Case 1

Part One

Age: 56
Sex: Female
Gender: Female
Sexuality: Heterosexual
Ethnicity: African American
Relationship Status: Single
Counseling Setting: Agency
Type of Counseling: Individual
Presenting Problem: recurring depression
Diagnosis: Bipolar II Disorder

Presenting Problem: You are a mental health counselor working in private practice. A 56-year-old single, black female presents to your office as a self-referral. She reports feeling depressed for the past two weeks, and she is seeking counseling to better understand her moods. She describes her depression as feeling like a heavy weight on her chest. She states she’s having a hard time focusing at work, and she’s not interested in anything other than sleeping. When asked, she states she has felt this way on and off since her mid-twenties. She becomes tearful and states, “I just feel so worthless, sometimes I think I’d rather be dead than deal with these moods.” She tells you she worries that her symptoms might cause her to lose her job, and she finally decided to seek counseling after her boss approached her with concern over her work performance.

Family History: The client is the second youngest of four siblings. Her youngest sibling lives in France and is married to a Japanese chef who owns one of the highest rated Japanese restaurants in France. Your client states that she was planning on visiting her sister and brother-in-law a few months ago, but couldn’t find the motivation to go online and browse for airline tickets. Since then, her passport has expired. Her oldest brother lives in Florida and works at a large amusement park as an animal trainer and performer. He performs in front of large crowds, and says he loves his job. He gets free tickets for the family numerous times per year, and going to visit him is one of the things your client enjoys the most. Her other sister lives next door and also works with the client. They eat lunch together every day and often spend time together on the weekends.

Work History: Client works as an executive at a marketing firm, where she has been employed for 20 years. She is a valued member of the team, though she has been put on disciplinary notice multiple times over the course of her career. Her boss reports that client has a pattern of missing deadlines and calling in sick, but she “always makes up for it” by increasing her productivity afterwards. Client’s co-workers have expressed frustration over her unreliability and inconsistent work performance.

Relationships: Client has a close relationship with her sister and two women who she considers her best friends. She sometimes goes on dates with men she meets online, but she hasn’t maintained a serious relationship since college. She expresses desire for male companionship and regrets that she never got married and started a family. Client reports the men she dates often don’t understand her, and they tell her she’s “too moody.” She admits to being unfaithful in past relationships and states she has “random streaks of promiscuity.” Client expresses shame and identifies feeling guilty for her past indiscretions.
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Domain: Intake, Assessment, and Diagnosis

Which of the following details from Part One best affirms the client's diagnosis?

Domain: Core Counseling Attributes

_______ is showing the client that you have ‘heard’ not only what is being said, but also what feelings and emotions the client is experiencing when sharing their story with you.

Domain: Intake, Assessment, and Diagnosis

All of the following would be helpful assessments for evaluating Bipolar II Disorder except which?

Domain: Intake, Assessment, and Diagnosis

Based on the information revealed in Part One, which of the following most clearly points to a diagnosis of Bipolar II for this client?

Domain: Professional Practice and Ethics

Which of the following is not considered a standard client right?

Part Two

First session, three weeks after the intake session

She states she met a man through an online dating application, and they are going on their second date tonight. She rushes to describe details of their first meeting. She tells you that the pair had been messaging for a couple hours when he asked her to choose a place to have dinner together. “He said I could choose any place in the city, so I looked at some reviews and I chose that new restaurant that just opened up down by the river. I forget what it’s called, but it has a great patio with those hanging lights on it,” she exclaims with pressured affect. She talks about being intimate with her date and finally feeling free and relaxed. You ask if her sister has met this man yet, and she stares at you blankly and asks, “Why would I tell her I’m seeing someone new? I don’t need her sticking her nose into my business, and plus I don’t need her trying to seduce yet another one of my dates. She needs to set up her own online profile if she wants to find someone. That’s not my job.” You interrupt to note that her mood seems improved from your previous session, and she expresses irritation over the change of subject. She exhales loudly and agrees with you, stating she’s felt so much better that she hasn’t even needed much sleep over the past few days. She states she is planning on going shopping after your session to purchase a whole new wardrobe that will impress her friends, co-workers, and new romantic interest. You challenge the thought that client needs new clothes to gain others’ approval. She again becomes irritated and states, “I don’t need anyone’s approval, I already know they adore me.”
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Domain: Treatment Planning

Which would be the best assessment to aid in diagnosis?

Domain: Intake, Assessment, and Diagnosis

Which of the following is true regarding the use of pre-test and post-test measures?

Domain: Counseling Skills and Interventions

Bipolar II Disorder would best be addressed by which of the following techniques?

Domain: Counseling Skills and Interventions

It is the second week of a group you are running. The members do not habitually offer information without being asked directly. You notice that disenfranchised grief is a common theme in this group. What is it called when you point out this theme to promote more member-to-member interaction?

Part Three

Second session, six weeks after the intake session

Client arrives on time for session. She presents with reduced affect and intermittent tearfulness. She reports she is no longer seeing the man she met online. You provide empathetic listening. Client states her sister has been supportive by calling to check on her often. She reports feeling guilty for being “such a burden.” You acknowledge that client’s sister seems to care deeply for her, and you ask client for evidence that she is being a burden. Client concedes that her sister has never told her she is a burden, and she has always been willing to help when client is feeling down. Given this, you ask her to consider whether her feeling of guilt is appropriate, and client replies, “No, I guess not.” You ask her to reframe her original thought to something that more closely fits the facts, and she is receptive. She tells you that she has a habit of throwing her sister to the wayside when she gets into a new relationship, and although the two see each other every day at work, she has a habit of skipping lunch to keep up with the conversation with her partners via text and private message. He sister has expressed her sadness in the past, but your client states that there are certain times when it doesn’t mean much to her, and other times when she feels bad for doing that. She has plans to eat dinner at her sister’s apartment after the session, and makes a comment about bringing up this comment to once again apologize to her. She also says the two have plans to travel to Florida next month to see one of her brother’s performances, and she is thinking about disabling her dating apps for the duration of the trip. Client mentions that she will be helping her sister move into a new house next week.
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Domain: Intake, Assessment, and Diagnosis

From a Positive Psychology approach, what could you say to the client to reinforce her support system?

Domain: Core Counseling Attributes

At the beginning of a session, a different one of your client's calmly states, “My kids don’t listen to me, and it’s starting to get on my nerves.” Which statement is the most accurate way to reflect their feelings?

Domain: Counseling Skills and Interventions

Why would you ask the client for evidence that she is being a burden to her sister?

Domain: Counseling Skills and Interventions

Nothing seems to be working for a client’s personality disorder that a colleague has been treating with Cognitive Behavioral Therapy. Your colleague wishes to refer the client to you with hopes that your type of therapy will get better results. You are known in your area for being able to help people work through “early maladaptive emotional and cognitive patterns established in childhood and repeated throughout life.” The therapy you specialize in is called:

Case 2

Part One

Age: 16
Sex: Male
Gender: Male
Sexuality: Heterosexual
Ethnicity: Latino American
Relationship Status: Single
Counseling Setting: School clinic
Type of Counseling: Individual
Presenting Problem: Shoplifting and cheating on tests
Diagnosis: Adjustment Disorder (With disturbance of conduct)

Presenting problem: You are a school counselor at a high school and your client is a 16 year-old Latino male who has been sent to your office because he was recently caught cheating on tests in multiple classes. He has been snatching other students’ tests off their desks and copying answers. The school resource officer has also gotten in touch to report that the client has recently gotten in trouble for shoplifting at two different stores over the last week. Charges were not filed because the client returned the merchandise and apologized to the store managers. He discloses that he found out five weeks ago that his parents are getting divorced. The school principal hopes you can help him get his behavior back under control.

Mental Status Exam: Client comes to session tearful and makes little eye contact during session. Client does not report any presence of hallucinations. Client is oriented to person, place, and time. Speech and tone of voice are appropriate throughout conversation.

Academic History: Client has always been a straight A student. Numerous teachers have stated that the client is a pleasure to have in class and he has always been helpful during group projects and has always turned in quality work. The client’s teachers are concerned because his grades have suffered considerably over the past few months. The teachers have noticed the client forgetting school supplies and he has been mouthing off to lunchroom monitors and other school personnel. The client states that he started cheating on tests because he really cares about his grades, but hasn’t been able to study like he used to.

Living Situation: The client lives with both of his parents and three younger siblings. The parents told the family they would be getting a divorce five weeks ago, and the client was completely caught off guard because he thought the parents had a decent relationship. After that conversation, once the younger siblings had gone to bed, they explained to him that the reason for the divorce is because his dad was unfaithful to his mom. The client states that, although the parents are getting divorced, both of them are still living in the home due to financial reasons. The client states that he feels uncomfortable at home, especially since he has to keep a secret from his younger siblings.

Vocational History: The client has worked for the past six months at a local grocery store where he packs customers’ groceries into bags. The store has started to encourage the use of reusable bags at the checkout, so the client has been encouraged to use a script to ask every customer if they would like to purchase reusable bags or if they are supplying their own. The store manager states that the store is doing away with the typical plastic bags by the end of the summer, so it is the client’s job to ensure that the customers are aware of this change. Some of the customers have made angry remarks when the client asks if they would like to purchase reusable bags, while others support the upcoming change. The client reports he gets along with most of his coworkers and tries to stay out of management’s way because he doesn’t want any trouble.
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Domain: Intake, Assessment, and Diagnosis

What would be the most likely alternative diagnosis to consider for this client?

