Free Sample Case

Part One

Intake

Client

Age: 14
Sex Assigned at Birth: Male
Gender Identity: Male
Pronouns: He/Him
Sexual Orientation: Heterosexual
Race/Ethnicity: White
Relationship Status: Single
Setting: Community clinic
Type of Counseling: Individual
Provisional Diagnosis: Obsessive-Compulsive Disorder

Presenting Problem: You are a clinical counselor at a community mental health clinic. Your client is a 14-year old White male who comes to you to get help so his school day runs more smoothly. Over the past six months, the client has received numerous detentions for being late to class. He states that the issue is that when he goes to his locker to get the books he needs for the next class, he often walks away, but feels like he forgot something in his locker, so he goes back to his locker and opens it only to find that he has everything he needs. He states that he feels better after checking, but there have been times where he opens his locker five times during a class change and reports to class late.

Relevant Mental Status Observation: The client comes to session well groomed and makes good eye contact. Mood and affect are appropriate. The client is visibly anxious as evidenced by shallow breathing and tenseness. The client has a bandana that is very special to him. He wipes his brow with his bandana three times when he comes into your office.

Family History: The client lives with his mom in a small apartment. Mom reports that the client spends about an hour and a half each night in the shower. Mom has found the client still showering well after the hot water has run out. The client states that he has a very specific showering ritual that he must perform, and if one of the steps is out of order he has to start over. Sometimes he loses track in the middle and has to get out and start all over again. He states that he knows that if he does not complete the ritual then “something bad will happen.”

Academic History: The client has always been a good student. He has perfect handwriting and always has his supplies organized. Teachers often say that he is very responsible and a pleasure to have in class. The detention monitor, who is also the client’s English teacher, was surprised to see him in detention over the last few months, and upon learning of his situation, recommended that he see the school counselor who referred the client to your agency. The client has good grades and has not missed a homework assignment all year.

Family History: The client has three younger half siblings who live with dad full time. The client’s parents got divorced when he was 9 years old, and the client found himself caught in the middle of an intense custody battle. He had to go to numerous court hearings and met with social workers and lawyers on a regular basis. Although his parents encouraged him to always tell the truth, he found himself intimidated by all of the conversations and appointments. He recalls that many of them ended abruptly, leaving him unsure if he said something he shouldn’t have said. He says that TV was an escape for him during that time and he would often imagine himself in the cartoon worlds depicted on the screen. He also says that he developed a love for school during this time of his life because school was the one place where it didn’t feel like people were fighting over him.
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Domain: Intake, Assessment, and Diagnosis

You elect to utilize an Exposure and Response Prevention (ERP) approach while working with this client. Which area would be MOST important to explore during the early stages of treatment?
1. The client’s beliefs about how his parents’ custody dispute contributed to his need for control and predictability.
2. The specific situations that trigger his obsessive fears, the compulsive behaviors he uses to reduce anxiety, and the level of distress associated with resisting those behaviors.
3. Relaxation strategies the client can use to eliminate anxiety before attempting to resist his locker-checking and showering rituals.
4. Ways the client can organize his school materials more effectively so he can feel certain that he has everything he needs before leaving his locker.
Domain: Professional Practice and Ethics

As you begin working with the client, you also meet regularly with your clinical supervisor. During supervision, your supervisor explains the evaluation process, performance expectations, remediation procedures, and the steps that would be followed if concerns regarding competence arise.

This process is BEST described as:
1. Supervision Informed Consent
2. Gatekeeping
3. Due Process
4. Vicarious Liability
Domain: Counseling Skills and Interventions

From an Acceptance and Commitment Therapy (ACT) perspective, which response would BEST help build therapeutic alliance with this client?
1. “Many people struggle with OCD. Let's work together to identify the thoughts that are causing your anxiety and replace them with more realistic ones.”
2. “It sounds exhausting to spend so much time fighting these fears. What would become possible for you if you could make room for some of that discomfort while still moving toward the things that matter to you?”
3. “What if, instead of trying to get rid of these thoughts, you practiced noticing them as just thoughts and continued doing what is important to you?”
4. “Your checking behaviors are interfering with your goals. Are you willing to commit to eliminating them so that your life can improve?”
Domain: Intake, Assessment, and Diagnosis

Which detail from the intake evaluation provides the strongest support for the client’s diagnosis?
1. The client experiences significant anxiety and shallow breathing during the intake session.
2. The client reports frequently worrying that he may have forgotten something important when changing classes.
3. The client demonstrates a strong attachment to a special bandana and uses it throughout the session.
4. The client's mother reports that he spends up to an hour and a half performing a showering ritual and will restart the entire sequence if a step is completed out of order.
Domain: Treatment Planning

You have completed the intake assessment and are preparing a formal treatment plan with the client.

