Domain: Intake, Assessment, and Diagnosis

What client statement disclosed during the session affirms your client’s diagnosis of panic disorder?

Domain: Counseling Skills and Interventions

Which of the following techniques would best address this client’s Obsessive Compulsive Disorder?

Domain: Professional Practice and Ethics

Which of the following is not a potential ethical concern regarding dual relationships?

Domain: Intake, Assessment, and Diagnosis

Which of the following assessments can be used in assessing for Obsessive-Compulsive Disorder?

Domain: Counseling Skills and Interventions

In your first session with a different client, they begin talking about their prior work history, and their goal to keep their current job. Which of the following responses would be most effective in building the therapeutic alliance?

Part Two

First session, two weeks after initial intake appointment

The client provides an update about her work situation, stating that the school has found a long-term sub, however the client’s job position is not guaranteed for next year. She expresses a deep desire to get back into the classroom, and back onto the PTA board because she receives a generous stipend for her participation on the board. She states that she has become good friends with some of the parents from the PTA, and some have found her on social media to ask if she is okay. The client tells you that she has a hard time knowing how to answer the parents’ questions because, although she would love to provide them with a timeline for when she’ll be back, she is unsure of how realistic it is that it will be soon. She tells you that he has frequent dreams that she is in her classroom and she feels as though she is at home among the desks, papers, pencil shavings on the floor, and art supplies that she has organized in the cubbies on the wall. “I know my classroom is my happy place,” she says, “The question is whether or not I can make it through all the scariness on the way to actually get there.” You provide the client with psychoeducation about panic attacks and answer the questions she has, specifically focusing on whether or not panic attacks tend to cause fatalities. The client states that her panic worsens when the thought of her dying comes to mind. You normalize the experience and provide factual evidence that panic attacks are not fatal. The client clings to the phrase, “It’s just a thought. It doesn’t mean it’s true.” You encourage her to post it somewhere where she can see it at home and in the car. The client thanks you for the information and states that she is hopeful at the end of session.
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Domain: Counseling Skills and Interventions

When asking the client about past counseling experiences, why would you say, “What did you find most beneficial about the work you did with your past counselors?”

Domain: Intake, Assessment, and Diagnosis

The phrase that the client clings to as disclosed in Part 2 belongs to which model of counseling?

Domain: Treatment Planning

What is the best intervention for a client who has a history of not completing goals?

Domain: Core Counseling Attributes

How would you interpret this client’s hopefulness at the end of the session?

Part Three

Second session, three weeks after the initial intake appointment

The client comes to session excited to discuss her progress. She states that it has helped to know that she is not going to die every time she feels her heart beating faster. She reports the same amount of panic attacks per week as in her diagnostic interview, however she has noted that they have decreased in intensity. The client discusses trying to drive once since the last appointment, and trying out her phrase “It’s just a thought. It doesn’t mean it’s true” when she thinks she has hit someone on the road. She states that she almost had a panic attack while driving, so for the safety of other drivers, she has decided to hold off on driving for now. This has resulted in her not seeing her boyfriend as often. She tells you he has been depressed lately, so he hasn’t made his way over to visit in a few weeks, which makes her feel sad. She tells you she realizes that a lot of her relationship depends on her taking the initiative to visit her boyfriend, but she doesn’t get the same from him. She tells you about some advice her mom, who is a Reiki master, gave her about how each person needs to take charge of their own mental health, and one person can’t control another person’s symptoms or journey. The client states that she has decided to express her concerns to her boyfriend to give him a chance to make a change, but she is at a point where she is releasing herself from the obligation to improve his mental health. You address with her some common cognitive distortions associated with anxiety and she provides feedback on which cognitive distortions might be coming into play when driving.
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Domain: Professional Practice and Ethics

You are discussing the Health Insurance Portability & Accountability Act with your client. Under HIPAA, therapists are permitted to use and disclose a client's protected health information for all of the following except which?

Domain: Treatment Planning

You are also seeing a different client whose most recent suicide attempt was two weeks ago. He comes to see you after getting discharged from the hospital, and tells you that he is having serious thoughts of suicide again, but by using different means than the most recent time. What is your best course of action?

Domain: Intake, Assessment, and Diagnosis

You ask your client, “What are the most important aspects of your background or identity”. What assessment tool are you utilizing?

Domain: Counseling Skills and Interventions

A different one of your clients states, “I'm just not sure I'm ready. I want to be in a relationship, but I don’t want to be taken advantage of again.” What therapeutic technique would you implement to best target his ambivalence?

Case 2

Part One

Age: 12
Sex: Female
Gender: Female
Sexuality: Heterosexual
Ethnicity: African American
Relationship Status: Single
Counseling Setting: School Counseling
Type of Counseling: Individual
Presenting Problem: Anxiety at school
Diagnosis: Specific Learning Disorder (Written Expression)

Presenting Problem: You are a school counselor at a private middle school in an upper middle-class neighborhood. Your new client is an African-American female, age 12, who has been referred to you by her English teacher. The client is often tearful in the morning but has been unwilling to talk with her teacher about the cause of her being upset. The client is also often late to school, with complaints of a stomachache.

Health History: Last year the client was taken to the hospital while visiting Niagara Falls after a spell of vomiting. The client started feeling nauseous while shopping for souvenirs, and she ran out of the store and threw up all over the sidewalk, much to the disgust of the other tourists walking by. When her grandma realized she was outside, she went out and directed the client to a trash can where she could continue vomiting. Eventually she emptied the contents of her stomach, but continued vomiting water and bile. The force was so strong that the blood vessels in her eyes burst, resulting in weeks of bloodshot eyes. She was taken to the hospital and treated for severe dehydration. The family spent two days of their vacation in the hospital waiting for the client to recover, and by the time she was discharged the family had to fly back home. The episode was determined to have been caused by food poisoning and hasn’t happened again since.

Family History: During your initial session, the client is soft-spoken but willing to speak with you. Her family moved across country this past summer and this is her first year here. This is the third move her family has made in the last five years. The client is involved in the art club and plays flute in the band, where she has made a few good friends. She lives with both parents in the home and has one sibling, a brother who is two years older. She feels that her parents favor her brother, as he has always gotten straight A’s and plays many sports. Her feelings are often hurt when her parents criticize her academic performance and point out how successful her brother is.

Academic History: The client works hard in school and has received average grades. Moving to different schools has been difficult for her. This year she is struggling more with written assignments. She has been getting C’s and D’s on her papers. She tears up as she describes this to you. “I guess I’m just not very smart,” she says.
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Domain: Professional Practice and Ethics

The primary purpose of obtaining Informed Consent is which of the following?

Domain: Intake, Assessment, and Diagnosis

Based on the information revealed in Part One, other plausible diagnoses for this client could include all of the following except which?

Domain: Core Counseling Attributes

You notice that you are zoning out more and more during sessions and lapses of time go by where you cannot recall what the client has been talking about. According to the ACA code of ethics, which activity do you need to focus on to reduce this phenomena?

Domain: Counseling Skills and Interventions

Which skill below is not modeled by therapists to help clients build communication skills?

Domain: Treatment Planning

As you begin to form the treatment plan and diagnosis for this client, what might be the most appropriate metaphor to help the client see the importance of being honest about her symptoms?

Part Two

First session, two weeks after the intake session

The client initially reports that math, science, art and band are going fine, but she is still struggling in English. Last week her mom threatened to ground her if her grades didn’t improve. She is still having trouble with stomachaches and was late to school two mornings last week. When you ask about the stomachaches, she reports that she gets really nervous before essay tests. Her stomach gets upset, she gets sweaty and her heart beats fast. She thinks she knows the words but can’t get them out on paper. One of her teachers suggested that she write with pen instead of pencil, and another teacher lets her write her essays out in the hallway. None of these ideas have helped, however, because she states that pen feels too permanent, and she would have less control over her mistakes. Doing her work out in the hallway also hasn’t helped because she feels different, and almost excluded, from the kids that get good grades. She expresses to you that she really feels like school is out of her control, and she asks that you talk with her mom to help her not get grounded because of her grades. You help her identify where in her body she feels the anxiety and she illustrates the sensations. You also help her label it with words from a magazine that she cuts and pastes to the drawing. You teach her a deep breathing method and practice it with her a few times.
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Domain: Intake, Assessment, and Diagnosis

You say to the client, “It sounds like your stomach is trying to talk to you. What do you think it is trying to say?” This represents which model of counseling?

Domain: Intake, Assessment, and Diagnosis

You are also counseling an adult client who has been struggling with multiple episodes of abnormally heightened and depressed states for the last year. Their episodes do not meet criteria for hypomanic or depressive episodes. What is the most likely provisional DSM-5 diagnosis?