Domain: Treatment Planning

At this early stage of therapy, how would you respond to the client's admission about feeling uncomfortable at home?

Domain: Counseling Skills and Interventions

_____ is when people focus exclusively on the most negative and upsetting features of a situation, ignoring all of the more positive aspects.

Domain: Professional Practice and Ethics

Which of the following apply to soliciting testimonials from clients for use on social media?

Domain: Counseling Skills and Interventions

Your client tells you, “I’m going to fail my exam anyways, so why study?” What is your response to this thinking error?

Part Two

First session, one week after the initial intake session

The client states that he has signed up for basketball to get out of the house more, as things have become unbearable for him at home. He states that the coach told him that he has to get his grades back up to be able to make the team. He asks you for help with this. You ask him when he first started having trouble in school and with his behavior. He discussed in detail the conversation he had with his parents. He processes feeling fooled for thinking that everything was okay. Lately he has been reflecting upon some red flags that he noticed in his parents relationship and how he feels guilty for not saying something to them. He recalls numerous times when he woke up for school and found his dad sleeping on the couch. There was another time when his dad went on a business trip that was supposed to last for just a weekend, but it ended up getting extended for the whole next week. Your client wonders out loud if he was even on a business trip at all or if it was a mini-separation. He also recalls a time when he woke up to the sound of his parents arguing, so he went downstairs to see what they were arguing about, and they told him that they were just rehearsing lines for a play, and they weren’t actually fighting. He thinks back on all of the family vacations they all went on, and your client wonders if they were just faking their happiness to trick him and his siblings into thinking they had a normal family. He asks you if you can treat couples too and if maybe, instead of spending time with him you could help his parents stay together because that’s what the real problem is, according to him. The client is tearful as he expresses regret over not having been able to save his parent’s marriage. He discusses the stress of not knowing where everyone will live once the divorce is finalized. You demonstrate reflective listening and use empathy to build rapport with the client. You encourage him to write letters to both of his parents between now and the next time you see him.
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Domain: Intake, Assessment, and Diagnosis

Which of the following assessments would best help you to better understand the client's relational dynamics?

Domain: Counseling Skills and Interventions

What insights from the homework would you hope to elicit from your client?

Domain: Treatment Planning

After about five sessions, a different one of your clients comes to session stating that she would like to begin to work through some PTSD symptoms that she failed to mention when you made the treatment plan in an earlier session. She stated that she was not ready to talk about these events until now. What would be the best way to move forward?

Domain: Counseling Skills and Interventions

From a Rational Emotive Behavior Therapy perspective, how would you respond to the client's expression of regret regarding not being able to save his parent's marriage?

Part Three

Second session, two weeks after the initial intake session

The client comes to session stating that he made the basketball team and has been working hard over the past week to make up missed assignments. He expresses gratitude that his teachers have been so helpful. He shares with you the letters he wrote to his parents throughout the week. You point out themes that you notice—especially themes of disappointment and anger in the letter he wrote to his dad. You help the client identify what factors are in his control and what factors are not in his control. In session you spend a considerable amount of time analyzing how much responsibility a child has to make sure a marriage is healthy. The client comes to the conclusion that the marriage is not his own and that the strength of a marriage depends on those involved—not the children. You reinforce client’s insight and provide unconditional positive regard and reflective listening. Your client states that he feels comfortable talking to you, and he would like to share something he hasn’t told anyone—not even his best friend. He tells you that his dad has been talking about moving to another state once the divorce is finalized and that his dad had a private conversation with him about wanting him to move with him. He said he was excited at first because his dad made the new house sound amazing, but he quickly learned that he would have to leave his siblings behind because they would stay with his mom. He asks if you can talk about this next session because it is yet another secret that he’s having to keep from the rest of the family and it is stressing him out. You tell him that you will make a note for next time and you can revisit this topic.
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Domain: Professional Practice and Ethics

Which of the following are not accepted benefits of the informed consent process?

Domain: Treatment Planning

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

Domain: Treatment Planning

With the client's improvements as evidenced in Part 3, what would be the most likely treatment plan consideration at this point?

Domain: Professional Practice and Ethics

Which of the following reflects the importance of professional self care as a therapist?

Case 3

Part One

Age: 42
Sex: Male
Gender: Male
Sexuality: Heterosexual
Ethnicity: Asian American
Relationship Status: Single
Counseling Setting: Private Practice
Type of Counseling: Individual
Presenting Problem: High anxiety in elevators and public transport
Diagnosis: Agoraphobia

Presenting Problem: You are a therapist in private practice and receive a referral from a colleague for a 42-year-old, Heterosexual, single, Asian American, male. Your colleague informs you that the client is experiencing “severe anxiety in elevators” and that they do not have appropriate training to treat his presenting condition. During your initial evaluation, you learn that the client is the Marketing Advisor for a social media firm and works on the 11th floor of a large office building. Due to an intense fear of elevators, client stated that he takes the stairs daily to his office and is often late for important meetings. Upon further inquiry, client shared, “it’s not just elevators that I won’t go in. I will not take the bus or train because they get overly crowded and I feel like I can’t move or breathe.” Client reported that when he has been “forced” to use public transport or elevators in the past, he begins shaking uncontrollably with intense chest pain and a racing heart. Client endorsed, “I have a few close friends that want me to meet them in the city for drinks after work, but I won’t do it. It’s really starting to cause a strain in my friendships.”

Mental Status Exam: Clients presents well-groomed in a suit and noted, “I just got off work. I didn’t have time to change.” He appears anxious as he is fidgeting with a pen during the duration of the session and makes intermittent eye contact. You notice that he is breathing deeply after sharing with you his fear of elevators and public transportation. Client expressed, “It’s hard to talk about. Talking about the anxiety gives me more anxiety.” Client presents with fair insight and notes that he is logically able to understand that his fears are unreasonable but unsure how to “fix it.” He expressed that his fears keep him up at night leading to difficulty concentrating during the day, anxious mood, and fatigue. He denied suicidal and homicidal ideation.

Family History: Client grew up in San Francisco, California, where he currently resides. He was raised by two parents and has one older sister, a lawyer in Burbank, CA. Client endorsed that his parents were supportive, but also noted feeling pressure to achieve excellent grades in school and continue to a successful career. Client remembers fearing the bus during a high school trip but felt like he could not talk to his parents without feeling judged. He notes feeling undervalued at home and inability to express his emotions as a child.

Vocational History: The client studied his bachelor’s in human development at a university in Spain. He finished the program in just three years because of some trouble renewing his visa. He states that the last year he was in college he had double the normal workload so he would graduate on time. “I literally don’t remember a thing I studied that year, but I guess it doesn’t matter in the long run,” he says with a sigh as he continues to wring his hands. After coming back to the United States, he studied his MBA, and then a second master’s degree in marketing. He worked his way up at his firm, and provides professional consultation services on the side. He feels well respected at work, and satisfied with his position, although he tends to interview with other companies from time to time just to see what other opportunities are out there.

Relationships: Client shared that most people find him friendly once they get to know him. He endorsed difficulty engaging with new people, as he reflected that he is scared his fear of elevators and public transport will come up in conversation. He has two close friends, a roommate from college and a best friend from high school. He noted his best friend from high school suggested counseling after growing increasingly frustrated that client would continue to cancel their plans. Client expressed that he has not dated in years, either and the thought of going on dates gives him anxiety.
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Domain: Professional Practice and Ethics

The client expresses their fear that others may find out about what they are sharing in therapy. You remind them that everything they share in session is strictly confidential as discussed in the informed consent policy that was discussed at the start of treatment. What is the primary purpose of this response?

Domain: Intake, Assessment, and Diagnosis

Which of the following is not classified under the Anxiety Disorders domain of the DSM-5?

Domain: Counseling Skills and Interventions

This client’s Agoraphobia would best be addressed by which of the following techniques?

Domain: Treatment Planning

Which of the following is not a common goal of counseling?

Domain: Counseling Skills and Interventions

You begin to suspect that a different one of your clients is in an abusive relationship because her partner limits the amount of contact she can have with other people and she has mentioned that he has threatened her multiple times. What is the best course of action?

Part Two

First session, two weeks after intake

Client presents in session a few minutes late with appropriate attire. Client reveals that he began working from home due to the COVID-19 pandemic and further reflected, “I’ll never have to deal with elevators or public transportation again.” At first, he presents as unmotivated to address his anxiety and is hesitant to engage in conversation. He continues to fidget with his pen and gazes at the clock frequently. You utilize supportive reflection and gentle summarizing to reflect that the client does not appear ready for treatment. Client expresses, “well, you know, maybe I should start to work on this stuff now so that when this pandemic is over, I’ll be ready to go back to the office.” He tells you that he thinks the pandemic will be over in a month or two, so that leaves just a few sessions to work on his symptoms before he’ supposed to go back into the office. You tell him that your office doesn’t plan on closing, as it seems that the only cases that have been reported so far are overseas. He states that he feels optimistic that the whole thing will blow over, and the media will soon be focused on another topic. You use cognitive redirection to bring his focus back to his goals. You help him establish a baseline reading of his anxiety and level of tolerance for discomfort. He states that he is currently unable to be in an elevator for more than 30 seconds at a time, and he can barely carpool with his coworkers in a midsize SUV and feel comfortable. The client states that he feels better if he’s driving, but if he’s in a passenger seat, the anxiety is unbearable. He shares that he would like to try exposing himself to his fears slowly with the goal of one day taking the train again.
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Domain: Treatment Planning

What is the most reasonable short-term therapeutic goal for this client?

