What does the right to treatment entail?

Providing treatment that has a reasonable chance to succeed

Providing any kind of treatment

Providing treatment if the client is deserving of it

Providing treatment that has a reasonable chance to succeed

Which one of the following is a professional obligation counselors are expected to adhere to under the ACA code of ethics?

Maintain a non-discriminatory approach in the counseling relationship

Ensure clients they are expert counselors in all areas, even those in which they have no training

Make comments in professional settings on behalf of the ACA

Maintain a non-discriminatory approach in the counseling relationship

Practice in multi-disciplinary areas regardless of training

In Donald Super’s development of self-concept theory, he establishes five stages of career and life development. One of these stages is the exploration stage, which is characterized by ________ . Choose all that apply.

Discerns which career choices are realistic

Part Three Twentieth Session, 22 Weeks After the Initial Intake You are meeting with the client for the termination session. You review the treatment goals and the client’s progress. The client is no longer experiencing panic attacks, and she reports that she has felt panic attacks coming on but that she intervenes early and often to prevent them from occurring. You and the client have prepared for this date during the last few sessions in order to prepare the client for transitioning to independence from therapy. You and the client discuss her use of coping skills and natural supports to continue to manage panic symptoms. You also inform the client of how to reconnect if she needs to receive therapeutic support again and then terminate services. You are supervising a counseling resident, and their established client has canceled several sessions in a row. Which of the following would you encourage the counselor to do?

follow up with the client to ascertain the reason for their cancellations

cancel ongoing sessions until the client can commit to regular sessions

support the client by providing an option to have a referral if they think that counseling is not working

follow up with the client to ascertain the reason for their cancellations

contact the client to encourage them to trust the therapeutic process and continue to have sessions

Alfred Adler’s phase of treatment known as Exploration and Analysis explores an individual’s lifestyle. This lifestyle assessment includes two phases including ________ , and ________ .

Family constellation, early memories

Current vocation, early memories

Vocational status, family constellation

Family constellation, early memories

Family constellation, future goals

A goal of existential therapy is for clients to face their fears. A common fear clients’ present is the fear of death. To address this fear, clinicians frequently ask this question:

How would you live your life differently if you knew you would die next week?

Where do you want to be buried?

What do you wish you could change about your life?

What does your religion say about death?

How would you live your life differently if you knew you would die next week?

Initial Intake: Age: 26 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Private Practice Type of Counseling: Individual Presenting Problem: You are a counselor in a private practice setting. Your client is a 26-year-old male who presents for counseling at the request of his family and his employer, with whom he is close and who knows his history. The client tells you that he has been angry for the past 15 years, beginning a year after the death of his father from a heart attack. He says that his anger is triggered very quickly when frustrated by people or situations and that his “fuse is very short these days.” He states that he has been in some “loud arguments” with his mother, and later his stepfather. He admits that there have been times in the past when he and his stepfather have “almost come to blows” but his mother stepped in and made them stop. He admits to having hit or kicked walls at times in his anger, but has never hit a person. He tells you that he doesn’t want to feel this way because it interferes with his relationships and his former girlfriends have never understood that when the anniversary of his dad’s death comes around, he just wants to be alone for a couple days and not have to talk to anyone. He tells you that he has never had a long-term relationship with a woman because either he gets “depressed” for a few days during certain times of the year (i.e., father’s birthdate and death date) or because he is too quick to get angry and then says things he doesn’t mean. He says that he has been in a relationship with a woman now for eight months and really wants to get himself together because he feels “she’s the one.” Mental Status Exam: The client appears his stated age and is dressed appropriately for the circumstances in clean jeans and a t-shirt. He identifies his mood as “anxious but a little excited” because he “is hopeful that he can finally let his anger go.” He tells you he is tired because he has difficulty falling asleep and staying asleep most nights. His affect is pleasant with emotional lability evident. He demonstrates appropriate insight and judgment, memory, and orientation. He reports never “seriously” having considered suicide but acknowledges that there were times when he wondered “if dying would make this pain go away.” He has never attempted suicide and states he would never consider harming himself or anyone else. Family History: The client reports a family history of being the youngest of three siblings born to his mother and father. He reports a “great life” with his family and that they regularly spent time together playing, camping, traveling, and “just being a family.” He tells you that he is sure there were occasional arguments but that he doesn’t remember anything significant, except that he had been mad at his dad the night he died because his dad wouldn’t let him stay up late, but that before the client went to bed, he had come down, apologized to his dad, and they had both said “I love you.” He states his parents had been married for 15 years prior to his father’s death, which occurred when the client was 11 years old. He states his dad died of a heart attack while sleeping, so while he did not see it, he knew something had happened because his mother woke him and his siblings and rushed them over to the next door neighbors’ house. He said that his mother went to the hospital with his father in the ambulance and came home that night to tell him and his siblings that their father had died. He tells you that he and his siblings are still very close and that they now have three much younger siblings born after his mother married his stepfather. He says that he is very close to his mother and stepfather, although he lives three hours away from them. He tells you that he tries to get home for big family events, like birthdays. He states that his stepfather adopted him and his siblings after the wedding and the client loves him very much. He tells you that he and his stepfather have gotten in what the client thinks are “typical teenager/parent” conflicts but that they have often been made worse by the client’s anger that seems to always be inside and erupts quickly. Which of the following treatments would be least helpful for treating this client?

Trauma-focused Cognitive Behavioral Therapy (TF-CBT)

Prolonged Exposure Therapy (PE)

Trauma-focused Cognitive Behavioral Therapy (TF-CBT)

Eye Movement Desensitization Reprocessing (EMDR)

Initial Intake: Age: 20 Gender: Male Sexual Orientation: Homosexual Race/Ethnicity: African American Relationship Status: Single Counseling Setting: University counseling center Type of Counseling: Individual Presenting Problem: Stress, anxiety, depression Diagnosis: Anxiety disorder, unspecified (F41.9), Major depressive disorder, single episode, unspecified (F32.9) Presenting Problem: You are a brand-new counseling intern in the counseling resource center of a local university. Jonathan is a junior in college and comes to speak with you, as you are his newly assigned college university counselor. Jonathan is concerned about finals that he feels unprepared for, stating he is “overwhelmed” and “under too much pressure” from his family to “allow himself” to fail. He is making disparaging, negative remarks about himself and his abilities, often repeating himself and talking in circles using emotional reasoning. He asks you for help in getting his teachers to modify his deadlines so that he can have enough time to accomplish all his assignments, mentioning that his last counselor did that and called it “playing the mental health card”. There are no previous records on file for this student, but when you ask him who he met with he just changes the subject and continues to express his worry that he will “never amount to anything or graduate” if he fails these exams. Mental Status Exam: Jonathan presents as anxious with congruent affect, evidenced by client self-report and therapist observations of fidgeting, inability to sit still, tearfulness and shallow breathing with rapid paced speech. Jonathan occasionally closes his eyes and takes deep breaths when he begins to cry in attempt to slow himself down and prevent what he calls “another emotional breakdown.” He has prior inpatient treatment history of a one-week episode where he was involuntarily committed at 17 for making comments about planning to kill himself in response to his stress over finishing high school. He admits to passive suicidal ideations in the past few weeks while studying for exams but does not report considering a method or plan. He reports that he has been losing sleep because of long study hours and feeling too keyed up to calm down. You assess him as having distress primarily associated with anxiety, which at times of abundant stress turns to episodes of depression and hopelessness. Education and Work History: Jonathan has a high academic performance history, despite short periods of time where he experiences heightened stress. Jonathan has never gotten in trouble in school or had any infractions at part-time jobs later as a teenager. He has worked after-school jobs at the grocery store, bowling alley, and local town library. Jonathan had only one work-related incident where he broke down emotionally when feeling overwhelmed and left work in the middle of his shift, but his supervisor was supportive and helped him. Current Living Situation: Jonathan lives in the college dormitory with a peer and is supported by his mother. His mother is a single mom who works full-time in Jonathan’s hometown, which is almost a full day’s worth of driving from where Jonathan goes to college. Jonathan mentions that his friends call him “Jonny.” He adds that the food available to him is not very healthy and he has poor eating habits due to prioritizing studying and his involvement in extra-curricular activities. How should you format a goal for suicidal ideation?

ensure the goal aims to eliminate SI

describe levels of SI as more or less severe

ensure the goal aims to eliminate SI

project seeing reduction in six months

conduct updated assessments monthly

Initial Intake: Age: 53 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Married Counseling Setting: Community Agency Type of Counseling: Individual Presenting Problem: You are a counselor in a community agency setting. Your client is a 53 year-old male who presents with complaints of feeling insignificant, unworthy, and a failure. He admits to having these feelings for the past 30 years and while he has never had suicidal ideations or plans, he has often wondered if his life had purpose and what that purpose was. Your client additionally tells you that he doesn’t feel happy on most days though he does have happy feelings at times; they just don’t last. He is good at his job and finds it challenging, yet tells you “it’s a job” and that there is nothing special or “exciting” about it to him. He tells you that he has been married for twenty years and has five children; three of whom he adopted when he married his wife. He states he adores his wife and children, though he knows that he often does not meet their needs emotionally, “tunes out,” and frequently puts his own “wants and desires” before their requests, needs, or previously made plans. He admits he gets “jealous, I guess” when someone else in the family gets something that he didn’t. He also says that he often says “the wrong thing” when his wife or children are upset about something and he struggles to understand how they are feeling. He tells you that these actions cause conflict in his marriage and with his children and he is ashamed that he does this, but feels hopeless that things will change because he cannot figure out how to change or why he does these things. He reports that he does not believe himself to be better than others but that others often perceive that he sees himself that way because of how he interacts with them. He also tells you that his family often wishes he would “think before I speak or make decisions.” He reports that in spite of these “failures,” he and his wife have a very strong marriage and express their love for each other daily. They enjoy activities together although he needs very active recreation such as roller coasters, bike riding, and swimming while his wife leans towards less physical activities. Finally, your client tells you that over the years he has had some trouble focusing at work and at home. He views himself as “forgetful” and says “I don’t have a good memory.” He says this causes troubles at home and work when he frequently forgets to do something that he said he would do or when he is not as careful or gets distracted in his work and is slow to finish projects or makes small mistakes that have greater impacts on reports. Mental Status Exam: The client appears his stated age and is dressed appropriately for the circumstances. He rates his mood as “anxious.” His affect is congruent though he appears to relax as the session continues. He demonstrates some limited insight and frequently responds with “I don’t know” but when encouraged, is able to access thoughts and emotions that are disturbing to him. He demonstrates appropriate judgment, memory, and orientation. He reports never having considered suicide or harming himself or anyone else. He states that he is very engaged individually and with his family in their religious practices and views these as a source of strength. He currently takes 50 mg of Pristiq and Concerta 18 mg. Family History: The client reports his parents were married to each other until his father’s death at age 60. Your client states he was very close to his father although his father’s activities were often curtailed due to illness. He states that his father accompanied him to boy scouts and was involved with the client and his older siblings. The client states that he has always been close to his mother although he acknowledges often feeling angry at her but being unable to tell her that, so instead he “tuned her out.” He describes her as extremely “critical and consistent.” He tells you that the first time he decorated a Christmas tree was with his wife as his mother always decorated their family trees “so they were done right.” He also says his father and siblings could always count on her to be the one who made the family late for everything and left them waiting during outings. In one example, he shares that when going out together, his mother would often set a meeting place and time for him. He reports that he would either wait at the meeting spot for hours because she was late or that he would sometimes go looking for her and then get in trouble for leaving the meeting spot. He reports that his oldest sibling died in his 40s from excessive drug and alcohol use, and that his other sibling has a very conflictual relationship with their mother and sees their mother “when needed” but is often angry with their mother. He describes his relationship with his mother over the past twenty-five years as one in which his mother makes promises without keeping them and was often dismissive of the client’s wife and children during the time that he was dating and for several years after their marriage. He relates one account where his mother was helping his wife organize something in their home, but refused to organize it in the manner that his wife needed it, and instead became very angry, defensive, and accusatory when his wife reorganized what his mother had done. Considering the information provided, which question will be most effective to ask when setting treatment goals for the client?