Domain: Counseling Skills and Interventions

During your 12th and final session, a different one of your client states, “Thank you so much for everything you’ve done for me. I don’t know where I’d be without you.” You respond by saying, “Everything you’ve accomplished has been your doing. I’m not responsible for any of it— you are.” Which therapy model are you exercising here?

Domain: Core Counseling Attributes

Which two states must match in a congruent counselor?

Part Three

Second session, eight weeks after the intake session

Client reports that the deep breathing exercises have helped some. She remembers to do it sometimes when she starts to feel nervous. You affirm her application of what you practiced in the last session.Client's mother continues to criticize her for the low grades and grounded her last week. Client's mother told her that she will call the client's teacher to see if anything can be done to help her do better. The client says, "I'll be so embarrassed if she calls my teacher." Her mother asks to speak with you for the last ten minutes of the session, and states that she does not feel as though you are helping the client enough because her grades have not improved. You explain your scope of practice as a professional counselor and remind mom of the client’s specific counseling goals. Mom opens up about her own struggles in school, stating that she got poor grades in elementary school because she socialized too much and didn’t pay attention to her assignments. She processed the shame of embarrassing her parents at parent-teacher conferences. You help mom identify the similarities, but mainly the differences, between the two situations. You also provide a referral for a center in town that addresses academic challenges alongside mental health. She thanks you for the referral and considers engaging in this service alongside psychotherapy since the connections she made during the conversation were valuable.
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Domain: Core Counseling Attributes

What nonjudgmental response would you make in response to the client's statement in Part Three?

Domain: Counseling Skills and Interventions

From a transtheoretical perspective, how would you best use a simple reflection to indicate to this client that you understand how she is feeling?

Domain: Intake, Assessment, and Diagnosis

Which of the following assessments utilizes unstructured data gathering?

Domain: Core Counseling Attributes

You also have a teenage client who states that they identify as transgender. What is the best follow up comment?

Case 3

Part One

Age: 68
Sex: Male
Gender: Male
Sexuality: Heterosexual
Ethnicity: Caucasian
Relationship Status: Divorcing
Counseling Setting: Agency
Type of Counseling: Individual
Presenting Problem: Weight loss
Diagnosis:Major Depressive Disorder

Presenting Problem: Client is a 68 year old male who presents saying, “I don’t know why I keep losing so much weight. I don’t care that I am getting divorced, she was annoying anyway! She was crazy, all I did was pay for everything for her!” He reports to you that he has lost all of his friends and everyone is siding with his wife. He also admits that he gets so angry at times that he calls her to “put her in her place.”

Mental Status Exam: Client presents as well-groomed but looking very tired. He appears flat but starts to get very angry the more he talks about his situation. He mentions that he is an attorney, member of the country club and that he makes a lot of money. He is alert to person, place and time. He says that he cannot sleep at night and he keeps drinking to numb the pain. He admits to some suicidal ideation but says that he wouldn't do that to his kids.

Family History: He and his wife were married for 30 years and they have two adult children. Their daughter is getting married in a few months and they have a grandchild on the way. Their son has recently come out as gay. Client discloses that he isn't very close with his children.

Work History: Client has worked in solo private practice for years. He states, “I tried working in a group practice, but those other lawyers just don't have the juice I have”. Client admits to also carrying additional stress as he is frequently needing to hire new staff since most of his employees tend to end up being, “losers who can't keep up with me”.

Current Living Situation: The client’s divorce attorney suggested that the couple try to live together throughout the divorce proceedings to help make the process of the division of assets go more smoothly, however the client’s wife stated that she could no longer handle his pompous attitude, and living with him was like living in a pressure cooker. She moved out shortly after the client was served with paperwork, and he does not know who she lives with or where she moved. “She’s probably freeloading off of someone else,” he says as he shakes his head and throws his hands up. You notice a tear form in his eyes when he talks about his wife. The client states that he notices all of the blank spaces on the walls of their home where family pictures and wall decor used to hang. He describes his home as a blank bachelor’s pad that holds memories of what once was.
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Domain: Intake, Assessment, and Diagnosis

You spend part of the session asking the client about their coping skills, past trauma history, exercise regimen and legal history. What are you performing?

Domain: Intake, Assessment, and Diagnosis

Based on the narrative from Part One, which of the following alternate diagnoses would most be worth considering?

Domain: Intake, Assessment, and Diagnosis

What information from the intake is most indicative that he is at an increased risk for suicide?

Domain: Counseling Skills and Interventions

This client’s Major Depressive Disorder would best be addressed by which of the following techniques:

Domain: Intake, Assessment, and Diagnosis

You are concerned that the client's suicidality is getting worse. He is continuing to agree to follow a safety contract, but his mood and behavior is deteriorating. What level of care would be appropriate at this point?

Part Two

First session, 2 weeks after intake session

During the session you ask about how he is feeling emotionally, and he says that he doesn’t really feel like doing anything. He used to golf with the guys and work out every day, but he is just going to the office and going home. His commute to work used to take about ten minutes, but since the traffic in his area has a increased so much due to people moving to his town from out of state, he now spends roughly 25 minutes in the car. He tells you that he has tried to listen to audio books about his hobbies, but he no longer has interest in those topics anymore. Although his city has grown quite a lot, he has maintained a close relationship with the neighbors in his gated community. He recognizes the majority of the cars that turn into his allotment on his way home. Many of the people that live near him have been his neighbors since he and his wife bought their house right after they got married. You ask him about what he does when he gets home, hoping that some sort of socialization will be part of his answer, and he states, “I have a few drinks, watch a little television and just go to sleep, what am I going to do now? I am 68 years old, who is going to want to start a relationship at this age? I was married for 30 years!” You continue the process of educating the client about loss and symptoms of depression.
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Domain: Treatment Planning

You would like to use an assessment to gauge this client’s progress. Which assessment’s results are most likely to change over time as the client goes through treatment?

Domain: Core Counseling Attributes

Your client is talking about how angry he has felt towards his son since the son announced to the family that he identifies as gay. After the session, you feel irritated and realize your answers became short and abrupt during the session. Which of the below can most increase your self awareness during sessions?

Domain: Intake, Assessment, and Diagnosis

Which of the following is not a criteria for Major Depressive Disorder?

Domain: Counseling Skills and Interventions

Which of the following is not an example of emotional transference in the therapy relationship?

Part Three

Second session, 4 weeks after the intake session

While you are in this session, your client asks if you have any pain killers as his back is killing him and he forgot to take anything. When questioned on how long this has been going on, he responds, about 4 weeks. He states, “I guess all of this laying around with no exercise is not doing me any good, but I just don’t feel like doing anything!” You decline to provide medication and remind client of your scope of practice. He tells you that his mom’s therapist used to prescribe her medication and would even give her samples from the office’s supply. “I guess you’re not the same kind of therapist that mom had,” he goes on, “You know, I didn’t trust therapists for the longest time. They kept mom drugged up, you know? I never felt like I was really talking to her. So, when my doctor told me to come see you, I didn’t feel right about it.” You thank the client for sharing that information with you, and you take time to review the client’s goals. You discuss your type of licensure, and state that if the client would like to have a consultation about medication, that he is welcome to discuss this with a prescriber. The client insists that he does not need medication, nor does he want someone telling him what to do with his body. You empathize with the client and discuss the session’s homework assignment and its potential benefits. You assign the client a thought record worksheet as homework to complete for the next session.
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Domain: Treatment Planning

Which would be the most important source of information as you begin to create this client’s treatment plan?

Domain: Professional Practice and Ethics

What insight do you hope the client gets out of the homework you assigned?

Domain: Counseling Skills and Interventions

How will you know if a client’s hopelessness becomes clinically significant?

Domain: Counseling Skills and Interventions

What could you say to develop a discrepancy within the client, to move him toward change?

Case 4

Part One

Age: 71
Sex: Male
Gender: Male
Sexuality: Heterosexual
Ethnicity: African American
Relationship Status: Widowed
Counseling Setting: Private practice
Type of Counseling: Individual
Presenting Problem: Sleep disturbances due to trauma
Diagnosis: Post-Traumatic Stress Disorder

Presenting Problem: You are a clinical mental health counselor working in a group private practice setting. You receive a referral from the Intake Coordinator for a 71-year-old, African American, retired, widowed, male. During your initial clinical interview, you learn that client has been experiencing sleep disturbances for the last year. Client expressed nightmares “almost daily” and intense fear of going to sleep. Later in the session, he reveals that he was physically, emotionally, and sexually abused by his uncle from ages 8-12. He vividly recalls his uncle entering his bedroom in the middle of the night and abusing him. He also reveals that his parents passed away when he was 14 and he experienced sexual abuse in the foster care system. He notes that he was taught to “be tough and strong” and did not notice how awful the nightmares were until after his wife passed away. He requests help with sleep and building relationships again.