Which of the following steps should occur FIRST?
1. Prioritizing and selecting the problems to be addressed in treatment
2. Developing measurable objectives related to treatment goals
3. Collaboratively establishing treatment goals
4. Identifying interventions that will help the client achieve treatment objectives
REVIEW SCREEN

At the end of Parts 1, 2 and 3 you will encounter a Review Screen that will allow you to review the questions from that Part. Once you start the next Part, you will no longer be able to review or change answers from prior Parts.

Select answer A to move forward.
1. Select this 'answer' by clicking the ? and then move on to the next question (This 'question' has no points).
Part Two

Second session, two weeks after the initial intake

The client wipes his brow three times as he enters your office. He reports feeling nervous about coming to counseling because your office is located in such a large building. “I know it's going to collapse one of these days,” he says. You ask whether he has ever personally witnessed a building collapse. He says he has only seen them in videos involving earthquakes and tsunamis. When you point out that your area is not at risk for tsunamis, he responds that there is still enough water in the ocean to cover the entire continent. The client states, "I've never actually seen a building collapse with my own eyes. It just seems like it could happen, though."

After discussing the evidence for and against this belief, you ask the client to close his eyes and imagine walking away from his locker with all of the books he needs for class. He pictures noticing the urge to return and check the locker again, taking a deep breath, looking at the books in his hands, and continuing to class without reopening the locker. You ask him to mentally rehearse this sequence several times. The client reports that his anxiety initially increases but gradually decreases with each repetition.

The client adds that his mother recently limited the amount of disaster movies he watches because he often worries that movie events could happen in real life. Although he believes she is being overprotective, he admits that he has been sleeping better since reducing his exposure to those movies. Together, you identify several intrusive thoughts, including fears about buildings collapsing and forgetting school materials. You encourage him to ask himself, “What’s the evidence?” when these thoughts occur. The client also decides to look at the books in his hands rather than repeatedly reopening his locker. You encourage him to practice these strategies during the week. The client wipes his brow three times as he leaves your office.

Domain: Counseling Skills and Interventions

The visualization exercise used in Part Two is BEST described as which technique?
1. Cognitive Reframing
2. Covert Sensitization
3. Cognitive Rehearsal
4. Covert Desensitization
Domain: Counseling Skills and Interventions

The client states, "I know it's going to collapse one of these days," despite having never personally witnessed a building collapse and having no evidence that the building is unsafe. Which cognitive distortion is BEST demonstrated by the client's statement?
1. Emotional Reasoning
2. Catastrophizing
3. Overgeneralization
4. Jumping to Conclusions
Domain: Counseling Skills and Interventions

Using Motivational Interviewing, which statement would BEST encourage movement toward change regarding the client's locker-checking behavior?
1. “You've told me that every time you go back to check your locker, you find that you already have everything you need. What does that tell you about how accurate these worries tend to be?”
2. “You mentioned that checking your locker multiple times helps your anxiety in the moment, but it also leads to detentions. What do you make of that?”
3. “Imagine making it to class on time without having to return to your locker. What would be different about your school day?”
4. “You've already come up with the idea of looking at the books in your hands instead of reopening your locker. What makes you think that strategy might work?”
Domain: Professional Practice and Ethics

As treatment progresses, the counselor believes that educating relevant school personnel about OCD and Exposure and Response Prevention (ERP) could help support the client’s treatment at school. Which of the following would be the BEST course of action?
1. Contact the school counselor and the client’s teachers to explain the client’s OCD symptoms and ERP plan because coordination of care is clinically appropriate when symptoms interfere with school functioning.
2. Obtain appropriate authorization from the client’s parent or legal guardian and involve the client in the decision before consulting with relevant school personnel, while limiting the information disclosed to what is necessary to support the client’s treatment.
3. Ask the client to give verbal permission to speak with the school counselor and teachers, since adolescents may authorize disclosure of counseling information when the purpose is to improve their functioning at school.
4. Provide the school counselor and teachers with general information about OCD and ERP while mentioning the client, as long as the counselor does not disclose his diagnosis or specific information from counseling sessions.
REVIEW SCREEN

At the end of Parts 1, 2 and 3 you will encounter a Review Screen that will allow you to review the questions from that Part. Once you start the next Part, you will no longer be able to review or change answers from prior Parts.