What do you hope to gain from working together in counseling?

Which is most important to work on: your depression, narcissistic traits, or ADHD?

What do you hope to gain from working together in counseling?

What have you tried in the past to make changes that haven't worked?

Initial Intake: Age: 45 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Married Counseling Setting: Private Practice Type of Counseling: Individual Presenting Problem: You are a counselor in a private practice setting. Your client is a 45-year-old male who reports that his wife of two years suggested he seek help for what she says is “OCD.” The client says that several months after their marriage, his wife began complaining that the client had so many expectations for her and her children that they are overwhelmed and feel unable to please him. The client tells you that he has had friends tell him in the past that he is “OCD” and sometimes his employees make fun of him because he wants everything done a certain way. He says that they sometimes call him “the eye” because they say he is always watching to make sure they do things correctly. Some of his closer friends will “test me” sometimes by moving something to see if the client notices it. He tells you they are doing it in fun, and he doesn’t really mind because he automatically notices things, whether they moved something or it has accidentally got put in the wrong place. He admits that he is concerned that things are done well because he owns his own business and needs it to be managed correctly, but he doesn’t really understand his wife and stepchildren’s concerns. He tells you that he would like to know if he “is the problem” and if so, how he can make changes to help his marriage. He tells you that he doesn’t see a problem with how he runs his business and thinks that his employees are just “complainers.” Mental Status Exam: The client appears his stated age and is dressed appropriately for the circumstances. He rates his mood as “happy” and this is congruent with his affect. He demonstrates some social awkwardness in presentation and conversation both in missing social cues and oversharing. He demonstrates some motor hyperactivity, indicated by fidgeting, shifting in his seat, and upon entering the office, is invited to sit as he was touching items on the bookshelf. He presents as very talkative, distractible, and tangential in his conversation. It is necessary to redirect him often as his explanations and responses include excessive and irrelevant details, and provides responses before the question is completely stated. He demonstrates limited insight into his presentation or the concerns others have shared with him. He demonstrates appropriate judgment, memory, and orientation. He reports no substance use, no sleep or waking problems, and does not smoke. He is emphatic in his negative responses to questions related to suicidal or homicidal thoughts and intentions. Family History: The client reports being the youngest of two sons born to his parents. His parents have been married for 40-plus years. He tells you that his mother did complete high school with some difficulty and has never been employed. His father is now retired but was an accountant previously. He says his older brother had a difficult time several years ago with holding a job and going through a divorce, but is now doing much better. The client tells you that his family is still very close, his parents come over to visit often, and prior to buying his business, he often vacationed with family. He says that while growing up, their mother has always been overprotective of him and his brother and has always made sure that they did things the right way. The client states that until his marriage, he continued to live in his parent’s home in his childhood bedroom. He says that even though he took care of his own things, his mother still checked behind him every day to make sure the bed was made correctly and that nothing needed cleaning up. The client says that his parents were constantly frustrated with his brother because he didn’t take care of his room and things. The client reports that he completed a college degree in business and chose to open his own franchise business so that he could work for himself. He has owned his business for six years and enjoys it, although he rarely has time off. He tells you that his father and mother stop by the store frequently “just to help out.” He says his mother likes to help with cleaning and his father helps with the accounting. Second Session, six weeks after the intake session The client arrives for his session and tells you that he had an argument with one of his stepchildren the other day and that it really disturbed him. He says that he asked his stepson to mow the lawn and to make sure that he did so horizontally across the yard since the client changes the direction each time he mows. He tells you that his stepson didn’t do as asked and ran the mower vertically across the yard so that it was in the same pattern as last week’s mowing. The client reports that he and his stepson ended up arguing about it and his stepson yelled at him, “if you can’t be satisfied with the job that I did, then do it yourself next time!” The client tells you that this made him very angry but later as he was talking with his wife, she explained that even though it wasn’t the way the client wanted it done, that her son had contributed to helping the family and doing something that the client wanted completed. The client says he struggled because he wants the grass to grow well and alternating the pattern of mowing is important, but there was a part of him that felt sad and angry at himself for getting mad at his stepson, even though the client knew his stepson was wrong for not doing what he was told. Which of the following would be most appropriate for helping the client navigate his dilemma?

The rules say your stepson was wrong, but a part of you seems to be questioning the rules

Why do you think you feel sad and angry at yourself?

Your stepson didn't do it the way you wanted but you feel upset for getting angry

Your rules created a barrier between you and your stepson's relationship

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NCMHCE
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Initial Intake: Age: 15 Sex: Non-binary        Gender: chose not to answer Sexuality: chose not to answer Ethnicity: East Indian Relationship Status: Single Counseling Setting: Community Outpatient Clinic Type of Counseling: Individual Presenting Problem: Shar was brought it by their mother, Nadia, for concerns about being isolated and argumentative. Mental Status: Shar is 15-years old and looks younger than stated age due to their weight. Shar had a flat affect throughout the interview and looked down frequently. Despite there being an empty seat on the couch next to their mother, Shar sat in a chair across the room. History: Shar and Nadia reported that they used to have a close relationship. There have been no issues or discord until now. Recently, Nadia noticed Shar staying to themself more in their room, which is unlike them. Shar recently lost a significant amount of weight and teachers reported their grades have declined. Nadia shared problems started when the topic of the sophomore dance came up and Nadia asked Shar what boy they were going with. When this topic came up during the intake, Shar rolled their eyes at this and stated, “Mom, you are so narrow minded. Why do I have to go with a boy, why can’t you just ask me WHO I am going with?” Nadia looked at the counselor and stated, “Do you see why I brought her here? She is so disrespectful, and she is lucky that her father did not hear her say these things. We used to be so close.”  Session One Information gathered at intake showed that Shar displayed desire to be a boy at an early age and would often want to dress in “boy” clothes as opposed to dresses and wanted to urinate standing up, instead of sitting down. Nadia brushed this off as Shar being close to their father and having “tomboy” like characteristics. It wasn’t until Shar went through puberty that they began making comments such as wanting to cut off their breasts. Shar would also get angry when filling out any kind of forms where she had to identify their gender, stating that she wished that she could fill out anything else but female. Shar asked if their mother could not be around for the session. Shar shared with the counselor that they never felt like they belonged anywhere. Ever since Shar was young, they have felt out of place, like there was something wrong with them. At first, their parents tried to discourage them from wearing “boy clothes” and participating in activities normally reserved for boys. Shar's friends throughout elementary school and junior high accepted them for who they are. However, once Shar entered high school, they were bullied for appearance and since then, lost their group of childhood friends. For the past few months, Shar has had feelings of sadness and hopelessness, has had difficulty sleeping and feels guilty for the obvious distress this is putting on their parents. After the session, Nadia asks the counselor if she can share with her what Shar said. At this point the counselor should:

Correct — D. Working with a minor often brings up issues of confidentiality. The best option out of the choices above is to help facilitate communication between Shar and Nadia. It is unethical to share with Nadia what is said in the counseling sessions unless there are safety concerns. Client confidentiality and privacy rights should be discussed at intake so this should not be the time to first introduce this. Regardless of the mother being the guardian, confidentiality and privacy rights still apply.

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Initial Intake: Age: 15 Sex: Non-binary        Gender: chose not to answer Sexuality: chose not to answer Ethnicity: East Indian Relationship Status: Single Counseling Setting: Community Outpatient Clinic Type of Counseling: Individual Presenting Problem: Shar was brought it by their mother, Nadia, for concerns about being isolated and argumentative. Mental Status: Shar is 15-years old and looks younger than stated age due to their weight. Shar had a flat affect throughout the interview and looked down frequently. Despite there being an empty seat on the couch next to their mother, Shar sat in a chair across the room. History: Shar and Nadia reported that they used to have a close relationship. There have been no issues or discord until now. Recently, Nadia noticed Shar staying to themself more in their room, which is unlike them. Shar recently lost a significant amount of weight and teachers reported their grades have declined. Nadia shared problems started when the topic of the sophomore dance came up and Nadia asked Shar what boy they were going with. When this topic came up during the intake, Shar rolled their eyes at this and stated, “Mom, you are so narrow minded. Why do I have to go with a boy, why can’t you just ask me WHO I am going with?” Nadia looked at the counselor and stated, “Do you see why I brought her here? She is so disrespectful, and she is lucky that her father did not hear her say these things. We used to be so close.”  Session One Information gathered at intake showed that Shar displayed desire to be a boy at an early age and would often want to dress in “boy” clothes as opposed to dresses and wanted to urinate standing up, instead of sitting down. Nadia brushed this off as Shar being close to their father and having “tomboy” like characteristics. It wasn’t until Shar went through puberty that they began making comments such as wanting to cut off their breasts. Shar would also get angry when filling out any kind of forms where she had to identify their gender, stating that she wished that she could fill out anything else but female. Shar asked if their mother could not be around for the session. Shar shared with the counselor that they never felt like they belonged anywhere. Ever since Shar was young, they have felt out of place, like there was something wrong with them. At first, their parents tried to discourage them from wearing “boy clothes” and participating in activities normally reserved for boys. Shar's friends throughout elementary school and junior high accepted them for who they are. However, once Shar entered high school, they were bullied for appearance and since then, lost their group of childhood friends. For the past few months, Shar has had feelings of sadness and hopelessness, has had difficulty sleeping and feels guilty for the obvious distress this is putting on their parents. After the session, Nadia asks the counselor if she can share with her what Shar said. At this point the counselor should:

Correct — D. Working with a minor often brings up issues of confidentiality. The best option out of the choices above is to help facilitate communication between Shar and Nadia. It is unethical to share with Nadia what is said in the counseling sessions unless there are safety concerns. Client confidentiality and privacy rights should be discussed at intake so this should not be the time to first introduce this. Regardless of the mother being the guardian, confidentiality and privacy rights still apply.
NCMHCE

What does the right to treatment entail?

Correct — D. According to a famous article by Morton Birnbaum, psychological patients have a constitutional right to receive such individual treatment as will give them a realistic opportunity to be cured or to improve his or her mental condition. Essentially, Birnbaum argued that psychologists have a duty to provide treatment that will help the patient.
NCMHCE

Which one of the following is a professional obligation counselors are expected to adhere to under the ACA code of ethics?

Correct — C. The ACA expects all counseling professionals to adopt a non-discriminatory approach when working with clients.
NCMHCE

In Donald Super’s development of self-concept theory, he establishes five stages of career and life development. One of these stages is the exploration stage, which is characterized by <code>________</code> . Choose all that apply.

Correct — C. Exploration, which usually occurs between an individual’s mid-teens to early twenties, is described by exploring a variety of careers, and skill development. In the establishment stage, the individual discerns realistic vs. unrealistic career choices.
NCMHCE

<h3>Part Three</h3> <h4>Twentieth Session, 22 Weeks After the Initial Intake</h4> You are meeting with the client for the termination session. You review the treatment goals and the client’s progress. The client is no longer experiencing panic attacks, and she reports that she has felt panic attacks coming on but that she intervenes early and often to prevent them from occurring. You and the client have prepared for this date during the last few sessions in order to prepare the client for transitioning to independence from therapy. You and the client discuss her use of coping skills and natural supports to continue to manage panic symptoms. You also inform the client of how to reconnect if she needs to receive therapeutic support again and then terminate services. You are supervising a counseling resident, and their established client has canceled several sessions in a row. Which of the following would you encourage the counselor to do?