Mental Status Exam: Client presents in therapy with anxious mood and oscillates between tearful and blunted affect. He endorses symptoms of intrusive memories, difficulty concentrating, nightmares, and flashbacks. He tearfully recalls a moment three years ago where has driving to work and almost crashed into a fence because he thought he was a child again. He becomes emotionally disengaged when exploring his childhood trauma and notes, “Maybe this isn’t for me. I can just pop an Ambien and take a shot of whiskey to sleep.” He denies suicidal or homicidal ideation.

Family and Work History: Client was born in Chicago, IL, to two parents, three younger sisters and one older brother. Client has remained in contact with his three sisters, but lost contact with his brother. His father and mother died in a car accident when client was 14 and he was subsequently placed in foster care. His uncle was addicted to cocaine and lived with the family during client’s childhood. After client aged out of foster care, he went on to the military and had a successful career as an Army officer. He noted witnessing trauma in combat but further expressed, “those stories of war don’t bother me. It was my job.”

Relationship History: The client met his wife while overseas and serving in the military. She was working as a communications director in a telegram office, and they met while he was on temporary mail delivery duty. This new position took a fair amount of training and resulted in a slightly slower delivery time throughout the base, but he got used to it quickly. He stated that this type of work was not typical during his time overseas, but he was assigned to the mailroom after having injured his left hand in an accident. Once he recovered, he was placed in his previous position, however he made it a point to stop by the telegram office on a regular basis. The client was honorably discharged after his future wife, and after a few months of making phone calls, he secured her mailing address. He moved across the country to live near her, and the couple was soon married and settled where they would live until her death.

History of Alcohol and Substance Use: Client revealed that he drank whiskey much more before his wife died, “She liked to throw parties. We would have friends over every weekend, and we drank and drank and drank.” He noted that it was also customary to attend military parties and that his colleagues would often go out to bars after deployments. Since he has retired and his wife passed away, he drinks about once per week. He denied cannabis and substance use.
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Domain: Core Counseling Attributes

All of the following are included in the Psychological Sphere of a Biopsychosocial Assessment except which?

Domain: Intake, Assessment, and Diagnosis

Based on the information revealed in Part One, all of the following PTSD criteria apply to this client except which?

Domain: Intake, Assessment, and Diagnosis

You evaluate the client regarding their support network, level of impairment and risk to self and others. The primary reason for this is to:

Domain: Counseling Skills and Interventions

Based on the client's statements as disclosed in the Presenting Problem, what could you say to this client to begin building therapeutic alliance?

Domain: Professional Practice and Ethics

Which of the following does not reflect the informed consent process?

Part Two

First session, two weeks after intake

Originally, the client was a “no-show.” Within the first fifteen minutes of him not showing up to the session, you look through your intake paperwork to see who the client had listed as an emergency contact, and realize that this information was left blank. You go to the receptionist’s office to point out this paperwork discrepancy and to reiterate the importance of maintaining complete client records. The receptionist insists that this is the counselor’s job to ensure all forms are filled out, however she offers to call the client to see if he would like to reschedule the session. You sit in her office and listen as she leaves a voicemail because the client does not answer. You hold two more sessions, and then see that his name has been placed on your calendar for the following day because he called in to reschedule. The receptionist includes a note stating that the client overslept, which was why he missed his appointment. He presents as agitated and has trouble regulating his emotions. He shares that he was taught not to talk about his experiences or to cry in front of anyone. During the session, you explore his current situation, including his sleep disturbances and flashbacks. He verbalizes that he understands his home is safe but cannot control the nightmares and feeling that someone will enter his bedroom at any time. He hears a car go by and begins yelling, “that’s how I knew my uncle was home! I heard his car drive in!” You maintain an open posture and utilize grounding and deep breathing techniques to support client in returning to the present moment. He calms down and reluctantly schedules an appointment for next week.
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Domain: Treatment Planning

Which case would warrant a referral to another professional?

Domain: Counseling Skills and Interventions

From a transtheoretical perspective, how would you use reframing to discuss your client’s symptomology?

Domain: Intake, Assessment, and Diagnosis

When utilizing assessments with clients, which of the following is of the highest ethical importance?

Domain: Intake, Assessment, and Diagnosis

You say to the client, “I understand that you were 'taught not to talk about your experiences or to cry in front of anyone', but these memories and difficult feelings are part of you. It is better to face them so as to move past them then to keep stuffing them down”. You are practicing from a ________ model of therapy.

Part Three

Second session, one week after first session

Client arrives ten minutes late to the session. You smell alcohol on his breath, and he expresses that he woke up late after ten whiskey shots the night before. He frequently spends time at the local Veterans of Foreign Wars club that is located about two blocks away from his home. He tells you that many of his friends spend time there, and he is grateful for the connection. He states that he normally doesn’t drink that much whiskey, but a newlywed couple was celebrating their marriage, and they bought shots for everyone at the bar. He tells you that the men at the bar all have a certain understanding about what topics they can talk about in public, and which ones they should refrain from talking about, and for the most part the conversation at the club is about mundane topics such as cars, civilian jobs, and family. His friend, Walt, a Vietnam veteran, often talks about his three dogs’ personalities, and once he even brought the pups to the bar with him to show them off to everyone. Your client tells you he isn’t really a dog person, but was entertained by the amount of energy the dogs had that day. After the introduction and small talk about last night’s endeavors, he selects a seat by the door and makes intermittent eye contact. He expresses that he is not sure therapy will work and that the nightmares are so intense that he will do anything to silence them. You provide space for client to explore his concerns about therapy, including his underlying fear that he will live with the nightmares and flashbacks for the rest of his life. You gently provide psychoeducation regarding trauma treatment and create a “triggers” list together to remind client to practice his grounding and deep breathing techniques before sleep. He softly mutters that he is beginning to trust you and schedules a session for next week.
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Domain: Core Counseling Attributes

How would you interpret the client stating that he is unsure therapy will work?

Domain: Counseling Skills and Interventions

You have a different client who struggles with low levels of motivation. You discuss his sleep hygiene and educate him on the importance of keeping a balanced routine. At the end of session the client states, “I think going to bed by 10 each night is feasible.” You say, “Great! Maybe try that out this week and let me know how it goes at your next session.” What technique is being used here?

Domain: Counseling Skills and Interventions

Which action is physiologically incompatible with anxiety?

Domain: Core Counseling Attributes

Which of the following is not one of Rogers Three Characteristics/Attributes Needed for Client-Therapist Relationship?

Case 5

Part One

Age: 11
Sex: Male
Gender: Male
Sexuality: Heterosexual
Ethnicity: Caucasian
Relationship Status: Single
Counseling Setting: School clinic
Type of Counseling: Individual
Presenting Problem: “trouble getting homework done and school avoidance”
Diagnosis: Adjustment Disorder (With anxiety)

Presenting Problem: You are a counseling intern at a middle school. Your supervisor tells you that the parents of a Caucasian 11 year-old sixth grader called seeking guidance. Your supervisor says that the male student has been increasingly “avoiding” school due to alleged physical ailments (“stomach ache, headache, feeling dizzy, tired, sore throat”). His parents also report increased difficulty getting homework done and that the boy says he can’t do it because he’s worried and overwhelmed by the amount of work he has to do. His parents offer him help, but he appears “paralyzed” at times with excessive worry around assignments. His parents also say that he seems to show an increased desire to stay home much more than he used to (i.e. doesn’t play outside as much anymore) and does not want to play with his friends on the weekends.

Mental status exam: The 6th grade boy appears shy and anxious when he comes to your office. He is appropriately clothed and groomed and appears his chronological age. He is thin and pale and has dark circles around his eyes. He appears nervous about talking to you, and squirms in his chair and unties his shoelaces and then reties them and repeats this several times. You ask how he feels, and he states “ok I just don’t want to be at school.” His affect is blunted. You ask why and he says he prefers to stay at home with his father and feels nervous when he’s away from home for too long.

Family history: The student is an only child with a mother and a father who are married and live in a private residence. Since he was born, his mother stayed at home while his father worked full time as a contractor. As of 2 months ago, his mother returned to work, and started a full time job as an accountant. His father remains employed but adjusted his work hours so he can take their son to and from school. They also hired a babysitter for the first time. His parents say that initially, their son seemed to handle these changes well, but they don’t understand what is happening now.

Current Living Situation: When his mom got hired at her new job, the couple applied for a nanny from an international agency, and a Honduran woman came to live in the family’s spare bedroom to help take care of the client and his baby sister. When she moved in, she asked if she could paint the spare bedroom, so the family went to the paint store and picked out some paint samples. The client got to help paint the sample swatches on the wall, and share his opinions on the color the family should choose for the guest room. Everyone in the immediate family liked a shade of yellow for the nanny’s room, but the nanny insisted on painting it dark purple, so the client’s parents allowed her to choose the color since she would be spending most of the time in that room. The trip to the store gave the client the idea to paint his own room one day.