Domain: Intake, Assessment, and Diagnosis

Which of the following is not a Domain on the Mental Status Exam?

Domain: Counseling Skills and Interventions

The emotional state of the client as described in the first session after intake is best defined as:

Domain: Core Counseling Attributes

Why would you say, “You can tell me anything, and I won’t think any less of you.”

Part Three

Second session, three weeks after first session

During your previous session, client made progress in practicing deep breathing techniques when he begins to feel his chest pounding and palms sweaty. He demonstrates this skill to you today and throughout the session as he becomes anxious when processing his fear of returning to work and seeing his friends again. Client reflected, “After work I’ll just play video games and lose track of time. It makes me forget about the isolation.” As you explored in the previous session, client noted that he walked to the bus station and only began to feel anxious when he saw passengers get off. You ask what made him nervous about the people getting off. He talked about the different individuals he saw riding the bus. There was a mother who was holding both of her toddler’s hands as she walked behind him. She allowed him to feel like he was walking independently. Your client states that he thought this was sweet, and nothing to feel nervous about. He then discussed an older couple he saw who was dressed in very nice clothes and how he wondered where they were headed dressed up so nice. Then, he noticed a male nurse get off the bus. “Everyone is just headed somewhere. The bus is like a little representation of the whole world all wrapped up into a neat package. I’m always thinking about marketing, you know. Everyone has their own opinions, style, and preferences. There’s just a lot of information there inside a bus. It’s a lot to take in.” He endorsed that he used to get anxious by simply the thought of public transportation and noted this is gradually improving. He then laughed and shared, “Oh, but don’t think I’m even close to ready to work on elevators yet. Or crowds. I’m not there yet.” You highlighted client’s progress and scheduled a session for next week.
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Domain: Counseling Skills and Interventions

Before engaging in the exposure portion of systematic desentization, what needs to be done first in therapy sessions?

Domain: Counseling Skills and Interventions

How would you reflect the meaning of the client’s recounting of how he felt at the bus station?

Domain: Intake, Assessment, and Diagnosis

The term Psychasthenia is associated with which assessment instrument?

Domain: Intake, Assessment, and Diagnosis

What would be the most likely alternative diagnosis to consider for this client?

Case 4

Part One

Age: 26
Sex: Female
Gender: Female
Sexuality: Heterosexual
Ethnicity: Asian American
Relationship Status: Single
Counseling Setting: Agency
Type of Counseling: Individual
Presenting Problem: Constant worry
Diagnosis: Generalized Anxiety Disorder

Presenting Problem: Client is a 26-year-old, Asian American female, who is a self-referral, presents for an intake assessment with an inability to concentrate and constant, daily worry about every aspect of her life. The client reports, as far back as she remembers, there has never been a time when she felt relaxed and comfortable with where she is in life. During the last seven months, she has been increasingly irritable with family and friends and has been isolating herself from others out of fear that they constantly judge her.

Psychosocial and Relationship History: Client has only had one serious boyfriend in her life. She met Duke at a bar while she was studying her undergrad degree. He was a professional bull rider in a rodeo circuit. During the two years they dated, the client would often attend rodeos to watch her boyfriend try to last 8 long seconds on the back of a bucking bull. One day, he fell off, landed on his back, and the bull stepped on his stomach, breaking three of his ribs. She asked him to take the next season off so he could recover properly, but he said he wasn’t willing to miss more rodeos than he had to. He quickly got back on the rodeo circuit and won numerous awards. Your client then urged him to stop going to rodeos so they could spend more time together. Her boyfriend refused to give up the rodeo, so she broke up with him.

Mental Status Exam: Client presents with a strong cigarette odor, fidgety and on-edge. The client speaks rapidly and often forgets the topic of conversation. She reports an inability to sleep throughout the night and reports she has been feeling fatigued due to a lack of sleep. The client reports no suicidal ideation and no self-harming behaviors. The client is mostly cooperative throughout the assessment; however, at times, she appears irritated when you ask certain questions about her background.

Family History: The client is single and lives with her mother. The client is the youngest of two older siblings. She mostly avoids her mother and sister and stays alone in her room because she feels as if they talk about her behind her back and does not feel comfortable around them.

History of Condition: The client reports she noticed seven months ago she became more irritable and struggles to leave the house to look for work. The client reported her mother constantly nags her to leave the house, but she does not like being in public places due to feeling people are constantly staring and judging her. She reported she tenses up when she is around other people and her mind often goes blank.

Work History: The client has been unemployed for almost one year. She reported she used to work as a waitress, but the job was too demanding. She reported feeling uncomfortable on the job due to the amount of people she interacted with on a daily basis. She reported she was trying to save up money to buy a car because she did not like using public transportation, but she quit because she was always nervous. The client reports she is struggling to find a job because each time she has to complete an application for a job, her heart races and she starts to worry about everything that could go wrong in the interview.
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Domain: Intake, Assessment, and Diagnosis

Which of the following is not a criteria for Generalized Anxiety Disorder?

Domain: Counseling Skills and Interventions

At this early stage of counseling, what could you say to best address the client's irritation evident when you ask her questions about her background during the Mental Status Exam?

Domain: Professional Practice and Ethics

You are researching articles regarding GAD. You encounter the term Z-Score. What does this refer to?

Domain: Counseling Skills and Interventions

Generalized Anxiety Disorder is well addressed by all of the following techniques except:

Domain: Intake, Assessment, and Diagnosis

You are assessing a different client who is a 25 year old male. Three weeks ago he was assaulted while walking home from work. Since then, he has been sleeping poorly and getting into multiple fights at work that involve both verbal and behavioral outbursts at work. He has been avoiding walking home. What is the most likely provisional DSM-5 diagnosis?

Part Two

First session one week after initial intake:

Client arrived for session fidgety, talkative with a strong cigarette odor. She reported she had to take the bus to the session which always makes her feel keyed up. During session, you focused on building rapport, establishing trust by providing empathy and support to the client through active listening. You engaged client in a discussion about additional situations/environments that make her feel keyed up and asked about current coping skills to manage these situations. Rather than focusing on current situations and environments that have a tendency to increase the client’s anxiety, she discusses past times when she has felt especially anxious, including when she would wait for her ex boyfriend to come out of the rodeo arena after his events. She stated that the worst part of the rodeos for her were when the rodeo clowns would make small talk with her. She states that she always felt nervous talking to people who were wearing excessive amounts of makeup because she never knew if she would recognize them if she ever encountered them outside of the rodeos. “The clowns just gave me the creeps. Also, what kind of person is willing to stand between a fence and an angry bull? That never made sense to me,” she stated. She talked about other times in college when she would feel especially anxious about checking her grades, resulting in avoiding it altogether. Towards the end of the session, you introduced worry coping cards that help client identify additional coping skills she could implement to help keep her calm and relaxed. The client shows reluctance to accept the worry cards because she doesn’t think “mere activities” will work for her. For homework, you asked client to monitor situations/triggers where she used coping skills and to rate their effectiveness.
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Domain: Treatment Planning

Which is the best long term goal for a client with Generalized Anxiety Disorder?

Domain: Counseling Skills and Interventions

Regarding the worry cards, what question would you ask to develop a discrepancy within the client, to move her toward change?

Domain: Core Counseling Attributes

What insight do you hope the client gleans from the homework assignment?

Domain: Counseling Skills and Interventions

Your client has started looking for work but is upset that she got called back to interview for “only” 2 out of 3 jobs she applied for. You point out that she has an opportunity to interview with two companies, and she states, “That doesn’t count. I’m sure they only called me because no one else applied.” Which thinking error is present here?

Part Three

Second session three weeks after initial intake:

Client presented more relaxed and does not smell of cigarettes. She reported she has been using a few of the activities from the worry coping cards and feels less on edge. You engaged her in an exploration activity where she discusses situations/triggers where she felt on edge this week. One example is when her mom decided to stop off at a grocery store on their way home from getting her mom’s van washed. Ever since the client became unemployed, her mom has given her extra tasks, mainly driving her around to different places. The night her mom decided to stop at the store, the client decided to stay in the car and scroll through her social media feeds while she waited for her mom. You asked her to identify any negative thought patterns related to the triggers. She told you she couldn’t really identify the thoughts that were making her nervous, but she just “felt like something bad was a going to happen.” She stated that she didn’t like the way the sun was going down and how it made the parking lot look dangerous. She also noticed that the lights in the parking lot were too dim for her liking. When you asked about how she has felt regarding her anxiety today, the client stated, "I felt like everyone was staring at me on the bus today." You provided psychoeducation about how thoughts, feelings and behaviors are related. For homework, you asked her to monitor any negative thought patterns and to track any feelings/behaviors related to her thoughts.
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Domain: Treatment Planning

You realize that your racial biases and stereotypes are getting in the way of your client’s treatment. You have found yourself getting annoyed and irritable when your client tells you each session that she did not complete her therapy homework. What is your best course of action?

Domain: Professional Practice and Ethics

When you ask a different one of your clients if they are experiencing suicidal thoughts, they reply, “Not really”. Which of the following would be your best response?

