. You explain that one of your responsibilities as a therapist is to provide a safe space where she can express her thoughts and feelings without fear of judgement or criticism. You explain that through understanding and integrating different aspects of herself, she has the potential to develop healthier relationships both in and outside of work. You emphasize the importance of building self-awareness and developing effective coping skills as part of her journey towards healing. Ultimately, you focus on empowering the client by providing support, guidance, and skills that will enable her to make positive changes in herself so she can function more effectively in life moving forward. You discuss the importance of the client taking an active role in her treatment process and explore methods she can use to become more mindful of her thoughts, feelings, and behavior. You suggest that this will help her gain better insight into the sources of her distress, which will enable her to take more control over how she copes with difficult situations in the future. The client appears relieved that there is something constructive she can do. You end the session by scheduling another appointment for next week and encourage the client to focus on self-care in between sessions. You also reassure her that you will be there as a supportive resource throughout the therapeutic journey ahead. The client leaves feeling empowered and energized to take the first steps towards change.

The client's mother was diagnosed with Bipolar I Disorder. The client's mother passed away ten years ago in a car accident. The client reported constant criticism from her father when she was growing up. When the client's mother was not depressed, she acted as a buffer between the client and her father. The client reports getting married immediately after graduating high school to an abusive man who was similar to her father in many ways. The couple divorced two years ago after the client wound up in the emergency room after reporting that she "slipped on the last step of the staircase and fell into a door jam." She got full custody of their son and went to live with her father until he passed away a year ago from suicide. He was chronically ill with cancer. The client is currently a science teacher. For the past three years, every school she has worked at has declined to renew her contract. The client's father left his house and all of his financial assets to her, so she does not have to make a mortgage payment. She has savings, but she is burning through it quickly. Previous Counseling: The client sought grief counseling at the time of her mother's death. She felt the therapist was "not spiritual enough" to deal with the client's beliefs. The client knew she needed help, and her pastor recommended a group. She attended four group sessions before leaving the group due to interpersonal conflicts with some of the group members. She tells you that she is not interested in participating in any group therapy.

Which of the following assessments would you use during the diagnostic interview to identify mental health domains which may have a significant impact on the client?

Personal History Questionnaire

Cultural Formulation Interview

Family genogram

Level 1 Cross-Cutting Symptom Measure

(A): Personal History Questionnaire (B): Cultural Formulation Interview (C): Family genogram (D): Level 1 Cross-Cutting Symptom Measure

Level 1 Cross-Cutting Symptom Measure

D

The DSM-5-TR Level 1 Cross-Cutting Symptom Measure is a self- or informant-rated measure which assesses mental health domains important across psychiatric diagnoses. It is intended to help clinicians identify additional areas of inquiry which may significantly impact the individual's treatment and prognosis. Therefore, the correct answer is (C)

intake, assessment, and diagnosis

Name: Rick Clinical Issues: Referred for emotional and behavior issues Diagnostic Category: No Diagnosis Provisional Diagnosis: No Diagnosis Age: 18 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: Korean Marital Status: Single Modality: Group Therapy Location of Therapy : Community Center

The client is slouched over in his seat and appears withdrawn with a flat affect. He keeps his head down. The client plays with his shirt sleeve, twisting the material and pulling at it. You cannot see any cuts on his arms as reported by the mother. He does not appear to be angry at this time, which was also a symptom reported by his mother. He responds to your questions with one-word answers. He seems uninterested. The client denies any suicidal and homicidal ideation. The client mumbles, "I don't want to talk about anything here."

First session You work as both an individual and group therapist at a community center that primarily sees adolescents with emotional and behavioral issues. Rick is a senior in high school and lives with his mother and two sisters. Rick does not want to participate in individual or group therapy, but his mother insists that he get help. During the intake, you work to establish rapport with Rick. You also gather information to determine if he is an appropriate candidate for one of the groups you are preparing to start, along with a co-facilitator. You suspect he may have trouble trusting females as he expresses anger when talking about his mother, sister, and ex-girlfriend. Since his father left, Rick says that his mother has been "in his business" all the time, and he does not feel like he has any real privacy. You remain patient with Rick, listening to his story and validating his feelings. You empathize with him, letting him know it is understandable to feel frustrated about not having much privacy. You explain that you are here to help him, not to control him and that you are interested in learning more about him. You explain to Rick that you are planning to start a group therapy session with a co-facilitator and that you would like to see if it would be a good fit for him. You explain that the group will provide an opportunity for him to talk about his experiences in a safe space with others who may have gone through similar situations In addition, you share that it could be an excellent way for him to practice expressing himself and developing trust in others. You also explain to Rick that individual therapy sessions could be beneficial in addition to group therapy. You discuss the possibility of one-on-one sessions that would give him a chance to talk more deeply about his experiences in a safe, private setting You emphasize that this could be an excellent way for him to explore his feelings and learn how to cope with them in a healthy way.

The client is a first-generation American whose parents immigrated from Korea. He has an old sister who, based on Korean culture, is his superior whom he must obey and be subservient to. His parents have high expectations for him and are very controlling, expecting him to study every night and attend tutoring sessions on the weekend. They have arranged for him to marry a daughter of a prestigious family in Korea after he completes medical school eight years from now, with the intention that he and his wife will live with them and provide financial support. However, this plan has drastically changed. Seven months ago, the client's father moved out after his mother had an affair. The client became sullen, angry, and withdrawn after this event. Four months ago, while doing laundry, the client's mother saw dried blood on his shirt sleeve. She also noticed that he was wearing long-sleeved shirts all the time. She waited until he was getting dressed, walked in on him, and found he had cuts up and down his arms. The client does not speak to his father much since his parents separated. The client expresses a lot of anger toward the women in his life, specifically his mother, sister and ex-girlfriend. The client is a senior in high school. His grades have been suffering lately, and he is currently failing his math and science classes. Personal/Social Relationships: The client had been concealing his romantic relationship with a girl from his Saturday tutoring class, but following his father's abrupt departure from the family, he chose to discontinue the relationship and cease attending the class. He has since refrained from any communication or contact with her. His mother's affair has caused him to feel overwhelmed with anger, leading him to develop a dislike of all women.

Which tool would provide the most comprehensive information about Rick before entering group therapy?

Thematic Apperception Test (TAT)

Millon Clinical Multiaxial Inventory (MCMI-III)

Columbia Impairment Scale (CIS)

BRIGANCE Comprehensive Inventory of Basic Skills (CIBS)

(A): Thematic Apperception Test (TAT) (B): Millon Clinical Multiaxial Inventory (MCMI-III) (C): Columbia Impairment Scale (CIS) (D): BRIGANCE Comprehensive Inventory of Basic Skills (CIBS)

Millon Clinical Multiaxial Inventory (MCMI-III)

B

The MCMI-III is used to assess for a wide range of psychological disorders and syndromes, including anxiety, depression, bipolar disorder, substance abuse, and other personality disorders. The MCMI-III consists of 175 multiple-choice questions that assess a person's current psychological functioning. Therefore, the correct answer is (B)

intake, assessment, and diagnosis

Client Age: 9 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Private practice clinic Type of Counseling: Individual counseling with family involvement Presenting Problem: Behavioral problems and social skills issues Diagnosis: Autism spectrum disorder, without accompanying intellectual impairment (F84.0)

Mental Status Exam: The client is oriented to person, place, situation, and time. The client appears clean and is wearing season-appropriate clothing; however, his parents report that he often wears the same outfit for several days because he gets frustrated with having to change his clothes and showering. The client was minimally involved in the intake session and was instead focused on reading a video game walk-through

You are a private practice, licensed counselor. The client is 9 years old and comes to the first session with his parents. The client has been previously diagnosed with autism via use of the Autism Diagnostic Observation Schedule-Second Edition by a psychologist, and you receive supporting documentation for this diagnosis. The client demonstrates difficulties with normal back-and-forth communication with peers, difficulty maintaining eye contact during the session, and difficulty with imaginative play with peers as reported by his parents. The client and his parents also report what they call “OCD behavior”—for example, he often lines up toys and insists that they “have to be this way”—and that he has trouble with changes in schedule, often becoming aggressive toward the parents if changes occur. The parents report that he is very rigid and that certain activities and play have to be done a certain way or he becomes upset, which affect the home, social, and school settings. The client’s intellectual quotient is above average for his age per the supportive testing provided. The parents report that the client’s difficulty with changing plans or daily changes causes him to become angry and confrontational.

This session is occurring in the client’s home in order to observe behaviors in his natural environment. The client’s parents and 8-year-old brother are present. You are observing during this session in order to gather information and then to provide psychoeducation at the end of the session to the parents. The client and his brother are sitting on the floor playing with a building toy, which the client’s parents report is often a toy that causes him frustration because he plays very specifically with it and his brother does not want to play how he does. After about 5 minutes, the client becomes visibly frustrated as he is telling his brother to put a brick in a certain place because it is the same color and his brother says he is not going to and goes to build on his own. The client continues to build and asks for the piece repeatedly over a few minutes. The client then picks up what he is building and throws it against the wall and leaves the room. After the session, you provide psychoeducation to the parents regarding how to support their son in coping with the denial of his request to have a block put in a certain place

After the session, you provide psychoeducation to the parents regarding how to support their son in coping with the denial of his request to have a block put in a certain place. Based on your short-term goals with the client, all of the following would be appropriate interventions, EXCEPT:

Instruct the client on anger management skills.

Remind the client that others have different ways of playing and that is okay.

Prompt the client to practice deep breathing.

Support the client to learn progressive muscle relaxation.

(A): Instruct the client on anger management skills. (B): Remind the client that others have different ways of playing and that is okay. (C): Prompt the client to practice deep breathing. (D): Support the client to learn progressive muscle relaxation.

Remind the client that others have different ways of playing and that is okay.

B

You compiled goals for the client in the first session based on the ASD diagnosis, and you identified the client’s difficulty with imaginative play. This barrier would make understanding that others have different ways of playing difficult for the client and would be the least appropriate intervention in this scenario. Deep breathing, progressive muscle relaxation, and other anger management skills would be helpful for this client because, although he will have trouble identifying with others, he can learn to manage his own strong emotions. Therefore, the correct answer is (C)

treatment planning

Name: Alexei Clinical Issues: Substance use/addiction issues Diagnostic Category: Substance Use Disorders Provisional Diagnosis: F10.99 Unspecified Alcohol-Related Disorder Age: 32 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: German American Marital Status: Married Modality: Individual Therapy Location of Therapy : Private Practice

A 32-year-old German American man confidently enters your office. He is tall and slender and appears older than his stated age. His physical appearance is unkempt. The client's voice quality is strong and loud, and his command of English is minimal. His posture and gait are limp and unsteady at times. He is slurring his words and appears to be actively intoxicated. He portrays no accountability or responsibility for his actions with substance use. He denies any current thoughts of homicidal ideations. The client lacks insight, and his thought processes are not logical or appropriate.

First session You are a psychoanalytic therapist in private practice and often work with clients who struggle with substance use issues. You believe these issues often arise from unresolved conflicts and the inability to manage emotions. Today, you are seeing a 32-year-old German American male named Alexei, who was referred to you due to occupational disciplinary issues related to alcohol use. Alexei was referred to you by his employer, where he works in a manufacturing plant in the Midwest. His supervisor noticed marked changes in his behavior and productivity over the last few months and was concerned that Alexei might be dealing with a drinking problem. The supervisor initially suggested an employee assistance program, but Alexei was adamantly opposed to talking to anyone involved in his workplace. You introduce yourself and explain to Alexei that this is a safe and confidential space where he can discuss whatever is troubling him. You reassure him that the only people who will know about the details of this session are himself and yourself. Then, you begin to ask open-ended questions to assess Alexei's current state of mind and identify his current challenges. You are particularly interested in understanding his thoughts and feelings about his substance use and the occupational problems it has created. You notice that Alexei seems excessively relaxed as you establish the confidentiality of the session. As you delve deeper into his thoughts and feelings, you ask him to describe his relationship with substances, particularly how they have affected his daily life and work performance. Alexei hesitantly opens up, admitting that his substance use has become a coping mechanism to deal with mounting stress and anxiety. You listen empathetically and validate his emotions while gently probing into the factors that have contributed to this pattern of behavior. Alexei tells you that his boss has never liked him and is trying to get him fired. He reports that he sees nothing wrong with having a few drinks in the morning and after lunch. He has been late to work "only a few times" because of a hangover. Alexei states that he needs help finding a new job. You ask Alexei if he can tell you more about his drinking habits. He says he usually starts drinking around 9 am and has been drinking more in the past few weeks. He also admits to drinking at work a couple of times. He looks at you suspiciously, wondering why you need to know this. You explain that it is important to understand his drinking habits and the context of his behavior to provide the best care. As the session continues, you observe that Alexei's cognitive functioning appears impaired, as he struggles to maintain focus and has difficulty recalling important details. He expresses frustration and anger when discussing his work situation but minimizes the impact of his alcohol consumption on his professional life. Alexei's denial of his alcohol-related problems and the escalating pattern of his drinking behavior indicate a potential substance use disorder. Furthermore, his physical symptoms, such as sweating and slurred speech, suggest that he may be experiencing acute effects of alcohol during the session. It becomes evident that addressing Alexei's alcohol use and its consequences is crucial to provide appropriate care and support for him in his current situation.

The client grew up in Germany and recently immigrated to America with his wife and mother. Both parents have a history of alcohol abuse and divorced when he was five. After his father left, his mother's enmeshment with her son intensified. She made him spend time with her rather than his school friends and used the threat of leaving him in an orphanage to control his behavior. Whenever he became upset or anxious, she would cuddle him and give him sips of whatever alcohol she consumed. The client was recently arrested for driving under the influence. The client's wife is contemplating separating because of her husband's continued drinking. He identifies a couple of bartenders as "friends" but cannot recall anyone he knows in an alcohol-free context. He has also been late or missed work due to hangovers and will likely lose his job. His co-workers have often complained that he smells of alcohol. Previous Counseling: The client has had suicidal thoughts thrice, all of which were recent. The initial occurrence was after a DUI incident, followed by a write-up at work, and the third after his wife proposed a separation. The client has shared that he has a specific plan in mind for ending his life, which involves either ingesting pills or cutting his wrists.

How would you proceed with the client as he presents for this therapy session in his current state?

Empathize with the client, and utilize the situation to attempt to establish rapport.

Be direct and reschedule the appointment.

Consider this session a 'non-event', since the client was too impaired for him to have been competent to give consent.

Explore with the client what was happening before the session that led to his coming to the session intoxicated.

(A): Empathize with the client, and utilize the situation to attempt to establish rapport. (B): Be direct and reschedule the appointment. (C): Consider this session a 'non-event', since the client was too impaired for him to have been competent to give consent. (D): Explore with the client what was happening before the session that led to his coming to the session intoxicated.

Be direct and reschedule the appointment.

B

It is critical to set limits with clients in general, especially in setting standards for managing substance use issues. Being under the influence while attending therapy is not clinically appropriate nor professionally acceptable. Therefore, the correct answer is (A)

counseling skills and interventions

Name: Carter Clinical Issues: Developmental processes/tasks/issues Diagnostic Category: Neurodevelopmental Disorders Provisional Diagnosis: F90.0 Attention-Deficit/Hyperactivity Disorder, Predominately Inattentive Presentation; F81.2 Specific Learning Disorder with Impairment in Mathematics Age: 11 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Not Assessed Ethnicity: White Marital Status: Not Applicable Modality: Individual Therapy Location of Therapy : School

The client is of average build. He is dressed in a neat and appropriate manner for school. He is reluctant to engage in the conversation but does not display any hostility or aggression. The client displays a flat affect with occasional brief moments of animation which appear to be fueled by fleeting interests. His mood appears to be somewhat dysphoric as he often responds with a shrug or a one-word answer. The client’s thought process is non-linear and circumstantial. He is able to answer questions in a straightforward manner once he understands the topic being discussed. The client’s speech is of normal rate and volume for his age but it does contain some articulation errors due to his speech disorder. His memory appears intact as he can recall details from previous conversations with ease.

First session You are a mental health therapist in a public school. The client, an 11-year-old male, and his parents arrive at your office for the intake appointment per a referral from the committee on special education. The parents express concerns with their son's ongoing lack of concentration, being easily distracted, requiring multiple prompts and redirection throughout his day, and not following multi-step processes. The mother states that he tends to "drift off and is fidgety." He has trouble sitting still and cannot focus on anything for more than a few minutes. According to the parents, this behavior is present at both school and at home. As you progress with the intake session, you ask the parents to describe their current goals and any treatment barriers they have experienced up to this point. They state that they would like their son to be more focused throughout the day and be better able to follow instructions. They also mention that so far their efforts in trying to help him have been unsuccessful and he is still struggling. After gathering more insight into the client's home life, school performance, and developmental history from the parents, you turn your attention to the client. He has been looking around the room and has not been actively engaged in the conversation. When asked directly about his feelings about school, he shrugs and says, "It's okay." You ask him if there is anything that makes it hard for him to stay focused in class, and after a few seconds of reflection he admits that it is sometimes difficult because "there are too many things happening at the same time." He states that he cannot keep up with all of the activity going on around him and it is distracting. You inquire further as to what else may be contributing to his difficulty maintaining attention in school and he admits that sometimes he gets frustrated when tasks are too challenging for him. While he is answering your questions, he is looking at the small tabletop clock sitting on the corner of your desk. Once you feel that you have an accurate understanding of the current presenting issues, you discuss next steps with the parents. You discuss meeting with the client for individual weekly sessions to help him develop effective coping skills, build self-esteem, and manage emotions associated with frustration, failure, and low self-worth. You also suggest collateral sessions with the parents to check in with them about their son's progress and discuss strategies they can use at home to help him. They agree to this arrangement and ask if there are any tools or techniques they can try between now and the next time they meet with you. You suggest they start by creating a daily routine that will provide a sense of predictability and help to reduce chaos, and having a set time for homework, meals, and bedtime. You also mention that stimulant medication is often prescribed for children with ADHD, which can help to improve focus and concentration. Lastly, you let the parents know there is some evidence that certain foods can trigger or worsen ADHD symptoms, such as sugary, processed, or artificial foods.