Academic history: Teacher and parents report satisfactory school performance. They say that he is generally able to get classwork done on his own, but that within the past 2 weeks, they’ve noticed more incomplete assignments and careless errors. His teachers also say he seems more distracted and restless during class. He also seems to get more overwhelmed by larger assignments.
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Domain: Intake, Assessment, and Diagnosis

Which of the following are specifiers for Adjustment Disorder?

Domain: Counseling Skills and Interventions

What could you say to the client to best build therapeutic alliance?

Domain: Counseling Skills and Interventions

This client’s Adjustment Disorder with Anxiety can be addressed by all but which of the following techniques:

Domain: Professional Practice and Ethics

Under the Health Insurance Portability & Accountability Act, “Health care operations” includes all the following except which?

Domain: Counseling Skills and Interventions

This client’s Anxious Distress should not be treated by which of the following:

Part Two

First session, two weeks after intake

After a bit of coaxing, the client agrees to sit with you for a session after school. He says he’d rather be home and appears restless when he’s talking about his father picking him up from school on time. You provide him with age-appropriate psychoeducation about worry and anxiety and demonstrate with him how to become aware of his breathing. The main source of psychoeducation comes from a children’s book that you purchased at a recent therapy convention held by your state’s licensure board. At the convention, you stopped at a booth run by a business called Mindfulness for Kids, and knew this book would be an asset for your clients. The person running the stand asked you if you would be interested in their newsletter as well, which you have found helpful. In session, you pull it off the shelf and encourage the client to feel the smooth cover, listen to the whooshing of the pages as he flips them, and notice the textures he feels on the pages that have fabric, feathers, and sandpaper pasted to them. The last page of the book includes a guided meditation exercise that you read to the client as he notices the temperature of the air he inhales versus the temperature of the air he exhales. Together, you practice deep-belly breaths and teach him how to count as he exhales. He says he will try to do these exercises when he feels nervous at school and at home.
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Domain: Intake, Assessment, and Diagnosis

Which of the following would best represent a Logotherapy approach to helping this client?

Domain: Intake, Assessment, and Diagnosis

Which of the following are not included in the Thought Content Domain of the Mental Status Exam?

Domain: Treatment Planning

Which of the following is most likely to happen if the therapist does not prioritize client progress?

Domain: Core Counseling Attributes

Why would you say, “I know you’re concerned about your dad picking you up on time. Would it help if we called him after the session is over?”

Part Three

Second session, two weeks after first session

The client has opened up to you more and is less reluctant to talk. He says the breathing has helped but he still dreads going to school and feels “different” than he did in the past, but doesn’t know why. He says he doesn’t feel comfortable with the new babysitter and wishes his family routine would “go back to normal.” He tells you that he does not understand everything the nanny says, and that mom and dad have to explain things to her that the client already knows. He thinks dinnertime is so boring because the nanny talks about new words she has learned, and his parents teach her more words. He has also told you that he does not like the food she makes for breakfast, and she does not allow him to eat sugary foods. The client explains that, when he complained about this to his mom, she agreed with the nanny that sugary cereals and snacks were not a very good option, and the client should at least try the new dishes that his babysitter prepares for him. He states that he is tired of trying something new every day of his life, and having a babysitter isn’t worth the trouble. The client asks if you would be willing to bring him some PopTarts to his next session because he “can’t live without them.” You reflect back to him what he’s saying and offer empathetic statements about what he is experiencing emotionally. You then normalize the fact that it’s hard to know what one is feeling all the time and the confusion is a normal experience to have but that talking it through with a trusted adult can help.
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Domain: Professional Practice and Ethics

You are contacted by a prospective client who is requesting Telehealth services instead of in-person therapy. Which of the following is not an accepted Telehealth ethical standard?

Domain: Treatment Planning

Now that you have made progress in building rapport with the client, what question would you ask to help this client establish goals?

Domain: Treatment Planning

Which of the following would be the best tool to monitor this client’s progress?

Domain: Counseling Skills and Interventions

You are in a family counseling session and you ask the family, “If a miracle happened tonight where all of your problems were solved, how would you know? What would you be doing differently?” Which counseling model are you using in this question?

BREAK TIME! Look at your clock and take a 15 minute break. The exam clock will not stop but your start time included an extra 15 minutes for this break. You should have 123 minutes remaining on your exam clock as you begin Case 6. Select answer 'A' when you are ready to continue.

Case 6

Part One

Age: 14
Sex: Female
Gender: Female
Sexuality: Heterosexual
Ethnicity: Latina American
Relationship Status: Single
Counseling Setting: School clinic
Type of Counseling: Individual
Presenting Problem: Disordered eating
Diagnosis: Anorexia Nervosa

Presenting Problem: You are a counselor in a school setting, and your client is a 14 year-old Latina American client who has been referred to you by her parents because of some concern they have about the client’s eating and social media habits. The client has lost a considerable amount of weight over the past year and often skips meals or only eats a very small amount of food (ie. two cups of coffee and a small salad) per day. The client has gotten involved with online communities that praise starvation and alarmingly low BMIs. She spends up to three hours a day chatting online and compiling weight loss tips.

History of Condition: The client started to restrict the amount of food she eats after going to a birthday party two years ago where her peers were comparing the clothing they brought. Someone picked the client’s jeans up out of her bag and screeched, “Ewww! Who is wearing a 14/16?! I didn’t even know they made junior’s jeans that big!” She spent the rest of the night ashamed and admittedly zoned out, and when she went home she started searching online for information about crash dieting and weight loss. She eventually found a link to a secret community where she had to send pictures of her body, her scale when she weighed herself every day, and pictures of all of the food she was consuming. The community standards were strict, and she was compliant with all of them. The weight quickly came off because she was starving herself and finding excuses to skip meals. As the days went on, she became more enveloped in and protective of her online community.

Mental Status Exam: The client appears emaciated and unhealthy. She is oriented to person, place, and time and dozes off at one point during session, stating that she is exhausted. The client does not have any suicidal ideation. Thought content is normal, and speech is weak.


Medical History: The client started her period at age 12, but has stopped having periods altogether for the past year. The client’s pediatrician is concerned about the client’s weight and eating habits. The doctor has discussed residential treatment with the parents, however the parents would like to see if you can help before they decide on a more restrictive treatment plan. Client only weighs 98 pounds at 5 foot 6 inches.

Family History: The client’s parents moved to the United States two years before the client was born. The client is the oldest of three children, and the family speaks Spanish at home. The client states that she tries to spend as much time as possible at other peoples’ homes because she does not feel comfortable eating in front of her family. She states that almost all of the conversations she has with her parents, or adults in general, have to do with body image and adults’ worries about the client.
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Domain: Professional Practice and Ethics

The client expresses that they are not sure they can share some specific information with you. Which of the following statements would be most effective for building trust?

Domain: Intake, Assessment, and Diagnosis

Which of the following is not evaluated on the Mental Status Exam?

Domain: Treatment Planning

What would be the most appropriate short-term goal for this client?

Domain: Counseling Skills and Interventions

The act of replacing negative thoughts with positive ones as soon as the negative thought occurs is called…

Domain: Treatment Planning

A different one of your clients, who is currently considered an undocumented immigrant, confides in you that her boss is threatening to call immigration on her if she quits her job. Which type of professional are you least likely to collaborate with for this situation (with the client’s signed approval)?

Part Two

First session, one week after the initial intake session

The client discusses with you how happy she is that she has found an online community that does not express worry about her, but that actually helps her reach her goals. You ask her if she would be willing to show you some of the forums and chats she belongs to, however she declines, stating that you wouldn’t understand their humor. She apologizes to you, and you reply by stating that the counseling process is hers, and she can share as much or as little as she pleases. The client thanks you for granting her the privacy to decide what she shares with you. You discuss goals with the client, and you realize that she has very low insight into the seriousness of her condition. The goals she mentions right away involve numbers–poundage, clothing sizes, low calorie intake, and the list goes on. You try to use some motivational interviewing techniques to nudge the client in the direction of having a healthier mindset with more kindness and compassion towards her body, however your efforts are met with more resistance. She tells you to just stop talking about “counseling stuff” and to stop being so “stiff,” and just talk to her like a normal person. She says you remind her of her mom– always wanting to talk about body image and being healthy. “I finally have something that works for me,” she says, “Why is everyone trying to take that away from me?” You inform the client of some options her parents have been looking at regarding inpatient treatment, and provide information about what these programs entail. The client continues to show little insight about the gravity of her condition. You provide the client with a non-judgmental environment as you discuss topics such as goals for counseling and client’s interests.
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Domain: Intake, Assessment, and Diagnosis

You are working on your client's genogram when you notice she is becoming short of breath and agitated while discussing her maternal uncle. Which of the following would be the most appropriate response?

Domain: Counseling Skills and Interventions

Which of the following is considered an affective technique?