Domain: Core Counseling Attributes

What nonjudgmental response would you make in response to the client's statement about the bus ride?

Domain: Core Counseling Attributes

You are also counseling a married couple, and the husband is noticeably shut down. He presents with closed body posture and limited words. You ask him how he is feeling, and he says that he is “Sick of fighting and done with this conversation.” You ask him what made him feel this way, and he tells you that he cannot put his finger on it. Which would be best to focus on before moving on to conflict resolution?

Case 5

Part One

Age: 14
Sex: Male
Gender: Male
Sexuality: Heterosexual
Ethnicity: Caucasian
Relationship Status: Single
Counseling Setting: Agency
Type of Counseling: Individual
Presenting Problem: referred by school due to poor grades, low mood, and relational problems
Diagnosis: ADHD

Presenting Problem: You are a counselor working in private practice and specializing in child and adolescent mental health. A 14-year-old Caucasian male presents to your office upon referral from his high school counselor. He arrives 10 minutes late, explaining he rode his bike and didn’t consider the distance to your office. He reports feeling sad and worthless after his girlfriend of 2 months dumped him. When you ask for additional details, he doesn’t seem to hear you. He stands up to examine a painting of a sunflower field hanging on your wall. The client comments that he enjoys the calming atmosphere of your office. When you return to the subject of his break-up, he laments that he can’t seem to do anything right. He reports other people, including his ex-girlfriend, call him unreliable and selfish. He worries about being perceived this way and asks for your help.

Mental Status Exam: Client presents somewhat disheveled with wrinkled shirt and unkempt hair. He is alert and oriented to person, place, time, and situation. He maintains fair eye contact, though he is distractible. His mood is anxious, and he is talkative throughout session. He displays restlessness and fidgets while seated. Client reports he enjoys being social but has been told he is a “bad listener.” As a result, he has several strained friendships, and he reports often feeling sad and lonely. He denies thoughts, plans, or intent for suicide or violence. He admits to having difficulty making decisions on his own and expresses gratitude that this appointment was scheduled for him.

Family History: The client states that he frequently got in trouble when he was younger for not completing household tasks. His parents said that he would leave things done half way and they would catch him playing on his tablet when he was supposed to be cleaning his room. He recalls one time when his dad threatened to throw any toy he left on the floor in the garbage, and when the client got home from school that day, his toys were indeed in the garbage can. His parents would also frequently tell him that they were going to call the police on him for being bad. One time, the client was playing outside instead of matching the family’s socks from the laundry, and the client heard police sirens in the distance. His mom came outside and told him that the police were going to pick him up if he didn’t come back in and help her with the laundry.

Academic History: Client has struggled to maintain passing grades over the past school-year. He reports desire to improve, but he often avoids or forgets to finish homework. During class time, client frequently leaves to use the restroom and he admits to taking extra time to roam the halls before returning. He has received multiple detentions this year for skipping class altogether. When asked about this, client states he gets tired of teachers reprimanding him, and he feels embarrassed when he is caught daydreaming during lectures.
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Domain: Counseling Skills and Interventions

Which of the following might your client have said during the mental status examination to affirm your client’s diagnosis?

Domain: Core Counseling Attributes

In practice (no client in particular) which of the following is the best example of a clinical empathic response?

Domain: Intake, Assessment, and Diagnosis

Which of the following details from Part One for this client is most indicative of a diagnosis of ADHD?

Domain: Intake, Assessment, and Diagnosis

Which assessment is used as a quick, entry level instrument in order to better select more specialized assessments (for adults)?

Domain: Professional Practice and Ethics

How do you interpret the client standing up in the middle of your conversation?

Part Two

First session, three weeks after the intake session

Client arrives on time today, stating his mother reminded him of the appointment and offered to give him a ride. He reports feeling better about his break-up and states he is interested in asking out a new girl who he met at the skate park. He identifies feeling nervous to approach her. You reflect client’s feeling of nervousness and ask him to consider what information this emotion is conveying to him. He interrupts before you finish your sentence to tell you about a new video game he purchased. It is the sequel to his favorite video game, whose protagonist is a blue hedghog. He goes into detail about the other characters in the video game, their mission, and the themes of each world and level. He tells you about the websites one can go on to find cheat codes, as well as who his favorite video game streamers are on Twitch. The client states that he has plans to go to the movie theater this weekend to watch a movie that is about his favorite video game, and that he might ask the girl from the skate park to join him. He wonders if he will be able to complete all of his chores on time to get his allowance, because without that, he won’t be able to buy his own ticket—let alone two of them. The client then discusses some advice his parents gave him about how to be a gentleman on a date. “It seems like common sense,” he states as he flips the hair out of his eyes. You try to redirect the conversation, but client continues to speak animatedly and without pause. He taps is foot throughout session and his eyes sometimes dart to the window or clock on the wall behind you.
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Domain: Treatment Planning

Which assessment would provide the most valuable information to aid in the treatment planning process?

Domain: Intake, Assessment, and Diagnosis

You choose to ask, “Do you feel like your (symptom) has changed since we began therapy?” The primary motivation for this question is to:

Domain: Counseling Skills and Interventions

You are utilizing the services of an interpreter to perform an intake interview with a different client from Mexico. You ask the client, “People often understand problems in their own way, which may be similar or different to how professionals might describe the problem. How would you describe the problem?” What is the purpose of this question?

Domain: Professional Practice and Ethics

Regarding Consents for Release of Information:

Part Three

Second session, six weeks after the intake session

Client paces your office while describing an argument he had with his mother. He states she came home from a parent-teacher conference and yelled at him for failing 3 classes. His mom also expressed to him that she is embarrassed because the school counselor told her that he is in danger of failing a grade, and she has tried everything to prevent this. “Why can’t you just pay attention? School is your one responsibility!” the client exclaims in a mocking tone. He tells you he has heard the same thing year after year, and he hasn’t failed a grade yet. He speculates that everyone is just trying to scare him. Client defends himself to you, stating he wants to do better but he can’t focus on studying. He reports he was rejected by the girl at the skate park, and his friends seem annoyed by him lately. He tells you he feels like a failure and wonders, “What’s wrong with me?” You summarize client’s complaints and validate his feelings of distress. You normalize the feelings of rejection he is experiencing and provide an appropriate amount of self-disclosure to strengthen the therapeutic alliance and express empathy to the client. He asks you follow up questions about how you handled the rejection and what your opinion is of a conversation that he had with the girl in question via text. He expresses relief that someone understands and throws himself into the chair opposite yours.
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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: Core Counseling Attributes

You have a different client who is venting about not being able to lose weight, and you say, “I get it, you’re frustrated because you’ve tried everything and nothing has worked. Of course it’s weighing on you.” What is your main goal by making this statement?

Domain: Counseling Skills and Interventions

Which of the following is not true of distance counseling?

Domain: Counseling Skills and Interventions

You, along with an intern, are leading a group of nine adolescents in a juvenile detention center. Your group is getting more and more hostile as it has entered into the Power Struggle (Storming) stage. What is your course of action as you notice cliques forming?

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: 16
Sex: Female
Gender: Female
Sexuality: Heterosexual
Ethnicity: Caucasian
Relationship Status: Single
Counseling Setting: Agency
Type of Counseling: Individual
Presenting Problem: Extremely preoccupied with appearance
Diagnosis: Bulimia Nervosa

Presenting Problem: You are a counselor in an agency in a small town. Your new client is a sixteen-year-old, Caucasian female. Her mother has brought her to see you because she is concerned about some behaviors that she has started noticing in her daughter for the past three or four months. The client has joined a local 24-hour gym and works out every morning before school. Her mother reports that her daughter has also become extremely preoccupied with and openly critical of her appearance.

Mental Status Exam: The client comes to your office dressed nicely in black pants and a blouse. She is slightly overweight, and has her hair pulled back in a long braid. She tells you that she thinks her mother is overreacting and isn’t sure what the big deal is. She is oriented times three, and her movements are unremarkable. The client is a junior in high school and shrugs when you ask her how school is going. She denies any suicidal or homicidal ideation. She expresses concern about people at her school knowing she is coming to a counselor.

Family History: Both parents are athletic and physically fit. Her father played baseball in college and her mother was a volleyball player. Her middle sister was involved in high school sports. The family places a high value on being in good physical shape as well as achieving high grades in school. Her mother reports that the client tried playing soccer in middle school but lacked the coordination skills and motivation necessary to be a successful player. She gave the sport up in her second year.

Substance Use History: The client has a 19-year old neighbor that she met when the two were on the school’s soccer team in middle school. The neighbor works at the local smoke and vape shop, and gave client a vape at the beginning of the school year. The client quickly went through the first cartridge by vaping secretly, and when she asked her neighbor if she would supply her with another one, the friend was surprised at how quickly it had run out. She gave her another one, thinking that the first cartridge was potentially partially empty, but the client went through the second one just as fast. Her neighbor told her not to vape as frequently because it could be dangerous to start smoking so much, so soon. The client’s parents discovered the vape pen shortly after, grounded her, and forbade her from speaking to the neighbor. The client hasn’t smoked in over 6 months and didn’t have trouble quitting.