The client is currently a fifth grader participating in the general education curriculum. He has a disability classification with his school district as learning disabled. He receives consultant teacher services via classroom support aide for English Language Arts (ELA) and Math. In addition, he attends the resource room daily for added support. The client arrives to class prepared with necessary materials and homework assignments but requires prompts throughout his day to stay on track. He is conscientious about his grades and doing well academically but is easily distracted by environmental factors surrounding him. Three years ago, the client's triennial evaluation report indicated a classification of Speech Language Disorder. To date, staff suggests that the client's speech deficits manifesting as notably impaired speech do not seem to cause concern in social situations. Additional Characteristics: The client is a very pleasant, quiet, shy, reserved boy. He tends to lack confidence in his academic abilities, which seems to cause him stress. Small glimpses of the client's good sense of humor can often be seen in small group settings.

Based on your observations of the client in session, what might you do to build a therapeutic alliance with him?

Bring a two-person video game to play with the client.

Speak in a clear and authoritative voice to the child and request that he respond

Use therapeutic silence until the client responds

Ask the child if he would like to examine the clock on your desk

(A): Bring a two-person video game to play with the client. (B): Speak in a clear and authoritative voice to the child and request that he respond (C): Use therapeutic silence until the client responds (D): Ask the child if he would like to examine the clock on your desk

Ask the child if he would like to examine the clock on your desk

D

This may help the child gain trust and form a therapeutic alliance with you. Recall that while he was hiding behind his mother during the session, he appeared to be interested in the clock on your desk. Therefore, the correct answer is (D)

counseling skills and interventions

Client Age: 54 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Multiracial Relationship Status: Divorced Counseling Setting: Local Government Mental Health Agency Type of Counseling: Individual Presenting Problem: Opioid Use Diagnosis: Opioid Use Disorder, Severe (F11.20), Homelessness (Z59.0)

Mental Status Exam: The client has not maintained hygiene, as evidenced by him not smelling clean and wearing clothes that are visibly dirty. He appears to have bilateral tremors in his hands. The client is oriented to person, place, situation, and time. The client appears malnourished because he is very thin and f

You are a mental health counselor working at a local government mental health agency, specializing in substance use counseling. An individual came in today to become a client for mental health case management and was encouraged to meet with a counselor to begin receiving therapy. The 54-year-old male client is currently living in a tent in the woods behind a local grocery store and reports that he lost his job a year ago following a divorce from his wife of 26 years. The client stated that about 3 years ago he had a back injury and following surgery was prescribed oxycodone. The client continued that he had difficulty stopping his use of the medication when the prescription ran out and connected with a friend to get fentanyl. He reports that he spends a lot of time on a street corner asking for money to get fentanyl and that he cannot seem to go a day without it. The client feels that he cannot sleep or function without the use of fentanyl and that this has affected his housing, marriage, employment, and social life. He acknowledges that fentanyl has negatively affected his life and that he is not sure if he wants to stop using it because he knows it would be hard to deal with life without it.

Since the start of counseling and services with the local government mental health agency, the client has maintained sobriety from fentanyl and has been moved into stable housing via assistance from the agency. The client reports that the management of his anxiety has been better, but that he often feels lonely and unengaged. The client states that he is not sleeping well and thinks it is because he does not do much during the day. He continues to participate in Narcotics Anonymous daily in order to have interactions with other people. The client says that he tried to reach out to his children but they would not answer his phone call. You empathize with the client regarding his difficulty reaching out to his children. You and the client use this session in order to review progress and identify new goals

Which of the following would be a helpful career aptitude tool for a client with limited resources?

O*Net Interest Profiler

Motivational Appraisal Personal Potential

Criteria Cognitive Aptitude Test

Career Assessment Inventory

(A): O*Net Interest Profiler (B): Motivational Appraisal Personal Potential (C): Criteria Cognitive Aptitude Test (D): Career Assessment Inventory

O*Net Interest Profiler

A

The O*Net Interest Profiler is a free online tool that is used to determine what abilities can lead to careers that match an individual’s existing skills and abilities. The Motivational Appraisal Personal Potential, Career Assessment Inventory, and Criteria Cognitive Aptitude Test are all clinical counseling assessments that cost money. Although they would be helpful career assessments, they would not be accessible to the client with his current level of resources because he is currently financially reliant on the government. The O*Net Interest Profiler would give a good direction for the client to consider potential fields of work. Therefore, the correct answer is (A)

professional practice and ethics

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."

Given the client's physical condition, what should you do first?

Determine the client's blood alcohol content (BAC) for proper notation.

Establish boundaries regarding therapy and being intoxicated

Reschedule the session and address your concerns at that time

Refer the client to a residential program

(A): Determine the client's blood alcohol content (BAC) for proper notation. (B): Establish boundaries regarding therapy and being intoxicated (C): Reschedule the session and address your concerns at that time (D): Refer the client to a residential program

Establish boundaries regarding therapy and being intoxicated

B

Taking advantage of a difficult situation could facilitate possible changes needed in the client by implementing motivational interviewing techniques while at the same time being able to be firm with the client to reinforce what is minimally expected as part of the therapeutic experience would be helpful. Therefore, the correct answer is (B)

professional practice and ethics

Initial Intake: Age: 38 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Married Counseling Setting: VA Type of Counseling: Individual

Carl came to the intake session alone and angrily stated, “I really don’t know why they are making me come to therapy - it doesn’t help anyway.” Carl appeared edgy throughout the interview and responded to questions with minimal effort.

Carl is a 38-year-old Army Veteran who is attending counseling at the local VA. Carl was referred after he was arrested for a DUI last week. History: Carl has been on four deployments to the Middle East, he returned from the most recent tour 11 months ago, after he was injured during a military strike. Some of his team members were injured as well. Since his return, Carl and his civilian wife, Lori, have discussed separation because of their frequent arguing and Carl’s drinking. Carl began drinking when he was deployed and since then has used it as a coping mechanism to combat the frequent flashbacks and nightmares that he gets. Carl and Lori mostly argue about money since Carl has not been able to sustain employment as a construction worker because of his drinking problems. Carl has been arrested several times for assault and disorderly conduct. Carl recently assaulted his last counselor after he had made a comment about Carl not being able to sustain work. The counselor thanked Carl for his service and reviewed with him that he was referred as a part of his probation. He must attend individual therapy and an anger management group for veterans. The counselor then described to Carl the purpose of the meeting and what would be reviewed and discussed during their time together. This included the intake paperwork, including informed consent and several assessments.

Symptoms indicate the possibility of?

Post-Traumatic Stress Disorder and Major Depressive Disorder

Post-traumatic Stress Disorder and Dissociative Amnesia

Adjustment Disorder and Dissociative Amnesia

Post-Traumatic Stress Disorder and Traumatic Brain Injury

(A): Post-Traumatic Stress Disorder and Major Depressive Disorder (B): Post-traumatic Stress Disorder and Dissociative Amnesia (C): Adjustment Disorder and Dissociative Amnesia (D): Post-Traumatic Stress Disorder and Traumatic Brain Injury

Post-Traumatic Stress Disorder and Traumatic Brain Injury

D

Carl's symptoms -- avoidance, guilt, distressing dreams, reckless and self-destructive behaviors -- have caused significant distress and impairment, indicate Post Traumatic Stress Disorder. He lost consciousness for half a day after the blast and could not remember who he was for two days. According to his medical records, he suffered from disorientation and confusion for about 11 days. Since he has been home, Carl has suffered from light sensitivity and seizures. Other symptoms included irritability, aggression, and apathy. In adjustment disorder, the severity of the stressor does not meet Criteria A of PTSD. Dissociative amnesia may or may not include exposure to a traumatic event and does not include light sensitivity, physical injury to the brain. Major Depressive Disorder also does not have to include a traumatic event and may not include any PTSD Criterion B or C symptoms (intrusion symptoms and avoidance of stimuli). Therefore, the correct answer is (D)

counseling skills and interventions

Name: Denise Clinical Issues: Hopelessness/depression Diagnostic Category: Bipolar and Related Disorders Provisional Diagnosis: F34.0 Cyclothymic Disorder Age: 38 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: White Marital Status: Divorced Modality: Individual Therapy Location of Therapy : Private Practice

The client is appropriately dressed. She is overweight and appears edgy and irritable. Her attention wanders during the intake. She is articulate and able to communicate her thoughts logically. The client focuses on the negative aspects of life and appears to have a strong external locus of control. Insight is low, and judgment is strong.

First session You are a mental health counselor in a community agency. The client is a 38-year-old White female teacher referred to you by her principal. The client is experiencing difficulty with her school colleagues. She wants to keep her job and is motivated to improve her social skills. Since she was a young adult, she has had tumultuous relationships with co-workers, friends, and family. She tells you she has periods of highs and lows. During the high periods, she is overly talkative, impulsive, and insensitive to others. However, during the low periods, she withdraws from social contact, feels hopeless and helpless, and has trouble concentrating. She expresses a desire to be liked, but people see her as an "emotional roller coaster" and avoid her. She is very talkative throughout the session and changes the topic frequently. You raise your hand periodically to summarize what she is telling you. Early on during the session, the client says, "Please help me. I know something is wrong, but I don't know what to do. Can you fix me?" You discuss the scope of your practice and explore options for treatment with her. You explain that one of your responsibilities as a therapist is to provide a safe space where she can express her thoughts and feelings without fear of judgement or criticism. You explain that through understanding and integrating different aspects of herself, she has the potential to develop healthier relationships both in and outside of work. You emphasize the importance of building self-awareness and developing effective coping skills as part of her journey towards healing. Ultimately, you focus on empowering the client by providing support, guidance, and skills that will enable her to make positive changes in herself so she can function more effectively in life moving forward. You discuss the importance of the client taking an active role in her treatment process and explore methods she can use to become more mindful of her thoughts, feelings, and behavior. You suggest that this will help her gain better insight into the sources of her distress, which will enable her to take more control over how she copes with difficult situations in the future. The client appears relieved that there is something constructive she can do. You end the session by scheduling another appointment for next week and encourage the client to focus on self-care in between sessions. You also reassure her that you will be there as a supportive resource throughout the therapeutic journey ahead. The client leaves feeling empowered and energized to take the first steps towards change. Fourth session During the previous two sessions, you spent the majority of the time listening to the client describing her conflicted relationships. You asked her to start keeping a mood diary, and while you review it together today, you notice that entries involving her father always precipitate a depressive mood. While you try to bring her attention to this trigger, she says, "I bet my dad enjoys watching this from the grave," and laughs. She tells you that she never felt like her father really loved her, and she believes that he blamed her for her mother's death. You demonstrate empathy and unconditional positive regard in response to her feelings. You begin to explore the client's thoughts about her father's suicide. Her demeanor changes, and she begins to talk about finding his body and the pain he must have gone through. She has "an epiphany" as she describes how she feels and realizes that he must have suffered a lot. Following the client's disclosure, you take the time to normalize her feelings and process her experience. You acknowledge the immense amount of pain and suffering she has endured, both from her father's death, as well as his emotionally distant behavior during life. Through your therapeutic dialogue, you emphasize that it is natural for a person to feel overwhelmed and disconnected in such circumstances, and that these feelings are not a source of shame or weakness. You prompt her to think of new ways in which she can build healthier relationships with others, including developing more meaningful connections through open and honest communication. Finally, you ask her to brainstorm different activities and interests that she finds joy in doing so she can incorporate them into daily life as a way for her to find balance amidst the chaos. At the end of the session, the client mentions that she is going to be visiting a friend who lives on the other side of the country. They are planning to explore one of the national parks for a few days and spend the remainder of the time "just chilling" at her friend's house. She tells you that she is looking forward to spending some time in nature. The client does not want to miss her weekly appointment with you and asks if you can meet with her for a virtual session next week instead of your usual in-person counseling session. Sixth session The client has not been following through with her mood journal. She says that she "got bored and didn't feel like writing in it anymore." During this session, a month and a half into therapy, she relays an incident that happened with the friend she went to visit out-of-state. They argued due to political differences and are currently not talking to each other. The client now considers her friend "a drunk who doesn't know what she's talking about." You suggest that the client's anger and judgment may be a defense that she uses to avoid feeling rejected as she did with her father. You state, "It seems that in an attempt to avoid feeling hurt and rejected, you use anger and alcohol to push people away." The client responds with reflective silence and begins to tear up. You guide the client to examine her defensive behavior and understand why she relies on it when faced with difficult emotions. You emphasize that her feelings of hurt, rejection, and anger are valid, however, they can be managed in healthier ways. You suggest that part of processing these feelings is to recognize them and make attempts at reconnecting with her friend. Additionally, you recommend cultivating self-care practices. The client acknowledges the importance of looking after herself during this difficult time, understanding that if she is able to take care of herself first she will be in a better position to address her relationships. You remind the client that it is important to take steps to move forward, even if those steps are small. You highlight her willingness to talk through her emotions and gain insight into her reactions as an opportunity to grow in self-awareness. You explain that having knowledge of one’s own feelings helps them to make better decisions and boundaries, which can lead to healthier relationships with others and ultimately, more peace within oneself. With this understanding, you create a plan of action together for how she will move forward between now and your next session. You close the session by telling the client that she has made progress today by having gained insight into her feelings, and that will lead to exploration of how to respond to them more productively. You conclude by encouraging her to keep exploring new methods of self-care and to bring up any additional topics she wants to discuss in the next session.

The client's mother was diagnosed with Bipolar I Disorder. The client's mother passed away ten years ago in a car accident. The client reported constant criticism from her father when she was growing up. When the client's mother was not depressed, she acted as a buffer between the client and her father. The client reports getting married immediately after graduating high school to an abusive man who was similar to her father in many ways. The couple divorced two years ago after the client wound up in the emergency room after reporting that she "slipped on the last step of the staircase and fell into a door jam." She got full custody of their son and went to live with her father until he passed away a year ago from suicide. He was chronically ill with cancer. The client is currently a science teacher. For the past three years, every school she has worked at has declined to renew her contract. The client's father left his house and all of his financial assets to her, so she does not have to make a mortgage payment. She has savings, but she is burning through it quickly. Previous Counseling: The client sought grief counseling at the time of her mother's death. She felt the therapist was "not spiritual enough" to deal with the client's beliefs. The client knew she needed help, and her pastor recommended a group. She attended four group sessions before leaving the group due to interpersonal conflicts with some of the group members. She tells you that she is not interested in participating in any group therapy.

Which of the following is not a benefit of reviewing the client's progress in treatment?

It helps you determine whether treatment goals are being met.

It allows you to assess your therapy effectiveness.

It helps you to uncover the client's motivation for seeking therapy.

It enables you to reevaluate the client's needs.

(A): It helps you determine whether treatment goals are being met. (B): It allows you to assess your therapy effectiveness. (C): It helps you to uncover the client's motivation for seeking therapy. (D): It enables you to reevaluate the client's needs.

It helps you to uncover the client's motivation for seeking therapy.

C

Uncovering a client's motivation for seeking therapy happens at intake when she expresses her concerns. Assessing mental health is a process, not a one-time event. It is important, therefore, to monitor a person's mental health symptoms throughout treatment as they may change over time. Therefore, the correct answer is (B)

treatment planning

Initial Intake: Age: 43 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Married Counseling Setting: Private Practice Type of Counseling: Individual

The client presents appropriately dressed in a long-sleeved t-shirt and jeans and is well-groomed. Her weight appears appropriate to height and frame. Her movements and speech demonstrate no retardation and she is cooperative and engaged. The client reports her mood as anxious, however you note her to be relaxed in speech and appearance. She reports no recent suicidal ideations and demonstrates no evidence of hallucinations or delusions. The client reports that she is in good health and takes no medication except birth control. She reports she has difficulty falling asleep at night because she worries whether her husband finds her attractive. She states she also frequently worries about the children or situations that have happened during the day, but is often able to dismiss these after a few minutes.

You are a counselor in a private practice setting. During the intake session, you learn that your client has been married for 15 years and has four children and is currently struggling with her marital relationship. She states her husband does not want to attend counseling with her. Your client complains of occasional feelings of unhappiness, irritation, difficulty sleeping, as well as worrying. These have been present for the past 8 to 10 months, with the worry being almost daily. She states she feels alone in the marriage because her husband is an introvert and is often too tired after work to engage emotionally with her. She views the marriage as “good” and they engage in sex at least 5 times per week, where she is often the initiator. She reports that she repeatedly asks her husband and best friend to reassure her that she is still attractive. She tells you that her best friend is encouraging, but her husband tells her he is tired of her constant, daily questioning and says she must be in a midlife crisis. She confides that her husband frequently looks at pornography and sometimes they watch pornographic movies together prior to sex.

Family History: Approximately 6 years ago, the client’s family doctor prescribed a short course of Valium, while she and her husband were building their house. She also was diagnosed with postpartum depression after her first child was born. She reports she did not seek counseling at the time but her obstetrician prescribed antidepressants, which she took for 10 months with good results. Her doctor then prescribed the same antidepressants for 12 months as a preventative against postpartum depression prior to each of her subsequent births.

Which of the following assessments would be used next in most effectively understanding your client's substance use?