Domain: Core Counseling Attributes

The interaction between the counselor and client regarding the online forum as described in the first session after intake is an example of which of kitchener's 5 moral principles?

Domain: Treatment Planning

It comes to your attention that a different one of your clients has reached all of their goals. What is the best course of action?

Part Three

Second session, two weeks after the initial intake session

The client’s mom checks in with you during the first ten minutes of the session, and she expresses hope in the process because the client told her that she feels excited to come to counseling. Her mom also has noticed that the client has added crackers into her diet. “I know it’s not much,” she whispers with her eyes on the door to ensure that the client isn’t listening, “but I think there’s progress being made.” You tell the mom that you’re glad that she is noticing small changes, however you continue to express your concern for the gravity of her condition, and encourage her to reach out to another agency that provides intensive outpatient and group therapy. The client’s mom shows willingness to follow through with your suggestion, and contracts with you to call the agency while she is in the waiting room waiting for the client’s session to come to an end. The client comes to session annoyed that her friends have started to express concern for the client’s body. She shows you a note that a friend wrote to her. You ask her about all of the people that have annoyed her in the past with their comments about her weight. She makes a list of people, both in person and online, that have made comments that have stuck with the client. You point out a pattern you notice, being that the people she has on the list in the “in person” column have discussed feeling worried, whereas the “online” people have made hurtful and insulting comments. You ask the client which community has her long-term wellbeing in mind, and the client says that she will have to think about that. You provide the client with unconditional positive regard and empathy.
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Domain: Counseling Skills and Interventions

What would you say to help the therapeutic alliance at this point?

Domain: Intake, Assessment, and Diagnosis

Your client has just completed some emotionally difficult work in session and they ask if they can have a hug. What would be your best response?

Domain: Counseling Skills and Interventions

From a transtheoretical perspective, how would you use agreement with a twist to formulate a response to client's statements from the second session after intake?

Domain: Core Counseling Attributes

Which of the following does not correlate with a specific ineffective conflict resolution pattern?

Case 7

Part One

Age: 22
Sex: Male
Gender: Male
Sexuality: Homosexual
Ethnicity: Caucasian
Relationship Status: Single
Counseling Setting: College Clinic
Type of Counseling: Individual
Presenting Problem: Paranoia and school refusal
Diagnosis: Schizophreniform Disorder

Presenting Problem: You work as a mental health counselor at a university clinic. Your client is a 22 year-old marine biology major. For the last three months, the client’s peers and professors have been noticing some strange behavior patterns. Ever since a new female TA joined the client’s anatomy class, the client has begun to believe that the TA is stalking him and has been sent to the school by his parents to make sure he fails. He has been found writing down license plates in the parking lots so he can find out which car belongs to the TA so he can avoid her at all costs. He has missed considerable amounts of class as he has been spending most of his time in parking lots. He has made comments to several students that the staff has installed cameras throughout the building to catch him doing something wrong so they can keep him from graduating. Part of his improvement plan includes mandatory counseling at the clinic where you work.

Family History: The client had a hard time convincing his parents that he could handle living on campus at the university. During his senior year of high school, they had numerous meetings with the client’s school counselor and academic advisor to look at university options close to home. When the client asked his parents why they wouldn’t let him have the college experience he’s always wanted, they told him that they weren’t ready for him to leave home and they would miss him too much. The client tells you that his parents were having secretive meetings with his school counselor behind his back all throughout his senior year, and she was in on the ploy to get him to live at home while in college. Since he beat the odds and signed his own paperwork to live in on campus housing, he has become convinced that his parents will do anything to force him to return home to live with them.

Mental Status Exam: The client comes to session disheveled. He has bags under his eyes, yet appears hypervigilant throughout the session. He asks for the meeting to take place in another office because he states that there were too many cameras set up in yours. You point out that there are no cameras set up, and he points to an empty corner of the room and states, “What do you call that then?” You notice that he meticulously picks at his skin and brushes something off of his legs. You ask what he is brushing off and he states that they are “Mortrax,” insects sent by his parents to spy on him. The client denies suicidal ideation.

Living Situation: The client lives on campus with the same roommate he has had since freshman year. The roommate states that the client stays up late most nights watching out the window for the TA “spy” to drive by. Over the past few months the roommate has noticed notebooks full of notes and observations about people, license plates, and insects on campus piling up. The roommate also reports that the client has covered their walls in newspaper because your client believes the room has been bugged. The roommate sought help from an RA when the client woke him up in the middle of the night to help him “disconnect the cameras.”
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Domain: Counseling Skills and Interventions

Which of the following would you say to build a therapeutic alliance with this client?

Domain: Professional Practice and Ethics

Which one of the following does not reflect accepted ethical standards for counselors regarding social media?

Domain: Professional Practice and Ethics

The client is reluctant to sign the Informed Consent form and asks if he can receive counseling without signing the form. What is your best response?

Domain: Counseling Skills and Interventions

Which group would most directly benefit from relaxation and mindfulness techniques?

Domain: Intake, Assessment, and Diagnosis

Which of the following is included as a DSM-5 criteria for Schizophrenia?

Part Two

First session, one week after the original intake

The client comes to session again disheveled and not well rested. He continues to pick at his skin and clothes throughout the session and wonders aloud when he will finally be left alone. He shows you various notebooks and discusses his observations with you. He delves into his family history, stating that he had a cousin who moved to Maryland his Freshman year of college and got alcohol poisoning after a party. Your client’s aunt and uncle were embarrassed at first, but then filed a lawsuit against the school due to the administration’s gross negligence. It seemed like the jury would rule in favor of your client’s cousin’s family, however at the end of the trial, the court ruled that the alcohol poisoning was his cousin’s fault, and the family would be responsible for all medical bills associated with the incident. The medical bills amounted to over $100,000 because his cousin was in a coma for several days. Despite crowdfunding efforts, the family unfortunately remains in debt from medical bills and legal fees. Recalling this story makes your client wonder out loud if he would be able to sue his university for allowing a school employee to stalk him. You listen intently to his concerns and respond with empathy statements. You make a referral for the client to be seen by a psychiatrist so he can obtain a medication evaluation. You express to the client that you hope he can find peace from everything that has been bothering him and explain that multiple people can help him attain this goal.
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Domain: Counseling Attributes

As the client is showing you drawings and notes about the Motrax, which of the following responses shows genuineness?

Domain: Core Counseling Attributes

Which of the following is not one of Irvin Yalom’s curative factors in a group setting?

Domain: Counseling Skills and Interventions

You have a client who is afraid of being in a car for long periods of time, and has a road trip coming up. She begins shaking as she tells you about the plans. You ask her to close her eyes and allow the worst case scenario play out to its conclusion. What is the purpose of this technique?

Domain: Intake, Assessment, and Diagnosis

Which of the following would preclude this client from being diagnosed with Schizophreniform Disorder?

Part Three

Second session, two weeks after the original intake

The client comes to session very upset because he just received a document stating that he is in danger of failing this semester since he has not reported to class once. “See? I knew this was what they were out to do!” he yells. The client wonders about your involvement with his parents’ plan, and you review with him the exceptions to confidentiality that you discussed during the intake session. You work to strengthen the therapeutic alliance and logically reason with the client so that he knows that you are working in his best interest. He shows you an email from his roommate expressing concern for him. At the end of the email, his roommate reminds him that he is always available to talk or to help him study. Your client expresses that he is suspicious of his roommate’s phrasing, accusing the roommate of looking through his mail: “How would he know I need help with school? He had to have seen this notice I got about almost failing. No one in this world is willing to give me privacy, and I’m getting sick of it!” You encourage the client to continue with the improvement plan he was given, which includes going to the psychiatrist appointment that is scheduled for the following day. You answer the questions he has about what to expect from the psychiatrist and reassure him that neither you nor the psychiatrist wants to see him fail, and that both of you are working to help him get back on track with his education.
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Domain: Treatment Planning

_______ is a client’s attempt to restrict or control the type of information communicated to the counselor.

Domain: Counseling Skills and Interventions

How would you use Emphasis on choice and control to help this client?

Domain: Professional Practice and Ethics

Which of the following best describes the intersection of Culture and Informed Consent?

Domain: Counseling Skills and Interventions

You have a different client who is tearfully discussing seeing pictures of all of her friends at a party on social media and not having been invited. She states, “I’m always left out and have no friends. I’m alone in this world.” Which thinking error is this client demonstrating?

Case 8

Part One

Age: 11
Sex: Male
Gender: Male
Sexuality: Heterosexual
Ethnicity: Asian American
Relationship Status: Single
Counseling Setting: Community clinic
Type of Counseling: Individual
Presenting Problem: Defiant and withdrawn behavior
Diagnosis: Specific Phobia (Animal- Dog)

Presenting Problem: Client is an 11-year-old Asian-American male, brought in by his mother due to reported concerns over the client’s social functioning. You see the boy and his mother together. The client presents as shy, often providing one-word answers or deferring to his mother to respond for him. His mother reports that over the past 6 months or so, she has noticed client becoming defiant and argumentative when they prepare to leave the house in the mornings. She states that lately he refuses to go outside when the neighborhood kids get together. She expresses bewilderment at her son’s behavior and asks for your help in determining the problem.