Correct — C. Determining the reason for the cancellations is most important because this can open up a dialogue for getting back on track in the counseling relationship. It may be helpful to cancel future sessions if the client will receive cancellation fees, but this does not get to the bottom of what is happening with the client. It can also be helpful to encourage the client to trust the process, but this does not open up dialogue about what they are experiencing. If the client would like a referral, you should support them. However, it is more helpful to process what is happening with the client to cause the cancellations because this may be an issue related to why they are in treatment, and if unresolved, they may continue to have this issue with the next therapist.
NCMHCE

Initial Intake: Age: 54 Gender: Male Sexual Orientation: Heterosexual Ethnicity: African American Relationship Status: Divorced, In a relationship Counseling Setting: Private Practice Type of Counseling: Individual Presenting Problem: Anger, relationship distress Diagnosis: Adjustment disorder with mixed disturbance of emotions and conduct (F43.25), provisional Presenting Problem: John calls your practice asking to speak to a counselor to help him with his relationship. John tells you he’s never been to a counselor before and does not want anyone to know that he is seeing one, mentioning he will pay for sessions privately using cash. John admits to struggling with anger, specifically with his ex-wife of 15 years whom he divorced three years ago. John asks for availability in the evening hours and demonstrates hesitancy and reluctance to commit to more than a handful of sessions. In the initial assessment session, you notice he has difficulty making eye contact and is uncomfortable talking about his situation. After some rapport building, he begins to share that he is only seeing you because his girlfriend Sherry told him she would break up with him if he did not get his “anger issues under control.” John denied physically hitting Sherry, but alluded to several interactions that he stated, “got so heated I lost it on her, and she wouldn’t stop crying.” John complained of women he gets involved with being overly controlling of him and that he doesn’t understand why they are so “needy.” John works a demanding job in the sports marketing industry where he takes frequent trips out of state and spends long nights out, entertaining clients. He wishes he had the freedom to “do what he has to do” without “being treated like a child” by his romantic partners. Mental Status Exam: John presents as well-groomed with good hygiene and is dressed professionally. Motor movements are slightly fidgety, indicating nervousness or moderate anxiety. Eye contact is intermittent. Denies suicidal or homicidal ideation, no evidence of hallucinations or delusions. John tightens his fists when elaborating on situational issues between him and his ex-wife, with the same controlled expression and tense disposition when sharing about his girlfriend. John mentioned that his girlfriend is also unreasonable for complaining about how often John comes home smelling of alcohol, saying that meeting people for drinks is part of his job. He added the comment “I need to drink to deal with her attitude all the time.” Family History: John tells you he has two children, a 34-year-old son he had with a one-night stand in college and an 18-year-old daughter with his ex-wife the first year they were married. He has a decent relationship with his son and provides him and his family occasional financial support, visiting with his grandchild over social media video once a month. He reports once being close with his daughter but that their relationship became strained as she got older and that now they hardly speak, saying “she took her mother’s side during the divorce, so she doesn’t want anything to do with me right now.” While conducting further interviewing about John’s family health you learn that John’s father passed away at 56 after several heart attacks and his mother died of heart failure and diabetes complications at 49. John has no other living relatives besides an uncle in another state and his cousins who live near him. He tells you growing up he used to go to church with his mother every Sunday until she got sick and has not been to church since. Work History: John has a master’s degree in Business Marketing and made his connections with his current position through contacts he made while playing on collegiate basketball teams. John has always worked busy jobs with which he becomes heavily engaged in and puts in overtime hours. John prefers work that keeps him on the road and traveling often, as he does not like to engage in the same routine every day. He mentions when he was younger, he could not keep a 9-5 office job or at any place that did not encourage individuality, saying he “butted heads” with all his managers and bosses until he was older. Legal History: John has had two arrests made for domestic disturbances in his home that his wife called in after heated arguments that left his wife afraid for her life. He was always able to make bail and was never tried or sentenced as charges were usually dropped thereafter. John admits to one drinking and driving accident when he was 19 where he served community service and fines as punishment. First session, three weeks after the intake session After screening John for Alcohol Use Disorder, you find that he does not meet criteria, despite his apparent unhealthy behaviors and habits. John presents for session as less anxious than previously noted in your last session, with a stern look on his face and is not making any eye contact. He tells you Sherry broke up with him despite his willingness to undergo counseling. He shares that nothing he tried worked and all they did was fight, but he wants to talk with you again because he “got a good vibe” from you in your first session and he thinks you might be able to help him regain his daughter’s trust. He wants to know how to get his ex-wife and daughter to speak to him again. What is the most empathic approach for redirecting John back to addressing his treatment plan goals of anger management?

Correct — C. John is visibly upset when he comes to you for support with how to win his family back. Using confrontational dialogue like in answer b) in the form of interviewing questions can be harmful, not only for your therapeutic alliance but for John's fragile state of mind and emotions especially if he has not come to those conclusions himself. Telling him what you think is best to do before he has come to terms with his anger on his own is not the most effective strategy for gaining his buy-in to the counseling process. Clients may often seem as though they want a clear answer for what to do, but counseling is intended to help a person find their own answers instead of handing answers to them. Clients may also push back defensively if they feel you are telling them what to do or might respond in opposition if they are in denial. Answer d) is not coming from a person-centered approach as the counselor is insisting on teaching new coping skill while putting off the subject of interest to the client until later. Answer a) is the most empathic approach and best way to help guide John to observe his condition and build insight on his own.
NCMHCE

Initial Intake: Age: 29  Gender: Female  Sexual Orientation: Heterosexual  Ethnicity: Caucasian  Relationship Status: Engaged  Counseling Setting: Agency - Telehealth  Type of Counseling: Individual  Presenting Problem: Anxiety  Diagnosis: Anxiety disorder, unspecified (F41.9), Reaction to severe stress, unspecified (F43.9)  Presenting Problem: You are a new counseling intern in a community agency conducting virtual individual counseling sessions using Telemedicine technology. You were referred a 29-year-old female client by your agency’s Psychiatrist who felt she needed to return to weekly psychotherapy as she had previously been doing two years ago. During your initial assessment session, you learn she has three young children under age 8, lives with her fiancé who is the father of the two youngest children, and that due to medical reasons she is on disability through Medicaid and is unable to work. She tells you she has been depressed and contemplating suicide because she cannot find relief from her anxious thoughts. She wants to be a better mom to her children than her mother was to her and wants help overcoming grief and loss, traumatic memories, panic attacks and irritability. Mental Status Exam: Client presents as unkempt, hygiene unknown as it is unable to be assessed via telehealth. She is appropriately dressed. Motor movements are within normal limits. Her eye contact is intermittent as she appears to have difficulty focusing both eyes in the same direction (amblyopia or “lazy eye”). She is cooperative and engaged. She admits to having passive suicidal ideation when triggered with distressing emotions and has considered taking pills as a method that would be the most comfortable but declines having intent or plan to collect pills for this purpose. She states her anxiety increases when she takes her children to the grocery store and when she is around crowds, experiencing panic-like symptoms necessitating her to call a friend to calm her down. She reports experiencing flashbacks of sexual trauma and prefers to stay at home as often as possible. She is alert despite being distracted often by her children in the background and is oriented to person, place, time, and situation. She is fidgeting with her hands and speaking circumstantially, often changing topics and going on rants in different directions before returning to her main points. She reports low energy, sleeping too much and weight gain. She adds that she cries every night over losing her paternal grandfather over 10 years ago. Family History: Client has a strained relationship with her mother whom she reports is “always dating an alcoholic” and has been abusive to her growing up. She adds that her mother has “Bipolar depression and ADHD.” She complains often about both her mother and her fiance’s mother mistreating her, making her feel resentful and angry. Client has two sisters, one of which lives with her mother and is mentally challenged. Her other sister has little to no contact with her family. Her father, who has been divorced from her mother for over 20 years, was once accused of child sexual abuse which has alienated him from the rest of their family. The client is the only one who remains in contact with him.  What would be the most effective person-centered objective within the client's treatment plan goal of addressing trauma?

Correct — D. Objectives must call the client to action while also being SMART (specific, measurable, achievable, realistic, timely). Answer a) is not specific, measurable, or timely. Answer b) is not person-centered; it is too direct in its interventions which might be challenging for a person with high anxiety who is processing her unresolved trauma while transitioning psychiatric medications. The client has already accomplished answer d) by electing to re-engage in therapy when referred.
NCMHCE

Alfred Adler’s phase of treatment known as Exploration and Analysis explores an individual’s lifestyle. This lifestyle assessment includes two phases including <code>________</code>, and <code>________</code> .

Correct — C. Adler’s lifestyle assessment is a process of analysis, and interpretation of a person’s style of living. This includes his or her family constellation or makeup (including family values, parental interactions, birth order, challenges in adolescence, etc.), and early memories.
NCMHCE

What kind of therapy helps clients identify subconscious issues through interventions, like guided imagery and role-playing?

Correct — A. Experiential family therapy helps clients’ uncover subconscious struggles that are associated with present-day relationship issues within the family. Experiential therapy stems from Gestalt therapy, and puts the emphasis on individual responsibility.
NCMHCE

Clients live <code>________</code> when enrolled in partial hospitalization programs.

Correct — A. Clients who are in partial hospitalization programs go home at the end of their daily therapeutic services. They will have a support network of family or case managers to help support treatment goals and safety.
NCMHCE

Initial Intake: Age: 82 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Widowed Counseling Setting: Community Clinic Type of Counseling: Individual Presenting Problem: Theodore is an 82-year-old who was referred for grief counseling by his son, Nate. Theodore’s wife, Nancy died one month ago after a 4-year battle with cancer. Mental Status: Theodore is tearful most days and has dropped a significant amount of weight. He has not been sleeping and stays up watching videos of his deceased wife. History: Theodore was the primary caretaker for Nancy and has not paid attention to his own health in years. Nate would like his father to move in with him and his family and sell the house his parents lived in to pay off their debt. However, Theodore refuses to sell the house and stated that he will not give away or sell anything that they owned. Nate drove Theodore to the initial session and sat in for the intake, with Theodore’s consent. Once everyone sat down, Theodore looked at the counselor and stated, “I am only here so my son stops bugging me about selling the house. I am not getting rid of anything in that house- and especially not the house itself!” Nate explained that his father cannot maintain the house on his own and is worried about him being lonely. Theodore insists that he has other options and thinks that living with Nate would put a burden on him.  Session One Theodore came to the next session on his own. He stated that the only reason Nate drove him for the intake was because Nate was always trying to control everything. When asked how he was doing, Theodore stated that he attended the bereavement group the week before. It was good for him to go as he felt validated and heard. Theodore stated that he felt it was good for him to see others in different stages of grief and to be around others who can relate to losing a spouse. Theodore then spoke to the counselor about not wanting to live with his son and that he wanted to be able to live on his own, even if it is at an assisted living place. Theodore stated he believed Nate was worried that he would lose Theodore just like he lost his mother. Theodore further stated that he is at the stage of his life where he is accepting of death and believes he has led a meaningful life. When asked about his rapid weight loss, Theodore stated that he and his wife used to make dinner together every night. After her death, it pains him to cook in the kitchen where so many memories come back to him. An immediate objective for Theodore should be:

Correct — C. Although there are several areas of concern, it is important for the client to make choices for themselves and establish their own goals. By establishing their own goals, this also increases the likelihood of attainability and success. Housing is a priority for Theodore, but it was not stated that this is an emergency. Theodore was able to care for his wife, so he is likely able to care for himself. It is also not an emergency for Theodore to tell his son he doesn't want to live with him. If that is something that Theodore would like to set as a goal, then it can be made a priority. Making meals is a more pressing matter in terms of overall health. However, it is a goal that Theodore should be making for himself.
NCMHCE

