Part One

Client

Age: 53

Sex Assigned at Birth: Male

Gender Identity: Male

Pronouns: He/him

Sexual Orientation: Heterosexual

Race/Ethnicity: White

Relationship Status: Widowed

Setting: Private Practice

Type of Counseling: Individual

Provisional Diagnosis: Posttraumatic Stress Disorder, Tobacco Use Disorder

Presenting Problem: You are a clinician working at a private practice in a small town on the Canadian border. Your client is a 53 year-old widowed male who comes to you because of some sleep disturbance he has been experiencing. The client states that he has been having trouble with nightmares since about a year and a half ago when he and his late wife went hunting on their annual hunting trip. They were walking through the woods when his wife was accidentally shot by another hunter. Your client did all he could to stop the bleeding, but she died a short time after she was shot. He has recurring nightmares about the events that took place on the day she died. He states that he has tried everything to get rest, and he hopes that counseling will help.

Legal History: The client was charged with a DUI in his early twenties. The situation was exacerbated because he was detected as a drunk driver by the Royal Canadian Mounted Police, but subsequently tried to outrun them by escaping to the US border. The client was apprehended by Canadian police while he was waiting in line to cross back into the United States. The United States government ruled that he was actually on US grounds when he was apprehended, therefore causing him to be charged in the state of Montana. He underwent a sobriety program run by a religious nonprofit who signed off on his court paperwork. He tells you that he is not religious, however he is grateful for the people who helped him get out of legal trouble after drinking too much and running from the police. He has since taken up smoking to help reduce his alcohol cravings, which he claims has worked well for the past three decades.

Mental Status Exam: The client comes to session well groomed. He is oriented to person, place, and time. The client yawns numerous times in session and apologizes each time. He comes in smelling strongly of cigarette smoke and asks to take a smoke break halfway through the session. He comes back in and continues the conversation right where he left off. He denies current suicidal and homicidal ideation.

History of Condition: The client has been noticing distress for the last year and a half. He states that he is no longer hunting, as he is afraid that he might get shot like his wife, and he states that he can't go near the woods, or even think of going there. He reports having nightmares most nights out of the week. The client states that he has been "really jumpy, even if it's just a sound on TV." He states that he feels guilty for not having been able to save his wife's life. The client becomes visibly emotional when discussing the incident and says, "She trusted me to keep her safe out there. Hunting was our thing. We did it every year together. Sometimes I keep thinking that if I had noticed the other hunter sooner, or gotten to her faster, maybe she'd still be here. I should've done something different."

Substance Use and other Addictive Behaviors: The client has smoked since his DUI, but has started smoking significantly more cigarettes since the week after his wife's funeral. He states that he intended to only smoke from time to time to be able to relax and reduce his alcohol cravings, but he has begun chain smoking for most of the day. He states that he even smokes in bed, hoping that having nicotine in his system will reduce the possibility of nightmares. He has noticed that he is not as productive at work as he used to be because of the increased need for more smoke breaks. He has been unsuccessful in reducing his smoking even though he knows it is bad for him.

Living Situation: The client currently lives alone. He has no children or pets. He states that last year he moved out of the home he always lived in because it reminded him of wife too much. He expresses that he feels as though he is always in danger because of how unpredictable the world has turned out to be.

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Domain: Intake, Assessment, and Diagnosis

Which symptom described in the case provides the strongest direct evidence for the intrusion symptom cluster required for a diagnosis of Posttraumatic Stress Disorder (PTSD)?

Domain: Intake, Assessment, and Diagnosis

Which of the following are not criteria for Posttraumatic Stress Disorder?

Domain: Intake, Assessment, and Diagnosis

Based on the information presented in Part One, which of the following is the MOST appropriate assessment of the client's Tobacco Use Disorder severity?

Domain: Professional Practice and Ethics

Question:

Which of the following is least consistent with the counselor's professional role in the therapeutic process?

Domain: Core Counseling Attributes

Question:

How would you best reflect the client's feelings expressed in the History of Condition section?

Part Two

First session, one week after initial intake session

The client discusses recent nightmares in detail and buries his face in his hands when he pictures the scene in the dream. In his latest dream, he finds himself waiting in line at an amusement park with his late wife when all of a sudden, an announcement comes over the loudspeaker that the ride they are waiting on will be closed for the rest of the day. He begins to feel his frustration grow inside of him, his face turning red as he notices his fists squeezing tight. He turns to his wife to lament the time they have wasted in line, but no one is next to him. He spends the rest of his dream searching through the crowd of people who are trying to get out of line, all talking about what a waste of time waiting in line was. "I don't know what it means," he confesses, "but I can't handle that thought of wasting all that time and then her not even being there when I try to do something about it. It really messes with me." He describes feeling nervous nearly all of the time, including when he is in your office. You lead him in a guided imagery exercise to reduce anxiety and the client gives you mixed feedback about the exercise. He again takes a smoke break in the middle of the session. When he comes back, he states that he feels helpless and that he misses his wife greatly. You lead the client in a breathing exercise and encourage him to practice it to reduce distress between sessions.

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Domain: Treatment Planning

The client reports mixed feelings about the guided imagery exercise and appears uncertain about its usefulness. Which response would be most effective in maintaining the therapeutic alliance while collaboratively planning future treatment?

Domain: Intake, Assessment, and Diagnosis

Question:

As part of the assessment process, you decide to evaluate the client's risk for suicide. Which factor is least supported by research as a major suicide risk factor?

Domain: Intake, Assessment, and Diagnosis

Before introducing the guided imagery exercise, which response would be most consistent with a Rogerian (Person-Centered) approach?

Domain: Counseling Skills and Interventions

Question:

Based on the client's presenting concerns and diagnosis, which intervention is most directly supported by research as a first-line treatment for Posttraumatic Stress Disorder (PTSD)?

Part Three

Second session, three weeks after initial intake session

The client comes to session stating that he tried practicing the breathing exercise you gave him, however it was too painful to breathe, given the state of his lungs. "That breathing stuff just throws me into a coughing fit. It's not going to work for me." You respect the client's observation and offer to change directions. He puts a folder of x-ray film on your desk. "I brought you this in case you didn't believe me. These are my latest x-rays. The doctor seems to think I could be at risk for lung cancer, can you believe that?" he asks between coughs. You tell him that you believe him, and he doesn't have to do any therapy techniques that are too painful for him. He urges you to hold the films up to the light, though, pointing out the same spots the doctor pointed out to him a few weeks before. "The tests are all inconclusive as of now, and my doctor wants me to quit smoking, but I know what's best for me." Your conversation eventually takes a turn towards client's nightmares that take place where his wife passed away. You help the client make a list of negative thoughts he often has as a result of the events that took place in the woods. You help him brainstorm positive phrases that could replace them. He becomes frustrated, stating that there is nothing positive about what happened. You take some time to provide psychoeducation about the exercise, and the client states that he understands and is willing to give it a shot as long as it doesn't have to do with deep breathing. The client resolves to put notes around his house with the positive phrases so he can read them on a daily basis. The client ends the session after 45 minutes stating that he needs to go outside to smoke.

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Domain: Core Counseling Attributes

Question:

Which response best reflects the underlying meaning of the client's comments about his continued smoking despite medical concerns?

Domain: Intake, Assessment, and Diagnosis

Question:

Which counselor response is most consistent with a Motivational Interviewing approach to addressing the client's smoking?

Domain: Counseling Skills and Interventions

Which of the following cultural factors is least likely to lead to PTSD symptoms?

Domain: Counseling Skills and Interventions

Question:

Regarding the list-making exercise from Part Three, what is the primary purpose of this exercise?

Part One

Client

Age: 17

Sex Assigned at Birth: Male

Gender Identity: Male

Pronouns: He/him

Sexual Orientation: Heterosexual

Race/Ethnicity: White

Relationship Status: Single

Setting: School clinic

Type of Counseling: Individual

Provisional Diagnosis: Conduct Disorder

Presenting Problem: You are a school counselor in a public school system and receive a referral for a 17-year-old White male. The client has received three suspensions during the current school year and is at risk of expulsion. School records indicate multiple incidents involving theft from classmates, truancy, and repeated violations of school rules. Teachers report that he frequently disrupts class, argues with authority figures, and has intimidated several younger students. His grades have declined from mostly C's to D's over the past two years.

The client's parents requested counseling after discovering that he had recently stayed away from home overnight without permission. They report increasing concern about his behavior and worry that he may eventually run away permanently. The client states that he only agreed to attend counseling because participation is required to remain enrolled in school.

Mental Status Observation: The client arrives wearing sweatpants and a hooded sweatshirt displaying a beer logo. He jokes that the shirt violates school policy and states, "I don't care what this school thinks anymore." He chooses a seat near the door and maintains intermittent eye contact throughout the session.

The client presents as guarded and irritable but remains cooperative enough to answer most questions. He frequently fidgets with a handheld gaming device beneath the desk and appears restless. His mood is described as "fine," although his affect becomes noticeably restricted when discussing family relationships. He reports difficulty concentrating in class and admits that he often feels angry without understanding why. He denies current suicidal or homicidal ideation but states, "Sometimes I feel like nothing really matters anymore."