Family History: Client was born in Korea, where he lived with his parents until they immigrated to the United States when client was 2 years old. He lives with both parents and his 8-year-old sister in a suburban neighborhood. Client has historically gotten along well with his sister and his parents, and they rarely have arguments within the family. His mother states that client’s father suffers from occasional anxiety, which usually flares up when he is stressed at work. She denies having knowledge of additional mental health issues within their family.

Academic History: Client has historically done well academically. He has maintained an A average throughout this school year, and his teachers describe him as a quiet, polite, and conscientious student. Client reports his favorite subjects are math and science. He wants to be an engineer when he’s older.

Health History: When the client was two months old, he was diagnosed with Tubular Renal Acidosis, a kidney disease resulting in plateaued growth as an infant. As a result of the diagnosis, the client had to be taken to a local hospital for frequent blood tests to ensure that the client’s blood’s pH level was within normal ranges. After a month of monitoring, the client was prescribed an oral, alkaline solution to reduce the acidity of his blood. Two months after he initiated treatment, his weight increased and remained within normal ranges until he was two and a half years old and was discharged from treatment by a pediatric nephrologist. His parents describe the first year of treatment as one of the most stressful times of their lives, but other than this added stress, the client is reported to have been a relatively pleasant infant and toddler.
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Domain: Core Counseling Attributes

Which of the following attitudes is not involved in non-judgmental listening?

Domain: Professional Practice and Ethics

The client's mother explains that in Korea, it is common to pay for professional services by exchanging labor. She says that her husband is a good painter and asks if they could pay for counseling by painting some rooms. How should you reply?

Domain: Intake, Assessment, and Diagnosis

Which of the following is not a phobic stimulus type for Specific Phobia?

Domain: Intake, Assessment, and Diagnosis

Which of the following is not an accepted norm regarding sharing assessment information with clients?

Domain: Counseling Skills and Interventions

You decide to use the 'Stone Flake on a Lake' technique to help the client with his Specific Phobia. This technique belongs to which modality?

Part Two

First session, three weeks after the intake session

Client arrives on time for his follow-up session, accompanied again by his mother. She immediately begins telling you about their weekend camping trip. She reports client seemed excited until they arrived at the campsite and he suddenly refused to get out of the car. She states client finally left the car once it was dark and they had retreated to their cabins for the night. For the rest of the weekend, client remained inside the cabin, only going out when no one else was nearby. You see client alone for the second half of the session. He reports his mother’s account of the weekend is accurate. You ask the client what he was doing alone in the cabin for such a long time, and he states that he likes to read, so he finished a few chapter books he brought with him. He enthusiastically talks about a few series he watched on Netflix ranging from anime cartoons to action movies. You help build rapport with the client by asking him which of the characters from these shows he identifies with, and which characters he would like to be more like. He seems to enjoy this activity. You then ask him to draw some of these characters and write words to describe them. He states that he is happy with how the drawings came out and he tells you he plans to hang them up at home. You realize you only have about ten more minutes left in the session and redirect the client back to the topic of his camping trip where he didn’t go outside for hours at a time. He hesitates, and then tells you he felt scared when he saw the neighbor’s dog. He describes experiencing racing heartbeat, sweating, and nausea, and he states, “I just froze.” You ask if this has ever happened before. He hangs his head low and quietly says yes, it happens every time he sees a dog. He reports feeling embarrassed. You normalize client’s experience and ask if he would feel comfortable bringing his mother back into the room to explain to her together what he is experiencing. Client agrees, stating “yeah, that’s probably a good idea.”
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Domain: Treatment Planning

What would you say to help this client understand his fear reaction?

Domain: Counseling Skills and Interventions

At what stage in therapy is a therapist most likely to implement the pie technique?

Domain: Counseling Skills and Interventions

This client’s Specific Phobia (Animal) would be best addressed by which technique?

Domain: Counseling Skills and Interventions

How would you help your client understand the link between his fears and his symptoms?

Part Three

Second session, six weeks after the intake session

Client presents to session alone and states his mother is in the waiting room. He reports feeling relieved that she knows about his fear, but he is still feeling embarrassed. He endorses a desire to play outside with his friends again, but the neighborhood dogs are always out in the yards. Client expresses frustration with himself and states, “I’m such a loser, I don’t know what’s wrong with me.” You challenge the thought that client is a loser by reflecting on his academic successes, popularity among his friends, and admiration of his parents. You help client recall what he drew last session, and the two of you list some of the words that he wrote on his drawings. Once you have the list written on your white board, you discuss some of the evidence towards the fact that he emulates these characteristics. At the beginning of this intervention, his self esteem level was at a 2 out of 10. After fifteen minutes of discussing the superhero characteristics, he stated that his level of self esteem had increased to a 7 out of 10. You revisit the topic about his fear of dogs and the areas in which it is holding him back in his social life. The client demonstrates some hesitation to switch topics so abruptly, but reasons that he might as well talk about that topic if that’s what brought him to counseling in the first place. Client acquiesces and asks for your help understanding his fear reaction.
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Domain: Core Counseling Attributes

You have been asked by your clinical director to lead a group for adolescents who struggle with self harm. As you are choosing a coworker as a partner to run the group with, you only consider candidates of the opposite sex. Why might you use this strategy?

Domain: Counseling Skills and Interventions

The client's self statement in the second session after intake is an example of which thinking error?

Domain: Counseling Skills and Interventions

“My anxiety just gets incredibly out of control, and I feel like I’ve been taken over by a trembling mouse who has been cornered by a cat. I just can’t shake it,” says one of your clients. You, operating from _______ therapy, say, “Let’s imagine your anxiety were sitting in this chair over here. What would you like to say to him or her?

Domain: Core Counseling Attributes

There are many ways to address parent-child conflict in sessions. Which of the following is not an appropriate approach?

Case 9

Part One

Age: 44
Sex: Female
Gender: Female
Sexuality: Heterosexual
Ethnicity: Caucasian
Relationship Status: Married
Counseling Setting: Agency
Type of Counseling: Individual
Presenting Problem: Chronic Pain
Diagnosis: Somatic Symptom Disorder

Presenting Problem: Client is a 44 year-old Caucasian female who states she comes to you “as a last resort.” She has visited many specialists to try to get to the bottom of her kidney pain, however all of her tests have come up as normal. She states that she has felt the pain every day for the past three years. Some of the specialists, after doing blood work and urinalysis, have refused to give the client the more extensive studies she has requested. About a month ago, she returned to her family doctor stating that she now has stomach pain. The doctor found no abnormalities in her physical exam. The doctor has referred the client to you, thinking that there might be a psychological reason for the pain.

Mental Status Exam: The client comes to session well groomed. She is oriented to person, place, and time. Her thought and speech content is normal. She denies current suicidal ideation. Psychomotor activity is adequate and she willingly participates throughout the intake.

Relationship History: The client started dating at around age 16, and was with the same boyfriend for four years until that boyfriend transferred from the college they both went to to another one out of state. Although the client wanted to remain in a long-distance relationship, her boyfriend told her that they were better off making a clean break. Her then ex-boyfriend dropped out of college the following year after his new girlfriend got pregnant because he had to work to support his new family. Your client has not been in touch with her ex since they broke up, however she admits that she occasionally looks at his online profiles to see what he has been up to. She comments that the couple frequently visit the beaches on Lake Erie. It also appears that they just bought a new four-bedroom house in the suburbs of Cleveland.

Medical History: The client typically spends 15-20 hours a week either visiting doctors, chatting online with medical professionals, or researching ailments. The client states that three doctors offices have banned the client from setting up appointments at this time because the client’s insurance started denying claims because the visits became too frequent. The client states that she offered to pay for additional visits out of pocket, however the doctors referred to the emergency room for future concerns. The client reports consistent pain in various areas of the body. The only medical history the client reports is having two miscarriages at age 22.

Family History: The client’s husband is a very successful attorney, and the client admits that she does not see him very often. He has dismissed many of her medical concerns, however he lets her indulge herself because it gives her something to do, and the appointments have become something to look forward to. The client has a 19 year-old daughter away at college.

Work History: The client met her husband while working at the same law firm. Once she had her miscarriages, the couple decided that it would be best if she take a leave of absence from work. When her daughter was born, she became a stay at home mom. She is currently unemployed.
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Domain: Intake, Assessment, and Diagnosis

Which of the following would be the best assessment choice for an in-depth survey into the client's inner state covering a broad range of DSM-5 domains?