Select answer A to move forward.
1. Select this 'answer' by clicking the ? and then move on to the next question (This 'question' has no points).
Part Three

Fifth session, six weeks after the initial intake

The client wipes his brow three times when he comes into your office. He states that he has been experiencing fewer intrusive images, however he still has to wipe his brow “just in case.” The client reports that it has helped to check what materials he has in his hands rather than returning to his locker, although he still typically opens it twice during class changes. He proudly reports that he has not been late to class all week. You praise the client for his progress in reducing the number of times he checks his locker.

The client then becomes more serious and says, “It's weird. Part of me knows I already have everything I need, but another part of me keeps saying, ‘What if this is the time you forgot something?’ Sometimes I get so frustrated with myself. I watch everyone else walk to class and they don't seem to have to think about this stuff.” He pauses and looks down at the floor. “I just wish my brain would give me a break sometimes.”

You teach the client the concept of “one and done,” encouraging him to check his locker once and then continue to class despite any lingering uncertainty. As homework, you ask him to keep a log of situations in which he successfully resisted the urge to recheck, including what he was thinking, how anxious he felt, and what happened after he walked away. You encourage him to look for patterns in the situations that go well and to pay particular attention to whether his feared outcomes actually occur.

The client tells you about a recent conversation with his school counselor, who has noticed his progress, including fewer detentions. “I just told her that I can think about things in a different way now. I mean, it’s not perfect all the time, but that’s okay. Hey, that sounds like something you'd say!” he remarks with a laugh.

Domain: Counseling Skills and Interventions

Regarding the homework assignment from Part Three, what would you MOST hope the client learns from this homework assignment?
1. That he is more capable of tolerating uncertainty and anxiety than he initially believed.
2. That his anxiety will gradually become more manageable when he resists relying on compulsive checking.
3. That feared outcomes often do not occur, even when he chooses not to engage in checking behaviors.
4. That he can use evidence from his daily experiences to evaluate the accuracy of his intrusive thoughts.
Domain: Core Counseling Attributes

Regarding the client’s ‘more serious’ statements from Part Three, which response BEST demonstrates a reflection of feeling?
1. “It sounds like you're feeling frustrated and worn out by how much energy these worries take from you.”
2. “Part of you recognizes that you probably have everything you need, but another part of you keeps telling you to go back and check.”
3. “It seems like these constant doubts are making you feel different from your classmates and are getting in the way of being the kind of student you want to be.”
4. “You wish you could go through your day the way your classmates do without constantly questioning yourself.”
Domain: Counseling Skills and Interventions

Given the progress the client has made in counseling, you decide to refer him to a peer support group for adolescents with Obsessive-Compulsive Disorder. During one of the first meetings, the client listens quietly as several members discuss their experiences with intrusive thoughts and compulsive behaviors. After the session, the client tells you, “I honestly thought I was the only person who had to do things like this. Hearing everyone talk made me feel a lot less alone.”

Which therapeutic factor is MOST clearly demonstrated by the client's statement?
1. Group Cohesion
2. Universality
3. Interpersonal Learning
4. Instillation of Hope
Domain: Core Counseling Attributes

During a counseling session, a client says, “I know I keep making the same mistakes in relationships. Sometimes I think you must be wondering why I don’t just leave when things get bad.” The counselor responds warmly, “I don’t agree with every choice you’ve made, but that doesn’t change my respect for you or my willingness to understand what these relationships have been like for you.”

According to Rogers’ three characteristics of the therapeutic relationship, the counselor’s response BEST demonstrates:
1. Accurate empathic understanding
2. Congruence
3. Immediacy
4. Unconditional positive regard

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