Work History: The client has worked part-time at a local take-and-bake pizza restaurant for approximately two years. His employer describes him as dependable, punctual, and hardworking. The client reports enjoying the structure of work and states that he likes being trusted with responsibilities. He recently suggested a change to a food-preparation procedure that was later adopted by the owner. The client reports that becoming a manager after graduation is one of the few goals he currently feels excited about.

Family History: The client resides with both parents and a younger sister who attends the same school. His parents describe him as an easygoing and affectionate child prior to adolescence. The family reports a significant change in his behavior following the death of his older brother in a motor vehicle accident five years ago.

The client and his brother were extremely close and frequently participated in sports and outdoor activities together. According to the parents, the client initially appeared devastated by the loss but became increasingly withdrawn over time. Several months later, he began skipping extracurricular activities, spending more time away from home, and getting into trouble at school.

When asked about his brother during the intake, the client initially shrugs and states, "That was a long time ago." Later in the session, however, he becomes tearful and admits that he still thinks about him frequently. He states, "Everybody else moved on. I guess I never really did."

Domain: Core Counseling Attributes

During the intake session, the client shrugs and states, "That was a long time ago," when asked about his older brother's death. Which counselor response best demonstrates a nonjudgmental and accepting stance?

Domain: Counseling Skills and Interventions

What are the essential elements of cognitive restructuring?

Domain: Core Counseling Attributes

Question:

Which statement about empathy is least accurate?

Domain: Counseling Skills and Interventions

The client frequently reacts impulsively, engages in fights, steals from classmates, and reports difficulty managing his anger. Which counselor response best utilizes the Dialectical Behavior Therapy (DBT) concept of Wise Mind?

Domain: Counseling Skills and Interventions

You notice that your client has all of a sudden gotten withdrawn and has crossed his arms and slumped down on the couch. You state, "Hey, I notice you've kind of checked out and your body language has gotten more closed. Did something happen that you'd like to discuss?" What is this interaction an example of?

Part Two

First session, two weeks after intake

The client arrives at the school clinic approximately ten minutes late. He smells of cigarettes and has noticeable bags under his eyes. The client reports that he has been staying up late playing video games and often feels exhausted during the school day. He states that he continues to struggle academically and has little interest in school. "I don't really care about any of this," he says. "Nobody there is my friend anyway."

You utilize active listening and focus on building rapport. Through continued conversation, the client briefly revisits the topic of his older brother's death. He initially shrugs and states, "That was a long time ago." After a long pause, however, he admits that he still thinks about his brother frequently and sometimes wonders what life would be like if the accident had never happened.

You gently begin exploring how the client's thoughts influence his emotions and behavior. He tells you about a girl who sits next to him in math class who recently asked him to stop talking to her during class. The client immediately assumes that her new boyfriend told her to stop interacting with him. When asked whether she provided another explanation, he responds, "No, but that's obviously what happened." He expresses anger toward the boyfriend and frustration that his classmate did not "stand up for herself."

You continue to observe an irritable tone and difficulty slowing down when discussing situations that make him angry. In contrast, when discussing his job at the local pizza shop, the client's demeanor becomes noticeably more positive. He reports that his manager recently praised him for helping train a newer employee and states that becoming a manager after graduation is "one of the only things I'm actually looking forward to."

At the end of the session, the client states that he is still unsure whether he can trust you, but agrees to return for another appointment in three weeks.

Domain: Counseling Skills and Interventions

The client states, "How do you expect me to have positive thoughts when people don't even want me to talk to them?"

Based on motivational interviewing principles, which counselor response is the BEST example of a simple reflection?

Domain: Intake, Assessment, and Diagnosis

You choose to administer the Outcome Questionnaire 45 (OQ-45) to your client. The primary purpose is to:

Domain: Core Counseling Attributes

Near the end of the session, the client states, "I'm still not sure if I can trust you." Which counselor response best demonstrates empathic attunement?

Domain: Professional Practice and Ethics

During a meeting, one of the client's teachers approaches you and states, "I've heard he's seeing you at the school clinic. Can you tell me what he's been talking about in counseling so I can better understand what's going on in my classroom?"

What is the most appropriate counselor response?

Part Three

Fourth Session 7 weeks after intake

At the beginning of the session, the client reports that he has started playing basketball again several times per week and has been making a greater effort to complete assignments. He proudly notes that his grades have improved from mostly D's to mostly C's. Although he continues to keep to himself at school, he reports fewer disciplinary problems and states that he has not been involved in any recent fights. His parents report that he still occasionally takes items from family members without permission, though less frequently than before.

You review some of the alternative coping strategies discussed during the previous session. The client reports that playing basketball and taking walks have helped him calm down when he feels angry. He states that he still gets irritated easily but is "not blowing up as much as before."

As the conversation shifts to work, the client's demeanor becomes noticeably more engaged. He reports that his manager recently asked him to help train a new employee and publicly praised him for his work in front of other staff members. The client smiles briefly as he describes the experience and states, "It was nice to actually get credit for something." He also reports getting along well with the new employee and says that work feels like "the one place where people don't automatically assume the worst about me."

You explore what made this experience meaningful to him. After a pause, the client states that his older brother was one of the few people who consistently believed in him. He explains that his brother used to encourage him to work hard and often talked with him about future career plans. The client's voice becomes quieter as he states, "He would've thought all of this was pretty cool."

You gently ask what it is like to think about his brother in those moments. The client suddenly becomes visibly tense and responds, "You know nothing about my brother. Stop talking about him." He crosses his arms and avoids eye contact as the session continues.

Domain: Professional Practice and Ethics

Question:

At the end of the session, the client's mother arrives with a friend to pick him up. As they prepare to leave, the mother's friend hangs back and asks if she can privately share some information about the client with you.

What is the most appropriate counselor response?

Domain: Core Counseling Attributes

Question:

After discussing his recent success at work, the client becomes visibly tense when talking about his brother and states, "You know nothing about my brother. Stop talking about him." He crosses his arms and avoids eye contact.

What is the most appropriate counselor response?

Domain: Counseling Skills and Interventions

From a Reality Therapy perspective, how would you summarize this client's progress?

Domain: Treatment Planning

Question:

The client reports fewer disciplinary problems, improved grades, successful use of basketball and walking to manage anger, and increasing satisfaction at work. However, he continues to isolate himself from peers, occasionally steals from family members, and becomes highly reactive when discussing his brother's death.

Which treatment goal would be the most appropriate next step?

Part One

Client

Age: 31

Sex Assigned at Birth: Male

Gender Identity: Male

Pronouns: He/him

Sexual Orientation: Heterosexual

Race/Ethnicity: African American

Relationship Status: Single

Setting: Prison Clinic

Type of Counseling: Individual

Provisional Diagnosis: Illness Anxiety Disorder, Care-seeking type

Presenting Problem: You are a clinician at a municipal jail, and your client is a 31 year-old African American male who has been in recent arguments with his case worker about his medical care. The client has been spending two hours each day checking his body for signs of leukemia. He frequently requests to see the nurse and has been, according to her, "begging" to see a specialist. The client states that the prison medical staff has not taken his needs seriously. He states that he has never found any physical signs of cancer, but he is worried that he has acquired it and it will get progressively worse as time goes on.

Legal History: A year and a half ago, the client made a trip to Mexico to stock up on pain medications so he would be ready "once the leukemia really starts to get bad." He was stopped for a routine inspection while crossing the border and was arrested for possession of a controlled substance. The client is currently mid-way through a 2 year sentence for the charge. He states that he never took the medication, but wanted to have a supply on hand just in case.

History of Condition: The client has had anxiety about having acquired leukemia after receiving a blood transfusion following surgery two years ago. He states that the idea of having someone else's blood in him makes him feel nauseous and has opened him up to all kinds of diseases. According to his medical records, there is no indication that the blood he received was contaminated.

The client states, "Ever since that transfusion, I haven't felt safe in my own body. I know everyone keeps telling me the blood was screened and that there's nothing wrong with me, but I can't stop thinking that something slipped through. Every morning I check myself for signs that the leukemia is finally showing up. Sometimes I spend hours looking for bruises or swollen glands. When the nurses tell me I'm fine, it helps for a few minutes, but then the fear comes back. It feels like I'm just waiting for terrible news that everyone else has somehow missed."

Health History: Client's health history is not significant. Two years ago he had a surgery to repair a hernia, but due to complications the client had to receive a blood transfusion.

Psychosocial and Family History: The client has two twin sisters who starred on a television show when they were kids. The show was about a group of kids who solved mysteries on their school playground during recess. The show ran for three seasons, but was canceled by the television network. Although the client did not star in the show, he was part of two episodes where he played minor roles. He tells you that it seems as though his parents were always more proud of his sisters, even though they insisted that they didn't play favorites. He tells you the name of the episodes he was in and urges you to look them up when you go home after work. You thank him for the information and think about whether or not it would be ethical to look up the show your client was in as a child. You wonder how this may affect your objectivity and ability to see his presenting concern clearly.

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Domain: Professional Practice and Ethics

When reviewing informed consent with a client, which of the following is not generally considered an exception to confidentiality?

Domain: Intake, Assessment, and Diagnosis

All of the following would be helpful assessments for evaluating Illness Anxiety Disorder except which?

Domain: Counseling Skills and Interventions

According to the information disclosed in Part One, which symptom provides the strongest evidence supporting a diagnosis of Illness Anxiety Disorder?

Domain: Core Counseling Attributes

Based on the client's statements in the History of Condition section, how would you best respond with empathic attunement?