Current Living Situation: The client lives at home with both parents. Her father is an orthopedic doctor in his privately-owned practice, and her mother is heavily involved in local politics, including the school board and city council. She is the youngest of three girls, each two years apart. Her middle sister recently graduated from high school, attends a local community college and works full-time. Her oldest sister lives a few hours away at a prestigious university and is preparing to graduate early with a degree in physical therapy.
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Domain: Intake, Assessment, and Diagnosis

From a Reality Therapy perspective, what would you say to build therapeutic alliance with this client?

Domain: Counseling Skills and Interventions

Which of the following is not an element of Roberts’ Seven-stage Crisis Intervention Model?

Domain: Professional Practice and Ethics

Which of the following assessments would be the best choice for monitoring the therapeutic relationship?

Domain: Counseling Skills and Interventions

What is the best way to begin to tend to a person’s current trauma?

Domain: Treatment Planning

Which of the following best describes what is included in a Superbill?

Part Two

First session, two weeks after initial intake session

The client comes to your office after school with a large convenient store soda. She expresses feeling stressed out lately and tells you about her recent frustration with her father. He is often critical of her and compares her to her sisters. A few days before, he told her that he was disappointed in her most recent report card, because she received a B in English. She expresses anger and shame connected to this and doesn’t understand why he isn’t pleased with all the A’s she received. You ask what she does when she feels stressed, and she reports that sometimes she eats more than she probably should. She often goes through a drive-through on her way home from school, eats a full meal and then eats dinner with her parents. She also has a secret stash of snacks she keeps hidden in her room. She expresses that she has a habit of eating salty foods in the middle of the night and early in the morning right before she has to wake up for school. She tells you that she started eating potato chips, but one night her mom came in because she heard all of the noise the client was making with the bag. When the client heard her mom coming, she quickly stashed the bag under the covers and acted like she was sleeping. Ever since then, she has opted for snacks in quieter containers, and the only chips she eats are the wavy ones that come in a cardboard tube. She also has eaten cupcakes late at night because those are considered to be a quiet snack as well. She tells you that you’re the only one that knows about this, and she doesn’t want her parents to know about the stress eating. You empathize with the difficulty of trying to live up to her parents’ expectations.
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Domain: Intake, Assessment, and Diagnosis

What is the best way to respond regarding the secret stash of snacks?

Domain: Treatment Planning

Which of the following is not a common barrier to a client’s ability to attain therapeutic goals?

Domain: Counseling Skills and Interventions

How should you respond to the client’s disclosure about her father being critical?

Domain: Core Counseling Attributes

Your client begins attending a group focused on eating disorders. In a group setting, direct advice is a factor that aids in group development. Typically, the advice given to group members comes most often from which source?

Part Three

Second session, four weeks after initial intake session

The client comes in during school hours to meet with you. She looks tired and has dark bags under her eyes. She has just come from a dental appointment and has been having some issues with her teeth lately related to damaged enamel. She sometimes throws up when her stomach feels too full. You ask how long this has been happening and she says she had done it before when she was younger, but it’s gotten worse in the last few months. Recently she throws up a few times a week. She tells you that she hasn’t noticed a pattern regarding when she feels too full, but the late night snacking might be a culprit. The first time she threw up for feeling too full was after she ate a mix of salty and sweet foods, and she thought that it was because of the combination of flavors that weighed heavily on her stomach. To help with this, she started to only eat foods from the same category if she felt she wanted a quiet snack to enjoy while the rest of the family was sleeping. Her other hypothesis is that she wasn’t drinking enough liquids with the foods she was eating, so she bought a 40-ounce insulated water bottle in her favorite color to keep in her room at all times. She tells you that she fills it with ice and chewing on ice has been helpful for her lately as well. Sometimes she feels badly about the vomiting, so she just doesn’t eat for a few days, but then she is weak and has difficulty working out. You begin the process of orienting to the dynamics of eating disorders.
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Domain: Professional Practice and Ethics

You receive a subpoena requesting the records regarding a former client. Which of the following are generally not covered by a standard court subpoena?

Domain: Counseling Skills and Interventions

From a transtheoretical perspective, how would you use Emphasis on choice and control to respond to client's disclosures from Part Three?

Domain: Treatment Planning

During an intake assessment with a different client, you ask them about their hobbies. They report that they have no hobbies, but that they work at an animal shelter most evenings during the weeks. What is the best response to this information in regards to building alliance?

Domain: Counseling Skills and Interventions

Which of the following techniques is least likely to be used in a crisis intervention?

Case 7

Part One

Age: 42
Sex: Female
Gender: Female
Sexuality: Heterosexual
Ethnicity: Latina American
Relationship Status: Married
Counseling Setting: Agency
Type of Counseling: Individual
Presenting Problem: Problems at work and home
Diagnosis: Unspecified Depressive Disorder

Presenting Problem: You are a mental health counselor in a community mental health agency. A 42-year-old, Latin-American female, who is a self-referral, presents for an intake assessment with work performance issues and ongoing conflicts with family members. The client reports she has not been motivated to do anything for the last month. She reports she struggles to complete tasks at home and work. She reports she has been arguing with her spouse and adult children on a daily basis. The client reports her family members told her she needs to talk to someone because she cries frequently throughout the day.

Mental Status Exam: Client presents with disheveled appearance and with poor hygiene. Client is sometimes tearful and otherwise maintains a flat affect throughout session. When client speaks, she presents with slowed thinking, does not maintain eye contact, and speaks at a soft, slow rate. She reports fleeting suicidal ideation with no plan or intent. She reports no self-harming behaviors.

Family History: The client has been married for twenty years and has two adult daughters, ages 19 and 21. Client’s mother and father both died within the last two years. The client has two older siblings but has not spoken to them for over a year.

History of Condition: The client reports she experiences low mood and irritability and has felt this way for the past several years. The client reported she talked to her primary care doctor after she stopped talking with her siblings, but client never filled the Prozac prescription the doctor prescribed. Client reported she thinks her father struggled with depression, but he was never formally diagnosed.

Legal History: The client stopped talking with her siblings because of disputes regarding the parents’ estate. Her parents left her as the executor of their will, and when she called a meeting with her two older siblings and the family attorney, both siblings brought their own attorneys with them. When the client tried to present what the will said, her siblings’ attorneys stated that the client was trying to commit fraud, and the will would have to be assessed at a later date in probate court. Both attorneys filed a motion to freeze all of the assets, and the matter still has not been resolved. Her late parents’ home sits empty, and is at risk of being annexed by the state. She expresses that she is sad that the relationship came to this, but she lacks the motivation to look into anything herself and allows her attorney to communicate with the other professionals about the estate. “I don’t really care what happens to all their stuff,” she sighs.

Work History: Client has been employed as a paralegal for the past five years. She reported she used to love her job but now feels disinterested in her work. Client was placed on an improvement plan three weeks ago due to her lateness, poor project performance, and inability to complete projects on time. She reported she used to make very few mistakes on her projects but for the past several weeks, she has been making many careless mistakes that resulted in multiple client complaints.
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Domain: Professional Practice and Ethics

The client asks if they will be able to get copies of their counseling records. What is your best response?

Domain: Treatment Planning

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

Domain: Intake, Assessment, and Diagnosis

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

Domain: Counseling Skills and Interventions

A different client who is 8 years old asks if you have any snacks in your office because she has not eaten anything since yesterday. She states that there is no food in the house where she is currently living. What is your best course of action?

Domain: Treatment Planning

You are also counseling a different client who has relapsed on cocaine for the second time since you began treatment 6 weeks ago. They come to you distraught that nothing seems to be working. Which type of program would you recommend they start out with to maximize his changes of sobriety?

Part Two

First session one week after initial intake:

Client arrived for session disheveled with flat affect and little eye contact. She reported she was fired from her job because she was late for work three times this past week due to her inability to sleep at night. During session, you focused on building rapport, establishing trust by providing empathy and support to the client through active listening. You asked about goal setting. The client reported she wants to learn ways to cope with recent losses, manage irritability, and improve communication with family members. When you ask her what she has lost, she gets irritated and asks if you didn’t listen to her at all last session or this one. “I’ve lost my parents, my siblings, and now my job,” she says through clenched teeth. You apologize for your lack of awareness in an attempt to repair this rupture in the therapeutic alliance. Your client seems willing to reengage in the session despite feeling shut down and irritable. She tells you that she would go on medication, but she has read about terrible side effects that she doesn’t want to deal with. She says that she has spent a lot of time researching antidepressants, and despite having numerous conversations with her doctor, she is unwilling to take them. You listen to her with empathy and demonstrate unconditional positive regard. The client continues to have a flat affect throughout your conversation. As a calming technique, you taught and practiced diaphragmatic breathing.
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Domain: Intake, Assessment, and Diagnosis

All of the following would be helpful assessments for evaluating Major Depressive Disorder except which?

Domain: Treatment Planning

The primary purpose of asking the client about goal setting in Part Two was to:

Domain: Counseling Skills and Interventions

In addictions counseling, ________________ gives individuals in recovery from stimulant addiction a framework for maintaining abstinence. It’s primarily used in patients recovering from methamphetamine or cocaine addiction.

Domain: Core Counseling Attributes

“Life is at times unfair and unjust,” and “There is no escape from pain or death” are discussed by the members of a group you are running. These are examples of ___________ factors.