Drug and Alcohol Screening (DAS)

Drug Abuse Screening Test (DAST)

Alcohol Use Disorders Identification Test (AUDIT)

Minnesota Multiphasic Personality Inventory - 2 (MMPI-2)

(A): Drug and Alcohol Screening (DAS) (B): Drug Abuse Screening Test (DAST) (C): Alcohol Use Disorders Identification Test (AUDIT) (D): Minnesota Multiphasic Personality Inventory - 2 (MMPI-2)

Drug Abuse Screening Test (DAST)

B

The DAST is a drug screening tool that does not include screening for alcohol. Since the MAST has already screened for alcohol use, it is important to screen for other substances. The MMPI-2 is a good instrument but is broader and more expensive than needed for substance screening. The AUDIT assesses alcohol use so duplicates what was learned from the MAST and does not screen for other substances. The DAS is not an actual instrument. Therefore, the correct answer is (B)

intake, assessment, and diagnosis

Name: Christopher Clinical Issues: Gender identity development Diagnostic Category: Gender Dysphoria Provisional Diagnosis: F64.1 Gender Dysphoria Age: 13 Sex Assigned at Birth: Male Gender and Sexual Orientation: Female, Heterosexual Ethnicity: White Marital Status: Not Applicable Modality: Individual Therapy Location of Therapy : Agency

The client presents partially as her preferred gender, wearing makeup and a semi-long hairstyle while still dressed as a cis-gendered 12-year-old male. She reports feelings of depression, anger, and suicidal ideation without a plan or intent. She appears to be her stated age, cooperates during the interview, and maintains good eye contact. Speech is normal in rate, rhythm, and volume. The client's thought processes are organized and goal-directed. She is alert and oriented X2. Insight and judgment are fair.

First session A 13-year-old, assigned male at birth and identifying as female, arrives at your office in a community mental health agency where you work as a mental health therapist. Both parents are also in attendance. The client introduces herself to you as "Christine," although the father says "Christopher" each time he addresses the client. The client appears dejected every time her father misgenders her. The client reports experiencing bullying from male peers at school and is upset that her father refuses to use her chosen pronouns or name. The client reports that she has been feeling increasingly isolated and hopeless since the start of her transition, leading to intrusive thoughts associated with suicide. She is trying to express her identity through clothing, hair, and physical appearance but is not allowed to do so by her father. The client's mother is somewhat more supportive of her transition and has been trying to advocate for her, but her father remains resistant to the idea and is often dismissive of her identity. The client expressed feeling frustrated and helpless in her home life, as she cannot express her gender identity freely. Once the client's parents leave the room, the client reports wanting to kill herself and tells you about the depression that sets in after being bullied at school or after arguments with her father. She also holds a lot of anger toward her father. Toward the end of the initial counseling session, the client says she feels safe with you and "would like to work together."

The client loves her mother but has difficulties with her father. Her parents differ in child-rearing styles, with her father not understanding her gender presentation. The client has a deep-seated fear of rejection and abandonment from her father due to the ongoing disagreement about her gender presentation. She feels that her father does not accept her for who she is and does not understand her identity. The client has a strong need for her father's acceptance and approval, but her attempts to bridge the gap between them have been unsuccessful. This has caused her to feel disconnected from her father and has created a sense of sadness and insecurity in the client. Neither parent supports her gender choice, but her father actively confronts her daily. Her mother is confused and worried for the client but does not know what to do. The client is high achieving academically and is well-liked by her teachers. In addition, she is involved in a community dance team where she excels. However, she is socially isolated and has few friends. Her classmates mock her for "acting like a girl" and bully her on the playground. She is especially bullied by her male peers in school. The client is displaying symptoms of social anxiety as she has difficulty developing and maintaining relationships with her peers. Her fear of being ridiculed and judged by her peers has resulted in her feeling socially isolated, impacting her self-esteem. The client is anxious in social situations, particularly when interacting with her male peers, and displays a pattern of avoiding social interactions due to the fear of being judged.

"Gender identity" refers to which of the following?

An individual's identification as male, female, or another category

A broad spectrum of individuals who transiently or persistently identify as a gender different than their natal gender.

The identification of a person based on physical characteristics, such as reproductive organs.

The initial assignment as male or female which occurs at birth

(A): An individual's identification as male, female, or another category (B): A broad spectrum of individuals who transiently or persistently identify as a gender different than their natal gender. (C): The identification of a person based on physical characteristics, such as reproductive organs. (D): The initial assignment as male or female which occurs at birth

An individual's identification as male, female, or another category

A

Gender is used to denote the publicly lived roles of an individual, and identity is how an individual lives. Therefore, the correct answer is (B)

intake, assessment, and diagnosis

Name: Andie Clinical Issues: Gender identity development Diagnostic Category: Gender Dysphoria Provisional Diagnosis: F64.1 Gender Dysphoria Age: 12 Sex Assigned at Birth: Male Gender and Sexual Orientation: Female, Questioning Ethnicity: Caucasian Marital Status: Never married Modality: Individual Therapy Location of Therapy : Agency

The client is quiet in the session and clingy toward his mother. His head is bent down, and he refuses to make any eye contact. When an attempt is made to engage the client in conversation, he responds with short statements such as, "I guess; I don't know."

First session You are a mental health therapist for an agency where two parents and their 12-year-old child named Andie present for their first counseling session with you. The father looks irritated, and the mother seems depressed. She expresses that they have been concerned for some years regarding their son's confusion around his gender identity. They feel he is too young to make any decisions that will affect the rest of his life. The father speaks up, saying, "He's getting all of this nonsense from school just to fit in, and it needs to stop." The mother expresses that Andie always likes to dress up in his sister's clothes and believes that one day he will become a girl. Andie appears anxious and is afraid of the father as evidenced by his withdrawing behavior. You discuss your role as therapist and tell Andie that your job is to help make people feel better. You also provide the parents with your initial observations and make a recommendation to start therapy with weekly appointments. Fourth session During the previous two sessions, you focused on making Andie feel comfortable and spent time learning about his interests and strengths. You have established a strong rapport with Andie. Today, he is quiet and reluctant to speak. He tells you about his family and that his dad is always yelling at him and calling him a "sissy boy." He states feeling sad and does not understand why his dad will not love him if he wants to be a girl. he also states that he feels confused by his mother's seeming acceptance of him, but her unwillingness or inability to "be on his side" when his father berates him. He admits that he feels happy when he thinks of himself as a girl, especially when he is free to express himself in that way. He said all the boys at school are mean to him and call him names. he feels most at ease with the girls in his class, or with the teacher. You work with the client on how to express his thoughts and feelings appropriately to his father rather than holding them in.

The client has three sisters, loves his mother but has difficulties with his father. His parents differ in child-rearing styles. The client is the youngest and has three older sisters and wishes that he had been born a girl. He acts out at home when he feels that he's not being "understood" by his parents. He withdraws from his family quite often (will not leave his room) and usually has "screaming matches" with his father in regard to his expression of his preferred gender. The client does not get along with the other boys in his class but relates to the girls without difficulty. Before the initial interview with the client, his father related that he is concerned about his son's long-standing "girlish ways." His son avoids contact sports but has expressed an interest in ballet.

What intervention would be most beneficial for the parents and client to address his behavior disturbances?

The family is not your client; interventions should be client-specific.

A behavior contract between the clients and the parents paired with the client keeping a self-reflective journal

Setting up a positive reward system in the house for good behavior (an "if/then" chart for the client) and giving a list to the parents of appropriate restrictions for the client

Discuss various disciplinary actions and their effectiveness with the parents, and instruct them on what is going to work best for the client

(A): The family is not your client; interventions should be client-specific. (B): A behavior contract between the clients and the parents paired with the client keeping a self-reflective journal (C): Setting up a positive reward system in the house for good behavior (an "if/then" chart for the client) and giving a list to the parents of appropriate restrictions for the client (D): Discuss various disciplinary actions and their effectiveness with the parents, and instruct them on what is going to work best for the client

A behavior contract between the clients and the parents paired with the client keeping a self-reflective journal

B

These options are age-appropriate and are helpful to the client to engage in self-awareness and self-confidence building. Therefore, the correct answer is (D)

counseling skills and interventions

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.

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.

As the group leader, which technique would you use to build cohesion and encourage group members to work together?

Modeling

Linking

Active listening

Unconditional Positive Regard

(A): Modeling (B): Linking (C): Active listening (D): Unconditional Positive Regard

Linking

B

In group therapy, linking involves the group leader compares members to each other based on what is shared. Finding commonalities encourages group members to work together. Therefore, the correct answer is (C)

counseling skills and interventions

Client Age: 74 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Divorced Counseling Setting: Community Mental Health Center Type of Counseling: Individual and psychoeducation Presenting Problem: Memory impairment Diagnosis: Mild Neurocognitive Disorder (MND) Unspecified with Behavioral Disturbance (apathy and mood disturbance) 799.59 (R41.9)

Mental Status Exam: The client is appropriately dressed and cooperative. She is tearful at times and often glances over at her daughter when she is unsure of how to respond to a question. The client denies suicidal and homicidal ideations. She is oriented to the day, month, and year, but she could not recall the date or place. She recalls the city with prompting. The client’s sleep is fair, and her appetite is normal. She reports feeling sad most of the day, every day. To date, medical procedures used to determine the etiology of the client’s cognitive impairment have been inconclusive. She awaits an appointment for a positron emission tomography (PET) scan, which can help determine the presence of brain activity associated with Alzheimer’s disease. She denies substance use and says that she is a social drinker. Her judgment and awareness are fair, and she denies audio and visual hallucinations. Fam

You work in a mental health center and are conducting an initial assessment on a 74-year-old Caucasian female. The client and her daughter arrive today with a copy of the client’s recent neuropsychological evaluation. The evaluation shows cognitive functioning deficits, and the neuropsychologist has diagnosed the client with mild neurocognitive disorder (MND). The client and her daughter fear that her memory issues could worsen and impact her independence. The daughter has seen a gradual decline in the client’s memory, which coincides with episodes of depression. The client expresses embarrassment over her memory issues and states, “remembering the simplest things—like doctor’s appointments or paying bills—has started to become more and more difficult.” She states that she no longer participates in things she once enjoyed, including her book club, church services, and fitness classes.

ily and Work History: The client divorced nearly 15 years ago and has lived alone since. She has two adult children and four grandchildren who all live locally. She reports experiencing depression and anxiety for most of her life. She currently takes an antidepressant and has done so for years. The client’s career was in school administration, where she dedicated nearly 30 years of service until retiring 6 years ago. She reports that retirement caused an increase in depression as she grieved the “loss of (her) identity.” The client’s mother had Alzheimer’s disease, which placed significant stress on the client and her father. The client’s sister is diagnosed with bipolar disorder, and there are no other noted mental health or substance use disorders in the family. You are a certified counselor who has never worked with a client diagnosed with MND. You assess your ability to work with this client based on your credentials and the information provided thus far

You are a certified counselor who has never worked with a client diagnosed with MND. You assess your ability to work with this client based on your credentials and the information provided thus far. At this point in treatment, which of the following statements is the most accurate?

You should refer the client to a counselor who specializes in neurocognitive disorders.

You should proceed with the client only after obtaining specialized training and consultation.

You should proceed with the client unless the results of the PET scan indicate advanced memory impairment.

Your background and training should permit you to work with this client.

(A): You should refer the client to a counselor who specializes in neurocognitive disorders. (B): You should proceed with the client only after obtaining specialized training and consultation. (C): You should proceed with the client unless the results of the PET scan indicate advanced memory impairment. (D): Your background and training should permit you to work with this client.

Your background and training should permit you to work with this client.

D

Despite never working with a client diagnosed with MND, your education, experience, and training should provide you with the skills to treat the client’s anxiety, apathy, and depression. You can provide supportive counseling, address psychosocial symptoms, teach coping skills, and suggest compensatory memory strategies. Section C2 of the ACA Code of Ethics states that counselors must only practice within the boundaries of their competence, which is specifically based on “their education, training, supervised experience, state and national professional credentials, and appropriate professional experience” Counselors have an ongoing ethical responsibility to remain current and increase their knowledge base by obtaining continuing education, but this would not be a prerequisite for working with this client. The counselor would not necessarily need the PET scan results to proceed because a mental status exam and neuropsychological report both show MND and associated behavioral disturbances. Therefore, the correct answer is (A)

professional practice and ethics

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 is resistant to actively participating in therapy and primarily seeks validation that she has attended sessions, how would you navigate this situation to foster genuine engagement while addressing her underlying motives and considering ethical implications?

Indicate that you will only report to her probation officer if she actively engages in the therapeutic process.

Begin the session, ignoring her resistance, and proceed with the therapy

Explain that treatment goals are predefined for mandated clients and are determined by the court jurisdiction

Engage in motivational interviewing

(A): Indicate that you will only report to her probation officer if she actively engages in the therapeutic process. (B): Begin the session, ignoring her resistance, and proceed with the therapy (C): Explain that treatment goals are predefined for mandated clients and are determined by the court jurisdiction (D): Engage in motivational interviewing

Engage in motivational interviewing

D

Motivational interviewing would be a good way to engage the client in the therapeutic process given that she has been court-ordered and is not happy about being in therapy. Therefore, the correct answer is (B)

counseling skills and interventions

Name: Logan Clinical Issues: Bullying Diagnostic Category: V-codes Provisional Diagnosis: Z60.4 Social Exclusion or Rejection Age: 11 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Not Assessed Ethnicity: Asian American Marital Status: Not Applicable Modality: Individual Therapy Location of Therapy : School

The client is wearing clean clothes appropriate to his age. Initially hesitant and withdrawn, he becomes more relaxed and responsive as the interview progresses. He is soft-spoken but articulates clearly. Mood is depressed, anxious, and irritable. Affect is euthymic with occasional sadness. Thought process is logical, goal-directed, and organized. No evidence of any cognitive deficits. Good insight into the impact the bullying has on his emotional well-being and his ability to make appropriate decisions is intact. No suicidal ideation was reported.

First session You are a school counselor seeing an 11-year-old male named Logan. He presents to your office with his mother. His mother reports that her son has been struggling in school and has been the target of bullying. She tells you that he recently started at a new school after their neighborhood was re-zoned. The bullying started a few weeks ago when he was sitting alone in class during lunch. A group of boys, whom Logan had never seen before, sat beside him and began teasing him about his clothes, shoes, and hair. When Logan tried to ignore them, they started calling him names. He went home that day feeling embarrassed and alone. Since then, the boys have devised new ways to make fun of Logan. They sneak behind him in the hallways, push him around when the teacher is not looking, and push him into the bathroom. Logan has been refusing to go to school, saying he has stomach aches. His mother says, "He used to love school. He even loved doing his homework. How many parents are lucky enough to have a child who likes doing homework?" When questioned, Logan says that he now hates school and wants to be home-schooled. He says he is being bullied throughout the day, and it does not stop until he leaves the bus. Logan's mother has been worried about him and wants to know how to stop the bullying. At first, she thought it was just "kids being kids" when they tease each other, but she is now concerned that it has gone too far. She also asks if you can help him to make friends in his new school. During today's session, you notice that Logan appears anxious and withdrawn. As you gently probe further, Logan shares that he feels overwhelmed by the constant bullying, which has begun to affect his self-esteem. You observe that he appears hesitant to discuss the specifics of his experiences, suggesting that he may fear rejection by you or be embarrassed by what was done to him. This indicates that the situation has caused significant distress and has started to erode his resilience. As you explore Logan's support network, he hesitantly reveals that he has been unable to make new friends since starting at the new school. The fear of being targeted by bullies has made it challenging for him to approach other students or engage in extracurricular activities. Consequently, Logan feels increasingly isolated and struggles to see a way out of his current situation. This lack of social connection exacerbates his feelings of loneliness and despair. As part of his treatment plan, you include developing and maintaining positive relationships with peers to work on his tendency to isolate himself. Toward the end of the session, Logan's mother inquires about possible strategies to address the bullying. You acknowledge her concerns and emphasize the importance of a collaborative approach involving the school, family, and community. You suggest initiating communication with Logan's teachers and school administrators to create a safe and supportive environment for him. Additionally, you recommend Logan's mother encourage her son's interests and hobbies outside of school to help him build self-esteem and form new friendships. Meanwhile, you will continue to work with Logan on developing coping strategies and strengthening his emotional resilience in future sessions. Third session As the session progresses with Logan, you notice that he seems more withdrawn and less willing to participate in your planned activities. You ask him how he has been feeling since your last session and if he has progressed in handling the bullying situation at school. Logan hesitates to answer your questions, looking down and avoiding eye contact. He eventually shares that the bullying has intensified and he feels overwhelmed and helpless. He tells you about the boys in his gym class calling him names and making fun of him. He says they continue to bully him, says he "won't ever go to school again," and "hopes those boys die." As an REBT practitioner, you emphasize the importance of determining some of his core issues contributing to his distress. You ask him to share some of the thoughts he has had about the bullying and the boys in his gym class. Logan admits that he believes he is "worthless" and "deserves the bullying" because he is not "cool" enough. You help him recognize that his self-worth is not dependent on the opinions of his bullies and that he does not deserve to be mistreated. You also address Logan's intense emotions and help him understand the relationship between his thoughts, feelings, and actions. You encourage Logan to reflect on the possible consequences of wishing harm upon his bullies and discuss alternative, healthier ways of coping with his feelings. You introduce Logan to relaxation techniques, such as deep breathing exercises and progressive muscle relaxation, which he can use to manage his emotional distress. In this session, you also explore Logan's social support network to identify potential allies to help him deal with the bullying. You ask him about friends, family members, or other school staff who he trusts and feels comfortable talking to about his experiences. Logan mentions a few friends who he thinks might be willing to help. You discuss ways he can approach these individuals and ask for their support, emphasizing the importance of open communication and honesty. When he gets ready to leave, you notice a cigarette fall out of his backpack. You ask him about the cigarette, and he admits that one of the boys in his gym class gave it to him. He says the boy said if Logan smoked it, he would be "cool" and finally accepted by them. You explain to Logan that smoking is not an excellent way to fit in and can harm his health. Instead, you encourage him to find other ways to express himself, such as participating in activities he enjoys or joining clubs at school. Following today's session, you check in with Logan's mother. You also advise her on how she can support her son by having conversations with him about the importance of making good choices and helping him find healthy ways to cope with his feelings. Ninth session Logan arrives at the session a few minutes late and apologizes. He says that he was outside playing kickball with his class. He reports that he has been feeling better about being in school lately. His classmates are friendlier to him, or at the very least, "they don't bother me so much," He is now eating lunch back in the lunchroom. He is learning to play soccer and plans to ask his parents if he can join the summer league. Next, you call Logan's mother and share his progress in counseling with her. Finally, you examine Logan's care plan and assess for any changes needed. Logan's progress in counseling has been notable as he has demonstrated increased social engagement and involvement in extracurricular activities. It appears that the therapeutic interventions implemented have successfully addressed his initial concerns regarding social anxiety and peer relationships. In addition, Logan's newfound interest in soccer and desire to join a summer league further demonstrates his willingness to engage with peers and develop new skills. In conversation with Logan's mother, you emphasize the importance of fostering a supportive home environment to encourage Logan's growth and self-confidence. The mother expresses gratitude for the improvements in her son's well-being and commits to facilitating Logan's involvement in the summer soccer league. Additionally, she agrees to maintain open communication with the counselor to address any potential concerns that may arise in the future. Upon reviewing Logan's care plan, the counselor determines that the current therapeutic goals and interventions remain appropriate and relevant to Logan's ongoing progress. However, it may be beneficial to introduce supplementary strategies to further enhance his self-esteem and resilience and promote effective communication and problem-solving skills. By doing so, Logan will be better equipped to navigate any challenges that may emerge as he develops and maintains positive relationships with his peers. After the session, you receive a phone call that your wife has passed away. In the midst of the sudden loss of your beloved wife, you find yourself struggling to maintain your usual level of composure, which is understandable, feeling overwhelmed and emotionally drained during this difficult time. Being a therapist, you recognize the weight of your emotional burden and decide to reach out to your supervisor to discuss your struggles. After a heartfelt conversation, you feel a sense of relief and connection with your supervisor, who has provided you with support and understanding. As the conversation draws to a close, you make an unexpected request of your supervisor: that she attend your wife's memorial and wake so that she can meet your family and share in the memories of your loved ones. This request may seem a lot to ask, but you feel comforted by the thought of having someone close to you share in this challenging time. You also ask if she can take over your caseload as you deal with your wife's passing.