Domain: Professional Practice and Ethics

From a transtheoretical perspective, which response best emphasizes client autonomy and self-direction while helping the client identify goals for counseling?

Part Two

First session, 2 weeks after initial intake session

The client arrives visibly frustrated and immediately begins describing his ongoing conflicts with the prison medical staff. He states that no one takes his concerns seriously and believes that decisions about his care are being made without listening to him. The client suggests that racial bias may be influencing how staff respond to his complaints and questions whether you might hold similar assumptions about him.

He reports feeling dismissed by multiple professionals and states, "People act like they're listening, but then they go behind my back and slap another diagnosis on me." He asks whether you are "actually on my side" and whether you would have approved the blood transfusion he received following surgery. The client lowers his head into his hands and says, "I just don't feel heard."

As he raises his voice, the correctional officer stationed outside the office looks through the window in the door, makes eye contact with you, and rolls his eyes before continuing down the hallway. The client notices the interaction and becomes more agitated.

He looks directly at you and asks, "Do you even know what it's like to have someone else's blood pumping through your veins every day and every night?" You invite him to share more about his concerns regarding the transfusion and ask what information he has received from medical providers. The client acknowledges that several physicians have reassured him that the blood was safe, but he remains unconvinced. He states, "They keep telling me there's nothing wrong, but how could they possibly know for sure?"

As the discussion continues, the client shifts his focus from the medical risks to the circumstances surrounding the transfusion itself. He states that he never felt he had a choice and describes feeling powerless while others made decisions about his body. You continue using empathic reflections and active listening as you work to establish rapport and better understand his concerns.

Domain: Core Counseling Attributes

Regarding the client's report of feeling 'dismissed' from Part Two, which counselor response best demonstrates a reflection of content?

Domain: Counseling Skills and Interventions

From a Reality Therapy perspective, which question would be most likely to help this client move toward change?

Domain: Intake, Assessment, and Diagnosis

Which of the following assessments utilizes a combination of direct and indirect data gathering?

Domain: Intake, Assessment, and Diagnosis

When conducting a biopsychosocial assessment, which of the following would be least appropriately categorized within the biological sphere?

Part Three

Second session, 3 weeks after initial intake session

The client comes to session frustrated that you have not provided him with a referral to see an oncologist. You provide information on the counseling process and discuss with him some goals he has in mind that fit into your scope of practice. The client states that too much of his day is taken up checking his body for signs of leukemia. You help him identify the negative cognitions that come up throughout the day, and you show him how to fill out an automatic thought record.

When you ask him to identify how true the thoughts feel, he tells you that the thoughts about his illness feel 100% true. Then, after reading through some of the ways to combat cognitive distortions, some of the thoughts he identified decreased to 75% true, and another decreased to 60% true. You review a thinking errors packet with him, and he supplements some of the evidence on his thought record worksheet.

The client says, "At first, I thought this worksheet was kind of pointless because I already know I have leukemia. But when I started writing down the evidence, I realized some of the thoughts weren't quite as certain as they felt. A few of them dropped quite a bit. The one about the blood transfusion still feels completely true, but I can see how looking at the evidence changes some of the others. So, the more evidence I gather and the more I challenge these thoughts, the easier it is to see that some of them might not be accurate, right?"

Domain: Core Counseling Attributes

Based on the client's statements in Part Three, how would you best respond with a reflection of content?

Domain: Counseling Skills and Interventions

From a CBT perspective, how would you most appropriately introduce an automatic thought record to this client?

Domain: Intake, Assessment, and Diagnosis

Which of the following statements regarding the relationship between culture and mental health is least accurate?

Domain: Core Counseling Attributes

Research on counseling outcomes suggests that which of the following generally has the least influence on treatment success?

Part One

Client

Age: 16

Sex Assigned at Birth: Female

Gender Identity: Female

Pronouns: She/her

Sexual Orientation: Heterosexual

Race/Ethnicity: Latina American

Relationship Status: Single

Setting: School

Type of Counseling: Individual

Provisional Diagnosis: Bulimia Nervosa, Acculturation

Presenting problem: You are a clinician working in a school setting. Your client is a 16 year-old Latina who states that she is not happy with how things are going. After about ten minutes of intentional rapport building, you find out that the client, along with her family, moved to the United States from Ecuador two years ago. The client states that she feels as though she does not fit in in the US and has no desire to make friends here. She states that she tried to keep in touch with her friends from Ecuador, but after a few failed video conferences, she stopped communicating with them. She states that her classmates in the US don't like the same things she does, and they all seem so "cold." She does not like her life here and would rather go back and live with family in Ecuador. She also tells you that she has not been eating how she would like to be eating.

Legal History: The client's dad came to the US five years ago as an undocumented immigrant. He was detained at the Mexican border and deported twice, however the third time he was able to cross successfully. He got employed at a meat packing plant, working long hours in sub zero temperatures, and was eventually able to save enough money to send for the rest of the family. Her dad initiated immigration proceedings after the family arrived because his lawyer told him that it would be less likely, but still possible, that he would get deported if he could prove the family would endure hardship if he were separated from them. As a result, he wears an ankle monitor that he cannot take off-not even to swim or shower. Your client does not wear an ankle monitor, but will be meeting with the family lawyer next week to assess their next steps in immigration proceedings.

Mental Status Exam: The client comes to session well groomed with good hygiene. The client appears slightly overweight. The client denies any hallucinations or suicidal ideation. Her speech and affect are normal, however at times the client was tearful during session, resulting in quieter speech.

Family History: The client comes from a large family with many aunts, uncles, and cousins who all live in the same neighborhood in Ecuador. The client currently lives with both parents and her 7 year-old twin brothers. The twins have stopped speaking Spanish at home and prefer to speak English, which bothers the client because she fears that forgetting Spanish will result in less of a connection with family abroad. The client feels pressured to teach her siblings Spanish, however they have begun to call her the "Spanish police" and have not wanted her help.

History of Condition: The client states that she eats too much food after she gets home from school. She explains that school is the hardest part of her day because she feels lonely and disconnected from her classmates. She often spends lunch by herself and thinks about how much she misses her friends and extended family in Ecuador. When she gets home, she tells herself she is only going to have a small snack, but once she starts eating she feels unable to stop. She describes the eating as temporarily comforting because it helps her forget about feeling alone and homesick.

Afterward, she feels ashamed and worries about gaining weight. She states that she will often make herself vomit and sometimes use laxatives because she believes she needs to "undo the damage." She reports engaging in bingeing and compensatory behaviors approximately three times per week for the past four months.

Domain: Treatment Planning

Based on the information gathered during intake, which treatment goal would be the most appropriate initial focus for counseling?

Domain: Counseling Skills and Interventions

Based on the client's statements in the History of Condition section, how would you use a cognitive reframe to shift the client's perspective?

Domain: Professional Practice and Ethics

At a professional development seminar, you encounter the term 'Null Hypothesis'. This refers to which of the following?

Domain: Counseling Skills and Interventions

In Mindfulness-based Cognitive Therapy, the term "decentering" means:

Domain: Intake, Assessment, and Diagnosis

During the assessment process, which question would provide the most useful baseline information regarding the client's overall level of functioning?

Part Two

First Session

The client arrives to session and reports that she has felt uncomfortable in her body for as long as she can remember. She wonders aloud why she feels unable to control her eating after school, particularly on days when she feels lonely or disconnected from others.

As you explore the history of these feelings, the client recalls a family vacation to Manta, Ecuador when she was eight years old. It was the first time her mother allowed her to wear a two-piece swimsuit. The client states that she remembers looking down at her shadow in the sand and becoming convinced that her body looked different from everyone else's. "I know it sounds strange now," she says, "but I remember thinking something was wrong with me."

She describes feeling embarrassed and self-conscious throughout the trip. Although her family encouraged her to swim and participate in activities, she spent much of the vacation wearing a sweater despite the heat. "My mom kept asking what was wrong," she says. "I couldn't tell her. She wouldn't have understood."

As she speaks, the client's voice becomes quieter and she briefly looks away toward a bird outside the office window. You reflect that these memories still seem painful for her. The client nods and responds, "Nobody really understood how I felt back then."

You introduce the idea of tracking the antecedents, behaviors, and consequences associated with her binge-purge episodes. The client appears receptive and agrees to complete a monitoring log during the week. You also provide her with a Spanish-to-English emotions vocabulary list to help her identify and communicate emotional experiences more precisely. The client smiles and states, "Thank you. That actually means a lot. Sometimes I know what I'm feeling in Spanish, but I don't always know how to say it in English."

Domain: Core Counseling Attributes

After receiving the Spanish-to-English emotions vocabulary list, the client smiles and states, "Thank you. That actually means a lot. Sometimes I know what I'm feeling in Spanish, but I don't always know how to say it in English."

What appears to be occurring in the counseling relationship at this moment?

Domain: Intake, Assessment, and Diagnosis

The assigned task from Part Two belongs to which technique?

Domain: Core Counseling Attributes

A counselor maintains appropriate eye contact, leans forward slightly, matches the client's pace of communication, nods periodically, and uses brief verbal encouragers such as "I see" and "Go on."

These behaviors are most characteristic of which counseling skill?

Domain: Counseling Skills and Interventions

You provide the client with a worksheet designed to help her identify and label emotions related to a recent conflict at school. The client looks down and responds, "I really don't want to get into that right now."