A goal of existential therapy is for clients to face their fears. A common fear clients’ present is the fear of death. To address this fear, clinicians frequently ask this question:

Correct — D. Existentialism deals with philosophical concepts of life, and death. Individuals often fear death, and deal with it through denying its’ inevitability. Existential therapy asks questions about how clients might live life differently to bring the precious nature of life to the forefront.
NCMHCE

Initial Intake: Age: 26 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Private Practice Type of Counseling: Individual Presenting Problem: You are a counselor in a private practice setting.  Your client is a 26-year-old male who presents for counseling at the request of his family and his employer, with whom he is close and who knows his history. The client tells you that he has been angry for the past 15 years, beginning a year after the death of his father from a heart attack. He says that his anger is triggered very quickly when frustrated by people or situations and that his “fuse is very short these days.” He states that he has been in some “loud arguments” with his mother, and later his stepfather. He admits that there have been times in the past when he and his stepfather have “almost come to blows” but his mother stepped in and made them stop. He admits to having hit or kicked walls at times in his anger, but has never hit a person. He tells you that he doesn’t want to feel this way because it interferes with his relationships and his former girlfriends have never understood that when the anniversary of his dad’s death comes around, he just wants to be alone for a couple days and not have to talk to anyone. He tells you that he has never had a long-term relationship with a woman because either he gets “depressed” for a few days during certain times of the year (i.e., father’s birthdate and death date) or because he is too quick to get angry and then says things he doesn’t mean. He says that he has been in a relationship with a woman now for eight months and really wants to get himself together because he feels “she’s the one.” Mental Status Exam: The client appears his stated age and is dressed appropriately for the circumstances in clean jeans and a t-shirt. He identifies his mood as “anxious but a little excited” because he “is hopeful that he can finally let his anger go.” He tells you he is tired because he has difficulty falling asleep and staying asleep most nights. His affect is pleasant with emotional lability evident. He demonstrates appropriate insight and judgment, memory, and orientation.  He reports never “seriously” having considered suicide but acknowledges that there were times when he wondered “if dying would make this pain go away.” He has never attempted suicide and states he would never consider harming himself or anyone else. Family History: The client reports a family history of being the youngest of three siblings born to his mother and father. He reports a “great life” with his family and that they regularly spent time together playing, camping, traveling, and “just being a family.” He tells you that he is sure there were occasional arguments but that he doesn’t remember anything significant, except that he had been mad at his dad the night he died because his dad wouldn’t let him stay up late, but that before the client went to bed, he had come down, apologized to his dad, and they had both said “I love you.”  He states his parents had been married for 15 years prior to his father’s death, which occurred when the client was 11 years old. He states his dad died of a heart attack while sleeping, so while he did not see it, he knew something had happened because his mother woke him and his siblings and rushed them over to the next door neighbors’ house. He said that his mother went to the hospital with his father in the ambulance and came home that night to tell him and his siblings that their father had died. He tells you that he and his siblings are still very close and that they now have three much younger siblings born after his mother married his stepfather. He says that he is very close to his mother and stepfather, although he lives three hours away from them. He tells you that he tries to get home for big family events, like birthdays. He states that his stepfather adopted him and his siblings after the wedding and the client loves him very much. He tells you that he and his stepfather have gotten in what the client thinks are “typical teenager/parent” conflicts but that they have often been made worse by the client’s anger that seems to always be inside and erupts quickly. Which of the following treatments would be least helpful for treating this client?

Correct — C. TF-CBT is not appropriate treatment for this client because TF-CBT is engineered and modeled to be used with children and adolescents who have experienced trauma. EMDR, brain spotting, and PE are all appropriate treatments for adults with PTSD.
NCMHCE

Initial Intake: Age: 20 Gender: Male Sexual Orientation: Homosexual Race/Ethnicity: African American Relationship Status: Single Counseling Setting: University counseling center Type of Counseling: Individual Presenting Problem: Stress, anxiety, depression Diagnosis: Anxiety disorder, unspecified (F41.9), Major depressive disorder, single episode, unspecified (F32.9) Presenting Problem: You are a brand-new counseling intern in the counseling resource center of a local university. Jonathan is a junior in college and comes to speak with you, as you are his newly assigned college university counselor. Jonathan is concerned about finals that he feels unprepared for, stating he is “overwhelmed” and “under too much pressure” from his family to “allow himself” to fail. He is making disparaging, negative remarks about himself and his abilities, often repeating himself and talking in circles using emotional reasoning. He asks you for help in getting his teachers to modify his deadlines so that he can have enough time to accomplish all his assignments, mentioning that his last counselor did that and called it “playing the mental health card”. There are no previous records on file for this student, but when you ask him who he met with he just changes the subject and continues to express his worry that he will “never amount to anything or graduate” if he fails these exams. Mental Status Exam: Jonathan presents as anxious with congruent affect, evidenced by client self-report and therapist observations of fidgeting, inability to sit still, tearfulness and shallow breathing with rapid paced speech. Jonathan occasionally closes his eyes and takes deep breaths when he begins to cry in attempt to slow himself down and prevent what he calls “another emotional breakdown.” He has prior inpatient treatment history of a one-week episode where he was involuntarily committed at 17 for making comments about planning to kill himself in response to his stress over finishing high school. He admits to passive suicidal ideations in the past few weeks while studying for exams but does not report considering a method or plan. He reports that he has been losing sleep because of long study hours and feeling too keyed up to calm down. You assess him as having distress primarily associated with anxiety, which at times of abundant stress turns to episodes of depression and hopelessness. Education and Work History: Jonathan has a high academic performance history, despite short periods of time where he experiences heightened stress. Jonathan has never gotten in trouble in school or had any infractions at part-time jobs later as a teenager. He has worked after-school jobs at the grocery store, bowling alley, and local town library. Jonathan had only one work-related incident where he broke down emotionally when feeling overwhelmed and left work in the middle of his shift, but his supervisor was supportive and helped him. Current Living Situation: Jonathan lives in the college dormitory with a peer and is supported by his mother. His mother is a single mom who works full-time in Jonathan’s hometown, which is almost a full day’s worth of driving from where Jonathan goes to college. Jonathan mentions that his friends call him “Jonny.” He adds that the food available to him is not very healthy and he has poor eating habits due to prioritizing studying and his involvement in extra-curricular activities. How should you format a goal for suicidal ideation?

Correct — B. Your goal as the counselor should be to work towards elimination of SI and a return to a previous state of functioning before the SI began. Reduction or elimination of SI does not have to take six months; effective strategies implemented can yield positive results within days or weeks. However, if a client is not improving or is worsening, psychiatric interventions may be necessary. A client may also have long-term ideations without ever increasing in severity and still function well in daily life; but it is ethical and best practice to continually aim for elimination of this "norm" for their ultimate safety. Risk elevates with severity of ideations which progress to methods and plans, but a treatment plan goal is not considered strong if it aims to "reduce severe SI to mild SI". Check-ins regarding suicidality, whether informal or C-SSRS formatted, are appropriate at every visit until there has been a steady level of low-risk thoughts or behaviors. Again, therapists must aim to make their clients feel completely safe without any form of SI.
NCMHCE

Initial Intake: Age: 53 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Married Counseling Setting: Community Agency Type of Counseling: Individual Presenting Problem: You are a counselor in a community agency setting.  Your client is a 53 year-old male who presents with complaints of feeling insignificant, unworthy, and a failure. He admits to having these feelings for the past 30 years and while he has never had suicidal ideations or plans, he has often wondered if his life had purpose and what that purpose was. Your client additionally tells you that he doesn’t feel happy on most days though he does have happy feelings at times; they just don’t last. He is good at his job and finds it challenging, yet tells you “it’s a job” and that there is nothing special or “exciting” about it to him. He tells you that he has been married for twenty years and has five children; three of whom he adopted when he married his wife. He states he adores his wife and children, though he knows that he often does not meet their needs emotionally, “tunes out,” and frequently puts his own “wants and desires” before their requests, needs, or previously made plans. He admits he gets “jealous, I guess” when someone else in the family gets something that he didn’t. He also says that he often says “the wrong thing” when his wife or children are upset about something and he struggles to understand how they are feeling. He tells you that these actions cause conflict in his marriage and with his children and he is ashamed that he does this, but feels hopeless that things will change because he cannot figure out how to change or why he does these things. He reports that he does not believe himself to be better than others but that others often perceive that he sees himself that way because of how he interacts with them. He also tells you that his family often wishes he would “think before I speak or make decisions.” He reports that in spite of these “failures,” he and his wife have a very strong marriage and express their love for each other daily. They enjoy activities together although he needs very active recreation such as roller coasters, bike riding, and swimming while his wife leans towards less physical activities. Finally, your client tells you that over the years he has had some trouble focusing at work and at home. He views himself as “forgetful” and says “I don’t have a good memory.” He says this causes troubles at home and work when he frequently forgets to do something that he said he would do or when he is not as careful or gets distracted in his work and is slow to finish projects or makes small mistakes that have greater impacts on reports. Mental Status Exam: The client appears his stated age and is dressed appropriately for the circumstances. He rates his mood as “anxious.” His affect is congruent though he appears to relax as the session continues.  He demonstrates some limited insight and frequently responds with “I don’t know” but when encouraged, is able to access thoughts and emotions that are disturbing to him. He demonstrates appropriate judgment, memory, and orientation. He reports never having considered suicide or harming himself or anyone else. He states that he is very engaged individually and with his family in their religious practices and views these as a source of strength. He currently takes 50 mg of Pristiq and Concerta 18 mg. Family History: The client reports his parents were married to each other until his father’s death at age 60. Your client states he was very close to his father although his father’s activities were often curtailed due to illness. He states that his father accompanied him to boy scouts and was involved with the client and his older siblings. The client states that he has always been close to his mother although he acknowledges often feeling angry at her but being unable to tell her that, so instead he “tuned her out.” He describes her as extremely “critical and consistent.” He tells you that the first time he decorated a Christmas tree was with his wife as his mother always decorated their family trees “so they were done right.” He also says his father and siblings could always count on her to be the one who made the family late for everything and left them waiting during outings. In one example, he shares that when going out together, his mother would often set a meeting place and time for him. He reports that he would either wait at the meeting spot for hours because she was late or that he would sometimes go looking for her and then get in trouble for leaving the meeting spot. He reports that his oldest sibling died in his 40s from excessive drug and alcohol use, and that his other sibling has a very conflictual relationship with their mother and sees their mother “when needed” but is often angry with their mother. He describes his relationship with his mother over the past twenty-five years as one in which his mother makes promises without keeping them and was often dismissive of the client’s wife and children during the time that he was dating and for several years after their marriage. He relates one account where his mother was helping his wife organize something in their home, but refused to organize it in the manner that his wife needed it, and instead became very angry, defensive, and accusatory when his wife reorganized what his mother had done. Considering the information provided, which question will be most effective to ask when setting treatment goals for the client?