The client has a large supportive family. The extended family often gathers together for Sunday dinners. The client says that he has fun playing games with his cousins. The client's mother states that their family is very close, and she and her husband make a concerted effort to prioritize shared time with the extended family.

Which would be most beneficial to communicate in your last session with the client?

"You have succeeded at overcoming a major setback and it is the foundation for much greater success moving forward."

"Are there any other specific questions or concerns you would like to address at this moment?"

"It is important to prioritize self-care and not feel pressured to prioritize forming friendships, as you can be content and fulfilled on your own."

"You did an incredible job and I wish you the best going forward."

(A): "You have succeeded at overcoming a major setback and it is the foundation for much greater success moving forward." (B): "Are there any other specific questions or concerns you would like to address at this moment?" (C): "It is important to prioritize self-care and not feel pressured to prioritize forming friendships, as you can be content and fulfilled on your own." (D): "You did an incredible job and I wish you the best going forward."

"You have succeeded at overcoming a major setback and it is the foundation for much greater success moving forward."

A

The idea is to put both the past and the future into a positive perspective moving ahead for this client. You are also reinforcing his capacity to discover new ways of responding to difficulties in life and preparing at the same time for the future. Therefore, the correct answer is (B)

counseling skills and interventions

Client Age: 35 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Hispanic Relationship Status: Divorced Counseling Setting: Private Practice Clinic Type of Counseling: Individual Counseling Presenting Problem: Anxiety; Depressed Mood, Difficulty with Changing Relationship Roles Diagnosis: Adjustment Disorder with Mixed Anxiety and Depressed Mood (F43.23)

Mental Status Exam: The client presents as oriented to person, place, time, and situation. The client appears anxious because he avoids eye contact often and expresses that he has never been in counseling and is ner

You are a licensed counselor in Texas in a private practice. A 35-year-old male client comes to counseling for support during a recent divorce. The client says that he and his wife separated a year ago and had to wait a year for divorce per state law; therefore, they finalized the divorce recently. The client says that his wife decided she married him because she was lonely and that, after 8 years of being married, she wanted to find someone she loved. The client states that he still loves his ex-wife and that he has a hard time with his new relationship with her because he shares custody of his children and still has to communicate with her regularly. He continues saying that his wife often calls him for emotional support and he does not know how to respond when this happens because he loves her and wants to support her, but this is confusing for him. The client says that he knows he “shouldn’t be with someone who doesn’t want to be with him and that things won’t go back to how they were.” The client identifies that anxious and depressive symptoms are present and that they affect his ability to engage socially, engage with his children, and perform at work. The client wants to work on navigating his new relationship with his ex-wife, his relationship with his children, and being single again.

The client comes into your office and says hello in a quiet voice and then sits down, slumps his shoulders, and does not make eye contact. You inquire about what you see, and the client says that he has been feeling more depressed over the past week. The client says that he is experiencing low appetite, a down mood, fatigue, and irritability. You empathize with the client and discuss coping skills for depressive symptoms. The client expresses frustration with his church because he worked part-time in the church office until recently when they encouraged him to resign because he is divorced and he is now unable to work in the church because of this. You empathize with the client regarding his situation at church. You do not share the same religious views as the client

You do not share the same religious views as the client. Which of the following would be the most helpful approach when considering the impact of your own beliefs in counseling?

You support the client’s beliefs and do not impose your own values

You encourage the client to assess his own beliefs and if he really does believe them because he is currently feeling that they are incongruent with those of the church

You continuously assess how your beliefs may affect the counseling process

You explain to your client that you do not share his beliefs; therefore, you may not be very helpful in supporting him

(A): You support the client’s beliefs and do not impose your own values (B): You encourage the client to assess his own beliefs and if he really does believe them because he is currently feeling that they are incongruent with those of the church (C): You continuously assess how your beliefs may affect the counseling process (D): You explain to your client that you do not share his beliefs; therefore, you may not be very helpful in supporting him

You continuously assess how your beliefs may affect the counseling process

C

It would be most helpful to continuously assess how your own values and beliefs affect the counseling process. Although it is important to support your client’s beliefs and not impose your own, there is a level of self-reflection that is important in the process of counseling to ensure that you are not unintentionally imposing your own beliefs. Although it might be helpful to explain that you do not share beliefs with the client, it also undermines your own ability to help him because it invalidates your ability to connect with him. It may also be helpful to support the client in assessing his own beliefs because it appears that he is feeling the conflict; however, your goal is to support his beliefs and values. Therefore, the correct answer is (C)

core counseling attributes

Initial Intake: Age: 9 Gender: Female Sexual Orientation: Heterosexual Race/Ethnicity: Caucasian/Non-Hispanic Relationship Status: Single Counseling Setting: Private Practice Type of Counseling: Individual

Lottie presents as excited, over-stimulated and hyperactive, unable to sit still and does not take breaks from talking. Her appearance is highly disheveled with stained clothes and unbrushed hair. Lottie nervously walks around your office touching and commenting on everything. You ask her nicely to ask you before she touches your things, but she refuses and continues to do so. Lottie deflects from every question posed in your assessment. She denies SI/HI, hallucination, or delusion, which you were surprisingly able to find out from her.

Diagnosis: Attention Deficit Hyperactivity Disorder, predominantly hyperactive type (F90.1), Oppositional defiant disorder (F91.3), Reaction to severe stress (F43.9) Lottie is a 9-year-old girl in the fourth grade who has been referred to you by officials in her elementary school. You are a counseling intern of a private practice that specializes in adult personality disorders, but your supervisor accepted Lottie as a new client because Lottie’s mother is a former client of her agency, and she requested her daughter be seen by your practice as opposed to a school-based counselor. Lottie’s mother does not want Lottie’s peers to know she is in therapy. Lottie has been doing well in school academically but has not been able to behave appropriately for years, according to the referral report. Lottie bounces up and down in her chair constantly, makes impulsive noises throughout the day, and engages in inappropriate behaviors daily. Some of the behaviors listed include invading the personal space of her peers, licking and eating school supplies to garner reactions from fellow classmates, hiding on the playground and refusing to emerge, and many other behaviors. Lottie follows basic classroom directions but needs constant reminding or guiding that the teacher does not have time for. Lottie breaks down into hysterical emotional fits when she does not get her way and her behaviors have been spreading the school staff too thin to be capable of managing without intervention. This session is conducted with only Lottie in the room; her mother insists on waiting in the car outside so she can make some phone calls. She mentions her Medicaid has just been reactivated to pay for sessions.

Family History: Lottie lives at home with her mother and mother’s boyfriend, as well as their 1-year-old son Davie who is her half-brother. You learned from speaking with her mother beforehand that Lottie’s biological father was a drug addict and homeless, and he was recently shot and killed, about four months ago. Lottie knows and understands what happened. During the intake session you ask her to draw a picture of something important to her. She likes this assignment and draws you a picture of her father’s homeless camp where she last saw him. She explains to you the details surrounding his murder and mature, intimate details of her mother’s broken relationship with him. “How do you know all of this, Lottie?” you ask her, concerned. “Oh, my mother told me. She tells me everything.”

Lottie uses play to show how her father was killed. She notices you have let a tear out of your eye while observing her and says, "Why are you crying? Please don't!" What is the best clinical response?

"Why not, don't you cry when you think about your dad?"

"Lottie, what you shared was sad. I cried. But I am okay."

"I just have irritated eyes, nothing to do with you."

"I'm so sorry you saw that; I couldn't hold it back."

(A): "Why not, don't you cry when you think about your dad?" (B): "Lottie, what you shared was sad. I cried. But I am okay." (C): "I just have irritated eyes, nothing to do with you." (D): "I'm so sorry you saw that; I couldn't hold it back."

"Lottie, what you shared was sad. I cried. But I am okay."

B

Demonstrating to a child that a person can cry when something is sad, but that they can also be okay right afterwards, is a very powerful clinical lesson. Helping model for Lottie a healthy grief response and recovery is a great way for her to learn that she can do the same thing. Turning the response back onto her can be confrontational in a sensitive grief situation which may trigger a stronger response from her. This can be okay to ask, as in answer a), but do not miss the opportunity to first give a clinical response such as in answer d). It builds a more genuine therapeutic bond and offers sincere empathy, something Lottie desperately needs. Apologizing is setting the example that it is "not okay to cry when something is sad". Denying your feelings to her using excuses like in answer c) is in direct conflict with the skills you are working to show Lottie how to use, therefore it is not the best choice. Therefore, the correct answer is (D)

counseling skills and interventions

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 gained in this session, which attachment style seems most appropriate for this client's history and current presentation?

Ambivalent attachment

Disorganized attachment

Avoidant attachment

Secure attachment

(A): Ambivalent attachment (B): Disorganized attachment (C): Avoidant attachment (D): Secure attachment

Ambivalent attachment

A

Adults with parental figures who were inconsistently available and rejecting, or violated normal boundaries tend to be anxious and insecure, ruminate about relationships and may be dependent or needy. Adults with secure attachments create meaningful relationships and set healthy boundaries, those with avoidant attachment styles tend to avoid closeness or connection and may be perceived as rigid, critical, and intolerant. Individuals with a disorganized attachment style often are chronically vulnerable and tend to dissociate when triggered by perceived threats. Therefore, the correct answer is (D)

counseling skills and interventions

Name: Roger Clinical Issues: Physical/emotional issues related to trauma Diagnostic Category: Neurocognitive Disorders Provisional Diagnosis: F02.81 Major Neurocognitive Disorder Due to Traumatic Brain Injury, with Behavioral Disturbance Age: 36 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: White Marital Status: Married Modality: Individual Therapy Location of Therapy : Outpatient clinic

The client presents as tired. He reports a mild headache at the intake appointment, which he says is likely due to coming in from the bright day outside. Memory is slightly impaired. Mood is depressed, though he says this is impermanent, and his mood changes within a day, though the depressed mood is more prevalent and longer-lasting.

First session The client returned home from Afghanistan last month after separating from the Navy after 12 years of service. He states he is tired of trying to get an appointment at the VA Hospital, so he Googled locations that treat brain injuries, and your office was on the results page. He called to arrange a consultation with you. You have been practicing as a licensed mental health therapist at the outpatient clinic for over a decade, and you have worked with many clients diagnosed with traumatic brain injury. The client complains about difficulty sleeping, bad headaches, and feeling like he is on a roller coaster - feeling happy one minute and then down in the dumps the next. He states that the happy times don't last long, and he is "down in the dumps" most of the time. When asked why he left the Navy, he replies: "Toward the end of my last deployment, I just got sick and tired of everything and couldn't deal with it anymore. I couldn't sleep, was jumpy all the time, and didn't even want to go outside during the day." Now, I'm finally back home, but things only seem worse. My wife keeps nagging me to get a job, my kids look at me like I'm a monster, and nobody understands how I feel. I want to lay in bed all day and drink a couple of beers. I think something isn't right, and I can't take it anymore." Near the end of the session, the client asked what he could expect if a medical professional recommended medication management to treat NCD. The client discloses experiencing a highly distressing and psychologically damaging event during his military service in Afghanistan. While on patrol with his unit, their convoy was ambushed, and a fellow soldier directly next to the client was seized by insurgents. The client painfully witnessed his peer and friend being brutally beheaded, describing the horrific sight and sounds as permanently seared into his memory. Helplessly observing the brutal murder firsthand left him stunned and overwhelmed with grief and terror at the moment. The grotesque violence and knowing that could have just as quickly been his fate continues haunting him years later. The constant stress of combat and imminent danger already had the client in a perpetual state of hypervigilance and anxiety during his deployment. He shares that coming to terms with the abrupt, unfair loss of life was a daily reality there. While transporting supplies between bases in a standard jeep convoy, his vehicle triggered an IED explosion or was directly hit by artillery fire. The client was violently jolted and knocked completely unconscious as the blast disabled their jeep. He remained in and out of consciousness for over 24 distressing hours, being evacuated while critically injured to a military hospital. Once stabilized, he was thoroughly examined and diagnosed with a traumatic brain injury concussion along with other shrapnel wounds. Fourth session You and the client decided to meet for weekly sessions based on his current needs. You have established a trusting relationship with him, and he feels more comfortable knowing that you have experience in working with military populations. You provided psychoeducation regarding the effects of traumatic brain injuries and what he can expect from the counseling process. You were able to instill hope that he could recover emotionally following his injury and learn new skills along with coping mechanisms. He presents for today's session in a depressed mood which he states began the previous night. He reports that his family appears to now better understand what he is going through and they are getting along better. He is still drinking three beers at night to help him fall asleep, and his headaches have decreased in intensity due to finally getting a medication consult from the VA. However, he is still sensitive to light. He shares that he is ready to look for work but is concerned about finding a job and performing due to his ongoing symptoms. Ninth session Rober arrives elated at the session, appearing happy, talkative, and smiling. He states that he has felt this way for four days now, which has not been the typical length of time or the intensity of his positive mood episodes. He reports that his family relationships are satisfactory, and he has been somewhat successful at his part-time job at the local lumberyard. However, he is angry with his manager, who says he has been too distracted this past week and spends more time talking with customers than working. He is still drinking three beers at night to sleep but reports that he has not had to sleep much this past week and feels "wide awake." He says he is ready to open his own business but isn't sure what he wants to do yet. Roger reports feeling energized, creative, and motivated over the past several days. He has come up with many new business ideas that he is eager to pursue, including opening a restaurant, starting a landscaping company, and developing a crypto blockchain. Roger stays up late into the night brainstorming ideas and making extensive plans. He feels compelled to act on his ideas immediately and has already taken steps to register business names and research loans. However, the next day, Roger often changes course, dropping previous ideas for new ones that seem even more exciting. His friends notice his frenzied pace in bouncing from idea to idea, worrying he has taken on too much. But Roger reassures them this surge of creativity allows him to see endless possibilities for his future business success. Though well-intended, their skepticism only pushes him to work harder to bring his visions to life. Roger also mentions experiencing increased sociability and talkativeness lately. He says he has frequently called and texted friends and family to share his business ideas and other excited thoughts. Roger speaks rapidly, his thoughts racing as he tries to get loved ones as enthused as he feels. Though some gently try to interject realistic concerns, he remains unchecked in his ambitious optimism. A few close friends have expressed concern over Roger's intensified pace and plans, but he brushes them off, feeling very optimistic and self-assured about his ideas. Roger's confidence borders on grandiose as he envisions an incredibly successful entrepreneurial future. Attempts by caring friends and family to restrain his inflated self-assurance are met with irritation, as Roger feels unable to focus on anything but chasing his next big idea. He's optimistic that his new crypto blockchain will rival and surpass Bitcoin in a matter of months.

The client drinks three beers every night before bed to help him fall asleep. He started this pattern a few years ago after struggling with insomnia and finding it challenging to relax his mind. Though effective at first in inducing drowsiness, he has built up a growing tolerance and now needs to drink three beers minimum to feel any sedative effects. He discloses that he knows consuming alcohol regularly can be unhealthy, but he feels dependent on having those beers to wind down from the stresses of his day and quiet his anxious thoughts enough to get adequate rest. During his time serving in the military, the client reported smoking cannabis on occasion when it was available. However, he did not enjoy the experience or feel compelled to use it. He mainly partook when offered by peers to be social. Since his discharge five years ago, he states he has not had any cannabis. The client currently smokes approximately one pack of cigarettes per week, a habit he picked up during his military service as a way to cope with boredom and nerves. He expresses some interest in trying to cut back for health reasons but also shares smoking provides a sense of relief and routine.

What is the primary step a therapist should take if a client is presenting in a manic state that impairs their capacity for autonomous decision-making or indicates a potential risk to others?

Respect the client's autonomy and ask how they would like to proceed.

Sit with the client until they are stable.

Call the client's spouse and arrange pickup.