Given the client's reluctance, which therapeutic approach would be most appropriate for addressing her resistance?

Part Three

Second session, 2 weeks after the initial intake session

The client comes to session with a notebook of observations in Spanish about thoughts and feelings that have emerged throughout the week. She states that the food in the United States is not like the food in Ecuador, so she tries hard to find something that will satisfy her in that way, but there is nothing at home that tastes like her grandma's home cooking.

Back in Ecuador, cooking was a family affair. Nearly every holiday, family would travel from near and far to her grandma's village to gather at the house that has been in the family for many generations-even before there was plumbing and electricity in that part of the mountains. Her grandma would always recount the story about how she learned to cook on an open fire and how her mother would send her to the river to fetch water to wash dishes after each meal.

Nowadays, it is a lot easier to cook a meal for everyone in the family. A gas stove was installed in the mountain home a few years ago, along with pipes that carry water to her grandmother's part of the village, and the family got together to celebrate. As she describes these memories, the client becomes tearful and pauses several times.

She states that the abnormal eating cycle starts when she begins comparing the macaroni and cheese in the pantry to the food she misses from home. "I know it sounds silly," she says, "but sometimes when I'm standing in the kitchen, it feels like I'm realizing all over again that I'm not there anymore. It's like every meal reminds me of everything I lost."

You praise the client for her good insight and for putting forth the effort to complete her assignment. You brainstorm with the client ways to start a new chapter in the United States without losing the appreciation she has for previous chapters. The client brainstorms ideas with you while you provide empathy and unconditional positive regard.

Domain: Treatment Planning

When is a counselor least likely to introduce a discussion regarding termination?

Domain: Core Counseling Attributes

Based on the client's statements in Part Three, how would you best respond with empathic attunement?

Domain: Professional Practice and Ethics

Regarding a pre-screen phone call, which of the following is appropriate information to gather?

Domain: Intake, Assessment, and Diagnosis

Given the client's pattern of binge eating followed by self-induced vomiting and laxative use, which additional assessment question would be most important at this time?

Part One

Client

Age: 29

Sex Assigned at Birth: Female

Gender Identity: Female

Pronouns: She/her

Sexual Orientation: Homosexual

Race/Ethnicity: Asian American

Relationship Status: Married

Setting: Community clinic

Type of Counseling: Individual

Provisional Diagnosis: Cyclothymic Disorder with Anxious Distress

Presenting problem: You are a counselor at a community mental health agency and today a 29-year old Asian American female comes in to discuss some distress the client has been having at work. The client is an 11th grade English teacher who just had parent teacher conferences, and many of the parents told her that the students are afraid to approach her in class because the students are unsure how she might react on a day-to-day basis. The parents told the client that their children have described her as irritable and snappy at times and other times excited and motivated to help the students. Your client has noticed some increased frequency in conflict with her students, but she always thought the students were being too sensitive. Now she wonders if there is something she needs to work on to provide a more stable classroom atmosphere. Ever since the conferences, the client has been nervous around her students and second-guessing how to respond to their questions in class.

Mental Status Exam: The client comes to session well dressed and presents as tearful and sad. Affect is mostly flat and speech is rational and slow. Client denies presence of suicidal ideation and plans. At one point in session, client hid her face in her hands and apologized for "being emotional." Client is oriented to person, place, and time.

Social History: The client belongs to a bowling league at the local bowling alley, and was elected president of the organization last year. She assessed the data of each league member's bowling average to design tournament brackets. She was recently featured in the local newspaper for bowling her second 299 game this season. Your client has many friends at the bowling alley and is a point of contact for the employees to communicate with the league regarding scheduling, finances, and organization of the awards banquet that takes place at the end of the year. She is thinking about taking a step back from her leadership position in the league next year, but plans to continue bowling to get the coveted 300 game ring that many of her friends have earned in previous seasons. Although she has been an avid bowler nearly her whole life, she has yet to score a perfect game.

Work History: The client has worked at the same high school for the past five years. She received positive feedback from students, staff, and parents her first year of teaching. During her second year, however, she had some trouble motivating herself to grade papers and tests. Her grades always got turned in on time and she was never disciplined, but she noticed some "lagging" in energy and motivation. Other times the client felt slightly more energetic than normal and was excited to develop new lessons and projects. This year, the client's boss has expressed some concern not only about the client's interactions with students, but about how the client would abandon lesson plans for a couple of days at a time and put on a movie for students and just sit at her desk.

Family History: The client has been married for seven years and does not have any children. The client states that her marriage is good, however her wife has made a comment that she has some slight mood swings most of the time and has asked her why she can't just "be normal for once." The client reports that she had a great childhood, always got good grades, and was supported by her parents throughout all of her endeavors. She states that she can count on her family, but is too ashamed to discuss her recent negative feedback at work. She states that her older sister experiences more drastic mood swings than she does, and she worries that she could become like her.

History of Condition: The client began having these light mood swings starting four years ago. She has never had any suicidal ideation or instances where she has been hospitalized for mental health reasons. She says that she has never engaged in irrational behavior or erratic spending, but has experienced slight fluctuation in the amount she needs to sleep depending on her mood.

- - - - - - - -

Domain: Treatment Planning

Based on the client's presenting concerns and assessment data, which treatment goal would be the most appropriate initial focus of counseling?

Domain: Intake, Assessment, and Diagnosis

Which of the following is a diagnostic criterion for Cyclothymic Disorder?

Domain: Core Counseling Attributes

A client reports that she practices Cao Dai, a religion with which the counselor is unfamiliar. Which response best demonstrates cultural competence?

Domain: Professional Practice and Ethics

For a child who is in foster care, who holds the right to make medical decisions for the minor?

Domain: Professional Practice and Ethics

A counselor practices in a small rural community and learns that a current client has joined a bowling league in which the counselor participates. The client has been assigned to a competing team. What is the counselor's best course of action?

Part Two

First session, two weeks after the initial intake

The client comes to session stating that she does not understand what brings on her mood swings. She states that she feels as though she cannot follow through on any plans she sets because how she will feel in a few days is completely unpredictable.

For example, last Saturday she had plans to go see a movie with her friend, Veronica, after bowling. The two had been planning for two weeks to go to the movies and eat popcorn with Snow Caps mixed in. Veronica chuckles and says, "It's not every day you find someone who likes the same strange snack combinations as you."

The night before the outing, Veronica texted your client saying, "T-minus 14 hours until showtime!"

Your client looks down at her folded hands and laments, "I don't know what happened. I was really looking forward to going, but all of a sudden I didn't want to go. What does all of this mean? How can I all of a sudden feel that way?"

She pauses before continuing. "The worst part is that I don't trust myself anymore. If I make plans, I don't know whether I'll actually want to follow through. I feel like I can't count on my own emotions. What kind of friend cancels on someone they were excited to spend time with just a day earlier?"

She explains that her friendship with Veronica has not been the same since, even though she paid her back for both tickets because it was her fault for canceling at the last minute.

The client states that since your last session she has experienced five crying episodes before going into work. She states that just imagining interacting with the students makes her hands shake and she gets close to calling off work during these episodes. You ask her what stops her from calling off work. She says her career is important to her and she knows she can push through the day.

The client then becomes tearful and says, "I keep thinking about unintentionally hurting my students by snapping at them. They don't deserve that. Some of them probably come to school carrying enough stress already. I became a teacher because I wanted to help kids, not make them dread coming to class. Ever since those parent conferences, I've been paying much more attention to how I respond to students. I even started writing down situations that seem to trigger my irritability because I don't want to keep repeating the same mistakes."

You praise her perseverance, lead her through a progressive muscle relaxation exercise, and discuss times when the exercise might be useful.

Domain: Counseling Skills and Interventions

Based on the client's statement about snapping at students, which counselor response best uses reframing to strengthen the client's motivation for change?

Domain: Treatment Planning

Which of the following is most important for objectively monitoring a client's progress throughout treatment?

Domain: Intake, Assessment, and Diagnosis

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

Domain: Core Counseling Attributes

Based on the client's statements in Part Two, how would you best respond with a reflection of meaning?

Part Three

Second session, four weeks after the initial intake

The client arrives in a noticeably brighter mood and reports experiencing significantly less anxiety before work than she had in previous weeks. She states, "Now that all of this has a name, it doesn't feel so random anymore. I still have mood swings, but at least I understand what's happening."

You guide the client through an imagery exercise in which she visualizes feeling anxious while interacting with students and then practices using relaxation skills to manage the anxiety. She reports feeling more confident in her ability to remain composed during stressful situations at work.

The client also provides an update regarding her friendship with Veronica. Following the previous session, she spent time learning more about her diagnosis and decided to have an open conversation with Veronica. She invited Veronica to join her for several practice rounds of bowling, where she shared her experiences in counseling, her struggles with mood fluctuations, and her regret about canceling their movie plans. During breaks between games, the two discussed the impact the cancellation had on their friendship. The client reports that Veronica expressed appreciation for her honesty and willingness to explain what she had been experiencing.

Smiling, the client states, "We're going to try the movie again tomorrow. I've decided that unless there's a real emergency, I'm going to go. If I start feeling anxious beforehand, I can use some of the techniques we've practiced."