Part Three

Second session two weeks after initial intake:

Client arrived for session disheveled with flat affect. You aren’t sure if it’s just a coincidence, but she is wearing the exact same outfit that she was wearing at her appointment last week. It was Pink brand sweatpants with a dark blue T-shirt and a long white sweater. Her socks have little avocados printed on them, and they can be seen when she crosses her legs during the session. You go back and forth in your mind about whether you should point it out, but you remember how she got irritated with you last time, and you decide to ignore it, however you make a note of it to monitor next time. You know that it would be difficult to replicate that exact same outfit—socks and all— and the more you think about it, you become even more convinced that she hasn’t changed her clothes in a week. You resolve that, if the client is wearing the same outfit yet again, you will assess her level of self care. She maintained eye contact throughout the session and reported she has been using diaphramatic breathing this past week to help manage mood. The client stated, “I still feel sad a lot of the time, though.” You introduce a mood chart and asked her to begin to track her mood each day. You provide psychoeducation related to the connection between thoughts, feelings and behaviors during session. You teach an additional coping skill, progressive muscle relaxation, and practice towards the end of the session.
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Domain: Counseling Skills and Interventions

Regarding the new coping skill that you introduce in the second session after intake, which of the following diagnoses would least benefit from that technique?

Domain: Intake, Assessment, and Diagnosis

Why did you assign a mood chart to this client?

Domain: Counseling Skills and Interventions

How would you reframe the client's statement of, “I still feel sad a lot of the time, though.”?

Domain: Core Counseling Attributes

Which is most likely to be present in the forming stage of a group?

Case 8

Part One

Age: 13
Sex: Male
Gender: Male
Sexuality: Heterosexual
Ethnicity: Caucasian
Relationship Status: Single
Counseling Setting: School Counseling
Type of Counseling: Individual
Presenting Problem: Low test scores, insulting teachers, and destroying school supplies
Diagnosis: Specific Learning Disorder (Written Expression), Oppositional Defiant Disorder

Presenting Problem: You are a school counselor who works in a small rural community. Your client is a 13 year-old male who recently tore up a state achievement test packet, and is facing disciplinary consequences from the school. The student states that he knows that he is stupid and there is nothing anyone can do or say to change that. He has been known to break pens and pencils throughout the years and insult teachers and students. He has had some confrontations with the assistant principal, and got suspended last year for spitting at a male science teacher.

Academic History: The client has never gotten good grades. He was held back in first and second grade. Once he comes around to addressing you, he states that school is frustrating for him, especially writing. He states that he has never passed a spelling test and cannot get the words from his head onto the paper. He has trouble typing on the computer and has no desire or interest to read. He states that he has always been “on the teachers’ black list” because of his extremely sloppy handwriting. “Why try if I’m just going to get yelled at?” he asks.

Family History: The client lives at home with his mom, brother, and mom’s boyfriend. The client states that he’s always in trouble and does not listen to what mom and her boyfriend have to say. He states that he often times does the opposite of what his parents want because he does not feel like following anyone’s rules but his own.

Health History: The client’s grandfather and biological father both passed away of colon cancer in their early 40s. His brother, who is now 18 has undergone his first set of testing to monitor potential cancerous developments. The client states that his brother was being a big baby about having to get the tests done, and he won’t be scared to do the testing when he is older. He says he doesn’t remember much about his dad because he passed away when he was so young, but he finds himself wishing he were still alive so he wouldn’t have to live with his mom’s boyfriend who is always yelling at him and saying that he’s disappointed in him about his grades. Your client says that his mom’s boyfriend has no room to talk about grades because he dropped out of high school in 10th grade.

History of the condition: For the past eight months, parents and teachers have noticed the client being particularly angry and resentful. The client states that nothing significant happened eight months ago, but states that he “just decided to not take anyone’s crap anymore.” He states that he can’t help he’s stupid and is sick of people trying to rub it in.
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Domain: Intake, Assessment, and Diagnosis

You choose to administer a Mental Status Exam. Delusions, obsessions and phobias belong to which Domain on the Mental Status Exam?

Domain: Intake, Assessment, and Diagnosis

Based on the information disclosed at intake, which of the following statements about this client is most supportive of the diagnosis of Oppositional Defiance Disorder?

Domain: Professional Practice and Ethics

When evaluating statistical data, Discrete Data refers to which of the following?

Domain: Counseling Skills and Interventions

You have a different client who is preparing to take her bar exam to become a lawyer. She tells you she just knows that she is going to fail, and is upset that all of her work throughout law school has been a waste. She states that the shame she will feel after not passing the test devastates her. Which thinking error is surfacing here?

Domain: Intake, Assessment, and Diagnosis

Which of the following is not a common domain to screen among individuals with trauma history?

Part Two

First session, one week after the initial intake session

The client comes to session extremely angry because the principal stated that he would have to be seeing you twice per week, and the client was under the impression that the intake session was just a one-time appointment. You use empathy to build rapport with the client and apologize for the misunderstanding. He states, “The last thing I need is for another adult to be telling me what to do.” You provide psychoeducation on the counseling process and ask the client if there is anything at all that he feels like he needs help with. He says, “I know they already told you.” You explain that he is your priority and you would like to work on what he would like to work on. He says he will think about it. After a few minutes he states that he doesn’t want you to tutor him and he doesn’t want to talk about school or grades at all. You remind him of your scope of practice and tell him that you plan to leave the tutoring to tutors and teachers. “Does this mean that I can skip class to talk to you?” You laugh and tell him that you’ll try to get him out at the best times of day for everyone, but you can’t guarantee that he won’t miss something fun. “Nothing’s fun here,” he says. You tell him that you’d like to try to change that and allow him to pick a board game from your closet. He asks you to come over and explain the different games because he isn’t familiar with many of them. After a few minutes, he chooses a card game and you let him deal the cards. He seems to be warming up to you.
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Domain: Treatment Planning

At your second appointment with a different client, you go over the treatment plan with them, including medication compliance and psychiatric intervention, as well as outpatient counseling. Your client states that he feels overwhelmed at the amount of appointments and professionals that are involved in his treatment and is unsure if he is willing to dedicate this much time to his mental health. Which would be the most helpful approach?

Domain: Core Counseling Attributes

What would you say to demonstrate genuineness to this client?

Domain: Counseling Skills and Interventions

Which of the below is not a factor which can affect a foreign client’s access to adequate healthcare?

Domain: Counseling Skills and Interventions

From a transtheoretical perspective, how would you use an amplified reflection to elicit more information from the client?

Part Three

Second session, one week and a half after initial intake session

The client comes into session in a much better mood than last session as evidenced by providing more eye contact, voluntarily offering information, and asking follow up questions. You ask the client if he has thought about any goals you could work on in the counseling process, and he states that he is sick of feeling stupid and wants to stop thinking that way. He says that if he weren’t so stupid then maybe he wouldn’t be in so many people’s spotlights all the time. You probe his writing difficulties and encourage him to explain in detail what he is most frustrated with. You normalize his experiences and explain to him the difference between having a learning disability and being stupid. You refer him to an intervention specialist who has training in writing and language deficits. You discuss some steps that can be taken for client to reach his goal of improving self-esteem. The client asks if you would be willing to talk about these goals with his mom and her boyfriend because he says that they are the two people in his life that make him feel the dumbest. You spend the rest of the session discussing with him how he would like that conversation to go, and what is okay and what is not okay to share with his mom and her boyfriend. You also ask the client if he would like to be present for the conversation, but he declines. He talks about his relationship with his brother, and he thinks his mom’s boyfriend makes his brother feel stupid too, “But at least his grades aren’t as bad as mine,” the client mutters. You thank the client for sharing his feelings, and he asks when you are meeting next.
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Domain: Treatment Planning

As you are creating the treatment plan with another one of your clients, you notice that they mention riding their bike numerous times. Upon gathering more information, you learn that riding their bike has provided a lot of happiness in the past. You ask them if it would be a good idea to include bike riding once per week in their treatment plan. Which model of therapy are you working from?

Domain: Professional Practice and Ethics

All of the following are potential ethical concerns regarding a therapist's professional social media page except which?

Domain: Professional Practice and Ethics

You are contacted by the family of a deceased client who want you to release your deceased client's counseling records. What is your best course of action?

Domain: Counseling Skills and Interventions

You are conducting a Cultural Formulation Interview with a different client. From a cultural perspective, which of the following questions is least beneficial as you gather information about a client from a different culture?

Case 9

Part One

Age: 66
Sex: Female
Gender: Female
Sexuality: Heterosexual
Ethnicity: Caucasian
Relationship Status: Married
Counseling Setting: Agency
Type of Counseling: Individual
Presenting Problem: Martial problems due to hoarding
Diagnosis: Hoarding Disorder

Presenting Problem: You receive a referral for a 66-year-old, heterosexual, Caucasian, married, female from the client’s husband. Client’s husband notes that she is refusing to “throw away clothes from 10 years ago” and the clutter in the home has become “disastrous.” You learn that client’s husband has threatened divorce if client does not downsize her belongings and go to counseling. Client was homeless for 15 years and expresses strong sentimental value towards all her “treasures.” She shares with you that she has six cats and goes to estate sales to build her collection. She notes that she has been unemployed for the last six years and is on Social Security Benefits, allowing time to shop at thrift stores, yard sales, and malls. Client endorsed that it does not bother her that the kitchen is stacked with dishes, her mattress is in the living room, and her husband is currently staying in a hotel. Client expresses tearfully that she is not ready to part with her collection.