Coordination of inpatient care.

(A): Respect the client's autonomy and ask how they would like to proceed. (B): Sit with the client until they are stable. (C): Call the client's spouse and arrange pickup. (D): Coordination of inpatient care.

Coordination of inpatient care.

D

The therapist has an ethical duty to protect the client and community. Therefore, the correct answer is (D)

professional practice and ethics

Initial Intake: Age: 82 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Widowed Counseling Setting: Community Clinic Type of Counseling: Individual

Theodore is tearful most days and has dropped a significant amount of weight. He has not been sleeping and stays up watching videos of his deceased wife.

Theodore is an 82-year-old who was referred for grief counseling by his son, Nate. Theodore’s wife, Nancy died one month ago after a 4-year battle with cancer. History: Theodore was the primary caretaker for Nancy and has not paid attention to his own health in years. Nate would like his father to move in with him and his family and sell the house his parents lived in to pay off their debt. However, Theodore refuses to sell the house and stated that he will not give away or sell anything that they owned. Nate drove Theodore to the initial session and sat in for the intake, with Theodore’s consent. Once everyone sat down, Theodore looked at the counselor and stated, “I am only here so my son stops bugging me about selling the house. I am not getting rid of anything in that house- and especially not the house itself!” Nate explained that his father cannot maintain the house on his own and is worried about him being lonely. Theodore insists that he has other options and thinks that living with Nate would put a burden on him.

To understand Theodore in the context of his family, a systemic counselor would?

Use tools, such as a genogram, to show relationships

Teach Theodore coping mechanisms when he is frustrated with Nate

Focus on a diagnosis

Focus on Theodore's experiences since his wife's passing

(A): Use tools, such as a genogram, to show relationships (B): Teach Theodore coping mechanisms when he is frustrated with Nate (C): Focus on a diagnosis (D): Focus on Theodore's experiences since his wife's passing

Use tools, such as a genogram, to show relationships

A

A systemic counselor tries to look at a client within his/her system and not just individually. One way to do this, is by using a genogram. A genogram would be particularly helpful in this situation to understand the dynamic between Theodore and Nate. A systemic counselor would not just focus on obtaining information to come up with diagnosis. As opposed to teaching Theodore coping mechanisms when frustrated with Nate, they may bring Nate into a session. And instead of focusing on Theodore's experience with his wife passing, a systemic counselor may look at how the death affected the system. Therefore, the correct answer is (D)

counseling skills and interventions

Initial Intake: Age: 53 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Married Counseling Setting: Community Agency Type of Counseling: Individual

The client appears his stated age and is dressed appropriately for the circumstances. He rates his mood as “anxious.” His affect is congruent though he appears to relax as the session continues. He demonstrates some limited insight and frequently responds with “I don’t know” but when encouraged, is able to access thoughts and emotions that are disturbing to him. He demonstrates appropriate judgment, memory, and orientation. He reports never having considered suicide or harming himself or anyone else. He states that he is very engaged individually and with his family in their religious practices and views these as a source of strength. He currently takes 50 mg of Pristiq and Concerta 18 mg.

You are a counselor in a community agency setting. Your client is a 53 year-old male who presents with complaints of feeling insignificant, unworthy, and a failure. He admits to having these feelings for the past 30 years and while he has never had suicidal ideations or plans, he has often wondered if his life had purpose and what that purpose was. Your client additionally tells you that he doesn’t feel happy on most days though he does have happy feelings at times; they just don’t last. He is good at his job and finds it challenging, yet tells you “it’s a job” and that there is nothing special or “exciting” about it to him. He tells you that he has been married for twenty years and has five children; three of whom he adopted when he married his wife. He states he adores his wife and children, though he knows that he often does not meet their needs emotionally, “tunes out,” and frequently puts his own “wants and desires” before their requests, needs, or previously made plans. He admits he gets “jealous, I guess” when someone else in the family gets something that he didn’t. He also says that he often says “the wrong thing” when his wife or children are upset about something and he struggles to understand how they are feeling. He tells you that these actions cause conflict in his marriage and with his children and he is ashamed that he does this, but feels hopeless that things will change because he cannot figure out how to change or why he does these things. He reports that he does not believe himself to be better than others but that others often perceive that he sees himself that way because of how he interacts with them. He also tells you that his family often wishes he would “think before I speak or make decisions.” He reports that in spite of these “failures,” he and his wife have a very strong marriage and express their love for each other daily. They enjoy activities together although he needs very active recreation such as roller coasters, bike riding, and swimming while his wife leans towards less physical activities. Finally, your client tells you that over the years he has had some trouble focusing at work and at home. He views himself as “forgetful” and says “I don’t have a good memory.” He says this causes troubles at home and work when he frequently forgets to do something that he said he would do or when he is not as careful or gets distracted in his work and is slow to finish projects or makes small mistakes that have greater impacts on reports.

Family History: The client reports his parents were married to each other until his father’s death at age 60. Your client states he was very close to his father although his father’s activities were often curtailed due to illness. He states that his father accompanied him to boy scouts and was involved with the client and his older siblings. The client states that he has always been close to his mother although he acknowledges often feeling angry at her but being unable to tell her that, so instead he “tuned her out.” He describes her as extremely “critical and consistent.” He tells you that the first time he decorated a Christmas tree was with his wife as his mother always decorated their family trees “so they were done right.” He also says his father and siblings could always count on her to be the one who made the family late for everything and left them waiting during outings. In one example, he shares that when going out together, his mother would often set a meeting place and time for him. He reports that he would either wait at the meeting spot for hours because she was late or that he would sometimes go looking for her and then get in trouble for leaving the meeting spot. He reports that his oldest sibling died in his 40s from excessive drug and alcohol use, and that his other sibling has a very conflictual relationship with their mother and sees their mother “when needed” but is often angry with their mother. He describes his relationship with his mother over the past twenty-five years as one in which his mother makes promises without keeping them and was often dismissive of the client’s wife and children during the time that he was dating and for several years after their marriage. He relates one account where his mother was helping his wife organize something in their home, but refused to organize it in the manner that his wife needed it, and instead became very angry, defensive, and accusatory when his wife reorganized what his mother had done.

Which of the following interventions would be the most effective in helping the client learn how his traits impact his relationships with himself and others?

Invite client to join a long-term process group

Invite client to bring spouse to sessions

All of the above

Invite client to read a book about narcissism

(A): Invite client to join a long-term process group (B): Invite client to bring spouse to sessions (C): All of the above (D): Invite client to read a book about narcissism

All of the above

C

All of the above interventions are appropriate for a client with narcissistic traits and partial insight. Because the client recognizes his personality characteristics and wants to create changes, reading about the personality style will help him understand his defenses better and may allow him to view these as defense strategies rather than character flaws. Process groups, unlike psychoeducational groups, help clients work on personality change by recreating one's relationships in the group through transference. Inviting the client to bring his spouse to sessions will be helpful as he has described a good relationship, which is supportive to him. Including her in sessions is likely to help her be more supportive as she understands his personality better. Therefore, the correct answer is (D)

treatment planning

Name: Amy Clinical Issues: Hopelessness/depression Diagnostic Category: Depressive Disorders Provisional Diagnosis: F34.1 Persistent Depressive Disorder (Dysthymia), Severe Age: 15 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: White Marital Status: Not Applicable Modality: Individual Therapy Location of Therapy : Private Practice

The client appears in your office with loose clothing and a thin physical frame. She has inconsistent eye contact and portrays a drowsy level of consciousness. Her speech rate is slow, her volume is soft yet monotone, and her fluency and rhythm are unclear and hesitant at times. She talks about how much she hates her life. Her mood is depressed and discouraged, while her affect is flat and sad. The client has been previously hospitalized for suicidal ideation. Her thoughts are slowed, and she is easily distracted. Her concentration is impaired with frequent lapses in attention. She is unable to follow a long line of thought or argument. She also reports difficulty making decisions. Her insight and judgment are limited. The client's emotional state is characterized by a pervasive sadness, irritability, and feelings of hopelessness. She exhibits difficulty in concentrating, making decisions, and expressing herself coherently. Additionally, she is experiencing disrupted sleep patterns, including insomnia and excessive daytime sleepiness, and has reported a diminished appetite with subsequent weight loss

First session You are licensed as a mental health therapist working on a post-doctoral thesis related to depression and have been working with several clients diagnosed with Persistent Depressive Disorder. One of your new research participants is a 15-year-old client who arrives at your office with her mother after being released from the hospital. Before beginning the session, you ask to talk with the mother and daughter separately. When interviewing the mother, she tells you about her daughter's ongoing behavioral difficulties, experimenting with drugs and alcohol, and getting involved with a "bad group of kids." The client's academic performance has also been affected, with teachers reporting a notable decline in grades and participation in class. This behavior has been ongoing for approximately six months and appears to be intensifying. The strained familial relationships that the client is experiencing are a constant irritation to the entire family. The father's instability may have contributed to the client's current emotional distress, exacerbating her depressive symptoms. The client's mother, while providing primary care, struggles to maintain any bond with her daughter due to the increasing social withdrawal and lack of communication Next, you interview the daughter. You ask her questions about school, friends, and activities she enjoys. She states that she is picked on daily at school, has no "real" friends, and hates her life. The client sighs heavily, saying, "Some nights I go to bed hoping that I won't wake up in the morning. There's nothing to look forward to. School is horrible. She explains that she feels like she is "stuck in a dark hole" and that she cannot get out. She reports feeling hopeless, helpless, and alone. You summarize what she has told you, and she confirms your understanding of her feelings. After completing your interview with the daughter, you invite the mother to join you in your office. You continue to gather information about the client's personal and family history, symptoms of depression, and risk factors contributing to her current state. You explore potential triggers for her suicidal ideation and any protective factors in place. The mother reports that her daughter has been struggling with a lack of self-confidence and low self-esteem. You also discuss her current support system and any potential areas for improvement. Through the assessment, you can comprehensively understand the client's challenges and strengths. At the end of the intake, you check to ensure that both mother and daughter clearly understand what you have discussed today. You plan to meet with the client on a weekly basis, and you schedule a session for the following week. Third session As the client enters your office, you notice she has been crying. She states that she does not want to be here and feels like she has "no say" in what happens to her. She says that she wants to start attending a virtual school, but her mother "forced" her back to a physical school. The client says, "I can't stand it anymore. My mom yells at me every day about how I'm doing something wrong. Yesterday she blew up at me about leaving my shoes and backpack in the living room. It's my house, too. She's such a control freak." You respond to her with empathy and understanding. You ask her to tell you more about how she has felt since the argument. She explains that in addition to feeling like she has no control over her life, she feels guilty and confused because she loves her mother but does not understand why she is so controlling and demanding. You let her know that it is natural to have complicated feelings in this situation and that you are here to help her work through them. You create a plan with her, outlining different goals and activities she can do on her own or with the support of her mother. Through further exploration, you discover that she has an interest in drawing and is used to create characters for stories. She admits she feels calm when creating these drawings but that it does not take away from her depressive symptoms. You explain that having a creative outlet and developing it further can give her a healthy outlet for her emotions. The client appears to be receptive to this idea, expressing that she is willing to try it. She leaves your office feeling hopeful and slightly less overwhelmed. You make an appointment for the following week and suggest she come with a piece of art or design to share. She nods in agreement before leaving.

The client's mother reports that the client's father has a history of depression. The client's mother is her primary caregiver, as her father is in and out of psychiatric facilities. When the client was a child, she had a positive relationship with her mother, but as a teenager, she has been withdrawing from her mother and spending most of her time alone in her room. The client has missed many days of school in the past few months. She feels that no one at school likes her; she has tried to fit in by experimenting with alcohol and marijuana, controlling her weight, and staying out late at night. The client is struggling academically and lacks concentration in the classroom. At home, the client is withdrawn and spends most of her time in her room pretending she is doing homework but is actually scrolling through social media posts for several hours. In addition, she is having trouble sleeping and stays up late.

Which statement shows your support of the client in dealing with her feelings?

"What I hear you saying is that you feel like drawing helps your mood."

"What I hear you saying is that you feel better when you skip school."

"Your mother reports that you are difficult at home."

"What I hear you saying is you are feeling powerless, and you are not in control of your own life."

(A): "What I hear you saying is that you feel like drawing helps your mood." (B): "What I hear you saying is that you feel better when you skip school." (C): "Your mother reports that you are difficult at home." (D): "What I hear you saying is you are feeling powerless, and you are not in control of your own life."

"What I hear you saying is you are feeling powerless, and you are not in control of your own life."

D

Mirroring the client's feelings can help the client experience a sense of understanding and rapport. Therefore, the correct answer is (D)

counseling skills and interventions

Name: Tabitha Clinical Issues: Family conflict and pregnancy Diagnostic Category: V-codes Provisional Diagnosis: Z71.9 Other Counseling or Consultation Age: 16 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: Latina Marital Status: Not Married Modality: Individual Therapy Location of Therapy : School

The client appears healthy but tired and distracted. She is dressed in loose-fitting clothing and sits with her hands between her knees. Eye contact is minimal. Speech volume is low. She is reluctant to talk at first and denies having a problem. Thought processes are logical, and her thoughts are appropriate to the discussion. The client's estimated level of intelligence is within average range. She appears to have difficulty maintaining concentration and occasionally asks you to repeat your questions. The client denies suicidal ideation but states that she has been considering abortion. She has not acted on anything but is feeling very overwhelmed and desperate.

First session You are a school counselor in an urban school setting. The client is a 16-year-old student who is reluctant to see you. The session begins with a discussion of the teacher's concerns and your role as a school therapist. After some gentle probing and reassurance, the client is able to open up more and discuss her difficult relationship with her father. She identifies feeling overwhelmed and frustrated by his expectations, which leads to frequent arguments between them. She appears tired and has trouble sleeping at home because her parents constantly argue. She suggests that her parents "are the ones who need therapy, not me." She briefly describes the arguments that she claims her parents get into regularly. "They are always going at it, unless thay are at church. Then they act like everything is perfect." When you ask about her friends and activities, she tells you she is involved in her church youth group and has an on-again/off-again boyfriend. You ask the client, "Can you tell me more about your relationship with your boyfriend? How long have you been together?" She says that they have been seeing each other for about a year, and she thought he was 'the one', but they had a "big fight" last week and have not talked since. You ask what she means by 'the one'. She looks down at the floor and starts to bite her fingernails. You see a tear fall down her cheek. She says, "I don't know what to do." You continue the session by providing a safe space for her to express and explore her feelings about her relationship with her boyfriend. She takes a deep breath and tells you that there is something she has not told anyone and she is scared that if she says it out loud that "it will make it too real." You tell her to take her time and that you are here to listen without judgment. She tells you that she missed her last menstrual period, and several "in-home" tests confirm that she is pregnant. She has not told her boyfriend and is scared to tell her parents because she is afraid they will disown her, so she has decided to keep the pregnancy a secret. While you are tempted to try to talk the client into telling her parents and boyfriend about her pregnancy, you recognize that it is important to respect her autonomy and allow her to make the best decision for herself. You provide her with accurate information about the options available to her and encourage her to explore the pros and cons of each option. You share that having a support system and someone to talk to during this time can be helpful. She nods her head and tells you that she knows that her parents will find out about the baby eventually, whether she tells them or not, but she is anxious about how they will react to the news. You listen and provide empathetic reflections to help her gain insight into her feelings. You then focus on helping the client develop effective coping strategies for managing her stress and anxiety about the situation. You let the client know that she can come back to see you at any time if she feels overwhelmed or needs additional support. The session concludes with an understanding of what to expect in future sessions, including exploring possible solutions for dealing with her parents and boyfriend, as well as developing healthy coping skills for managing her emotions. Second session A fews day after the intake session with your client, she stopped by your office and asked if she could talk to you for a few minutes. She told you that since your last session, she decided that she wanted to tell her parents and asked if you could be there when she told them. You set up an appointment to meet with the family. This is your second session with the client and she appears very nervous. When she sits down in the chair in your office, she tells you that she changed her mind about telling her parents. She keeps repeating, "I can't do this. You tell them." Your office phone rings, and the secretary tells you the client's parents have arrived. The client immediately bursts into tears and begs you not to let them in. You calmly explain that you are here to provide a safe space for her and will support her. You walk her through a grounding exercise and encourage her to take slow, deep breaths. After a few minutes, she relaxes and indicates she is ready to talk to her parents. You welcome the parents into your office and introduce yourself as a mental health professional who has been working their daughter. You explain that the client has something she would like to tell them and you will be here to help facilitate their conversation. Her father says, "We know that something is going on." He starts talking about his daughter's academic issues and recent argumentative behavior at home. The mother adds, "We pray daily that she will grow out of this hormonal phase. We miss our innocent little girl." You listen and reflect on the parents' feelings as they talk about their daughter. The client is quiet and looks down, not making eye contact with anyone. After a few moments, you gently encourage the client to share her thoughts and feelings. She tells you that she has something important to tell them but does not know where to start. You suggest that she take her time and start with whatever feels most comfortable for her. The client takes a deep breath and slowly begins to tell her story. She tells them about her pregnancy and how scared and overwhelmed she has been. At that moment, everything changed. The client's parents are no longer focused on her academic or behavioral issues. Instead, they are now focused on their daughter and her pregnancy. They are full of questions and concerns for their daughter's well-being. The mother looks shocked, and the father demands to know who the boy is that "did this to our daughter." The initial conversation is difficult, but you provide support as the family talks through their feelings. Fifth session You have been seeing the client weekly during her lunch break. After their initial shock, her parents have accepted the news and are now focused on helping their daughter. The client told you that they have been discussing the options available to them, such as adoption or parenting the baby. When you met with the client last week, she opened up about how she was feeling physically and emotionally. She told you that although her parents have been supportive, she was still feeling overwhelmed and uncertain about the future. She told her boyfriend about the baby, but he has been distant and unsupportive. Her parents met with the boyfriend's parents and tried to talk about options, but his parents said they did not want to be involved. They said they "already had too many mouths to feed" and could not help with the baby. Today, the client and her mother come to see you for a scheduled appointment. The mother smiles as she pulls out a picture of the baby's sonogram to show you. She says, "We met with our minister, and the three of us have been praying for guidance as we have been trying to cope with this situation." They decided that the best option for their daughter and the unborn baby was to find a loving family who would be willing to adopt. The mother explains, "We want our daughter to focus on her education and not worry about the responsibilities of raising a child right now. We are hoping that by finding a good home, we can provide this baby with a bright future." As the mother talks, you notice that the client is more relaxed and looks alert and focused. You ask her about how she feels about the decision. She admits that although she still feels overwhelmed, she is also starting to feel more at peace with the idea of adoption. You nod your head in understanding and offer some words of support. Finally, the mother states, "What we need at this point is for you to reschedule our daughter's classes so that she can continue with schoolwork virtually and also ensure that she gets the rest she needs during her pregnancy." You assure them that you will work with the school administration to facilitate the client's needs. You end the session with a plan for the client's continued care. You will continue to meet with her as needed and provide additional support.