You explore the client's increased confidence, reinforce her recent successes, and help her identify how these same coping skills might be applied during future stressors, including the upcoming parent-teacher conferences in the spring.

Domain: Professional Practice and Ethics

During this session, the counselor notices feeling particularly protective of the client and finds themselves becoming emotionally invested in the client's success with Veronica and at work. Which of the following counselor responses would be the best way to manage potential countertransference?

Domain: Counseling Skills and Interventions

The technique employed in Part Three is an example of which of the following?

Domain: Counseling Skills and Interventions

You hand your client a worksheet that has columns on it, one column with a question asking the client a percentage pertaining to how true the client's thought is. What is this worksheet called?

Domain: Professional Practice and Ethics

In your final session, the client presents you with a Japanese tea set as thank-you gift, explaining that this is common practice in her culture. How should you respond?

BREAK TIME! Look at your clock and take a 15 minute break. The exam clock will not stop but your start time included an extra 15 minutes for this break. You should have at least 120 minutes remaining on your exam clock as you begin Case 6 (otherwise, your pace is too slow). Select answer 'A' when you are ready to continue.

Part One

Client

Age: 17

Sex Assigned at Birth: Male

Gender Identity: Male

Pronouns: He/him

Sexual Orientation: Heterosexual

Race/Ethnicity: Latino American

Relationship Status: Single

Setting: Community Clinic

Type of Counseling: Individual

Provisional Diagnosis: ADHD, Cannabis Use Disorder

Presenting Problem: You are a counselor at a community mental health clinic. Your client is a 17-year-old Latino American male who comes to counseling at the request of his adoptive parents. His parents state that the client has a history of not being able to focus in school. He was placed on a 504 plan in fourth grade to give him additional time to complete tests, and has continued to have a 504 plan on file through the current school year. Recently, the parents were notified that the client is in danger of failing his junior year. He has not turned in hardly any homework this semester. The client states that he is unmotivated and would rather hang out with his friend than go to school. The parents hope that counseling can help the client focus more and become more responsible with school work and daily tasks.

Mental Status Exam: The client comes to session poorly dressed and makes limited eye contact. He appears inattentive during session and asks you to repeat questions numerous times. He fidgeted with his hands in session and interrupted numerous times while you were asking his parents questions. The client denies hallucinations or delusions. The client denies presence of suicidal or homicidal ideation.

History of Presenting Problem: Client has had problems with focusing in school and at home since client was 9 years old. Client has never been in danger of failing, however, until this year. His parents caught him with marijuana in his book bag about two months ago, and were unaware of his smoking habit up until that point, however the client states that he has been smoking regularly for the last two years, but feels that the habit has gotten out of control over the past year. He had a part time job, but was fired a month ago because he did not show up to work twice in one week. The client stated that both times he got high a few hours before his shift and was too afraid to drive to work.

Vocational History: The client explains that he was working at a local home improvement store as of last month. He expresses regret over getting fired because he loved his job responsibilities, his coworkers, and even his managers. When his manager called him in to break the news to him that he could no longer work there due to the company's policies, his manager told him that he could count on him for a letter of recommendation if needed in the future because he worked hard during his time there. The manager said that, from what he could tell, the client is going through a rough patch and things will get better soon if he starts taking care of himself. Your client spends half of his day at the local career center in the automotive wing where he learns basic mechanics skills. Next week he and his parents have a conference with the technical director to assess whether he will stay in the program or go back to typical high school classes all day.

Family history: The client was adopted from the foster care system at two years old. Not much is known about his biological family, but his adoptive family has always been supportive of his endeavors. In recent months, there has been some relationship strain at home. The client's mom states that the client has been careless with his responsibilities and left his guinea pigs without food or water for three days because he "kept forgetting." The client does not have any other siblings, and is spending less time at home than in the past. When he is not at school, he spends time with his friend at the friend's house where they smoke marijuana most nights.

History of Substance Use and Addictive Behaviors: The client states that he first smoked marijuana at age 14, and did not smoke it again until a year later. Over the past year, his marijuana use has increased to the point of smoking most nights out of the week. He states that he does not know how he got to the point of spending hundreds of dollars on marijuana, but it seems like he cannot function without it, and has over time needed to consume more to get the desired effect.

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Domain: Treatment Planning

The client reports that he would rather spend time with friends than attend school and appears minimally invested in counseling, while his parents are highly motivated for him to change. Which counselor response would best help establish a therapeutic alliance and support treatment planning?

Domain: Professional Practice and Ethics

You are educating one of your clients on their responsibilities as a client. Which of the following is not considered part of standard client's responsibilities?

Domain: Intake, Assessment, and Diagnosis

Based on the information provided in Part One, which piece of information most strongly supports the diagnosis of ADHD?

Domain: Counseling Skills and Interventions

This client's clinically significant Cannabis Use Disorder would best be addressed by which of the following techniques:

Domain: Treatment Planning

Which of the following is the most appropriate short-term treatment goal for this client?

First appointment, 2 weeks after initial intake session

At the beginning of the session, you spend a brief time educating the client and his parents on his diagnoses and answer any questions that they have. You spend some time building rapport with the client and allow him to freely communicate about his goals for counseling.

You assess his stage of change and determine that he is in the preparation stage. He states that he is sick of spending all of his money on marijuana when it does not make him feel as good as it used to.

You discuss with the client some goals that he has and help him outline the goals into smaller, measurable steps. He sets a goal for the next session to finish the essay that he was assigned at school today by working on it for 20 minutes per night this week.

You casually ask him what his essay is about, and his eyes light up as he talks about interior design theories and the ones he is most passionate about. He goes into detail about crown molding types and their various methods of application. He pulls his phone out of his pocket to show you some virtual paint swatches he has been compiling and arranging on an art file.

"The teacher said we could choose any topic we wanted as long as it relates to art, so I chose interior design. I used to work in the paint department down at the home improvement store, you know. I think I'm going to try to swing by there after this and pick up some of the interior design brochures they have sitting there."

The client smiles as he talks, but then his expression changes and he looks down at the floor.

"Man, I miss that place. I actually felt good about myself when I worked there. The managers trusted me. Customers would ask for me by name sometimes. I can't believe I threw that away. My manager was nicer to me than he should have been when he fired me. He kept telling me that things would get better and that he hoped I'd come back someday. Honestly, I don't know why he believed in me. Sometimes I think I messed up the best thing I had going for me."

You use immediacy to point out the client's level of excitement as he discusses interior design and his former job. You also reinforce his goal of spending 20 minutes per night on his essay.

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Domain: Intake, Assessment, and Diagnosis

During the session, the counselor determines that the client is in the Preparation stage of change regarding his marijuana use. Which client statement would best support this conclusion?

Domain: Counseling Skills and Interventions

Which group of clients is least likely to experience exposure techniques in therapy?

Domain: Core Counseling Attributes

As the client discusses losing his job, how would you best respond with empathic attunement?

Domain: Core Counseling Attributes

A counselor believes that effective counseling requires understanding and responding to a client's concerns according to the client's experience rather than the counselor's personal judgment of the situation. Which counseling attribute is best reflected by this perspective?

Part Three

Second appointment, four weeks after the initial intake

The client arrives on time and appears more engaged than during previous sessions. He reports that he completed his goal of working on his interior design essay for at least 20 minutes per night and ultimately submitted the assignment on time. Although he struggled with procrastination on several evenings, he found that once he started working, he often continued for longer than the planned 20 minutes.

The client reports that he has reduced his marijuana use from most nights of the week to approximately three nights per week. He states that he still experiences cravings, particularly when spending time with the friend he typically smokes with, but feels encouraged that he has been able to cut back.

You explore the factors that helped him complete his essay despite his difficulty focusing. The client explains that setting a timer and committing to only 20 minutes made the task feel less overwhelming. He also notes that he was more likely to complete schoolwork on nights when he spent less time using marijuana.

The client states that his parents scheduled an appointment with a pediatrician next month to discuss whether medication might help with his ADHD symptoms. He shrugs and says, "I don't know. Part of me thinks medication could help, but another part of me doesn't want to rely on pills to get through the day."

Later in the session, the client's mother asks to speak with you privately. She states, "We've already decided that he needs medication. When you meet with him next time, can you really push him to take it? I think he'd listen to you more than he listens to us."

You explain the limits of your role and continue discussing ways the family can support the client in making informed decisions about treatment.

Before the session ends, you assign the client homework. You ask him to keep a daily log during the next two weeks that tracks time spent on schoolwork, Marijuana use, situations that make it easier or harder to focus, and strategies that help him complete tasks

You explain that the goal is not perfection but gathering information about patterns that may be affecting his concentration, motivation, and academic performance.

Domain: Counseling Skills and Interventions

What is the primary purpose of the homework assignment from Part Three?

Domain: Counseling Skills and Interventions

Which of the following interventions would most directly help this client improve task completion, organization, and other ADHD-related difficulties?

Domain: Professional Practice and Ethics

A counselor is reviewing group norms and expectations during the first session of a therapy group. Which of the following is generally NOT considered a standard expectation for group members?

Domain: Professional Practice and Ethics

Regarding the mother's request concerning medication found in Part Three, what is the counselor's most appropriate response?