Correct — C. When setting goals, it is important for the client to want to make changes in counseling so having the client identify what they would like to gain from your work together will be an important first step in developing appropriate goals. Presenting the client with multiple and/or potential diagnoses can be disheartening and shaming to the client who is asking for help and looking for hope through counseling. Using behavioral terms to set goals would be a more appropriate, encouraging, and collaborative way of developing goals with a client. Asking the client what has not been helpful in the past may be a part of setting up interventions, but goal setting should be framed positively and focus on client's strengths and resilience as these are foundational to the counseling profession. All of the above is not correct as responses b and c are not appropriate for setting goals.
NCMHCE

Initial Intake: Age: 45 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Married Counseling Setting: Private Practice Type of Counseling: Individual Presenting Problem: You are a counselor in a private practice setting.  Your client is a 45-year-old male who reports that his wife of two years suggested he seek help for what she says is “OCD.” The client says that several months after their marriage, his wife began complaining that the client had so many expectations for her and her children that they are overwhelmed and feel unable to please him. The client tells you that he has had friends tell him in the past that he is “OCD” and sometimes his employees make fun of him because he wants everything done a certain way. He says that they sometimes call him “the eye” because they say he is always watching to make sure they do things correctly.  Some of his closer friends will “test me” sometimes by moving something to see if the client notices it. He tells you they are doing it in fun, and he doesn’t really mind because he automatically notices things, whether they moved something or it has accidentally got put in the wrong place. He admits that he is concerned that things are done well because he owns his own business and needs it to be managed correctly, but he doesn’t really understand his wife and stepchildren’s concerns. He tells you that he would like to know if he “is the problem” and if so, how he can make changes to help his marriage. He tells you that he doesn’t see a problem with how he runs his business and thinks that his employees are just “complainers.” Mental Status Exam: The client appears his stated age and is dressed appropriately for the circumstances. He rates his mood as “happy” and this is congruent with his affect. He demonstrates some social awkwardness in presentation and conversation both in missing social cues and oversharing. He demonstrates some motor hyperactivity, indicated by fidgeting, shifting in his seat, and upon entering the office, is invited to sit as he was touching items on the bookshelf. He presents as very talkative, distractible, and tangential in his conversation. It is necessary to redirect him often as his explanations and responses include excessive and irrelevant details, and provides responses before the question is completely stated. He demonstrates limited insight into his presentation or the concerns others have shared with him. He demonstrates appropriate judgment, memory, and orientation. He reports no substance use, no sleep or waking problems, and does not smoke. He is emphatic in his negative responses to questions related to suicidal or homicidal thoughts and intentions. Family History: The client reports being the youngest of two sons born to his parents. His parents have been married for 40-plus years. He tells you that his mother did complete high school with some difficulty and has never been employed. His father is now retired but was an accountant previously. He says his older brother had a difficult time several years ago with holding a job and going through a divorce, but is now doing much better. The client tells you that his family is still very close, his parents come over to visit often, and prior to buying his business, he often vacationed with family. He says that while growing up, their mother has always been overprotective of him and his brother and has always made sure that they did things the right way. The client states that until his marriage, he continued to live in his parent’s home in his childhood bedroom. He says that even though he took care of his own things, his mother still checked behind him every day to make sure the bed was made correctly and that nothing needed cleaning up. The client says that his parents were constantly frustrated with his brother because he didn’t take care of his room and things. The client reports that he completed a college degree in business and chose to open his own franchise business so that he could work for himself. He has owned his business for six years and enjoys it, although he rarely has time off. He tells you that his father and mother stop by the store frequently “just to help out.” He says his mother likes to help with cleaning and his father helps with the accounting. Second Session, six weeks after the intake session The client arrives for his session and tells you that he had an argument with one of his stepchildren the other day and that it really disturbed him. He says that he asked his stepson to mow the lawn and to make sure that he did so horizontally across the yard since the client changes the direction each time he mows. He tells you that his stepson didn’t do as asked and ran the mower vertically across the yard so that it was in the same pattern as last week’s mowing. The client reports that he and his stepson ended up arguing about it and his stepson yelled at him, “if you can’t be satisfied with the job that I did, then do it yourself next time!” The client tells you that this made him very angry but later as he was talking with his wife, she explained that even though it wasn’t the way the client wanted it done, that her son had contributed to helping the family and doing something that the client wanted completed. The client says he struggled because he wants the grass to grow well and alternating the pattern of mowing is important, but there was a part of him that felt sad and angry at himself for getting mad at his stepson, even though the client knew his stepson was wrong for not doing what he was told. Which of the following would be most appropriate for helping the client navigate his dilemma?

Correct — A. Acknowledging the rules are present but that his emotions suggest a part of him is questioning them is a paraphrase of the client's dilemma without inferring judgement towards the client. Additionally, by using the term, "the rules," it allows the client to focus on the rules as separate from himself instead of viewing himself as bad. This statement also provides the client an opportunity to hear that his dilemma is happening inside himself and allows him to react to the statement using the insight he appears to be developing. Asking the client "why" may make the client feel attacked and that he needs to defend his rules and why they are important. This is not helpful for the therapeutic relationship. Response c and d are both paraphrases of the client's dilemma but in each, the focus of the paraphrases are on the client as the problem, rather than the rules.
NCMHCE

<h3>Part Two</h3> <h4>Second Session, 2 Weeks After the Initial Intake</h4> The client enters the room and appears distracted when she sits down because she has a furrowed brow and is looking off to the side of the room. You ask her what is on her mind, and she reports that this morning she had a panic attack that led to her throwing up. You ask her to talk through the moments when she noticed it starting and how the panic attack progressed. She says that she woke up and was worried that she might have a panic attack because she typically has one on school days, and this turned into worry that she might be late for class, which compounded into worry about how it might affect her grades and eventually into certainty that she would fail. The client then experienced an increased heart rate, chest tightness, difficulty breathing, a feeling of impending doom, shaking, and finally vomiting. You empathize with the client and provide psychoeducation on the management of panic attacks. Which of the following would be considered a negative attending behavior?

Correct — D. Overusing mirroring with your posture and reflection can present as unnatural or manipulative to clients (Sommers-Flanagan & Sommers-Flanagan, 2015) and would therefore be considered a negative attending behavior. Leaning forward, using hand gestures, and turning your body about 30 degrees in relation to the client are typically not a negative experience for the client unless they are excessive. Overturning your body (past 45 degrees), can be considered a negative attending behavior (Sommers-Flanagan & Sommers-Flanagan, 2015).
NCMHCE

Sex indicates an individual’s biological gender, while gender refers to one’s cultural, and psychosocial concept of maleness or femaleness. Furthering the notion of gender and sex is the perception of gender identity, which refers to an individuals’ <code>________</code> as male, female, or gender neutral.

Correct — D. Gender identity refers to a person’s psychological identity as male, female, or gender neutral. There are also many other ways to “label” gender, and places to fall on the gender spectrum. Essentially, gender identity does not always match the biological sex, and often cannot fit into only two categories (male or female). Some distinguish themselves as being genderqueer, nonbinary, bigender, etc.
NCMHCE

As a person of color, Oliver's client experiences discrimination and racism every day. This makes him feel depressed and anxious. Which type of bias is Oliver's client experiencing?

Correct — C. Biases of society include the ways in which the world at large can cause pain for members of diverse populations.
NCMHCE

Initial Intake: Age: 82 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Widowed Counseling Setting: Community Clinic Type of Counseling: Individual Presenting Problem: Theodore is an 82-year-old who was referred for grief counseling by his son, Nate. Theodore’s wife, Nancy died one month ago after a 4-year battle with cancer. Mental Status: Theodore is tearful most days and has dropped a significant amount of weight. He has not been sleeping and stays up watching videos of his deceased wife. History: Theodore was the primary caretaker for Nancy and has not paid attention to his own health in years. Nate would like his father to move in with him and his family and sell the house his parents lived in to pay off their debt. However, Theodore refuses to sell the house and stated that he will not give away or sell anything that they owned. Nate drove Theodore to the initial session and sat in for the intake, with Theodore’s consent. Once everyone sat down, Theodore looked at the counselor and stated, “I am only here so my son stops bugging me about selling the house. I am not getting rid of anything in that house- and especially not the house itself!” Nate explained that his father cannot maintain the house on his own and is worried about him being lonely. Theodore insists that he has other options and thinks that living with Nate would put a burden on him.  Which of the following diagnoses can be ruled out based on the symptoms Theodore is exhibiting?

Correct — C. There is not enough information yet to rule out anything except Persistent Depressive Disorder (Dysthymia) in which one criterion is that the symptoms persist for at least two years. Adjustment Disorder is a possibility as the initial criteria is an emotional response to an identifiable stressor, within three months. Hoarding is another diagnosis to consider as Theodore does not want to get rid of anything that reminds him of his wife. However, it is also important to consider normal reactions to grief before finalizing a diagnosis.
NCMHCE

Initial Intake: Age: 31 Sex: Female Gender: Female Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Widowed Counseling Setting: Private Practice Type of Counseling: Individual Presenting Problem: You are a counselor in a private practice setting.  Your client is a 31 year-old female who reports that she is very impatient and feels angry all the time, and is taking it out on her children and others with angry outbursts. She says that her children are good but they don’t pick up when she tells them to and often, they put their toys away in the wrong places. The client states that her husband died while the family was on a vacation. She tells you that they had stopped for a break and her husband was hit by a car.  She says that it happened in front of her and the children, who are now 6 and 7 years old. She endorses feeling angry, restless, and having trouble making decisions. She tells you that she is having trouble falling asleep, is anxious and overwhelmed. The client tells you that her husband was a good man and “very much my opposite.” She has high expectations for neatness and being on time, he was often messy and ran late. She tells you that sometimes she felt like the whole activity they were doing was “ruined” because he made them late or the kids didn’t follow the rules. She states that she was the “controller” in their relationship, which worked well for both of them, except when she got angry with him for not doing what she wanted, when she wanted, or how she wanted it. She acknowledges that she was often angry and frustrated with his casual way of going through life but now regrets it because he’s gone. She states that her goals for counseling are to be more patient and decrease her anger. Mental Status Exam: The client appears her stated age, dressed appropriately for the circumstances. Her mood is identified as sad and frustrated and her affect is restricted and flat. Her primary emotion in the session is anger, though it is expressed in a tempered manner. She demonstrates limited insight, and appropriate judgment, memory, and orientation. She reports having considered suicide when she was in high school but made no attempt and would now never consider harming herself or anyone else. Family History: The client reports a significant family history with her mother diagnosed with schizophrenia, with catatonia and was not medicated. She describes her mother as a “zombie” who loved her children but never told them because she was “absent.” The client describes her father as verbally abusive and involved with drugs and alcohol, often yelling, screaming, and throwing things. She states he often told the client that any mistakes she made were the reason that their life was so bad. She has no siblings but her husband has two sisters, with whom the client does not engage. She states one of his sisters is living with her boyfriend and the other asked to borrow money from her and her husband, which made the client angry. She identifies her support system as her church and a group of couples whom she and her husband were friends with prior to his death, most of whom attended the client and her husband’s high school and college. The client says she tends to be drawn to overly controlling people and her church, though fundamentalist and legalistic, became like family to her in high school.  She tells you that the couple’s closest friends are her husband’s best friend, whom the client dated in high school, and his wife. She says that while dating, her then boyfriend was very attentive, “almost smothering,” but also very demanding by leaving her notes with things or work he wanted her to do for him. She states they dated for several years and then she met and married his best friend, who was her husband. She tells you that their best friend’s wife is her best friend, although “she irritates me all the time, and I don’t really like her that much.” She says her friend has a strong personality, is controlling, and wants to make all the decisions and plans in their relationship. Using the provided information, which of the following will best help you to understand the client's relationships with others?

Correct — A. Completing and evaluating a family genogram will help identify unhealthy patterns and interactional dynamics. These patterns may have served the client well in childhood but have become problematic in her adult life. The MMPI-2 is used to assess personality traits and psychopathology. This may help the counselor determine a client's psychological state or a diagnosis, but it will not help explain the client's relationships with others. The BAI-II measures the client's current level of anxiety at a particular moment when the test is given. It is helpful as a pre- and post-test for monitoring anxiety levels, but will not add to the counselor's understanding of the client's relationship patterns with others. The TAT is a projective test that helps the counselor learn more about a client's emotional conflicts, themes within the client's life experience, psychological conditions, and may help the client to express their feelings in an indirect way. It does not provide specific information on the client's relationships with others.
NCMHCE

Albert Bandura’s social cognitive theory emphasizes the importance of observational learning. This means learning through observation of others’ behavior (modeling). Common models of behavior are <code>________</code> . Choose all that apply.