The client has an older brother who is in college. The client lives at home with her parents. They are members of a Christian church and are all actively involved in their church group, and the client has a good relationship with her pastor. The client has never felt close with her father and says he has always had "high standards and expectations" for everyone in their family. The client says her parents "treat her like a child." She has not told her parents about her 16-year-old boyfriend as she knows they will disapprove. For the last year, she has been asserting her independence from her parents, which has caused conflict, friction, and discord within the family. The teacher who referred the client to you mentioned that the client has seemed distracted and anxious lately. She has not been completing homework assignments and failed a test last week. The client acknowledges these concerns and tells you she struggles to keep her grades up and has difficulty adjusting to hybrid learning. "One day, we're in school, and the next day we're virtual. It's just exhausting. I feel like giving up."

The client and her mother have made it clear that they as a family have decided that bringing the client's baby to term and seeking adoption is the best choice for them; a direction that the client seems comfortable with. In acknowledgment of the client's intentions, but also being mindful of the difficulties that she may face, how can you best assist the client in finding support to help her with the physical as well as psychological burdens she will face during this time?

Considering that the client has now decided firmly to seek adoption for her child, you should suggest that the boyfriend might now be amenable to providing emotional support.

In light of the client's situation of improved outlook and willingness to accept help, you should recommend a teen pregnancy support group.

Given the client's age, lack of maturity, and still tenuous psychological condition, you should provide psychoeducation on teen pregnancy.

You should advise that the client continue to meet with her minister, since his involvement was key to gaining the parents' positive involvement, and could still be helpful in providing spiritual comfort.

(A): Considering that the client has now decided firmly to seek adoption for her child, you should suggest that the boyfriend might now be amenable to providing emotional support. (B): In light of the client's situation of improved outlook and willingness to accept help, you should recommend a teen pregnancy support group. (C): Given the client's age, lack of maturity, and still tenuous psychological condition, you should provide psychoeducation on teen pregnancy. (D): You should advise that the client continue to meet with her minister, since his involvement was key to gaining the parents' positive involvement, and could still be helpful in providing spiritual comfort.

In light of the client's situation of improved outlook and willingness to accept help, you should recommend a teen pregnancy support group.

B

Attending a teen pregnancy support group would be helpful. Therefore, the correct answer is (A)

core counseling attributes

Initial Intake: Age: 42 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Hispanic Relationship Status: Married Counseling Setting: Private Practice Type of Counseling: Individual

The client appears her stated age and is dressed appropriately for the circumstances. She identifies her mood as “somewhat anxious” and her affect is labile and congruent. She is noted to rub her hands together at times and she appears uncomfortable at times as she talks about herself. She demonstrates good insight, appropriate judgment, memory, and orientation. She reports no history of trauma, suicidal thoughts, or harm towards others.

You are a non-Hispanic counselor in a private practice setting. Your client is a 42 year old female who reports that she has been working for the same accounting firm for 10 years and was recently laid off due to a downturn in the economy. She tells you that prior to this firm, she worked in a company doing managerial accounting that she joined right after college. She says that she has liked the people that she has worked with but over the past several years she has enjoyed her work less and less. She reports that she is upset to have lost her job but, in some ways, she sees it as an opportunity to find something else she is more passionate about, but she has no idea where to start. She does say that she wants a job and work environment that is a better fit for her personality. She also tells you that she is afraid that she is too old to begin again or that she doesn’t have “what it takes” to begin a new career.

Family History: The client reports no significant family history related to mental health issues or relationship problems. The client tells you that she chose accounting in college because she grew up in a small town and her parents told her that she needed a skill that would help her support herself. Additionally, she states that she has been married for 19 years and has a good relationship with her spouse. She tells you that he is supportive of her exploring new careers but that her income is helpful for the family and it is important that she works.

Having assessed the client as ISA type, which of the following will provide the client with the best occupational information that match her type?

The Occupation Finders Handbook

The Occupational Outlook Handbook

Occupational Network Encyclopedia of Titles

The Career Options Handbook of Occupational Titles

(A): The Occupation Finders Handbook (B): The Occupational Outlook Handbook (C): Occupational Network Encyclopedia of Titles (D): The Career Options Handbook of Occupational Titles

The Occupational Outlook Handbook

B

The Occupational Outlook Handbook (OOH) is published by the Bureau of Labor Statistics in the U S Department of Labor. It contains thousands of occupations and information about each that include work environment, job tasks, required training, salary and growth projections, and advancement opportunities. It is updated every two years and is the most popular source used by career counselors. The OOH is matched to Holland's RIASEC personality types and each occupation is coded with a type. Responses b, c, and d are not occupational resources. Therefore, the correct answer is (A)

intake, assessment, and diagnosis

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."

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."

Which might you use to provide additional information about this couple?

16 Personality Factor Questionnaire (16PF)

Myers-Briggs Type Indicator (MBTI)

Marital Satisfaction Inventory (MSI)

Sexual Interaction Inventory (SII)

(A): 16 Personality Factor Questionnaire (16PF) (B): Myers-Briggs Type Indicator (MBTI) (C): Marital Satisfaction Inventory (MSI) (D): Sexual Interaction Inventory (SII)

Marital Satisfaction Inventory (MSI)

C

This is a 150-item inventory to help determine the nature and intensity of the couple's distress. Therefore, the correct answer is (D)

intake, assessment, and diagnosis

Client Age: 51 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Divorced and single Counseling Setting: Local government mental health agency Type of Counseling: Individual counseling Presenting Problem: The client is experiencing a recent separation from her last partner who was verbally and physically abusive, and she is currently living in a domestic violence home. Diagnosis: Major depressive disorder, recurrent episode, moderate (F33.1) and post-traumatic stress disorder (PTSD) (F43.10)

Mental Status Exam: The client’s affect is flat, and she is hunched over in the chair. The client is oriented to person, place, time, and situation. She reports no hallucinations, paranoia, or depersonalization/dissocia

You are a licensed counselor working for a local government mental health agency in the counseling clinic. The client was referred to receive case management and counseling after experiencing homelessness due to leaving a physically and verbally abusive relationship with her last partner. The client is experiencing the following depressive symptoms: sadness more often than not, mental fogginess, suicidal ideation, insomnia, significant weight loss, feelings of worthlessness, and fatigue. The client experiences PTSD symptoms due to having experienced several abusive relationships, including recurrent distressing intrusive thoughts regarding the physical abuse, distressing dreams related to abuse, and physiological reactions (difficulty breathing, heart racing) when she goes near certain places that remind her of the abuse. She also explains that she has been avoiding triggers, believes that no one can be trusted, has an exaggerated startle response, and has had difficulty experiencing positive emotions. The client says that she does not know if therapy can help because she feels like these events have changed her and that she cannot get back to “normal,” but that she would like to make friends so she doesn’t feel so alone.

tion. Family History: The client has three adult children: a daughter(age 32), son (age 30), and a second daughter (age 28). The client reports on and off relationships with her children historically because they did not want to be around these men, but that they have rekindled their relationships recently. The client has been married twice, and, in addition to her most recent partner (unmarried), all three men have been physically and verbally abusive toward her

Based on the client’s past relationships, which of the following would be helpful in understanding the client’s relationship patterns?

Clinician Administered PTSD Scale for DSM-5-TR

Relationship Assessment Scale

A genogram

Adult Attachment Interview

(A): Clinician Administered PTSD Scale for DSM-5-TR (B): Relationship Assessment Scale (C): A genogram (D): Adult Attachment Interview

A genogram

C

Creating a genogram could be very helpful with this client because it examines relationships with family members and is a visual representation of these relationships including the psychological factors that affect the family and the client. This can be helpful in understanding where this client came from and how it shaped her current functioning. Creating a genogram can also help open up a conversation regarding her history. The Clinician-Administered PTSD Scale might be helpful in understanding the client’s level of PTSD symptomatology, but it would not give insight into the client’s relationship patterns. The Relationship Assessment Scale identifies general satisfaction levels in a current relationship and would not be helpful for this client. The Adult Attachment Interview might be helpful in understanding the client’s attachment with her parents, but the genogram would provide a more global understanding of the client’s family history and the client’s relationships with others in her family. Therefore, the correct answer is (A)

counseling skills and interventions

Name: Gary Clinical Issues: Behavioral problems Diagnostic Category: Disruptive/Impulse-Control/Conduct Disorders Provisional Diagnosis: F91.3 Oppositional Defiant Disorder Age: 10 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Not Assessed Ethnicity: White Marital Status: Not Assessed Modality: Individual Therapy Location of Therapy : Agency

The client reluctantly enters the session accompanied by his mother. He is slightly overweight for his age and is wearing clothes that appear too small for his physique. He is sitting in the chair with his arms crossed, refusing to make eye contact with you. His mood is angry, and his affect is irritable. His attitude during the initial part of the examination is defiant. Speech characterized by short responses and refusal to engage in conversation. Client refuses to discuss feelings or issues. He appears to have difficulty focusing. He lacks insight into his behavior and impact on others. Judgment and impulse control are poor. He denies suicidal or homicidal ideation.

First session You are a mental health therapist in an agency, and a 10-year-old male is referred to you due to behavioral issues. The client and his mother arrive at your office, and you note that he has an irritable look on his face. The two are arguing with each other. His mother threatens him with punishment if he does not cooperate with you and says that this is his "last chance". He glares at her and then stares at the floor. You introduce yourself and explain what you do as a therapist. The client barely says a word and keeps his head down with his arms crossed over his chest. You ask the mother to describe the issues that prompted her to seek help and she begins to tell you the story. She explains that her son has difficulty listening to adults and gets into verbal altercations with his peers. She informs you that he got suspended again from school because he lost his temper in the cafeteria when the student in front of him in the lunch line "wasn't moving fast enough". When you ask about how often his temper outbursts occur, the mother pauses for a moment to think and says, "It seems like he's always losing it, but I guess maybe a few times a month? The rest of the time, he's just angry, mostly at me and other adults. No matter what I do, he seems like he hates me." As she tells you this, you notice that the client is not paying attention and continues to look down at the floor, appearing disinterested in the conversation. His mother goes on to say that the school is threatening expulsion if her son's behavior does not improve. After thanking the mother for sharing this information with you, you look toward the client who has been sitting quietly the entire time. You explain that you understand it must be hard for him to be here and that you are not here to judge or criticize him. He looks up at you with a surprised expression on his face. He slowly nods and mumbles something under his breath. You let him know that you want to help him find ways to better manage his emotions so he can get along better with the people in his life. He looks away again, but this time there is a hint of curiosity in his eyes. You sit in silence for a moment. The client finally looks up at you and says, "It's just...everyone's always telling me what to do and they never listen to me. They think they know everything, but they don't. I can't help it if I get angry, but then everyone looks at me like I'm a monster. It's not fair." His mother looks away, tears in her eyes. You thank the client for expressing his feelings and explain that it is normal to feel upset when things are unfair. You further emphasize that you are here to help him find positive ways to handle his anger and other emotions. You then address the mother, "Parenting can be challenging, especially when it feels like your child is angry or upset with you. I'd like to work with both of you to improve your communication and relationship. It might be helpful to schedule separate sessions for you and your son, as well as joint sessions, so we can address individual concerns and work on improving your relationship together." The mother agrees, and you proceed to discuss a plan of action, including setting up regular weekly therapy appointments and providing resources to help support the family. Fifth session It has been over one month since you first began working with the client. You've been meeting with him for individual therapy and have implemented parent training with his mother. During previous counseling sessions, you focused on building rapport with the client and talked about different triggers for his outbursts. He said that he often gets angry when people do not listen to him or when they try to tell him what to do. You also discussed strategies for managing these triggers and the importance of communicating his needs in a respectful way. Last week, as part of your parent management training approach, you assigned the mother homework to read from a parent training handbook. When the client arrives for today's session, he is clearly upset, saying that he does not want to be here. His facial expression is one of anger and frustration. His mother is exasperated and apologetic. You calmly remind her that it is all right, that this is a normal part of the process. You ask if she would like to accompany them into your office, but she declines, saying that she needs some time to herself and she would like to wait in the waiting room for the first half of her son's session. Once inside your office, you start by asking the client why he does not want to be here. He says that he is tired of talking about his problems and he does not think it will make any difference. When you ask him to tell you more, he glares at you and says, "Why do you care? You're only asking because you want to get paid." You acknowledge how difficult it can be to keep coming back, but emphasize that whatever feelings he is having in this moment are valid and important. The client then looks away and sighs. He slowly says, "I don't know why I have to keep coming here...it feels like no matter what I do, nothing changes. I still get mad, my mom and teachers still get mad at me, and the school still threatens to kick me out." After a few moments of silence, you ask the client if he remembers what goals were set for the session today. He looks away and mumbles something under his breath. You gently remind him that you want to help him learn how to manage his emotions in a healthier way so he can get along better with the people in his life. He gradually relaxes and you ask him what strategies he has been using in the past week to work toward this goal. He thinks for a few moments before recounting an incident at school where instead of getting angry, he took a deep breath and walked away from the situation. You use behavioral modification techniques to encourage this positive behavior. You then move into today's activity, which is a role-play exercise. Once you have completed your planned tasks with the client, you invite his mother in to your office to provide her with feedback on her son's progress and discuss next steps with parent training.

The client's father left the family two years ago. The mother, still married to him, retains sole legal custody of the client. Since his father left, the client will not help out around the house, seems angry, and sometimes loses his temper when he does not get his way. The client receives frequent but inconsistent corporal punishment from his mother. His mother made the appointment with you but did not tell him where they were going. The relationship between the client and his mother has been strained as the mother does not know how to handle the abandonment of the father. The client is in fifth grade and has been skipping school for the last six months and refuses to do any homework. His school records were released to you and show A's and B's through third grade, but C's and D's during the past two years. His decline in grades coincides with his truancy. He is also known as a "bully" at school and has been suspended and given detention a few times due to his behavior. He has a history of walking out of classrooms, running down the hallways, refusing to sit in his chair, and running away from the school counselor or anyone in an authoritative position. Personal/Social Relationships: The client does not have friends his age in the neighborhood, and parents do not want their children playing with him because they believe he is a "troublemaker". In addition, children in school avoid him because they are afraid of upsetting him. He does not seem interested in making friends and does not care to engage in any play time with the neighborhood children. Instead, he spends most of his time alone playing video games.

What is the primary purpose of parental skills training?

To create a sense of trust between parent and child

To help parents understand their children's emotional needs

To help parents learn how to control their children's behavior

To provide parents with tools for engaging in positive parenting practices

(A): To create a sense of trust between parent and child (B): To help parents understand their children's emotional needs (C): To help parents learn how to control their children's behavior (D): To provide parents with tools for engaging in positive parenting practices

To provide parents with tools for engaging in positive parenting practices

D

The primary goal of parental skills training is to provide parents with evidence-based tools and techniques for fostering healthy relationships with their children. Therefore, the correct answer is (B)

counseling skills and interventions

Client Age: 8 Sex: Male Gender: Male Sexuality: Unknown Ethnicity: Hispanic Relationship Status: Single Counseling Setting: Home Health Outpatient Therapy Type of Counseling: Individual with Family Involvement Presenting Problem: Behavioral Issues Diagnosis: Oppositional Defiant Disorder, Severe (F91.3)

Mental Status Exam: The client was argumentative and did not engage in the entire intake session. The client was oriented to person, place, situation, and time. He was dressed appropriately for the weather and appeared well groomed. The client appeared clean and had appropriate hyg

You are a home health outpatient therapist working with an 8-year-old male in the home setting. The client’s parents will be actively involved in counseling due to the client’s age. The client was referred to receive counseling by his school social worker. He has been having behavioral issues in school that have led to difficulty staying in the classroom and is resultantly falling behind in academics. During the first session, the client refuses to engage and leaves the room. The client’s parents prompt him to return, and he calls them “jackasses” and leaves the room again. The parents finish the intake session with you and provide you with a report on their observations in the home and reports from the school social worker. The client reportedly often loses his temper and is generally easily annoyed or angered. The client has trouble taking direction from his teachers and parents. The client’s parents also state that he often blames his younger sister for things that he does and often tries to annoy her. The parents have trouble identifying any of the client’s friends and state that he does not get along with his peers.

iene. Family History: The client’s parents are married, and he has a younger sister who is 6 years old. The client often deliberately annoys or angers his younger sister and has difficulty following directions from his parents

Which of the following would be a clinically appropriate short-term goal at this point in therapy once rapport is built?

Improve the client’s ability to follow directions from his parents.

Improve social interactions with peers and his sister.

Improve grades and functioning in school.

Improve the client’s awareness of the consequences of his actions.

(A): Improve the client’s ability to follow directions from his parents. (B): Improve social interactions with peers and his sister. (C): Improve grades and functioning in school. (D): Improve the client’s awareness of the consequences of his actions.