Part One

Client

Age: 33

Sex Assigned at Birth: Male

Gender Identity: Male

Pronouns: He/him

Sexual Orientation: Heterosexual

Race/Ethnicity: White

Relationship Status: Single

Setting: Private Practice

Type of Counseling: Individual

Provisional Diagnosis: Panic Disorder

Presenting Problem: Your client is a 33 year-old White male who is the pastor of a local church. He comes to counseling because two months ago he was speaking at his church and was overtaken by what he describes as a heart attack. He had increased heartbeat, sweating, trembling, dizziness, and shortness of breath. He felt like he was going to die. He had to crawl off the stage and one of the church members called 9-1-1. By the time he got into the ambulance about 10 minutes had passed, along with his symptoms. He went to the hospital, however there was no indication that the client had had a heart attack. The doctors encouraged him to seek counseling at that time to manage stress. Over the past two months, he has been unable to go into the church building for fears that another episode will happen. He asks for you to help him as he feels like he is losing control of his life. As the client describes the panic attack, he becomes visibly uncomfortable and rubs his hands together. He states, "I've spent years helping other people through difficult times, but I never imagined I would be the one sitting in a counselor's office. To be honest, I don't even know what I'm supposed to say here. Part of me keeps wondering whether you're going to tell me I've lost my faith or that something is seriously wrong with me. I just know I can't keep living like this. Every Sunday feels like a test that I'm afraid to fail."

Family History: The client is a third generation pastor. He went to the same university both his father and grandfather went to, and got ordained in the same denomination as the other pastors in his family. The family members regularly get together during the holidays and on weekends, and your client describes his childhood as happy and warm, expressing gratitude for his mom's patience with him and his three brothers. He met his wife in their first year at Bible college, and married that summer. She became pregnant and dropped out of school before the couple's Sophomore year began. His wife is a stay at home mom to their 4 children, and is supportive of the client seeking counseling. None of the children were present for the client's latest episode because they were all in their Sunday School classes as they normally are when the client preaches. He remembers someone calling for his wife from the back of the sanctuary while he was having trouble breathing.

History of Condition: The client states that he experienced some increased anxiety in college, but it never reached an unmanageable level. He laughs and says, "They say some anxiety is good... it keeps you on track and all that." The client never experienced these kinds of symptoms until two months ago and they have been increasing in frequency.

Relationships: Most of the people the client associates with are members and staff of the church where he pastors. The client states that his social life has suffered quite a bit since the first attack happened. He expresses concern that people think he is broken, or that he went crazy.

History of Substance Use and Addictive Behavior: The client states that the last time he drank was over ten years ago when he got a DUI. He states that that turned his life around and that experience led him to study to be a pastor. He successfully completed a 12-step program and continues to be a sponsor of newer members. He denies having ever ingested illegal substances.

Domain: Intake, Assessment, and Diagnosis

Based on the client's statement in the Presenting Problem section, which response would best support the development of a therapeutic alliance?

Domain: Professional Practice and Ethics

From a psychodynamic perspective, a counselor notices increasing tension and resistance during a session and decides to explore the interaction with the client. What is the primary clinical rationale for addressing this dynamic?

Domain: Counseling Skills and Interventions

Panic Disorder would best be addressed by all of the following techniques except:

Domain: Counseling Skills and Interventions

From a cognitive behavioral therapy (CBT) perspective, which counselor response would best help establish a therapeutic alliance during the initial session?

Domain: Intake, Assessment, and Diagnosis

Which of the following tools best provides a broad overview of the client's reality?

Part Two

First session, 2 weeks after initial intake session

The client comes to session reporting that he has had eight panic attacks since the last time he saw you. He states that each time a panic attack strikes, he feels as though he is going to die which makes it worse. The most recent panic attack struck, ironically in the stairwell of a local hospital where he was going to visit an elderly member of his church who had fallen ill due to a history of gout which complicates their diabetes. "I was just jogging-kind of-up the stairwell, and all of a sudden it hit me. I felt dizzy and grabbed onto the railing and thought no one was going to help me. No one knew that I was in the stairwell, and I found out the hard way that employees only take the elevators, apparently." Your client spent over 15 minutes trying to breathe through his panic attack alone in the stairwell. He described the event as terrifying and jarring, yet manageable. After describing the stairwell incident, the client pauses and shakes his head. "The strange thing is that part of me knew I was probably having another panic attack, but it didn't matter. It felt completely real. I remember thinking, 'This is it. This is how I die.' Afterwards, I just sat there feeling exhausted and embarrassed. I kept wondering what would have happened if someone had walked in and seen me curled up on the stairs." Although his wife is supportive of his recent struggles, and although he considers her to be a key player in his support system, he tells you he doesn't feel comfortable calling her in moments like those. You discuss the nature of his diagnosis with him, stating that a common symptom of the diagnosis is that the individual often thinks they are dying, however panic attacks are hardly ever lethal. You provide psychoeducation about the diagnosis and encourage him to read an informational pamphlet about the diagnosis.

Domain: Core Counseling Attributes

Based on the client's description of the stairwell incident, how would you best respond with a reflection of feeling?

Domain: Counseling Skills and Interventions

The counselor encourages the client to examine the thought, "This panic attack is going to kill me," and evaluate the evidence for and against that belief. The counselor then helps the client develop a more balanced and realistic interpretation of the symptoms. Which intervention is the counselor primarily using?

Domain: Core Counseling Attributes

Which of the following is an essential component of empathic attunement?

Domain: Treatment Planning

Which of the following would NOT be an appropriate long-term treatment goal for a client diagnosed with Panic Disorder?

Part Three

Second session, 4 weeks after initial intake session

The client reports that he had seven episodes since the last time he saw you. He states, "Hey, that's one less than the last time, so I'll take it!" He discusses doing some research on the internet about his diagnosis, commenting that he joined an online support group where he found other people who undergo the same symptoms that he experiences. He tells you that one of the stories that stood out to him from the online forums was that of a forklift driver who thought he would lose his job due to having panic attacks, but the warehouse put him in a program where he would only be assigned shifts that had other forklift drivers available, that way if he could not control his panic attack, one of the other drivers could step in. The person in the support group stated that just knowing that there were other options for people who could step in for him made a world of difference, and he noticed that his panic attacks reduced because there was less pressure to perform. The client pauses for a moment and says, "I guess what scares me is that if I have a panic attack while preaching, everyone will expect me to handle it on my own. I'm the pastor. People come to me when they're struggling. It feels wrong to be the one who needs help. The forklift driver had other people who could step in, but I don't know if that's really an option for me."

He then reflects for a moment and adds, "Maybe that's part of the pressure. Every time I walk into church, it feels like I'm supposed to have everything together."

You engage in Socratic questioning with your client to assess and identify similarities between the forklift driver's situation and his own. You help him brainstorm a list of 3 people from his church and social circle that would be most supportive of him. Without being prompted, he sets a goal to have a conversation with at least one of them this week.

Domain: Counseling Skills and Interventions

The client states, "If I have a panic attack while preaching, everyone will expect me to handle it on my own. I'm the pastor. People come to me when they're struggling."

Which counselor response best demonstrates Socratic questioning?

Domain: Professional Practice and Ethics

'Duty to Warn' is a legal term that refers to which of the following?

Domain: Treatment Planning

A counselor is developing procedures for managing client crises that occur outside of normal office hours. Which of the following is the most appropriate approach?

Domain: Treatment Planning

As a counselor who does not share the client's religious background, which response would be most appropriate for helping him understand his avoidance of the church building?

Part One

Client

Age: 66

Sex Assigned at Birth: Male

Gender Identity: Male

Pronouns: He/him

Sexual Orientation: Heterosexual

Race/Ethnicity: Latino American

Relationship Status: Divorced

Setting: Community clinic

Type of Counseling: Individual

Provisional Diagnosis: Alcohol Use Disorder

Presenting Problem: You are a counselor at a community mental health clinic. Your client is a 66 year-old Latino man who comes to counseling to discuss his career goals. The client has worked for different companies throughout the years and has not saved up any money for retirement. He recently attended his twin brother's retirement party, and felt feelings of jealousy that he will likely never have the opportunity to retire. The client states, "I feel like I'm getting so old and I'm just not ready". He states that he started to feel more and more bitter about working as a toll booth operator and he quit his job all of a sudden. He states that he is looking for a job that is easy to do, keeps him interested, and will help sustain him throughout his elderly years.

Legal history: The client discloses that he does not currently have a driver's license because he has had 3 intoxicated driving charges within the last two years. He states that he has done the required programs and mandatory stays in jail, but none of it has made a difference. He states that the prosecutor told him that if he gets another charge having to do with intoxication that he will have to spend even more time in jail. Given the client's age, he worries about a long-term jail sentence.

Health History: Diabetes runs on both sides of the client's family. Both parents and both sets of grandparents have been diagnosed with diabetes at some point in their lives. When the client got a job as a toll booth operator, well-meaning family members from all sides of the family gave him advice for how to stay active while working at a sedentary job for most of the day. The first year he worked as a toll booth operator he got a smartwatch that tracked his steps, and many days he would only accumulate about 2,000 throughout the whole day. With no time to increase his step count, he quickly lost motivation and tried to manage his health with diet only. Since he didn't have access to a refrigerator, however, he had to rely mainly on packaged foods for two out of three meals per day. His blood work has been within normal range over the past year.