Domain: Treatment Planning

What is the most appropriate long-term therapeutic goal for this client?

Domain: Counseling Skills and Interventions

Why might you spend a considerable amount of time teaching a client about cognitive distortions?

Domain: Professional Practice and Ethics

Which of the following can impact a client's competency to provide informed consent?

Domain: Counseling Skills and Interventions

Which of the following techniques is not typically included in Cognitive Behavioral Therapy?

Part Two

First session, two weeks after the initial intake

The client comes to session with a list of questions she has for you about treatment. She expresses frustration that doctors have come to the conclusion that her pain is just a “mind game,” and wonders how you can help. You help the client set goals for your time together. You discuss her diagnosis and normalize her experience, as well as answer additional questions she has. You begin to make a timeline of events with her and discuss significant life events. She is tearful while discussing the miscarriages, but states, “I got over that a long time ago.” She is also tearful when discussing her daughter moving away to college recently. Again she states, “I got over that a year ago.” She states that her daughter has not disclosed any information about potential college romances, and she admittedly feels nervous that her daughter will soon experience her first heartbreak, as the client did in college. She tells you that she had numerous conversations with her daughter from the time she was sixteen about not jumping into relationships too quickly because the other person might not be as invested as one thinks. She compares her marriage to that past relationship, and states that she is glad the two broke it off in college because she is in a better place, and her house is bigger than her ex’s house anyways. She talks about the freedoms of being a stay at home mom, and expresses gratitude for her husband’s success. She abruptly asks for a copy of her treatment plan so she can add it to the accordion folder she is carrying with her other medical files. You explain that the treatment plan will be finalized next session and you can print it out for her then. You build rapport with the client by asking follow up questions and providing unconditional positive regard.
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Domain: Intake, Assessment, and Diagnosis

Which statement would you use to inspire this client towards change?

Domain: Treatment Planning

Which assessment should you administer to best inform this client’s treatment plan?

Domain: Counseling Skills and Interventions

How would you use Amplified Reflection to reflect the client's statements from the timeline exercise in the first session after intake?

Domain: Core Counseling Attributes

You have a different client who tells you that she is converting to another religion to have the same religion of the man she is marrying. You state, “Your religious values shouldn’t change for something like that. I’m only saying this because I have lived through something similar.” Which attitude related to the counseling attribute of non-judgmental listening do you need to strengthen in this case?

Part Three

Second session, three weeks after the initial intake

The client reports that she had a recent conversation with her daughter that brought up a lot of emotion. The client processes how her daughter has been so happy away at college that it makes her feel like she is no longer needed in her life. She processes feelings of worthlessness regarding her family dynamics, as well as her career situation. You process with her what is going right in her life currently, and she discusses having a love for baking, and how she often makes baked goods for her neighbors. There are two elderly couples that live on either side of the client. She states that the one couple is on a strict gluten free diet, which has helped her branch out a bit with her baking techniques, and it has driven her to experiment using different ingredients. She even has a special cupboard where all of the utensils she uses for gluten free baking are located to prevent cross-contamination. The wife in the other couple suffers from an egg allergy, so that modification has come with its own challenges. She can rarely make the same recipe for both couples because of one allergy or another. She also tells you that neither family consumes refined sugars, which has resulted in a need for even more creativity. You reinforce the fact that client has dedicated a great amount of care and concern for her neighbors, and you point out the excitement in her voice as she discusses various recipes and baking techniques. She mentions that she dreams of having her own bakery one day. You ask her what is stopping her from taking the next step, and she asks, “Do you really think I could?” You discuss what her next steps would look like. She gets more and more enthusiastic during the conversation, and states that she will have some thinking to do between now and the next session.
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Domain: Professional Practice and Ethics

You want to monitor the therapeutic relationship. Which of the following statements would best accomplish this?

Domain: Treatment Planning

Which of the following is not one of Holland’s six vocational types?

Domain: Counseling Skills and Interventions

You have a different client who states, “I just don’t know what to do about this disagreement my wife and I are having about moving. I think it’s time to just give up.” Your client could best benefit from a session about:

Domain: Counseling Skills and Interventions

You also provide some substance abuse counseling for your agency. In substance abuse counseling, what are two of the biggest issues that impede treatment?

Case 10

Part One

Age: 15
Sex: Male
Gender: Male
Sexuality: Heterosexual
Ethnicity: African American
Relationship Status: Single
Counseling Setting: School clinic
Type of Counseling: Individual
Presenting Problem: Disrespect towards authorities
Diagnosis: Oppositional Defiant Disorder

Presenting Problem: You are a clinician working in a school setting. A 15 year-old African American male has been referred to you by the school principal after having some run-ins with various staff members. The client has had some behavioral issues at home as well, and school authorities are worried that the client may suffer legal consequences due to his actions. The client’s teachers state that the client is often angry and irritable in class, and the client remains silent when teachers try to discuss the client’s academic performance with him. He has not completed any homework assignments so far this semester, and has purposely annoyed other students when doing group work.

Mental Status Exam: The client is not cooperative during the diagnostic session. He makes little to no eye contact and sits with his arms crossed. Once he begins talking, he demonstrates that he is oriented to person, place, and time. His tone of voice is remarkably quiet, and his mood appears irritable as evidenced by body language and facial expression. The client denies suicidal and homicidal ideation.

History of Presenting Problem: The client has an extensive record of suspensions and detentions over the past three years. In the past two months, the client has vandalized students’ lockers, as well as has destroyed textbooks by ripping them up and scattering the pieces on the floor under his desk. The only explanation he gives for this behavior is that his peers and teachers are always “showing him up,” and he has to “show them who’s boss.” The client has never engaged in substance use.

Legal History: Last summer, the client’s name was provided to the “Scared Straight” program, put on by the local sheriff’s department. Late at night, and with his aunt’s permission, law enforcement entered the client’s apartment and did a mock arrest, handcuffing the client and taking him out to the cruiser. The client was compliant during the arrest, however he was confused about what he did to get arrested. The sheriffs deputies took him to the local juvenile correction facility where he spent the night. The next day he attended the Scared Straight seminar at the correctional facility and was released after passing a written exam about the seminar’s contents. When his aunt picked him up, he refused to talk to her for a week. He tells you he thought the whole thing was stupid, and he could tell it was an act the whole time.

Family History: The client currently lives with his aunt in a small apartment. His mom has been in and out of jail throughout his life, and his biological father stays at the client’s home a few nights per month. The client’s relationship with his father is somewhat hostile, according to the school’s authorities. The client gets along with his aunt, but does not obey curfews or do any chores that are asked of him. The client’s aunt expresses concern about the client stealing from local stores.
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Domain: Professional Practice and Ethics

You begin addressing informed consent with the client and his aunt. Which of the following statements is not reflective of informed consent?

Domain: Intake, Assessment, and Diagnosis

Based on the information revealed in Part One, which of the following symptoms is most indicative of a diagnosis of Oppositional Defiant Disorder for this client?

Domain: Counseling Skills and Interventions

A different one of your clients states, “I'm just not sure I'm ready for this whole therapy thing. It seems so overwhelming,” what therapeutic technique would you implement to target his ambivalence?

Domain: Counseling Skills and Interventions

From a transtheoretical perspective, how would you use shifting focus to help the client understand his responsibility for his behaviors?

Domain: Treatment Planning

You are in session with a different client and you only have about ten minutes left of your session when your client reveals that she has an extensive trauma history. Which assessment tool would be most beneficial given the amount of time you have left?

Part Two

First session, one week after the initial intake session

The client spends much of the session in silence. You offer to play cards with the client to help the time go by, since he has been assigned to participate in counseling two times per week. The client agrees to play cards. You ask the client some rapport building questions about himself and his interests. The client reveals that he is a fan of cars and begins to discuss what his dream car will look like. He mentions a few car movies, none of which you’ve seen. You tell him you’re not familiar with the models of cars that he’s describing, so he pulls out his phone and shows you pictures of the vehicles from the movies. You comment on the paint colors while he lists the features and engine specs. You compliment him on his vast knowledge about cars. He tells you that his dad works as a car mechanic, and when he visits the home the two stay up late talking about cars, and the repairs his dad made that week. When you ask if he has visited the shop where his dad works, he looks down and shakes his head. “We don’t have to talk about this if you don’t want to,” you say as you deal out the cards for another game. The client continues to play cards in silence, and after five minutes he tells you about another car that came to mind. You provide consistent eye contact to the client, as well as unconditional positive regard. At the end of the session, the client asks when he will be coming back. He flashes you a half-smile as he leaves.
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Domain: Intake, Assessment, and Diagnosis

Which question is an appropriate rapport-building question at this point in the relationship?

Domain: Counseling Skills and Interventions

Which of the following techniques would best help to address this client’s Oppositional Defiant Disorder?