Correct — D. Humans learn through observing others. This is especially true in children. Bandura’s concept of observational learning posits that individuals understand information, and behavior through the modeling of others, such as siblings, parents, and teachers.
NCMHCE

Initial Intake: Age: 18 Sex: Female        Gender: Female Sexuality:  Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Community Residence Type of Counseling: Individual Presenting Problem: Nadia is an 18-year-old in a community residence for children in foster care. She was referred for counseling because she has been running away from the group home, often for days at a time. Currently she is not getting along with her peers and gets into fights when they make comments about her activities, which is starting to affect everyone in the house. Mental Status: Nadia was initially resistant to the interview. She stated that she had been seeing counselors her whole life and none of them ever helped. Nadia had limited insight regarding her risk-taking behaviors. The counselor assessed that Nadia’s cognitive functioning appeared low. She stated that although she had contemplated suicide in the past, she currently had no intention or plan. History: Nadia is one of 10 children by her birth parents. She has an extensive history of abuse and sexual exploitation by her parents until the age of 14 when she was removed from her parent’s care. Her and her siblings were sent to various foster homes as they could not all stay together. This is a subject that Nadia does not like to talk about since she was the oldest and had the responsibility to care for the younger ones. She feels as if she let them down. Nadia is frequently truant from school. For the past 4 years Nadia was in and out of foster homes due to her risk-taking behaviors and disrespect for others. She does have a good relationship with two staff members in the group home. Session Two The counselor conducted a comprehensive assessment with Nadia. Results of the assessment showed an IQ score of 73, low adaptive score functioning, as well episodes of depression and mania. When the counselor reviewed this data with Nadia, she stated that she was relieved that there were reasons behind her behavior and her fluctuations in mood. Nadia shared that she sometimes felt out of control. Nadia further stated that she was concerned that she will not be able to have a normal, healthy relationship and does want to have friends. Nadia is showing symptoms of:

Correct — A. Nadia is showing symptoms of bipolar disorder by risk taking behaviors as well as manic and depressive episodes. She is also showing intellectual development disorder with an IQ less than 70 to 75. Disruptive Mood Dysregulation disorder is ruled out as irritability is not the prominent feature. Although intellectual disability is common among individuals with autism spectrum disorder, Nadia is not showing apparent discrepancy between level of social-communicative skills and other intellectual skills.
NCMHCE

Initial Intake: Age: 35 Gender: Male Sexual Orientation: Heterosexual Ethnicity: African American Relationship Status: Divorced Counseling Setting: Community Mental Health Center Type of Counseling: Individual Presenting Problem: Court-mandated counseling for violating probation and continued legal issues Diagnosis: Adjustment disorder with mixed disturbance of emotions and conduct (F43.25) Provisional, Problems related to other legal circumstances (Z65.3) Presenting Problem: Davone is referred to you by his probation officer after being mandated by the court to undergo weekly emotional and behavioral health counseling sessions for a minimum of 9 months or until his next court hearing is scheduled, whichever is sooner. Davone’s Medicaid insurance cover his sessions. The probation officer tells you Davone is undergoing sentencing for violating his probation and restraining orders put in place by his ex-wife, which render him unable to set foot on their property or visit with his children (twin boys, age 9, and girl, age 4). In the initial assessment, Davone shares that he has had run-ins with the criminal justice system for most of his life “just like his father” and that he fears a lifetime of being in prison and not being able to be there to watch his kids grow up. Davone tells you he will do anything to get out of his situation and return to having a life where he can continue going to work and providing for his children. Mental Status Exam: Davone presents as well-groomed, of fair hygiene and motor movements are within normal limits. Davone makes decent eye contact throughout session. Speech tone and rate are normal. Thought process unremarkable. Denies SI/HI. Davone becomes tearful when he recalls past family information, sharing that his father was never around for him for the same reasons he is not around for his family. Davone frequently refers to his racial background and where he grew up, becomes angry as evidenced by tense expression, furrowed brow, and clenched fists, and then self-soothes without prompting by taking a deep breath and moving forward in conversation. When asked, Davone tells you he learned those skills in past anger management classes he was mandated to take years ago. Legal and Work History: You learn from Davone’s referral paperwork that Davone’s legal record extends back to age 9 when he was first beginning to show signs of conduct at school. Davone was often sent to the “recovery room” in elementary school for aggressive outbursts and defiance towards teachers. He has a record with the Juvenile Justice System for breaking rules and truancy in middle and high school. After age 18, he was arrested several times for misdemeanors of vandalism, shoplifting and reckless driving. He then married and became employed full-time by age 25, where he did not get into trouble with the law again until age 31 when he got fired for stealing from his company. This caused marital discord and led to Davone’s divorce two years ago. Davone has had a continued string of misbehavior, arrests, and short-term jail stays ever since. Davone adds that his ex-wife accused him of consistently endangering her and the kids without caring, which is why she got the restraining order. He disagrees with her, saying “I would never harm my kids.” First session, one week after the intake session You meet with Davone in your office for your second session. As you review his completed treatment plan and are reading for him the goals and objectives you have decided on with him in the last session, you notice he is darting his eyes, shifting his position often, and presenting as either agitated or disinterested. When you ask what is on his mind, he says “I’ve done all of this before, it doesn’t help because I keep getting locked up. I just want to see my kids! I don’t understand why Gina won’t let me.” After using several different interventions throughout the session, you realize that Davone repeats himself often, rejects feedback given, and defends his choices using emotional reasoning. He remains respectful in attempting to engage as requested but needs continual prompting to respond and frequently talks in circles around the same arguments. You respond to Davone saying “You are clearly disappointed, and obviously hurt as well! I can’t imagine not being able to see my children. It would be so hard.” This is an example of:

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

Initial Intake: Age: 40 Sex: Female Gender: Female Sexuality: Lesbian Ethnicity: African American Relationship Status: Partnered Counseling Setting: Community Agency Type of Counseling: Individual Presenting Problem: You are a counselor in a community agency. Your client presents with concerns about her lifelong history of being “anxious and emotional” since her parent’s divorce when she was 12. She tells you her feelings of “anxiety and feeling badly about myself” intensified when she was diagnosed with breast cancer four years ago and then again when her family moved to the area last year. She tells you that she thinks she managed her emotions well during her treatment because her focus was on getting through the crisis. She also was taking Klonopin twice a day for anxiety.  She says she feels that she has let her family down by having cancer because it costs them monetarily and emotionally; she wonders sometimes if her cancer is a punishment for something she’s done. She reports that she does not discuss these concerns and emotional fears with her partner because “she has become the breadwinner and I feel like I need to protect her from my negativity.” On intake forms, she endorses crying daily, trouble sleeping, concentrating on things, has been losing weight without trying, and constantly worrying about her health and the family’s finances. She tells you that her partner says she “runs around like a chicken with my head cut off because I start stuff like cleaning or cooking and then stop right in the middle of it. I just get restless and sometimes I just can’t stop fidgeting when I should be paying attention.” She notes that she is in menopause due to her cancer treatments, which included a removal of her ovaries three years ago and a hysterectomy one year ago. She tells you people often refer to her as a “cancer survivor” but she doesn’t feel like she has survived it because every surgery makes her feel like she “is losing another piece of me.” Additionally, she says that having to have body scans every six months and not being able to look in the mirror and see a “complete woman” makes her feel that she is still trying to survive, rather than putting it in the past. Mental Status Exam: The client appears to be slightly older than stated and demonstrates positive signs of self-care in her hygiene and dress. She states her mood fluctuates between “sad and okay.” Her affect is labile and mirrors topics discussed in session. She smiles when describing her children and her relationship with her former oncology team. She cries easily when discussing cancer, moving, instability, and fears. The client is cooperative and forthcoming, with easily understood speech. She offers insight into her thoughts and behaviors, is attentive, and shows no difficulties with memory or judgement. She acknowledges one episode of suicidal ideation, without plan, during her adolescence when she desperately missed her mother while on a custodial visit with her father. She has had no thoughts of harming herself since then and has no thoughts of harming others. Family History: Your client reports a four-year history of treatment for breast cancer. She has had 16 months of chemotherapy and 27 rounds of radiation, as well as a double mastectomy three years ago. She has completed reconstructive surgery for her breasts but has not yet added nipple tattooing for a more realistic image. She reports that she has three close female relatives with breast cancer, but no relapses after treatment. She states that she has been in a relationship with her partner for 17 years and they share two children, ages 12 and 8. She describes her partner as a “good person” and the relationship as “good.” She tells you that they moved to the area one year ago when her partner had an unexpected promotion. She reports this has been good but that their oldest child is “anxious, emotional, and just angry sometimes.” First Session, three weeks after the intake session The client presents with her partner for this session. She tells you that she spoke with her doctor who prescribed an SSRI and she is feeling somewhat better emotionally, but still feels upset. She says that is why she invited her partner to join her today, because she hopes that the three of you can figure out why she still feels bad. During the session, the client mentions that “you didn’t go with me” when talking to her partner about her early oncology appointments. You notice that her tone changes and she looks away from her partner as she says this. As the session continues, the client reports that her partner didn’t seem “interested” because she never read the pamphlets that the client left on the counter, never researched for cures or therapies, or came with her to chemotherapy appointments, even though the client acknowledges that she always told her partner she could go alone so her partner could work. At one point in the discussion, she talks about the loss of their sexual and intimate relationship. She uses a fast hand motion to wipe each tear quickly away as soon as it forms, never looking at her partner and only making eye contact with you. Based on the information provided, your client is most clearly demonstrating which of the following?

Correct — C. The client's change in tone and eye contact away from her partner, as well as blaming her partner for her lack of involvement and participation in her cancer treatment, strongly suggests that the client believes her partner should have known what the client needed, without being told. This passive-aggressive style of communication often leads to angry emotions. The client's eye contact with the counselor and hurriedly wiping away tears also suggests angry emotions about the loss of intimacy, though this is likely to be connected to her partner not meeting the client's unexpressed needs. The client's communication style appears to be holding in her emotions and then allowing them to come out in anger. This is not an effective style of communicating with others. The client may be using her independence, strength, and control as coping strategies, but they isolate her from her partner more than unite her, thus they are not positive in these circumstances.
NCMHCE

A major critique of structuralism was that the theory dealt predominantly with <code>________</code> concepts.

Correct — C. Behaviorist’s originally criticized structuralism for its’ focus on indistinguishable, unobservable generalizations. While structuralism allowed for descriptions of conscious experiences, these were thought to be ambiguous, hypothetical interpretations.
NCMHCE

Who is a well-known therapist who brought spiritual topics into the psychology field in the early 1900s?

Correct — E. Carl Jung was responsible for bringing spiritual discussions to therapy sessions in the early 1900's.
NCMHCE

What are the benefits of a peer-to-peer support group?