Substance Use: The client states that he can drink about 12 cans of beer per night. He states that he has tried to cut down on his alcohol consumption numerous times, however the guilt he feels about the drinking often results in him drinking more. He states that he has lost a few of his jobs due to coming to work smelling like alcohol. He explains, "I feel like I can't get the smell off of me. It has to be coming out in my sweat or something."

Family History: The client tells you that he got divorced three years ago. He says that his wife used his drinking as an excuse, but he thinks she just got bored of him. The client has four adult children and eight grandchildren. Two of his daughters have stated that they will not bring their children over to the client's house until he gets his drinking under control. They have made comments that his house reeks of alcohol and they do not want the children around his sometimes unpredictable drunken behavior. His other two children live out of state and only come to visit at Christmas.

- - - - - - - -

Domain: Core Counseling Attributes

While listening to the client's experiences of discrimination in the workplace, the counselor notices an internal tendency to assume that the client's coworkers' actions were justified and finds themselves questioning the client's interpretation of events. Which area of counselor development most needs attention?

Domain: Intake, Assessment, and Diagnosis

In addition to Alcohol Use Disorder, which of the following conditions would be most important to consider during the diagnostic assessment based on the information provided in Part One?

Domain: Intake, Assessment, and Diagnosis

Which assessment is best known for its direct adherence to the Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria?

Domain: Professional Practice and Ethics

During the informed consent process, a counselor reviews the potential benefits, limitations, risks, and alternatives to counseling with a new client. What is the primary ethical purpose of discussing the potential benefits of counseling?

Domain: Treatment Planning

Based on the information provided in Part One, which of the following is the most appropriate long-term treatment goal for this client?

Part Two

First session, two weeks after the initial intake session

The client comes to session smelling of alcohol, however he does not exhibit any signs of impairment. He discusses filling out some job applications throughout the past two weeks, but has only heard back from one job, which is at a local warehouse store and his duties would include restocking merchandise. Without a forklift operator's certificate, however, he would be on the crew that would manually lift and stock the merchandise, which is not ideal at your client's stage in life. He tells you that he is on the fence about going in for an interview because he knows that that job would be physically demanding. He explains to you that, due to his poor driving history he would likely not be able to obtain a forklift license, and he is concerned that the company's background check policy would hinder him from moving forward in the process anyways. He tells you that it's important to keep all of his options open, even if he feels like there is a small chance of actually getting the job. The client discloses that he misses working in the toll booth because he got to meet many people who were passing through on road trips, which he enjoyed. The client pauses for a moment and says, "You know, it wasn't really the toll booth itself that I miss. Every day I got to talk to people who were headed somewhere. They had vacations planned, families in the car, places to go. I felt like I was part of something. Since I quit, I mostly sit at home drinking and watching television. Sometimes I wonder if I still matter to anybody." You discuss other jobs that the client has enjoyed in the past, as well as jobs that the client thinks he would enjoy. You use motivational interviewing to encourage the client to set goals to cut down on the amount he drinks. He discusses knowing that smelling like alcohol would not be good for a job interview, and you reinforce his observation by pointing out his good insight. You administer the Self Directed Search (SDS) in session and go over the results with the client and answer any questions that he has. The client discusses information gleaned from the assessment.

Domain: Core Counseling Attributes

Regarding the client's comments regarding missing his job from Part Two, which counselor response best demonstrates a reflection of meaning?

Domain: Intake, Assessment, and Diagnosis

The purpose of the assessment that was utilized in the first session after intake is to:

Domain: Counseling Skills and Interventions

Which of the following interventions would be LEAST likely to be included as a primary treatment strategy for this client's Alcohol Use Disorder?

Domain: Intake, Assessment, and Diagnosis

Psychasthenia is a psychological disorder characterized by all but which of the following?

Part Three

Second session, three weeks after the initial intake session

The client provides an update on the jobs he has applied for since the last time you talked. He discusses how the list of professions on the SDS opened his eyes to some job possibilities that he never considered. You go over the list of jobs that he highlighted to indicate interest. He discusses his passion for sales and his success with working at a car lot in the past. He wonders out loud about a job listing he saw recently. You point out his job experience, and encourage him to keep applying so that he can reach his goal. You use motivational interviewing throughout the session. The client discloses that he has started meeting with an AA sponsor who has a similar driving history as he does. The sponsor also got divorced due to his drinking, and your client is coming to terms with the fact that that factor was more detrimental to his marriage than he was previously willing to accept. Ironically enough, both of the sponsor's parents, and both sets of grandparents, have also been diagnosed with Type II Diabetes as well. Your client states that his sponsor has added some fuel to client's fire regarding engaging in physical activity, and the two have been taking frequent walks around the local park as they discuss their sobriety and health in general. Your client states that he is grateful for his sponsor and he feels he can talk to him about anything, especially since he understands. Your client asks about your driving record, and you redirect the client to discussing his goals as well as communicating how proud you feel of the client for maintaining participation in his 12-step program. You provide unconditional positive regard and reflective listening.

Domain: Core Counseling Attributes

A counselor strives to demonstrate genuineness throughout the counseling relationship. Which of the following counselor behaviors is most consistent with this therapeutic attribute?

Domain: Intake, Assessment, and Diagnosis

Based on the Transtheoretical Model of Change and the information disclosed in Part Three, which stage best describes the client's current status regarding his alcohol use?

Domain: Counseling Skills and Interventions

A counselor is constructing a multigenerational genogram to better understand patterns within a client's family system. Which of the following types of information would be LEAST likely to be represented on a genogram?

Domain: Counseling Skills and Interventions

The client states that he is grateful for his AA sponsor because "he understands what I've been through," and reports that the sponsor has helped motivate him to focus on both sobriety and physical health. What therapeutic factor is most clearly contributing to the client's progress?

Part One

Client

Age: 40

Sex Assigned at Birth: Female

Gender Identity: Female

Pronouns: She/her

Sexual Orientation: Heterosexual

Race/Ethnicity: African American

Relationship Status: Single

Setting: Private practice

Type of Counseling: Joint Mother/Daughter

Provisional Diagnosis: Parent-Child Relational Problem

Presenting Problem: You are a clinician in private practice and receive a referral via insurance for a 40-year-old, single, African American female with her 15-year-old daughter. The mother reported that she divorced client's father two years ago and since then her daughter has been "acting out." She endorsed that she is a nurse at a nearby community clinic and works late hours. When she returns home, her daughter is out with friends and returns between 3:00AM-4:00AM smelling of alcohol. The mother expressed, "any time I bring up the late-night partying, it's a huge fight and she storms out. I don't know what to do anymore." Her daughter's grades are slipping, and she is at risk of failing the 10th grade.

Family History: The mother-daughter duo is from Brooklyn, NY. She met the daughter's father in nursing school and they were married for 12 years. After the mother had an affair, the father left and has intermittent contact with his daughter and retains parental rights. The daughter was sexually assaulted by a peer 1 year ago and is an only child. She attends a public school in the city and is involved in several peer groups.

Sexuality and Identity Development: The mother identifies as heterosexual. The daughter reports that she currently identifies as bisexual. She explains that before the sexual assault, she had only dated boys and generally assumed she was heterosexual. Following the assault, she began spending more time reflecting on her relationships, identity, and the kinds of people she felt drawn to. During that period, she recognized that she had experienced romantic and physical attraction toward both boys and girls for several years but had never given those feelings much attention. As she became more comfortable exploring her identity, she concluded that bisexual was the label that best described her experience.

The daughter reports that some friends have been supportive, while others have suggested that the assault "changed" her sexuality. She finds those comments upsetting and dismissive. She states, "The assault affected a lot of things in my life, but it didn't make me bisexual." She explains that the experience prompted self-reflection and made her more aware of feelings that were already present. The daughter reports feeling increasingly comfortable with her identity, although she remains cautious about discussing it with new people because she fears being judged or misunderstood.

Legal History: The client reported her sexual assault to the school, where the events transpired, and the school counselor recommended that the client and perpetrator speak about the assault in peer mediation, which is an in-house resource where students are provided training to help other students work out differences and arrive at a common understanding. When the client told her mom that the school was having the client participate in this program with her aggressor, her mom opened a lawsuit against the school district alleging that it was impeding her daughter from getting the help she needed, as well as for withholding information from a parent or guardian. The school district quickly dissolved the peer mediation proceedings, and assisted the client in making police reports to press charges against the other student. Her school counselor received disciplinary action as a result, and the client has not seen the counselor at school since.

History of Alcohol and Substance Use: The mother reveals that she was an alcoholic prior to going to nursing school and expresses concern that her daughter is traveling down the same path. The mother reports that she has been sober for 5 years, "I blame my affair on the drinking! But no one will forgive me. I don't even know if I forgive me." The daughter reluctantly reveals that she drinks malt beer after school with friends and smokes cannabis joints on rooftops.

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Domain: Intake, Assessment, and Diagnosis

During the intake session, the daughter asks, "Can I ask you something? Are you comfortable working with a bisexual client?"

Which response would best use this moment to strengthen the therapeutic alliance?

Domain: Intake, Assessment, and Diagnosis

Which of the following domains are explored in the DSM-5-TR Cultural Formulation Interview (CFI)?

Domain: Professional Practice and Ethics

The daughter's father calls the counseling office and requests information about what has been discussed during counseling sessions. He states that he retains parental rights but does not currently live with the client.

What is the counselor's MOST appropriate ethical response?