Domain: Core Counseling Attributes

Your supervisor encourages you to “get into your client’s world” when building rapport. Which counseling attribute is most exemplified by this suggestion?

Domain: Treatment Planning

There is a clear link between ________ and ________.

Part Three

Second session, one and a half weeks after the initial intake session

The client comes to the session angry, stating that he is done with school and would like to drop out. He expresses that the teachers do not leave him alone and are always saying that he doesn’t do enough. You ask the client where he believes he needs to improve and you make a list together about what is within his reach. You are understandably surprised at the high amount of insight the client has regarding his areas of opportunity, and you take some time to reinforce this. He expresses that at this point he is willing to try anything if it makes the adults in his life stop bothering him about every little thing. “Take my English teacher, for example,” he says, gesturing with his hands, “She tells me to do one thing, but then the next day she doesn’t even check to see if we did it, so I’m like, why even put forth all that effort if it’s just going to go unnoticed?” You empathize with the client and write “complete homework” on the list of what client can control, and “teacher revision” on the side of things client cannot control. You elaborate on the list by defining more things that are in client’s control and others that are not in his control. The client provides feedback about the categories. You empathize with the client, however discuss with him the importance of working towards his goals. You help the client come up with a small goal that he can reach this week regarding his behavior, and he chooses to apologize to his aunt for breaking his curfew last night. You tell the client you are impressed with his suggestion.
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Domain: Treatment Planning

What insight do you hope your client will gain from working on his goal list?

Domain: Counseling Skills and Interventions

What are the four processes of Motivational Interviewing?

Domain: Intake, Assessment, and Diagnosis

You are concerned about a different one of your client's safety. Which of the following should you use to evaluate the risk of the client committing suicide?

Domain: Core Counseling Attributes

Which of the following questions would not be asked by a clinician who is following the RESPECTFUL multicultural counseling model during an intake session?

Case 11

Part One

Age: 73
Sex: Male
Gender: Male
Sexuality: Heterosexual
Ethnicity: African American
Relationship Status: Widowed
Counseling Setting: Agency
Type of Counseling: Individual
Presenting Problem: Seeking counseling and wraparound services post hospitalization.
Diagnosis: Major Neurocognitive Disorder due to Traumatic Brain Injury

Presenting Problem: You are employed at a mental health agency that specializes in clients with neurocognitive disorders and receive a new referral for a 73-year-old, African American, Heterosexual, male. Client was referred by the hospital system after a recent hospitalization for inability to care for himself. The night prior to his hospitalization, his son went to his house to check-in on him and observed rotten food, empty alcohol bottles, cockroaches, and clothes all over his apartment. Client could not recall where he was or explain his current situation. He appeared disorientated and had not bathed in days. Two years ago, client experienced a major fall on the staircase of his home while intoxicated and was diagnosed with a Traumatic Brain Injury (TBI). He began drinking alcohol after his wife passed away of cancer three years ago.

Mental Status Exam: Client presents to your initial evaluation in jeans and a sweatshirt, although it is 80 degrees outside. Client selects a seat by the window and expresses, “I like to listen to the birds chirp daily. I’ll sit here. Who are you again?” After you explain your role at the mental health agency, client becomes agitated and expresses that he does not need counseling, “I’ll just go home to my house! I don’t need this crap!” Client does not recall his recent hospitalization and only complains to you of headaches. He denies all symptoms, but after reviewing the hospital reports and conducing your evaluation you observe symptoms of disorientation, difficulty concentrating, short-term memory loss, and difficulty performing daily tasks. According to client’s son, client will leave piles of newspapers on the front stoop for weeks, forgets to turn the stove off, and will leave the sink running for hours.

Family History: The client got married when he was 21 and his wife was 19. The two grew up together and their families were friends throughout their lives. His wife was a stay at home mom throughout their 6 children’s childhoods, and once the youngest reached kindergarten she began working as the school secretary at the children’s elementary school. All of the client’s children work in the hospitality industry, and his oldest two sons are in upper management for a large, nationwide hotel chain. His wife was diagnosed with bone cancer in her mid 50s, and the client was responsible for taking her to and from appointments. He was her caretaker while working as a police dispatcher. He says that he would complain about having to take care of her after working a long work shift, but it gave him a sense of purpose for all of those years.

History of Substance Use: Client denies cannabis and other substance use. He also denies alcohol use; however, the toxicology report from the hospital indicated that client tested positive for alcohol. Client’s son informs you that client began drinking beer and vodka after his wife passed away of cancer. He described his family has “close knit” and that his father has been in a state of “denial” regarding the loss of his wife.

Current living situation: Client currently resides in the home that he shared with his wife. His son is in the process of selling the home and assisting the client in finding a long-term group home. Post hospitalization, he is currently residing at a Short-Term Residential Nursing Facility.
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Domain: Intake, Assessment, and Diagnosis

Which of the following assessments incorporates 10 brief questions that are used as a 2 minute screening for potential Alcohol Use Disorder?

Domain: Intake, Assessment, and Diagnosis

What statement disclosed during this session affirms your client’s diagnosis?

Domain: Professional Practice and Ethics

You receive a subpoena requesting the records regarding a former client. Which of the following is your best first course of action?

Domain: Counseling Skills and Interventions

During an intake session, a different one of your clients gets angry and asks, “Why do you keep asking about what kind of a mom I had when I was a baby? What does that have to do with anything?” It might be a good idea to provide some background on the theory you are working from, which is called…

Domain: Intake, Assessment, and Diagnosis

Genograms provide information regarding all but which of the following:

Part Two

First session, two weeks after intake

Client presents to your second session on time after his son brought him in from the nursing facility. Client appears with flat affect and does not recall the details of your first session. Client has now been sober for three weeks since his hospitalization and you observe slight tremors in his hands. Client tells you a story of when he traveled to New Orleans with his wife six years ago and becomes tearful when he recalls that she will not be coming home. You utilize empathetic listening and provide psychoeducation regarding Major Neurocognitive Disorder due to a TBI to support client in understanding his condition. You explore that symptoms may improve with continued abstinence of alcohol intake. He asks if you could call his son in from the waiting room to discuss this information with him because he is having trouble understanding you, and remains visibly upset due to previous topics of conversation. When you walk out to the waiting room, his son is nowhere to be found, so you ask the security guard if he could keep an eye out for him and send him to your office as soon as possible. You go back into your office alone, and find your client staring out the window. He asks you where you went, and just as you were about to answer, his son walks into the room. Your client stands up and says, “Well, it looks like it’s time to go.” You make an arrangement to speak with his son over the phone at a later time to discuss your client’s diagnosis and information that can help the family members who are in a care-taking role. Your client’s son thanks you for your care.
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Domain: Treatment Planning

What is the most important factor to ensure that your clients follows through with treatment?

Domain: Core Counseling Attributes

A counselor was born into privilege and has never struggled financially. Her client expresses worry about affording rent next month and feeding her family. Which of the following is not likely to be stated by a culturally competent counselor?

Domain: Treatment Planning

What is the most appropriate long-term goal for this client?

Domain: Counseling Skills and Interventions

How would you interpret the client’s tearfulness after telling his story?

Part Three

Second session, three weeks after first session

Client presents to your session a few minutes late and complains of a tension migraine upon entering the counseling room. Client made progress in his first session of understanding the symptoms of his diagnosis, including impairments in speech and cognition. He continues to ask who you are at the onset of each session and is not yet able to perform daily tasks on his own, such as bathing and cooking. Client inquires when he will be returning home and becomes irritated when you do not have a time frame for when he will be placed in a group home. He tells you he does not want to get put into a group home, and he would rather stay in the hotel his daughter manages if he has to be “under lock and key all day.” You take some time to show client pictures of local group homes online, and describe to him their purpose and how the staff at a group home could help him more than hotel staff can. He has trouble distinguishing his current living situation from that of a group home, so you take additional time to provide information on his levels of treatment. He again asks about a time-frame for discharge, so you offer to set up an appointment with his case worker to discuss this further. You express to him that you understand he would like to go home, but for his own safety it is best that he follow his treatment protocol— even if it takes longer than expected. You begin to gently explore the use of coping skills that client can engage in at the facility, such as going for walks, reading, and doing puzzles. Reluctantly, client agrees to start a crossword puzzle with you during today’s session and then abruptly ends the session after he shares that he is going home to his wife.
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Domain: Treatment Planning

You decide to give the client a self-report assessment to gauge his progress toward therapeutic goals. Which of the following would be an appropriate assessment for this client?

Domain: Professional Practice and Ethics

You are supervising an intern who practices orthodox Judaism. They request that supervision meetings not be scheduled on Friday afternoons due to religious constraints. What is your best response?

Domain: Counseling Skills and Interventions

How would you best respond to the client's migraine complaint.

Domain: Counseling Skills and Interventions

Things one says or does to oneself to make oneself feel good or bad is