Improve the client’s awareness of the consequences of his actions.

D

The client becoming more aware of the consequences of his actions would be an appropriate short-term goal at this point in the therapeutic relationship. This would be appropriate because it is prioritizing creating awareness more than a significant change in behavior and would assist the client in knowing what he is doing and how it affects himself and others. Assisting the client with awareness of his behavior can also help because if the client can find more effective ways of meeting his needs, he may be more motivated to make changes. Grades, functioning in school, social interactions, and ability to take directions are more long-term goals of therapy because they require incremental change and will take time to achieve. Therefore, the correct answer is (C)

treatment planning

Name: Tabitha Clinical Issues: Family conflict and pregnancy Diagnostic Category: V-codes Provisional Diagnosis: Z71.9 Other Counseling or Consultation Age: 16 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: Latina Marital Status: Not Married Modality: Individual Therapy Location of Therapy : School

The client appears healthy but tired and distracted. She is dressed in loose-fitting clothing and sits with her hands between her knees. Eye contact is minimal. Speech volume is low. She is reluctant to talk at first and denies having a problem. Thought processes are logical, and her thoughts are appropriate to the discussion. The client's estimated level of intelligence is within average range. She appears to have difficulty maintaining concentration and occasionally asks you to repeat your questions. The client denies suicidal ideation but states that she has been considering abortion. She has not acted on anything but is feeling very overwhelmed and desperate.

First session You are a school counselor in an urban school setting. The client is a 16-year-old student who is reluctant to see you. The session begins with a discussion of the teacher's concerns and your role as a school therapist. After some gentle probing and reassurance, the client is able to open up more and discuss her difficult relationship with her father. She identifies feeling overwhelmed and frustrated by his expectations, which leads to frequent arguments between them. She appears tired and has trouble sleeping at home because her parents constantly argue. She suggests that her parents "are the ones who need therapy, not me." She briefly describes the arguments that she claims her parents get into regularly. "They are always going at it, unless thay are at church. Then they act like everything is perfect." When you ask about her friends and activities, she tells you she is involved in her church youth group and has an on-again/off-again boyfriend. You ask the client, "Can you tell me more about your relationship with your boyfriend? How long have you been together?" She says that they have been seeing each other for about a year, and she thought he was 'the one', but they had a "big fight" last week and have not talked since. You ask what she means by 'the one'. She looks down at the floor and starts to bite her fingernails. You see a tear fall down her cheek. She says, "I don't know what to do." You continue the session by providing a safe space for her to express and explore her feelings about her relationship with her boyfriend. She takes a deep breath and tells you that there is something she has not told anyone and she is scared that if she says it out loud that "it will make it too real." You tell her to take her time and that you are here to listen without judgment. She tells you that she missed her last menstrual period, and several "in-home" tests confirm that she is pregnant. She has not told her boyfriend and is scared to tell her parents because she is afraid they will disown her, so she has decided to keep the pregnancy a secret. While you are tempted to try to talk the client into telling her parents and boyfriend about her pregnancy, you recognize that it is important to respect her autonomy and allow her to make the best decision for herself. You provide her with accurate information about the options available to her and encourage her to explore the pros and cons of each option. You share that having a support system and someone to talk to during this time can be helpful. She nods her head and tells you that she knows that her parents will find out about the baby eventually, whether she tells them or not, but she is anxious about how they will react to the news. You listen and provide empathetic reflections to help her gain insight into her feelings. You then focus on helping the client develop effective coping strategies for managing her stress and anxiety about the situation. You let the client know that she can come back to see you at any time if she feels overwhelmed or needs additional support. The session concludes with an understanding of what to expect in future sessions, including exploring possible solutions for dealing with her parents and boyfriend, as well as developing healthy coping skills for managing her emotions. Second session A fews day after the intake session with your client, she stopped by your office and asked if she could talk to you for a few minutes. She told you that since your last session, she decided that she wanted to tell her parents and asked if you could be there when she told them. You set up an appointment to meet with the family. This is your second session with the client and she appears very nervous. When she sits down in the chair in your office, she tells you that she changed her mind about telling her parents. She keeps repeating, "I can't do this. You tell them." Your office phone rings, and the secretary tells you the client's parents have arrived. The client immediately bursts into tears and begs you not to let them in. You calmly explain that you are here to provide a safe space for her and will support her. You walk her through a grounding exercise and encourage her to take slow, deep breaths. After a few minutes, she relaxes and indicates she is ready to talk to her parents. You welcome the parents into your office and introduce yourself as a mental health professional who has been working their daughter. You explain that the client has something she would like to tell them and you will be here to help facilitate their conversation. Her father says, "We know that something is going on." He starts talking about his daughter's academic issues and recent argumentative behavior at home. The mother adds, "We pray daily that she will grow out of this hormonal phase. We miss our innocent little girl." You listen and reflect on the parents' feelings as they talk about their daughter. The client is quiet and looks down, not making eye contact with anyone. After a few moments, you gently encourage the client to share her thoughts and feelings. She tells you that she has something important to tell them but does not know where to start. You suggest that she take her time and start with whatever feels most comfortable for her. The client takes a deep breath and slowly begins to tell her story. She tells them about her pregnancy and how scared and overwhelmed she has been. At that moment, everything changed. The client's parents are no longer focused on her academic or behavioral issues. Instead, they are now focused on their daughter and her pregnancy. They are full of questions and concerns for their daughter's well-being. The mother looks shocked, and the father demands to know who the boy is that "did this to our daughter." The initial conversation is difficult, but you provide support as the family talks through their feelings.

The client has an older brother who is in college. The client lives at home with her parents. They are members of a Christian church and are all actively involved in their church group, and the client has a good relationship with her pastor. The client has never felt close with her father and says he has always had "high standards and expectations" for everyone in their family. The client says her parents "treat her like a child." She has not told her parents about her 16-year-old boyfriend as she knows they will disapprove. For the last year, she has been asserting her independence from her parents, which has caused conflict, friction, and discord within the family. The teacher who referred the client to you mentioned that the client has seemed distracted and anxious lately. She has not been completing homework assignments and failed a test last week. The client acknowledges these concerns and tells you she struggles to keep her grades up and has difficulty adjusting to hybrid learning. "One day, we're in school, and the next day we're virtual. It's just exhausting. I feel like giving up."

Based on the client's home life, the realities of her pregnancy, and her relationship with her parents, which would be the most beneficial short-term goal to include in a treatment plan?

The client will learn an array of emotion regulation strategies to assist her in effectively functioning with her parents in conflictual situations.

The family will learn and understand triggers and negative patterns contributing to their family problems.

The client and her parents will engage in a psychoeducational unit regarding the physiological and psychological implications of teen pregnancy.

The client and her parents will learn effective communication and conflict-resolution skills to overcome barriers to meaningful conversations.

(A): The client will learn an array of emotion regulation strategies to assist her in effectively functioning with her parents in conflictual situations. (B): The family will learn and understand triggers and negative patterns contributing to their family problems. (C): The client and her parents will engage in a psychoeducational unit regarding the physiological and psychological implications of teen pregnancy. (D): The client and her parents will learn effective communication and conflict-resolution skills to overcome barriers to meaningful conversations.

The client and her parents will learn effective communication and conflict-resolution skills to overcome barriers to meaningful conversations.

D

This is the most beneficial short-term goal to include in her treatment plan because it highlights their presenting problems. Therefore, the correct answer is (D)

treatment planning

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.

Which of the following is the most helpful response for the client when she reported experiencing panic out in public?

"You did the right thing by calling your friend to help you calm down, great job!"

"There's nothing to be afraid of right now, it's likely a reaction to your past trauma."

"Always ensure you know where the nearest police officer is, your safety is paramount."

"Next time you have anxiety, remind yourself of everything you are grateful for!"

(A): "You did the right thing by calling your friend to help you calm down, great job!" (B): "There's nothing to be afraid of right now, it's likely a reaction to your past trauma." (C): "Always ensure you know where the nearest police officer is, your safety is paramount." (D): "Next time you have anxiety, remind yourself of everything you are grateful for!"

"You did the right thing by calling your friend to help you calm down, great job!"

A

Using a strengths-based approach, affirming the client of what she did well is the best response. The client reached out to a safe contact requesting support in soothing her nerves; this is the next best thing to being able to soothe herself. Invalidating her experience of fear, assuring her safety where it is not felt, offering irrelevant interventions, or increasing her anxiety by elevating the severity of her fears are all things to be avoided when helping an anxious client overcome panic. Therefore, the correct answer is (A)

counseling skills and interventions

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.

Which of the following does not need immediate assessment in Nadia's case?

Mental status

Where Nadia goes when she is away

Cognitive and adaptive functioning

Parent/child relationship

(A): Mental status (B): Where Nadia goes when she is away (C): Cognitive and adaptive functioning (D): Parent/child relationship

Parent/child relationship

D

Although it is important to explore Nadia's relationship with her parents, there are more immediate concerns. These include knowing where Nadia goes when she runs away, to assess for safety. It is also important to assess Nadia's cognitive and adaptive functioning since her cognitive functioning seems low. This is not uncommon for those who have experience extensive abuse and trauma. A mental status exam would also assess for risk and current mental capacity. Therefore, the correct answer is (D)

intake, assessment, and diagnosis

Name: Chad Clinical Issues: Maladaptive eating behaviors Diagnostic Category: Feeding and Eating Disorders Provisional Diagnosis: F50.2 Bulimia Nervosa, Moderate Age: 16 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: White Marital Status: Not Assessed Modality: Individual Therapy Location of Therapy : Agency

The client is appropriately dressed but disheveled. He is dressed in clothes associated with anime characters. Concentration is drifting. His speech is somewhat low, and he keeps his head low to avoid making eye contact with you. His mood is anxious. There is no suicidal ideation. Thought content shows no current homicidal ideation or plans. Thoughts are appropriate. The estimated level of intelligence is in the low average range with abstract thinking.

First session You are a mental health therapist who works for an agency specializing in helping teens with eating disorders. The client is 16 years old. He presents for therapy along with his mother. You start by welcoming both of them into your office. Then you introduce yourself, explain your role as a therapist, and briefly describe the experience you have in treating eating disorders. Next, you ask the client to explain and his mother to share with you why they came to see you today and what their expectations are for therapy. The mother begins by telling you, "My son is doing dangerous things to his body. He needs help, but he won't listen to me." The client rolls his eyes and replies, "She doesn't get it. Look at her. She's fat and is always overeating!" His mother's face turns red and she starts to yell at him. You remain neutral and ask them both take a few deep breaths and give each other some space. You explain that your goal is to create a trusting relationship with the client and his mother so that you can start working together towards understanding the issues that bring them to counseling and how to best help. You ask the mother to take a seat in the waiting room while you speak with her son for the first part of the session. She reluctantly agrees and leaves the room. Once the mother leaves, you start by letting the client know that you understand that this situation is difficult, and that you are here to help. You focus on building rapport with the client, emphasizing that you are here to help him. You ask him open-ended questions to get to know more about him, and to help him feel seen and understood. You acknowledge the client's feelings of being misunderstood and provide empathy by validating that it must feel difficult not having his mother understand what he is going through. You also recognize his mother’s concerns by saying, "It sounds like your mom is really worried about you." He tells you that his mother is constantly trying to control him and that he does not understand why she is always so angry all the time. You continue your assessment with structured questioning to understand the client’s current experiences with food, including what he likes to eat and how often he eats. At the end of your discussion with the client, you thank him for being open and honest with you. You acknowledge how brave it is to come in and start talking about his experiences. You invite him to bring his mother back in to the office so you can start working together and discuss the next steps. Fourth session It has been three weeks since the first counseling session, and you have agreed to meet for weekly sessions. You have been able to develop a positive rapport with the client, and he arrives to the scheduled session on time. When you ask him how he has been feeling, he tells you that he has been experiencing some anxiety. He has been having trouble sleeping and difficulty concentrating. He tells you that during his last cheerleading routine at a football game, he froze up and forgot what to do. You ask him if his anxiety may have anything to do with being bullied years ago. He tells you, "I don't wanna talk about that. My anxiety is about cheerleading. Ugh! Haven't you been listening to what I've been saying?" You remain calm and acknowledge the client's frustration. You reply, "You're angry with me because you feel that I'm not listening. Am I hearing you right?" He glares at you. You apologize, saying that you are sorry that something you said made him upset and ask him to tell you more about his anxiety. The client takes a few deep breaths and begins to tell you about the anxiety he feels towards cheerleading. He mentions that his mother used to be a cheerleader and she often tries to relive her glory days through him. He tells you he feels like his mother is always pushing him to do more and be better, but "she just doesn't get how hard it is for me." He also talks about feeling guilty when he fails to meet her expectations. You respond by saying, "It sounds like there's a lot of pressure on you from your mom. How do you cope with these expectations?" He says that he has been trying to distract himself from his feelings by watching television, playing video games, and eating. You take a moment to process this information and validate his feelings. You and the client agree to explore some healthier coping strategies, along with continuing to build a stronger connection between him and his mother. You also discuss the importance of having a support system of people who can lend an ear when he needs someone to talk to and provide emotional support.

The client does well in high school. He is concerned that he could quickly gain weight and no longer be in optimum shape for cheerleading and gymnastics. The client's self-esteem is closely related to his weight and body image, and he appears to lack insight into the dangers of his current eating behaviors. Stressors & Trauma: The client tells you throughout elementary school he was overweight. As a result, he was bullied by other boys and girls alike. They would leave notes on his desk saying "fatty" or "crispy crème." One student pushed him down in the schoolyard, and all the others stood in a circle around him and laughed as the client cried. Pre-existing Conditions: No significant medical issues were reported based on his last medical exam. He does, however, admit to eating four hamburgers and a large bag of French fries at a fast-food restaurant "as a treat" about four or five times a week. He shares that after these fast food "splurges," he goes home and purges to not gain weight. Feeling guilty after each episode, he does not eat anything the next day and doubles his workout routine.

You feel the client may benefit from concurrent treatment. Who would you refer the client to based on symptoms?

Involuntary hospitalization

Psychiatrist

Marriage Family Therapist

Family Therapy

(A): Involuntary hospitalization (B): Psychiatrist (C): Marriage Family Therapist (D): Family Therapy

Psychiatrist

B

A psychiatrist would be beneficial for treatment of the client's anxiety, especially as medication may be needed at this time. Therefore, the correct answer is (D)

treatment planning

Client Age: 45 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Divorced, single Counseling Setting: Private practice Type of Counseling: Individual counseling Presenting Problem: The client is experiencing difficulty in functioning in all areas of his life due to inhalant use. Diagnosis: Inhalant use disorder, severe (F18.20)

Mental Status Exam: The client is oriented to person, place, time, and situation. The client does not appear to be under the influence of inhalants because he does not display any symptoms of use. The client is friendly and engaged in the ses

You are a licensed counselor working in a private practice. You specialize in substance use disorders. The client comes into the session, is very friendly, and states that although his sessions are court ordered, he wants to get help with his inhalant use. The client spent the first half of the session explaining what happened to lead to him getting his third charge of driving under the influence of inhalants. The client says that he had twin sons 13 years ago and they both were in the ICU; one of his sons died after about a month. The client began drinking alcohol to excess daily for about 6 months, which then transitioned to inhalant use. The client says that he uses contact cement, model glue, paint, and permanent markers to become intoxicated. The client identified the following symptoms of inhalant use disorder: increase in frequency and amount of use over the past 5 years, several failed attempts at cessation of inhalant use, craving inhalants throughout every day, losing several jobs because of his inability to get to work on time due to inhalant use, use that has affected his ability to have visits with his children and maintain employment, use that increases the risk of harm to himself and others such as driving under the influence, increased tolerance, and continued use even when he knows it is negatively affecting his life. The client wants to become sober, improve his relationship with his children, and maintain employment.

You meet with the client after he requested an emergency appointment. The client says that he had a supervised visit with his children and he had used inhalants prior to the visit because he was anxious. The supervisor noted the intoxication and ended the visit early. The client says that this was 3 days ago and that he has used inhalants several times daily since the visitation. Due to his intoxication at the visit, all future visits have been canceled until the next hearing in court regarding visitations. The client says that he has been very depressed and that is why he is using inhalants. During the session, the client asks if he can go to the lobby to get water and you tell him that this is fine. The client returns, sits down, and appears listless because he is not displaying any emotion and has a very flat affect. You suspect that he is now intoxicated. You want the client to know that you are listening because he is expressing strong emotions and you want to support him

You want the client to know that you are listening because he is expressing strong emotions and you want to support him. All of the following demonstrate therapeutic listening, EXCEPT:

Refraining from the use of “mm-hmm” and similar responses

Identifying and discussing verbal/nonverbal inconsistencies

Attentive silence

Mirroring

(A): Refraining from the use of “mm-hmm” and similar responses (B): Identifying and discussing verbal/nonverbal inconsistencies (C): Attentive silence (D): Mirroring

Refraining from the use of “mm-hmm” and similar responses

A

A balanced use of affirmative sounds (“mhmm,” “yeah,” etc). lets the client know that you are listening to him. Be conscientious about how often you use these responses because they can be distracting, may appear as though you are rushing the client, or may appear as though you are disinterested. Silence generally does not provide the client with the feedback that you are listening to him. However, attentive silence with body language that demonstrates you are listening can allow the client the space to speak freely. Mirroring involves repeating key words or phrases that the client uses to demonstrate that you heard the important pieces of what was said. Identifying and expressing that you notice inconsistencies in verbal and nonverbal communication is important but needs to be done carefully. This demonstrates to the client that you hear him and recognize how he feels. Therefore, the correct answer is (C)

counseling skills and interventions

Name: Bianca Clinical Issues: Difficulty adjusting to life changes Diagnostic Category: V-codes Provisional Diagnosis: Z60.0 Phase of Life Problem Age: 62 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: Black Marital Status: Separated Modality: Individual Therapy Location of Therapy : Agency

The client is a 62-year-old female, wearing work attire. She appears to be in good hygiene and her dress is neat and appropriate for the situation. Her facial expression is sad and she has tear tracks on her cheeks. Her mood is noticeably depressed, anxious, and tearful. Her affect is constricted. She has coherent thought processes with appropriate content. She expresses feelings of sadness over her failed marriage and overwhelm about being alone. The client has intact memory and concentration. She has fair insight into her current situation and is able to verbalize her feelings in a coherent manner.