Correct — B. Peer-to-peer support groups are sometimes referred to as self-help groups; participants are all usually dealing with the same struggle or issue, therefore the group itself becomes a safe place where participants can feel open; peer-to-peer support groups also tend to encourage and empower participants as they view others making progress; these groups are inexpensive to run, as there are not many costs involved, and often the space needed to hold the group is donated.
NCMHCE

Initial Intake: Age: 35 Sex: Male Gender: Male Sexuality: Gay Ethnicity: African American Relationship Status: Married Counseling Setting: Private Practice Type of Counseling: Individual Presenting Problem: You are a counselor in a private practice setting.  During the intake session, you learn that your client and his spouse have been married for 7 years and together for 10 years. He states they have 2 children and he is their primary caregiver from early afternoon until evenings; this includes transportation, preparing dinner and homework. He states his spouse and he moved their family here earlier this year to be closer to his husband’s family. He works as a high school teacher. He presents relationship issues as his main concern and rates these as “very difficult,” and has been told that he and his husband “may be heading for divorce.” He states he often feels “suspicious” because his husband has multiple friendships with other males, online and face-to-face, including old boyfriends. The client tells you he feels this is inappropriate but that his husband disagrees and will not end these friendships.  He admits being stressed, overwhelmed, sad, having little energy, and experiencing crying spells, irritability, and angry outbursts. He says he feels like a failure. He says his husband said he has not been “emotionally available” since their marriage. The client notes that during the year they married, he finished his teaching credentials, the couple adopted their first child, and he began working as a first year teacher in a high school with tenure requirements. Mental Status Exam: The client presents appropriately dressed and is well-groomed. His stated mood is congruent with stated affect but you note a limited range of emotions. He appears to be cooperative and forthcoming. He endorses no use of illegal or inappropriately prescribed drugs and a 20-year history of alcohol abuse, with one driving citation at age 21. He currently drinks 3 to 4 beers per day and 16 or more on the weekend. He acknowledges using alcohol to relieve emotional discomfort and feels the need to cut down. He is able to offer insight into his thoughts and behaviors, and demonstrates appropriate memory and judgement. Family History: The client states he has three siblings. He relates he has a “pretty good” relationship to his brother, a moderate connection to his younger sister, and a tenuous connection to his older sister. He says he has cut himself off “emotionally and physically” from his own parents and his husband’s family due to “conflicts.” He describes his mother as manipulative and attributes the lack of many extended family relationships to her. He describes the relationship between his parents as conflictual but that his father “goes along with her” and has cut off relationship with the client’s older sister, his father’s twin sister and her spouse. The client says his mother has never liked the client’s spouse. He said she was not happy he married a man, but was even more upset that his husband is White. During one family visit, his mother left a derogatory email about his husband in a visible place so he would find it. Second Session, six weeks after the intake session The client arrives for the session appearing tense and in some distress. As the session progresses, the client admits that the issues between him and his husband have worsened, particularly as the client is spending more energy working on his own issues. He tells you that he has been attending Alcoholics Anonymous several times a week and is working with his sponsor. He also states that he has been eating lunch with the other teachers at school and has begun developing some friendships where he can share his stresses related to work requirements because these are common irritations for all of them. This has made him feel happier, less tense when he comes home, and does not feel like he needs to rely solely on his husband to be able to work through his stressors. However, he reports that his husband seems angry because the client has refused to drink with him in the evening and keeps making negative remarks about the client’s sponsor. The client says that his husband has berated him several times for meeting with his sponsor several evenings a week, and leaving his husband responsible for caring for their children in the evenings.  Your client tells you he is “beginning to see an ugly side” of his spouse and wonders why his husband isn’t happier for him that he is taking better care of himself. Which of the following interventions should be implemented during this session?

Correct — D. Individuals exist in systems, and systems theory states that when one member of the system changes, this causes distress for the other members of the system as they respond to the change. The client's changes are helpful for him but create dissonance for his husband when the client is not responding as he usually does. Providing education on change and its impact on the family system allows the client to understand current circumstances and may help him respond with empathy to his partner as they navigate the changes. It would be inappropriate for the counselor to suggest the client might not want to stay in the relationship or suggest that the client should either strengthen or lower his boundaries to appease his spouse.
NCMHCE

Initial Intake: Age: 26 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Single Counseling Setting: Private Practice Type of Counseling: Individual Presenting Problem: You are a counselor in a private practice setting.  Your client is a 26-year-old male who presents for counseling at the request of his family and his employer, with whom he is close and who knows his history. The client tells you that he has been angry for the past 15 years, beginning a year after the death of his father from a heart attack. He says that his anger is triggered very quickly when frustrated by people or situations and that his “fuse is very short these days.” He states that he has been in some “loud arguments” with his mother, and later his stepfather. He admits that there have been times in the past when he and his stepfather have “almost come to blows” but his mother stepped in and made them stop. He admits to having hit or kicked walls at times in his anger, but has never hit a person. He tells you that he doesn’t want to feel this way because it interferes with his relationships and his former girlfriends have never understood that when the anniversary of his dad’s death comes around, he just wants to be alone for a couple days and not have to talk to anyone. He tells you that he has never had a long-term relationship with a woman because either he gets “depressed” for a few days during certain times of the year (i.e., father’s birthdate and death date) or because he is too quick to get angry and then says things he doesn’t mean. He says that he has been in a relationship with a woman now for eight months and really wants to get himself together because he feels “she’s the one.” Mental Status Exam: The client appears his stated age and is dressed appropriately for the circumstances in clean jeans and a t-shirt. He identifies his mood as “anxious but a little excited” because he “is hopeful that he can finally let his anger go.” He tells you he is tired because he has difficulty falling asleep and staying asleep most nights. His affect is pleasant with emotional lability evident. He demonstrates appropriate insight and judgment, memory, and orientation.  He reports never “seriously” having considered suicide but acknowledges that there were times when he wondered “if dying would make this pain go away.” He has never attempted suicide and states he would never consider harming himself or anyone else. Family History: The client reports a family history of being the youngest of three siblings born to his mother and father. He reports a “great life” with his family and that they regularly spent time together playing, camping, traveling, and “just being a family.” He tells you that he is sure there were occasional arguments but that he doesn’t remember anything significant, except that he had been mad at his dad the night he died because his dad wouldn’t let him stay up late, but that before the client went to bed, he had come down, apologized to his dad, and they had both said “I love you.”  He states his parents had been married for 15 years prior to his father’s death, which occurred when the client was 11 years old. He states his dad died of a heart attack while sleeping, so while he did not see it, he knew something had happened because his mother woke him and his siblings and rushed them over to the next door neighbors’ house. He said that his mother went to the hospital with his father in the ambulance and came home that night to tell him and his siblings that their father had died. He tells you that he and his siblings are still very close and that they now have three much younger siblings born after his mother married his stepfather. He says that he is very close to his mother and stepfather, although he lives three hours away from them. He tells you that he tries to get home for big family events, like birthdays. He states that his stepfather adopted him and his siblings after the wedding and the client loves him very much. He tells you that he and his stepfather have gotten in what the client thinks are “typical teenager/parent” conflicts but that they have often been made worse by the client’s anger that seems to always be inside and erupts quickly. First Session, three weeks after the intake session The client presents for his session having completed assessments that show he does not experience dissociation at a level above normal. He tells you that he knows he needs to work through the trauma that he experienced after his father’s death, but that he is very anxious about having to talk about that night or how much he misses him.  He says that even talking about it makes him very upset and he begins to get angry. He tells you that he can deal with feeling angry inside, but when people keep asking him “what’s wrong with you,” he gets even angrier and sometimes yells at them or walks away. He also tells you that he is afraid to remember that night because the pain is so hard that he feels like “it will swallow me up.” Which of the following interventions would be the least effective in helping the client manage the intense emotions that emerge in trauma treatment?

Correct — D. Working with traumatic content often requires a full session or sometimes a 90-minute session so that the counselor and client will have time to work through traumatic material and then help the client regain emotional equilibrium prior to leaving the session. Shorter sessions would not allow the client and counselor to work with disturbing emotional content and still have time to help the client recover from these before the session is over. Container exercises are helpful techniques that allow the client to place their intense emotions in a real or imagined container that will hold these until the next session. Having the client select a word or hand motion that signals the counselor that they need a break because of intense emotions allows the counselor to help the client ground themselves and take time to recover before proceeding again. Teaching and practicing breathing exercises are helpful tools for clients to use when they are overwhelmed with intense emotions. Concentrating on their breathing and relaxing each part of their body distracts the mind from the emotions and allows the client to feel more in control.

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Sample questions

NCMHCE sample questions

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Professional Practice Ethics Initial Intake: Age: 15 Sex: Non-binary        Gender: chose not to answer Sexuality: chose not to answer Ethnicity: East Indian Relationship Status: Single Counseling Setting: Community Outpatient Clinic Type of Counseling: Individual Presenting Problem: Shar was brought it by their mother, Nadia, for concerns about being isolated and argumentative. Mental Status: Shar is 15-years old and looks younger than stated age due to their weight. Shar had a flat affect throughout the interview and looked down frequently. Despite there being an empty seat on the couch next to their mother, Shar sat in a chair across the room. History: Shar and Nadia reported that they used to have a close relationship. There have been no issues or discord until now. Recently, Nadia noticed Shar staying to themself more in their room, which is unlike them. Shar recently lost a significant amount of weight and teachers reported their grades have declined. Nadia shared problems started when the topic of the sophomore dance came up and Nadia asked Shar what boy they were going with. When this topic came up during the intake, Shar rolled their eyes at this and stated, “Mom, you are so narrow minded. Why do I have to go with a boy, why can’t you just ask me WHO I am going with?” Nadia looked at the counselor and stated, “Do you see why I brought her here? She is so disrespectful, and she is lucky that her father did not hear her say these things. We used to be so close.”  Session One Information gathered at intake showed that Shar displayed desire to be a boy at an early age and would often want to dress in “boy” clothes as opposed to dresses and wanted to urinate standing up, instead of sitting down. Nadia brushed this off as Shar being close to their father and having “tomboy” like characteristics. It wasn’t until Shar went through puberty that they began making comments such as wanting to cut off their breasts. Shar would also get angry when filling out any kind of forms where she had to identify their gender, stating that she wished that she could fill out anything else but female. Shar asked if their mother could not be around for the session. Shar shared with the counselor that they never felt like they belonged anywhere. Ever since Shar was young, they have felt out of place, like there was something wrong with them. At first, their parents tried to discourage them from wearing “boy clothes” and participating in activities normally reserved for boys. Shar's friends throughout elementary school and junior high accepted them for who they are. However, once Shar entered high school, they were bullied for appearance and since then, lost their group of childhood friends. For the past few months, Shar has had feelings of sadness and hopelessness, has had difficulty sleeping and feels guilty for the obvious distress this is putting on their parents. After the session, Nadia asks the counselor if she can share with her what Shar said. At this point the counselor should:

A. Introduce client confidentiality and privacy rights.

B. Share minimal information with the mother.

C. Tell the mother that since she is the guardian, she can be told session details.

D. Encourage Shar to communicate what occurred in the session as they feel comfortable, with their mother. ✓

Treatment Planning Initial Intake: Age: 54 Gender: Male Sexual Orientation: Heterosexual Ethnicity: African American Relationship Status: Divorced, In a relationship Counseling Setting: Private Practice Type of Counseling: Individual Presenting Problem: Anger, relationship distress Diagnosis: Adjustment disorder with mixed disturbance of emotions and conduct (F43.25), provisional Presenting Problem: John calls your practice asking to speak to a counselor to help him with his relationship. John tells you he’s never been to a counselor before and does not want anyone to know that he is seeing one, mentioning he will pay for sessions privately using cash. John admits to struggling with anger, specifically with his ex-wife of 15 years whom he divorced three years ago. John asks for availability in the evening hours and demonstrates hesitancy and reluctance to commit to more than a handful of sessions. In the initial assessment session, you notice he has difficulty making eye contact and is uncomfortable talking about his situation. After some rapport building, he begins to share that he is only seeing you because his girlfriend Sherry told him she would break up with him if he did not get his “anger issues under control.” John denied physically hitting Sherry, but alluded to several interactions that he stated, “got so heated I lost it on her, and she wouldn’t stop crying.” John complained of women he gets involved with being overly controlling of him and that he doesn’t understand why they are so “needy.” John works a demanding job in the sports marketing industry where he takes frequent trips out of state and spends long nights out, entertaining clients. He wishes he had the freedom to “do what he has to do” without “being treated like a child” by his romantic partners. Mental Status Exam: John presents as well-groomed with good hygiene and is dressed professionally. Motor movements are slightly fidgety, indicating nervousness or moderate anxiety. Eye contact is intermittent. Denies suicidal or homicidal ideation, no evidence of hallucinations or delusions. John tightens his fists when elaborating on situational issues between him and his ex-wife, with the same controlled expression and tense disposition when sharing about his girlfriend. John mentioned that his girlfriend is also unreasonable for complaining about how often John comes home smelling of alcohol, saying that meeting people for drinks is part of his job. He added the comment “I need to drink to deal with her attitude all the time.” Family History: John tells you he has two children, a 34-year-old son he had with a one-night stand in college and an 18-year-old daughter with his ex-wife the first year they were married. He has a decent relationship with his son and provides him and his family occasional financial support, visiting with his grandchild over social media video once a month. He reports once being close with his daughter but that their relationship became strained as she got older and that now they hardly speak, saying “she took her mother’s side during the divorce, so she doesn’t want anything to do with me right now.” While conducting further interviewing about John’s family health you learn that John’s father passed away at 56 after several heart attacks and his mother died of heart failure and diabetes complications at 49. John has no other living relatives besides an uncle in another state and his cousins who live near him. He tells you growing up he used to go to church with his mother every Sunday until she got sick and has not been to church since. Work History: John has a master’s degree in Business Marketing and made his connections with his current position through contacts he made while playing on collegiate basketball teams. John has always worked busy jobs with which he becomes heavily engaged in and puts in overtime hours. John prefers work that keeps him on the road and traveling often, as he does not like to engage in the same routine every day. He mentions when he was younger, he could not keep a 9-5 office job or at any place that did not encourage individuality, saying he “butted heads” with all his managers and bosses until he was older. Legal History: John has had two arrests made for domestic disturbances in his home that his wife called in after heated arguments that left his wife afraid for her life. He was always able to make bail and was never tried or sentenced as charges were usually dropped thereafter. John admits to one drinking and driving accident when he was 19 where he served community service and fines as punishment. First session, three weeks after the intake session After screening John for Alcohol Use Disorder, you find that he does not meet criteria, despite his apparent unhealthy behaviors and habits. John presents for session as less anxious than previously noted in your last session, with a stern look on his face and is not making any eye contact. He tells you Sherry broke up with him despite his willingness to undergo counseling. He shares that nothing he tried worked and all they did was fight, but he wants to talk with you again because he “got a good vibe” from you in your first session and he thinks you might be able to help him regain his daughter’s trust. He wants to know how to get his ex-wife and daughter to speak to him again. What is the most empathic approach for redirecting John back to addressing his treatment plan goals of anger management?

A. "Carpe Diem, John. Let's focus on practicing our deep breathing and then discuss them."

B. "The best way for you to figure this out is to start implementing your anger management strategies before talking to your daughter."

C. "I'm sorry to hear things did not work out. Let's look at what problems we identified together in our last session and see if they apply to your most important relationships." ✓

D. "Why do you think Sherry left you? The same reasons your family won't speak to you?"

Correct — C. John is visibly upset when he comes to you for support with how to win his family back. Using confrontational dialogue like in answer b) in the form of interviewing questions can be harmful, not only for your therapeutic alliance but for John's fragile state of mind and emotions especially if he has not come to those conclusions himself. Telling him what you think is best to do before he has come to terms with his anger on his own is not the most effective strategy for gaining his buy-in to the counseling process. Clients may often seem as though they want a clear answer for what to do, but counseling is intended to help a person find their own answers instead of handing answers to them. Clients may also push back defensively if they feel you are telling them what to do or might respond in opposition if they are in denial. Answer d) is not coming from a person-centered approach as the counselor is insisting on teaching new coping skill while putting off the subject of interest to the client until later. Answer a) is the most empathic approach and best way to help guide John to observe his condition and build insight on his own.

Core Counseling Attributes Part Two Second Session, 2 Weeks After the Initial Intake The client enters the room and appears distracted when she sits down because she has a furrowed brow and is looking off to the side of the room. You ask her what is on her mind, and she reports that this morning she had a panic attack that led to her throwing up. You ask her to talk through the moments when she noticed it starting and how the panic attack progressed. She says that she woke up and was worried that she might have a panic attack because she typically has one on school days, and this turned into worry that she might be late for class, which compounded into worry about how it might affect her grades and eventually into certainty that she would fail. The client then experienced an increased heart rate, chest tightness, difficulty breathing, a feeling of impending doom, shaking, and finally vomiting. You empathize with the client and provide psychoeducation on the management of panic attacks. Which of the following would be considered a negative attending behavior?

A. leaning forward

B. turning your body 30 degrees in relation to the client throughout the session to present a less aggressive posture

C. using hand gestures for emphasis

D. consistently matching the client’s posture and repeating her statements throughout the session ✓

Correct — D. Overusing mirroring with your posture and reflection can present as unnatural or manipulative to clients (Sommers-Flanagan & Sommers-Flanagan, 2015) and would therefore be considered a negative attending behavior. Leaning forward, using hand gestures, and turning your body about 30 degrees in relation to the client are typically not a negative experience for the client unless they are excessive. Overturning your body (past 45 degrees), can be considered a negative attending behavior (Sommers-Flanagan & Sommers-Flanagan, 2015).

Intake Assessment Diagnosis Initial Intake: Age: 82 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Widowed Counseling Setting: Community Clinic Type of Counseling: Individual Presenting Problem: Theodore is an 82-year-old who was referred for grief counseling by his son, Nate. Theodore’s wife, Nancy died one month ago after a 4-year battle with cancer. Mental Status: Theodore is tearful most days and has dropped a significant amount of weight. He has not been sleeping and stays up watching videos of his deceased wife. History: Theodore was the primary caretaker for Nancy and has not paid attention to his own health in years. Nate would like his father to move in with him and his family and sell the house his parents lived in to pay off their debt. However, Theodore refuses to sell the house and stated that he will not give away or sell anything that they owned. Nate drove Theodore to the initial session and sat in for the intake, with Theodore’s consent. Once everyone sat down, Theodore looked at the counselor and stated, “I am only here so my son stops bugging me about selling the house. I am not getting rid of anything in that house- and especially not the house itself!” Nate explained that his father cannot maintain the house on his own and is worried about him being lonely. Theodore insists that he has other options and thinks that living with Nate would put a burden on him.  Which of the following diagnoses can be ruled out based on the symptoms Theodore is exhibiting?

A. Adjustment disorder

B. Hoarding

C. Persistent Depressive Disorder (Dysthymia) ✓

D. Normal grief reaction

Correct — C. There is not enough information yet to rule out anything except Persistent Depressive Disorder (Dysthymia) in which one criterion is that the symptoms persist for at least two years. Adjustment Disorder is a possibility as the initial criteria is an emotional response to an identifiable stressor, within three months. Hoarding is another diagnosis to consider as Theodore does not want to get rid of anything that reminds him of his wife. However, it is also important to consider normal reactions to grief before finalizing a diagnosis.

Counseling Skills Interventions A major critique of structuralism was that the theory dealt predominantly with ________ concepts.

A. Emotional

B. Tangible

C. Unobservable ✓

D. None of the above

Correct — C. Behaviorist’s originally criticized structuralism for its’ focus on indistinguishable, unobservable generalizations. While structuralism allowed for descriptions of conscious experiences, these were thought to be ambiguous, hypothetical interpretations.

Treatment Planning Initial Intake: Age: 29  Gender: Female  Sexual Orientation: Heterosexual  Ethnicity: Caucasian  Relationship Status: Engaged  Counseling Setting: Agency - Telehealth  Type of Counseling: Individual  Presenting Problem: Anxiety  Diagnosis: Anxiety disorder, unspecified (F41.9), Reaction to severe stress, unspecified (F43.9)  Presenting Problem: You are a new counseling intern in a community agency conducting virtual individual counseling sessions using Telemedicine technology. You were referred a 29-year-old female client by your agency’s Psychiatrist who felt she needed to return to weekly psychotherapy as she had previously been doing two years ago. During your initial assessment session, you learn she has three young children under age 8, lives with her fiancé who is the father of the two youngest children, and that due to medical reasons she is on disability through Medicaid and is unable to work. She tells you she has been depressed and contemplating suicide because she cannot find relief from her anxious thoughts. She wants to be a better mom to her children than her mother was to her and wants help overcoming grief and loss, traumatic memories, panic attacks and irritability. Mental Status Exam: Client presents as unkempt, hygiene unknown as it is unable to be assessed via telehealth. She is appropriately dressed. Motor movements are within normal limits. Her eye contact is intermittent as she appears to have difficulty focusing both eyes in the same direction (amblyopia or “lazy eye”). She is cooperative and engaged. She admits to having passive suicidal ideation when triggered with distressing emotions and has considered taking pills as a method that would be the most comfortable but declines having intent or plan to collect pills for this purpose. She states her anxiety increases when she takes her children to the grocery store and when she is around crowds, experiencing panic-like symptoms necessitating her to call a friend to calm her down. She reports experiencing flashbacks of sexual trauma and prefers to stay at home as often as possible. She is alert despite being distracted often by her children in the background and is oriented to person, place, time, and situation. She is fidgeting with her hands and speaking circumstantially, often changing topics and going on rants in different directions before returning to her main points. She reports low energy, sleeping too much and weight gain. She adds that she cries every night over losing her paternal grandfather over 10 years ago. Family History: Client has a strained relationship with her mother whom she reports is “always dating an alcoholic” and has been abusive to her growing up. She adds that her mother has “Bipolar depression and ADHD.” She complains often about both her mother and her fiance’s mother mistreating her, making her feel resentful and angry. Client has two sisters, one of which lives with her mother and is mentally challenged. Her other sister has little to no contact with her family. Her father, who has been divorced from her mother for over 20 years, was once accused of child sexual abuse which has alienated him from the rest of their family. The client is the only one who remains in contact with him.  What would be the most effective person-centered objective within the client's treatment plan goal of addressing trauma?

A. Client will learn new coping skills to help ameliorate anxious distress.

B. Client will engage in narrative and exposure therapy interventions weekly for six months.

C. Client will process her trauma by discussing and receiving feedback on thoughts, emotions, and behaviors on a weekly basis with therapist.

D. Client will identify at least three triggers that cause stress reactions in her daily life and determine her connection to her root trauma through weekly discussion for six months. ✓

Correct — D. Objectives must call the client to action while also being SMART (specific, measurable, achievable, realistic, timely). Answer a) is not specific, measurable, or timely. Answer b) is not person-centered; it is too direct in its interventions which might be challenging for a person with high anxiety who is processing her unresolved trauma while transitioning psychiatric medications. The client has already accomplished answer d) by electing to re-engage in therapy when referred.

Core Counseling Attributes Sex indicates an individual’s biological gender, while gender refers to one’s cultural, and psychosocial concept of maleness or femaleness. Furthering the notion of gender and sex is the perception of gender identity, which refers to an individuals’ ________ as male, female, or gender neutral.

A. Genetic identity

B. Inconsistency in identifying

C. Barriers to identifying

D. Psychological identity ✓

Correct — D. Gender identity refers to a person’s psychological identity as male, female, or gender neutral. There are also many other ways to “label” gender, and places to fall on the gender spectrum. Essentially, gender identity does not always match the biological sex, and often cannot fit into only two categories (male or female). Some distinguish themselves as being genderqueer, nonbinary, bigender, etc.

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