Mental Status Exam: The client presents relatively disheveled. Her hair is unkempt and her clothes have stains on them. The clothes look quite tattered, which the client points out stating that each stain and hole tells a story. She tells you where she was when different stains were added to the garments. She also tells you that the shirt she is wearing was bought when she hitchhiked down the Pacific Highway when she was younger. Her thought process is coherent and her affect is appropriate. The client is tearful at times, when discussing her husband moving out as well as potentially having to get rid of some of her belongings. She is oriented to person, place, and time and is able to recall 3 of 4 words that were given to her at the beginning of the mental status exam. The client does not present with visual or auditory hallucinations.


Family History Client grew up in Seattle, Washington, and was raised by an alcoholic mother and a father that left home when client was nine years old. Client has one older sister and two older brothers whom she has fallen out of contact with. Client endorsed experiencing significant financial difficulties throughout her childhood, “my mom always spent all our money on booze.” She noted she left home at age 17 which led to a period of homelessness for 15 years, “I was a free spirit. I slept in park benches, vans, trailers, whatever.” She was physically abused by her mother during drunken rages and expressed never having a parental figure to bond with.

Current living situation: Client is currently living in her two-bedroom home that she bought with her husband six years ago when she retired. She notes that there is not space to walk or sleep in the bedroom due to her belongings. As a result, client’s husband decided to move into a hotel until client receives counseling. She noted that the kitchen is inhabited by ants and “other creatures” due to the stockpile, but she just cannot bring herself to downsize. She orders takeout daily, causing financial strain and potential health problems.
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Domain: Core Counseling Attributes

If at some point, the client and her husband requested help with communication skills, from a conflict resolution treatment perspective, which of the following would not be a goal of counseling?

Domain: Intake, Assessment, and Diagnosis

How would you assess the client’s insight to this problem?

Domain: Intake, Assessment, and Diagnosis

From a Rational emotive behavioral therapy (REBT) perspective, what would you focus on to help this client?

Domain: Professional Practice and Ethics

If during therapy, a recently graduated counselor encounters complex legal or ethical issues, their best first course of action would be which of the following?

Domain: Professional Practice and Ethics

You are providing Telehealth services to a client who resides in a different state. Which of the following statements best describes the relevant ethical standard?

Part Two

First session, two weeks after intake

Client presents to your second session on time with weather-appropriate attire. She continues to appear disheveled but is not malodorous. She initially presents as irritable and selects a seat that is facing away from you. She notes that she has thought of downsizing her home and creating a list of items to give away, but the task feels incredibly daunting. The client tells you that she has broken her possessions down into categories, including kitchen utensils, clothes, wedding memorabilia, furniture, work files that she has to keep for six more years because of her state’s professional standards, cleaning products, and wall decor. The client tells you that the category of wall decor takes up the most space. Much of her garage is filled with framed art that she has found at numerous stores and flea markets around town. The client states that the client has all of the framed decor stacked against each other. Once the first layer filled the entire garage floor, she began to stack layers of additional pieces on top of the bottom ones, and now the garage door doesn’t even open because the stacks of wall decor have reached the opening mechanism. Her husband has stated in the past that the other items in the house are useful, but he doesn’t understand why she needs so much wall decor from dollar stores and craft stores. She expresses anger that her husband threatened to leave her if she does not receive counseling and reflects upon abandonment issues that she had as a child. You encourage client to notice her thoughts and feelings about her possessions and utilize gentle cognitive challenging to support client in exploring alternate beliefs. Collaboratively, you explore the options of available resources for supporting client.
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Domain: Treatment Planning

The resources referenced in the first session after intake could appropriately include all of the following except which?

Domain: Intake, Assessment, and Diagnosis

Which instrument is the quickest and simplest for assessing cognitive function in the elderly?

Domain: Counseling Skills and Interventions

This client’s Hoarding Disorder would best be addressed by which technique?

Domain: Professional Practice and Ethics

You consider referring the client to a support group for those who struggle with hoarding. Which of the following is not reflective of effective group termination?

Part Three

Second session, six weeks after first session

During your first session, client made progress in accepting help and working with the case managers at the community agency to clean her home. She established a plan with her husband that he will move home in two weeks. She expresses that she donated some of her belongings to Goodwill and has utilized the thought stopping techniques learned in counseling when she has the urge to spend at an estate sale. Although she enjoys going to estate sales on the weekends, she has developed a plan with her husband to go to other places to pass the time on Saturday afternoons when she typically goes. She tells you that going to estate sales is a good socialization activity for her, so they are coming up with ideas that will not only take up time, but have something to do with socializing. She tells you that one of the ideas on the table is to join a bowling league or to both volunteer at a homeless shelter because volunteers are needed to serve lunch and dinner. The client states that she is optimistic about finding new ways to spend her time. You reflect upon the progress client made in treatment and encourage client to utilize referrals for a support group and practice the cognitive reframing techniques.
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Domain: Counseling Skills and Interventions

What would be an appropriate paradoxical intervention to suggest for this client?

Domain: Core Counseling Attributes

You have a different client who is tearful as she describes the loss of her pet to a car accident. She expresses that she does not want to have another pet. Which of the below is the best empathic response?

Domain: Counseling Skills and Interventions

You are considering referring the client to a 12 step group for hoarders. Which of the following is not part of the 12-step program process?

Domain: Counseling Skills and Interventions

You have a different client who is depressed, and you recommend that he schedule a hike this weekend since hiking is something he used to enjoy. This technique is called:

Case 10

Part One

Age: 48
Sex: Female
Gender: Female
Sexuality: Heterosexual
Ethnicity: Latina American
Relationship Status: Single
Counseling Setting: Community clinic
Type of Counseling: Individual
Presenting Problem: Recent break up
Diagnosis: Histrionic Personality Disorder

Presenting Problem: A 48 year-old Latina client comes to see you with hopes that she can feel better about her recent breakup. The client states that the couple had been together for the past five months, and the only explanation she got for his breaking up with her was that she is “too over the top” for him. The client sobbed uncontrollably as she described her ex as “the most wonderful man in the world,” and “a prince who was like my knight in shining armor.” When you ask what she liked about him, she states, “He’s just him!” In an instant, her demeanor changes, she wipes her eyes, and enthusiastically begins talking about her primary care physician, who she calls by his first name: “Greg really thinks you can help me. He’s such a sweetie, but won’t prescribe me anything for this.”

Mental Status Exam: The client comes to session wearing revealing clothing. At one point she takes a hair tie out of her hair and seductively flips her hair. She looks at you flirtatiously and fishes for compliments by stating, “You know, so many people have told me I have the kind of hair you see in shampoo commercials.” When you don’t respond with a compliment, she frantically begins talking about her accomplishments as a multi level marketing representative. You notice her demeanor and emotions change as the conversation goes from topic to topic. The client is oriented to person, place, and time.

Relationship History: The client has dated men of all backgrounds, and the client boasts that she has had over 100 sexual partners. She tells you that she stays in touch with many of them, but has never had a serious relationship. She tells you that her parents disapprove of her relationship habits, and they expressed their disdain for the way client has dated others since the client was in her first year of high school. The client tells you that she finds dating to be very exciting, and she considers herself a social butterfly. You ask the client how she feels about all of these surface-level relationships, and she states that it’s good to have someone to talk to all the time. “I look at it as I have the world’s largest support system, and now I get to add you to the list!” she exclaims.

Living Situation: The client lives alone. She had a female roommate, but the roommate recently moved out. The client states that her roommate was always jealous of her and she couldn’t help if her roommate’s boyfriend would stare at the client as she walked around the apartment wearing lingerie. She lives in the same city as her family, however there was a recent falling out when she got upset at her cousin’s wedding because her cousins wouldn’t let her be in enough pictures.
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Domain: Intake, Assessment, and Diagnosis

From an Object Relations perspective, what would you focus on to help this client?

Domain: Intake, Assessment, and Diagnosis

Which of the following assessments is the best choice for a relatively quick, broad screen of multiple mental health domains?

Domain: Counseling Skills and Interventions

Your client dramatically makes the observation, “Everyone else is just so much farther ahead of me in life. I have nothing to show for it.” This client is:

Domain: Professional Practice and Ethics

A different client is seeing you under their employer's Employee Assistance Program. What clinical information is typically released to the EAP administrator?

Domain: Counseling Skills and Interventions

Your client who is convinced people at work are talking about her. As the conversation progresses, you notice that she isn’t able to recall any instances where she has heard or read that others are having conversations about her. You ask her how she found out that this is going on, and she states, “I feel it, so I know it’s true.” What thinking error is she committing here?

Part Two

FIrst session, two weeks after the initial intake session

Client comes to session and places a gift bag on your desk. You explain to the client that due to your agency’s policy you are unable to accept gifts, and the client begins to sob and gesture wildly about your ungratefulness. You ask the client to identify her feelings, and all she will say is that you have ripped her heart out. At one point she sits on the floor. You state, “It sounds like gifts are important to you.” She gets up, gets her phone out, and starts excitedly showing you gift bags that she made for her team of employees. She tells you that she has been in the multi level marketing world for nearly her whole adult life, but the company she works with now has been her best experience yet. She started out selling makeup out of catalogs, and then she moved into health products. Now she sells beauty products. “I don’t allow any Ugg-os on my team. You definitely have to look the part if you want to sell products like these. No one wants to see you go live on social media if you’re not put together. That’s not going to inspire anyone to join your team,” she advises. She discusses all of the awards her team has won over the years, and how they will be going on a company-wide conference on a cruise ship this summer as a part of heir incentive to keep growing their team. She states that she throws an event every quarter in which she requires her staff to dress up and come to an awards banquet that she emcees. “They look good, but I look better,” she says to you with a wink. You discuss boundaries with the client, and she mocks you with a laugh. You provide unconditional positive regard and reflective listening throughout the session.
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Domain: Intake, Assessment, and Diagnosis

Given this client’s diagnosis, what is not an appropriate long term therapeutic goal for this client?