First session The client comes to the agency practice where you currently work as a licensed mental health therapist. She is a 62-year-old female who recently retired from an accounting firm employment. She is seeking treatment after her marriage recently failed. A few months ago, he husband filed for a legal separation and is currently romantically involved with another woman. The client looks at you tearfully and says, "I can't believe this is happening at my age. I am all alone. What am I going to do?" She continues to cry uncontrollably. You focus on providing a safe and secure environment. You assure her that she will not be judged or criticized in any way, and all of the conversations during the session will remain confidential. You gently let her know that it is okay to cry, and you are there to listen without judgement. You also tell the client that it is natural to feel lost and alone after a separation, especially since she and her husband have been together for such a long time. She says, "I just feel like such a fool. He cheated on me once before - that I know of - and now he's done it again. I stayed with him for over 30 years, and now I have nothing." She describes having mixed feelings of anger, sadness, fear, and confusion. She states, "There are moments where I'm so mad at him for leaving. Mad enough that I could break something! Our marriage wasn't perfect, but I thought he was committed to me. Well, obviously he wasn't. Then I start to question what's wrong with me that made him leave. And then I think about the future and how I'm going to live by myself. It's all so overwhelming." She further discloses that she is worried about having panic attacks again because "that's what happened the last time something of this magnitude happened to me." You reinforce the idea that it is important to focus on the fact that she is not alone and many people in similar situations feel overwhelmed and uncertain about their future. You let her know she is in a safe space to explore her feelings, work through her loss, and develop a plan for moving forward. You encourage her to reach out for support during this challenging time rather than isolate herself as she goes through this difficult change. Fifth session The client has been seeing you for individual therapy sessions every week. You have developed a strong rapport with her and collaborated on treatment goals, with her overall goal being to have a positive outlook on her life. During the last session, you gave her a homework assignment to begin keeping a journal, using the ABC model of rational emotive behavior therapy to identify self-defeating beliefs and understand how they are contributing to her emotional distress. You have also been working with her to process her feelings about her separation and develop coping skills. During today's session, she seems depressed, as she tells you her husband met with an attorney and officially filed for divorce. You explore her journal entries, noting one in particular in which she describes an experience in which she was driving and saw her husband sitting outside a café with "the other woman." She circled back a few times in her car, hoping he would see her. In her mind, she fantasized that he would leave his new girlfriend and drive away with her, and everything would return to normal. You ask her to tell you more about what "normal" means to her. She says, "I guess I just want things to go back to how it was before. When I mattered, when I felt loved, and when he was committed to our marriage." You acknowledge her feelings and explain that while it may not be possible to go back to exactly how things were, there is still hope for the future. You express compassion and understanding, emphasizing that there is no right or wrong way to feel. She states, "I just have mixed feelings about everything! I feel angry and betrayed by my husband, but sometimes I want him to come back. I start to feel lonely and realize the reality of my situation and that I have no purpose anymore and am alone. What's the point? My kids don't care; I have nothing in my life now. Things are so painful I'd be better off dead." You reassure her that you are here to support her as she works through all of her difficult emotions. Eighth session The client has been attending sessions weekly for two months. Today, you begin by reviewing the progress the client has made in therapy. She has joined a support group and has made some new friends but still feels anxious about her future. She has also joined a bridge group but is finding that she is having difficulty remembering what cards are being played. At your suggestion, she also made an appointment with a psychiatrist and was prescribed a low dosage of Paxil. She feels more positive and states that she may volunteer at a local animal shelter. The client also mentions that yesterday she received official divorce documents in the mail. As she tells you about this, you notice her mood shifts. She quietly shares, "On some level, I think I've known that my marriage has been over for a while, but when I got the legal papers, it made it feel real for the first time. My thoughts are all over the place. I'm still very hurt by all of this, but I know that I need to move forward with my life." The client tells you one of the friends she met in her support group suggested that she consider joining a dating app, and she asks if you could help her. She says, "Technology has changed so much since I first started dating my soon-to-be ex-husband. I don't know how any of this works!" You validate her feelings and offer her reassurance that these kinds of emotions are completely normal in this situation. You suggest she take some time to process and grieve the end of her marriage. You also remind her that it is important to focus on some of the positive aspects of starting a new chapter in her life. You talk about how she can use the skills she has learned in therapy to manage her negative emotions and focus on positive self-talk. Additionally, you suggest some healthy coping strategies for managing the stress of this transition including exercise, meditation, journaling, and spending time with her new friends. You then refocus on the topic of dating, and you provide some helpful tips such as creating a profile that accurately reflects her interests, making sure to be honest about who she is, and being mindful of safety when meeting people in person. Finally, you remind her that it is important to take things slow and enjoy the process of getting to know someone. You also encourage her to remember that relationships can take different forms and that it is okay if she is not ready for a romantic relationship right now. At the end of the session, you check in with her and ask how she is feeling. She tells you that while she still feels overwhelmed, she is feeling more prepared to move forward with her life. You end the session with words of encouragement and remind her that you are here to support her.

Why would the psychiatrist you referred the client to prescribe a low dosage of Paxil?

Address her panic attacks

Address her anxiety

Address her insomnia

Address her forgetfulness

(A): Address her panic attacks (B): Address her anxiety (C): Address her insomnia (D): Address her forgetfulness

Address her anxiety

B

Paroxetine (Paxil) is an antidepressant used to treat various mental health conditions in adults, including depression, anxiety, and panic disorder. Therefore, the correct answer is (B)

counseling skills and interventions

Initial Intake: Age: 70 Gender: Female Sexual Orientation: Heterosexual Race/Ethnicity: Caucasian/Non-Hispanic Relationship Status: Widowed Counseling Setting: Private Practice Telemedicine Type of Counseling: Virtual Individual

Mary presents with anxious mood and congruent affect. Speech is normal rate and tone, motor movements within normal limits. Denies hallucinations, delusions, suicidal or homicidal ideation. Mary is well-dressed, adorned with makeup, jewelry, and stylish hairstyle. Mary frequently resists the urge to cry as evidenced by smiling and deflecting when becoming tearful. She tells you she wants to work on herself but appears mildly offended whenever given feedback or asked a personal question and then changes the subject.

Diagnosis: Anxiety disorder, unspecified (F41.9), Adjustment disorder, unspecified (F43.20) You are an associate counselor and receive a new referral for a virtual client through your company’s telehealth practice. Mary is a 70-year-old widow who lives alone with her dog in a 55+ active living community. Mary moved to her town to live closer to her daughter and son-in-law when she lost her husband suddenly to cancer four years ago. Mary is struggling with feeling comfortable leaving the house or engaging in any social gatherings outside of being with her children. She wants to make friends her age and take local activity classes, but her anxiety prevents her from committing to plans. Mary has been widowed for four years but has not yet committed to counseling or attendance in grief support groups. She has felt insecure socially since her husband died, but reports being a “social butterfly” before his passing. She admitted to only visiting her husband’s grave on his birthday but is unable to do so any other time. Also, since the COVID-19 outbreak, Mary’s fears and concerns have increased as she is immunocompromised. She asks you for counseling but cannot define what she wants to get out of it.

Family History: Mary was married to her children’s father for 25 years until he had an affair and left her for the other woman. After a few years, Mary met her late husband and was married another 20 years until he became diagnosed with lymphoma and died within three months of being diagnosed. Mary has three older sisters, all of whom live in different states but come to visit seasonally. She celebrates her late mother’s birthday annually, expressing symptoms of grief each year, and becomes inconsolable on the anniversaries of her late husband’s passing. She tells you only country music calms her down. Work History: Mary was a stay-at-home mother and wife for both of her marriages, working several jobs in-between marriages as a children’s dental receptionist and an antiques shopkeeper. She opened her own shoppe after meeting her late husband where she sold and displayed southern home décor. She had to close her store down when her husband moved for work. She spent much of her free time making greeting cards and crafts at home, until her hands developed arthritis and she lost enjoyment of her hobbies. She now lives off social security and her late husband’s estate that he left for her.

In assessing for Social Phobia, which is the best description of Mary's presentation?

Avoidance causes clinically significant impairment in social functioning

Persistent concern or worry about people noticing her anxiety

Mary is afraid of getting sick by others in public

Complex grief has developed into severe social phobia

(A): Avoidance causes clinically significant impairment in social functioning (B): Persistent concern or worry about people noticing her anxiety (C): Mary is afraid of getting sick by others in public (D): Complex grief has developed into severe social phobia

Avoidance causes clinically significant impairment in social functioning

A

Mary's contributing factors to her social anxiety are numerous, however her response to her fears is the same in that all are subject to her avoidance. Therefore, summarizing her symptoms because of specific factors (such as in answers a, b, or d) is not the best choice. Therefore, the correct answer is (C)

intake, assessment, and diagnosis

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

All of the following are helpful cognitive behavioral therapy (CBT) techniques to manage the anxious thoughts that lead to a panic attack, EXCEPT:

Reframing

Progressive muscle relaxation

Radical acceptance

Thought stopping

(A): Reframing (B): Progressive muscle relaxation (C): Radical acceptance (D): Thought stopping

Radical acceptance

C

Radical acceptance is a DBT technique that does help with anxiety because it is about seeing the world how it is and accepting your reality, but it is not a CBT technique. Although acknowledging that a panic attack is occurring is helpful, it takes away the individual’s power to change her situation if she simply accepts it. Thought stopping and reframing are helpful cognitive techniques to manage the spiraling anxious thoughts that build into panic attacks. Progressive muscle relaxation is a helpful technique to use in the moment to calm her body down physically and to calm her mind. Therefore, the correct answer is (D)

counseling skills and interventions

Client Age: 26 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Community Mental Health Agency Type of Counseling: Individual Presenting Problem: Hallucinations and Delusions Diagnosis: Schizophrenia 295.90 (F20.9)

Mental Status Exam: The client displays an angry affect, and his mood is irritable. His speech is disorganized and pressured. He is oriented to person, place, time, and situation. He reports audiovisual hallucinations, which include seeing “the shadow man” and hearing voices others cannot hear. The client exhibits tangential and disconnected thinking. He is firm in his conviction that he is being poisoned and says he is exhausted from constantly trying to maintain vigilance. The client’s insight and judgment are poor. He denies suicidal ideation, homicidal ideation, and command hallucinations. The client first experienced symptoms of schizophrenia in his late teens but was misdiagnosed with bipolar disorder until rece

You are a counselor working in an outpatient community mental health center serving clients with severe psychiatric disorders. A 26-year-old male, accompanied by his caseworker, presents for counseling due to symptoms of schizophrenia. The caseworker reports that the client was doing well until he stopped taking his prescription medication. He resides in assisted living, where he was placed after being discharged from the hospital last month. The client claims someone he calls “the shadow man” is following him and putting poison in his food. The caseworker reports that the client has been more agitated recently and has engaged in verbal altercations with other residents. The client is refusing to take his medication because of the side effects. He had an initial therapeutic response to Haldol, an antipsychotic, but stopped taking it because it made him restless and nervous. He explains, “I felt like I constantly had to keep moving.” The client is adamant about his desire to stay off medication and becomes angry when his caseworker mentions the possibility of going back into the hospital.

ntly. Family History: The client has an older brother who transports the client to appointments and periodically checks in with the client. Hospital records indicate that the client becomes increasingly agitated during visits with his parents. The hospital social worker noted that his father was critical and dismissive toward the client during family therapy. The client’s mother is diagnosed with generalized anxiety disorder and had to quit her job due to the overwhelming burden of the client’s care. The father blames the client for the excessive toll his illness has placed on the family

Which of the following medication side effects is the client experiencing?

Akathisia

Dystonia

Tardive dyskinesia

Parkinsonism

(A): Akathisia (B): Dystonia (C): Tardive dyskinesia (D): Parkinsonism

Akathisia

A

The client is experiencing akathisia. Akathisia manifests as nervousness, restlessness, tension, and creates the need for individuals to feel like they constantly need to move. First-generation antipsychotics, such as haloperidol (Haldol), are commonly associated with extrapyramidal side effects (EPS). There are several EPS associated with antipsychotic medications, such as phenothiazine neuroleptics and haloperidol, and many are painful and can be serious if not treated. Dystonia, tardive dyskinesia, and Parkinsonism are all examples of EPS. Dystonia involves involuntary muscle contractions and can occur in various body parts, including the neck, jaw, head, and back. Tardive dyskinesia affects individuals by causing involuntary movements of the tongue and may impede eating and swallowing. Parkinsonism is commonly expressed as unsteadiness and is characterized by a slow, shuffling gait. Therefore, the correct answer is (B)

intake, assessment, and diagnosis

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 is the value of recommending the client keep a mood journal at this stage of therapy?

It assists her in becoming more introspective rather than too externally focused.

It allows her to identify triggers for different emotional states.

It enables her to practice becoming more aware of her feelings.

It helps her to identify the frequency of the moods she is experiencing.

(A): It assists her in becoming more introspective rather than too externally focused. (B): It allows her to identify triggers for different emotional states. (C): It enables her to practice becoming more aware of her feelings. (D): It helps her to identify the frequency of the moods she is experiencing.

It allows her to identify triggers for different emotional states.

B

Identifying triggers is essential to helping the client curb her mood dysregulation. This is particularly the case for those on the bipolar spectrum. Journaling helps control symptoms and improve mood by assisting with prioritized problems, fears, and concerns. Tracking symptoms on a day-to-day basis both helps the client to recognize triggers as well as to learn techniques to control them better. Therefore, the correct answer is (C)

counseling skills and interventions

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.

An important area to gain more information on at this point is?

Source of anxiety

Cultural factors

Financial situation

Social support

(A): Source of anxiety (B): Cultural factors (C): Financial situation (D): Social support

Source of anxiety

A

It is evident that Li is distressed enough to come to counseling even though she believes she is putting herself at risk and maybe cannot afford it. Starting with the source of her anxiety is important. This may lead to discussion about the other areas which would all be discussed during a comprehensive intake. However, the source of Li's anxiety should be addressed first. Therefore, the correct answer is (B)

counseling skills and interventions

Name: Luna Clinical Issues: Developmental processes/tasks/issues Diagnostic Category: Neurodevelopmental Disorders Provisional Diagnosis: F81.0 Specific Learning Disorder, with Impairment in Reading Age: 13 Sex Assigned at Birth: Female Gender and Sexual Orientation: Female, Heterosexual Ethnicity: Hispanic Marital Status: Not Applicable Modality: Individual Therapy Location of Therapy : School

The client is an average-built individual who is alert. The client is casually dressed and adequately groomed. Speech volume is quiet, and speech flow is slow. She has difficulty maintaining eye contact for extended periods and often looks down at her feet. She demonstrates irritability at times during the interview and sighs several times. Her thought process is logical. Her estimated level of intelligence is in the low average range, with limited abstract thinking. Concentration is intact. The client shows no problems with memory impairment.

First session As the mental health therapist working in a school setting, you welcomed your new client and her parents into your office. They explained their daughter's struggle with reading and how it caused her to freeze when faced with a spelling or math test. After listening to them closely, you asked the client why she did not enjoy reading. She said that words confused her and made no sense, so she found it difficult to remember what she read. You consider possible solutions for your client, who was having difficulty with schooling due to a lack of literacy skills. You proposed an idea: "Let's try incorporating creative activities as part of our therapy sessions." Doing so, we can develop strategies for improving written language comprehension and expression while making learning fun for your daughter." The parents were hesitant but agreed to try it after seeing their daughter's enthusiasm about trying something different than traditional methods like instruction books or worksheets, as those have not been effective in the past. During the session, you brainstormed ideas around stories, role-playing games, and drawing activities focusing on using everyday experiences as inspiration for creating unique narratives within each session – not only reinforcing literacy skills but also providing an opportunity for emotional growth through storytelling exercises.

The client says she is only poor at reading and "good at everything else." She says that she feels stressed when she has to read. The client's IQ is 89. A reading specialist assessed her, and her reading skills are abnormally low. Throughout elementary school, teachers noted the client has difficulty reading and that, in turn, it has adversely affected the client's academic achievement. As a result, special needs are implemented in the client's school setting. The client has an active Individualized Education Plan (IEP). Pre-existing Conditions: The client has also been diagnosed with epilepsy and is on medication for seizures. The client had frequent seizures for many years until a medication that lessened the occurrence of her symptoms was prescribed. The client fell when she was eight, hit her head, and fractured her skull. She was not diagnosed with any traumatic brain injury, but she did need stitches. Additional Characteristics: The client portrays positive interactions with both staff and peers at school. The client does state she feels she is "stupid" when it comes to reading and wishes she could get better. The client's family is supportive and values education. They are hands-on in supporting the client in any way they can.

When developing a treatment plan for this client, what approach has the most likelihood of success given her diagnosis?

Creating a treatment plan that is focused on decreasing anxiety

Creating a treatment plan that prioritizes postponing gratification

Creating a treatment plan that seeks to address social deficits

Creating a treatment plan based on the skill-building and identifying strengths

(A): Creating a treatment plan that is focused on decreasing anxiety (B): Creating a treatment plan that prioritizes postponing gratification (C): Creating a treatment plan that seeks to address social deficits (D): Creating a treatment plan based on the skill-building and identifying strengths

Creating a treatment plan based on the skill-building and identifying strengths

D

There is no "cure" for Specific Learning Disorder, but clients who are struggling with a learning disorder can improve their skills and explore alternate methods of learning that are based on their unique strengths. Therefore, the correct answer is (C)

treatment planning