Domain: Intake, Assessment, and Diagnosis

Which of the following client actions from Part 2 is most indicative of her diagnosis?

Domain: Treatment Planning

Cultural safety is about awareness of  _________ in the healthcare setting.

Domain: Core Counseling Attributes

You have a different client who states that he feels inadequate because he has had to seek so much help for himself. Nevertheless, you encourage him to sign up for group therapy. Which group therapeutic factor is likely to be most beneficial to this client given his current struggle?

Part Three

Second session, five weeks after the initial intake session

The client comes to session and states, “I could die from sadness.” You ask the client to go into more detail about what she is feeling, and all she will say is “Life is a tragedy.” She discusses a family conflict over the weekend in which she attended her niece’s birthday party, but got agitated when it was time for the child to open her gifts. Her brother and his wife were throwing the party, and the client was fixing herself a plate when the parents of the birthday girl announced that they would be opening gifts. The client states that she left her plate of food on the table and insisted upon going over and having the birthday girl sit on her lap while she was opening presents. The client states that she wanted to be in the pictures so that everyone on social media would know what a good aunt she is. Her sister-in-law got angry, and asked the client to sit in the circle with the rest of the family. Your client states she felt so rejected that she began to cry, and could not control herself. She locked herself in the only bathroom in the house because she was too embarrassed to come out. She eventually left without saying anything to anyone, and is unsure if she will go to another family gathering. She discusses not being able to stay at the party and wondering what upset her so much. You make a list with the client about times when she felt a similar way and help her identify patterns in the events.
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Domain: Intake, Assessment, and Diagnosis

From a transtheoretical perspective, how would you use an amplified reflection to respond to the client's recounting of her niece's birthday party?

Domain: Professional Practice and Ethics

You are supervising a counseling intern. The principle of Due Process in this context involves all of the following except which?

Domain: Treatment Planning

Which of the following is not considered a Psychotherapist-Initiated Interruption to treatment?

Domain: Counseling Skills and Interventions

Which of the following is considered an outside factor that affects clients’ access to healthcare?

Case 11

Part One

Age: 15
Sex: Male
Gender: Male
Sexuality: Heterosexual
Ethnicity: Native American
Relationship Status: Single
Counseling Setting: Community clinic
Type of Counseling: Individual
Presenting Problem: Trauma symptoms after friend suddenly commits suicide.
Diagnosis: Acute Stress Disorder

Presenting Problem: You are employed at a mental health agency that specializes in working with Native American youth. You receive consent from the client’s guardian, his uncle, before conducting your intake. During the initial counseling session, a 15-year-old, Native American, heterosexual, male reveals that his best friend committed suicide last week on the reservation and he feels lost and alone. He shares that he chose your clinic because he received discrimination from other mental health agencies and wants to work with someone that understands his culture. He expresses that he needs to process the grief and learn how to heal.

History of Condition: Client presents to your intake session carrying a sketchbook. You notice that he is trembling, and you offer him a stress ball to self-soothe during your session. He tearfully shares that his best friend found a gun and shot himself back home on the reservation, “I feel so guilty! I knew he was in trouble because he was using drugs and getting high! I should have gone over to his house!” He presents with symptoms of anxiety, difficulty concentrating, irritability, and hopelessness. He reports that he will never be able to walk by his friend’s home again and expresses intense sleep disturbances, “I’ve barely slept in the last week. I can’t even paint.” Client presents with dark circles under his eyes and denies suicidal and homicidal ideation.

Family History: The client’s mother passed away when the client was three years old due to an undisclosed illness. The client went to her funeral, but is not sure of the circumstances surrounding his mother’s death, and his uncle and grandparents refuse to talk about it. Shortly after his mom died, his dad moved to a big city, leaving the client with his uncle. The client states that he hasn’t seen his dad since, but his dad sends a couple hundred dollars to his uncle every year around his birthday. The client states that he has a good relationship with his uncle, however he thinks it will get better once the client can get a job to help support the household. He states that he often feels like a burden even though his uncle has told him time and time again that it is a privilege to raise him.

History of Alcohol and Substance Use: Client denies alcohol and substance use. He reflects that drug use is common on the reservation, “I guess I got lucky. It’s 'cuz I paint.” He reported that his friend that committed suicide was utilizing crystal methamphetamine and many of his siblings struggle with methamphetamine use.
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Domain: Intake, Assessment, and Diagnosis

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

Domain: Intake, Assessment, and Diagnosis

What information in this session indicates your client is at an increased risk for suicide?

Domain: Counseling Skills and Interventions

_____________ involves clearing the mind and focusing on the sensations and thoughts in the moment, observing them and allowing them to pass.

Domain: Counseling Skills and Interventions

Acute Stress Disorder is common among clients who have recently witnessed or experienced a traumatic event. Which of the following technique is the best choice to use in treatment?

Domain: Treatment Planning

You also work at a residential treatment facility for clients who have attempted suicide. One of your clients is celebrating her last day at the facility and expresses to you that she is most excited to see her children upon discharge. Which of the following is the most important action for you to take?

Part Two

First session, two weeks after intake

Client arrives to session 15 minutes late with dark circles under his eyes, “I’m sorry I was late. I still cannot sleep. I feel so sad and hopeless all the time.” During the intake session, you learn about client’s friend that passed away and the close bond they shared. Client reveals that he was like a “brother to me” and feels hopeless about the future. He reflects that he is unsure if he will ever be able to paint again if he cannot sleep or stop trembling to pick up a paint brush. He begins shaking uncontrollably and appears detached as he stairs out the window with a blank gaze. You utilize “here-and-now” techniques to support him in returning to the moment and teach a mindfulness exercise that he can practice daily. You originally encourage him to close his eyes during the mindfulness activity, and the client gives you mixed feedback after the intervention ends. He states that closing his eyes reminds him of his sleeping troubles, and he sees unpleasant images when he tries to connect with the guided imagery you mention. You ask the client if it would be okay to try the exercise again, this time with his eyes open, with his gaze fixed on the carpet in front of him. He expresses willingness to do so, and the second time he reports that he felt more comfortable and grounded. You ask him to imagine that he has tree roots growing out of the soles of his feet, and every time he inhales he is pulling the air from the tips of the roots, and when he exhales he is sending the air back down, deep into the earth. He states that this is his favorite activity yet. You encourage him to try the technique when he paints and before bed to promote relaxation and healing.
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Domain: Counseling Skills and Interventions

What insights from the homework would you hope to elicit from your client?

Domain: Intake, Assessment, and Diagnosis

Distractibility, flight of ideas and talkativeness could be indicative of which of the following?

Domain: Counseling Skills and Interventions

You have a different client who tells you that this past Wednesday she accidentally set off the fire alarm in her dorm, resulting in a mass evacuation. “I’m such an idiot. I don’t deserve to be in college,” she says. Which thinking error is represented here?

Domain: Core Counseling Attributes

Which of the following is least likely to happen as a group enters Yalom’s stage of developing cohesiveness?

Part Three

Second session, two weeks after first session

Before your second session, you provide client’s uncle with an update on his treatment and goals for therapy. Client’s uncle brings him in for his session and expresses financial hardship. Today is your last session, as client’s uncle cannot continue paying or driving to the agency for treatment. When you begin the session with client, he notes fear in ending your work together. He tells you that his uncle broke the news about ending therapy to him last night while the two were eating dinner. His uncle didn’t have time to cook, so he brought subs from a restaurant that just opened in the nearest town. His uncle told him that he was having to choose between paying for therapy or putting gas in his truck and having enough money for groceries next week. The client’s birthday is coming up in two months, and he hopes that his dad sends a couple hundred dollars as he normally does, but this is never guaranteed. Even then, he states that that money will probably get spent on their typical expenses. Your client states that his uncle said that he feels terrible about having to cut off therapy, because he can tell it is making a difference and perhaps one day your client will be able to start again. He reports that “some days are better than others,” but still feels lingering hopelessness and intrusive memories. He endorses sleep disturbances have improved as a result of practicing the guided imagery and mindfulness techniques. You provide a referral for a free support group that the agency runs for survivors of trauma and grief, as well as a few counselors in the area that provide free/sliding scale services. Client notes he will talk to his uncle about it and hands you a painting that he drew of a horse, “I also painted a portrait of my friend, but I want you to keep this one. Thanks for everything.”
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Domain: Counseling Skills and Interventions

What metaphor would you use to encourage the client to continue practicing his coping skills even though your work together is ending?

Domain: Intake, Assessment, and Diagnosis

Which of the following is not a criteria for Posttraumatic Stress Disorder?

Domain: Core Counseling Attributes

You often tell your clients, “There is nothing you can say to me that is going to make me think less of you.” What is your reasoning behind this statement?

Domain: Treatment Planning

Which of the following would not be part of an AOD rehabilitation facility’s follow-up plan for discharged clients?