Domain: Professional Practice and Ethics

During the informed consent process, a new client asks about potential risks associated with participating in psychotherapy. Which of the following would NOT typically be considered a foreseeable risk of therapy that should be discussed by the counselor?

Domain: Counseling Skills and Interventions

The counselor is developing a treatment plan to address the Parent-Child Relational Problem described in this case. Which of the following interventions would be LEAST appropriate as a primary treatment approach?

Part Two

First session, two weeks after intake

The family arrives for their session five minutes late. During the session, you make gradual progress in the mother-daughter engaging with each other. You initiate a discussion surrounding the family's strengths. The daughter smirks and states, "we have no strengths! That's why we're here!" The mother becomes tearful and proclaims, "I just want her to love me again." You reflect that their relationship is in a difficult place and that hope is possible for reconciliation. The daughter softly admits that her mother has demonstrated strong work ethic, "she taught me never to give up when she went back to nursing school. She was just a clerk before." The client goes on to discuss her admiration for how her mom got their old house on the market, remembering her mom's gentle instructions when they were working to get it ready to sell. The client reflects on the hours they spent together painting the home and making trips to the hardware store to make small, affordable upgrades to their house. Once the house was finally sold, the client states that she wanted to stay there a little longer to enjoy the improvements that they had made to the property. Mom nods as she reflects on the details that came to her mind as the client revisited that chapter of their lives. The daughter asks her mom if they could make a trip across town to visit the property for old time's sake. Mom stated that she would love to, and fixing up that house was one of the most harmonious times of her life. At the end of the session, you practice psychoeducation and summarization to reflect the family's strengths explored in session and the significance of establishing a foundation of empathy and respect.

- - - - - - - -

Domain: Counseling Skills and Interventions

The daughter responds to the counselor's effort to identify family strengths by stating, "We have no strengths! That's why we're here!" Using a transtheoretical approach, which of the following best demonstrates agreement with a twist?

Domain: Intake, Assessment, and Diagnosis

Which of the following is not found in the Cognition Domain on the Mental Status Exam?

Domain: Counseling Skills and Interventions

During the session, the daughter recalls helping her mother prepare their former home for sale and describes it as a time when they worked together effectively and enjoyed each other's company. From a solution-focused perspective, which intervention would be MOST appropriate for the counselor to use next?

Domain: Core Counseling Attributes

Which of the following concepts does not form part of person-centered counseling?

Part Three

Second session, two weeks after first session

The family arrives on time for their session. You notice the daughter is wearing jeans and appears to have gained weight since the first session. The mother is also wearing jeans and laughs that she is attempting to create a "work-life" balance. In the first session, you made progress in exploring the maladaptive communication patterns and family strengths.

When you inquire about the daughter's drinking and cannabis use, she becomes irritable and shuts down, stating, "I don't want to talk about it." The mother becomes frustrated and shares that her grades have improved but she is still staying out late. The daughter explains that she has been spending time with a friend whose parents are currently going through a divorce. "She needs to get out of the house!" the daughter exclaims. "What do you want me to do? Say, 'tough cookies for you,' when she calls me crying? I'm just trying to help her," the client insists.

Mom gently discusses with her daughter why she is so concerned with the two staying out so late. She pulls up newspaper articles from the past week about gang violence and drug activity that takes place near the city's reservoir, where young people tend to hang out. The daughter rolls her eyes and says if her mom cared at all she would at least try to understand her friend's perspective. Mom opens up about her own experience as a child of divorce and asks her daughter how she can support both her and her friend.

You gently explore substance use referrals for treatment and coach the mother on skills to become more involved in her daughter's life and coordinate with school officials in a supportive manner. To strengthen empathy and communication between family members, you assign a homework exercise. You ask each family member to spend ten minutes during the week writing a brief letter from the other person's perspective, describing what they believe the other person has been feeling, fearing, and hoping for recently. They are instructed not to argue with the contents of the letters but instead to discuss what they learned from the exercise during the next session.

The daughter expresses that she will think about substance use treatment, and you schedule their next family session.

Domain: Treatment Planning

The daughter becomes visibly irritated when the topic of alcohol and cannabis use is raised and states, "I don't want to talk about it."

Which intervention would be MOST appropriate for helping the daughter explore her resistance and increase engagement in treatment?

Domain: Professional Practice and Ethics

A counseling intern is providing services under clinical supervision. During a supervision meeting, the intern asks what information should be included in the informed consent process regarding the supervisory relationship. Which of the following is NOT generally considered a required element of informed consent?

Domain: Counseling Skills and Interventions

The counselor assigns a homework exercise in which the mother and daughter write a brief letter from the other person's perspective, describing what they believe the other person has been feeling, fearing, and hoping for recently. What is the PRIMARY purpose of this homework assignment?

Domain: Treatment Planning

A counselor is considering whether collaboration with a school principal is warranted as part of treatment planning for a minor client. Which of the following situations would MOST strongly justify immediate involvement of the school principal?

Part One

Client

Age: 35

Sex Assigned at Birth: Male

Gender Identity: Male

Pronouns: He/him

Sexual Orientation: Heterosexual

Race/Ethnicity: Asian American

Relationship Status: Married

Setting: Agency

Type of Counseling: Individual

Provisional Diagnosis: Delusional Disorder, erotomanic type, continuous

Presenting Problem: You are a licensed counselor at a private practice. Your client is a 35 year-old Asian American who works as a nurse practitioner at a local hospital. His wife urged him to come to counseling because she has perceived some relationship instability and incoherent thinking. In session he states that about three months ago, a candidate for state governor put up a billboard near his home and he took it as a sign that she wanted to get in a relationship with the client. He has written numerous letters to her campaign office to extend his support. He expresses to you that he needs you to keep all of the information shared in session confidential, because no one can know that she is in love with him and is including hidden messages in her commercials on TV.

Mental Status Exam: The client comes to session in his work uniform, complaining of being tired after having worked a 10-hour shift. His thought process is delusional, speech is coherent, and mood and affect are appropriate during session. At times he speaks in hushed tones about "confidential information." You assess for hallucinations, and determine there is no presence of hallucinations.

Work History: The client is very successful at his job and has been leading teams of interns and medical assistants for the past year. He is well respected by his colleagues and by the students at a local community college where he works as an adjunct professor. He states that one of his goals is to go back to medical school to become a doctor, but is holding off on these plans until after the upcoming election.

Current Living Situation: The client, his wife, and their two children live in a five-bedroom home in the suburbs. The client volunteers for the board of his home owner's association (HOA), and attends monthly neighborhood crime watch meetings. He and his wife have placed a Safe House sign in their front window so community members in distress can seek help with them. They say that this is a small way to give back to their community. No one has ever actually come to their house for support, but they take pride in leaving it up because it may help someone when they least expect it. They take continuing education courses in crisis management once a year to remain part of the Safe House network. Instead of volunteering for the HOA next year, your client states that he is contemplating dedicating that time to political lobbying activities.

Relationship History: The client has been married to his wife for 10 years. His wife is also a nurse practitioner, but not at the same hospital. She has noticed the client spending up to an hour a night writing email drafts and letters to the political candidate. The client told her within the last two weeks all of his thoughts, which led his wife to encourage him to set up a counseling appointment. She stated that he was very excited about his new love interest, as well as the messages she has been sending him, and that he has no other choice but to divorce his wife after the upcoming election. His relationship became strained recently when the client donated $2,000 to the campaign. He stated that he felt compelled to do so when he saw a city bus drive by with the candidate's picture on it. He stated, "She planned for that bus to drive by right at that time to ask me for her support with the campaign. When someone loves you enough to reach out like that, how can you say no?"

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Domain: Professional Practice and Ethics

When evaluating whether a client possesses the capacity to provide informed consent for treatment, which of the following is NOT generally considered an essential element of decision-making capacity?

Domain: Treatment Planning

Based on the client's presenting concerns, which of the following would be the most appropriate short-term treatment goal?

Domain: Core Counseling Attributes

The ability to understand one's own motivational patterns and the ability to use them productively in the helping relationship best enhances which of the following:

Domain: Counseling Skills and Interventions

Which of the following interventions would be MOST appropriate when treating a client diagnosed with Delusional Disorder, Erotomanic Type?

Domain: Intake, Assessment, and Diagnosis

Which aspect of the client's presentation most strongly supports a diagnosis of Delusional Disorder rather than Schizophrenia?

Part Two

First session, two weeks after initial appointment

The client comes to the office to discuss recent developments and messages the client has received from the political candidate. One of the "messages" came in the form of fine print at the end of a television commercial. The fine print said "Paid for by this candidate's campaign team. All rights reserved," and your client explained that the inclusion of the word "team" on this specific commercial was direct communication to him that the candidate is thinking about his future position in her family. "She sees us as equals, you see, like a husband and wife," he states proudly. He also discusses the subtle meaning in the phrase "all rights reserved," although the connection with the campaign isn't as clear. He speculates that she is saying that she has a spot reserved for him in her life, however he plans to ask for clarification once the election is over. He tells you he is planning on donating another $500 to the campaign if his wife is willing to give him a check since she has locked the checkbook in a safe in the attic for the time being. You respond with unconditional positive regard and reflective listening to build rapport with the client. You ask the client, "What do others in your family and your community think is causing your problem?" You provide a non-judgmental environment for the client to express thoughts and feelings. As the client describes the candidate's hidden messages and future plans together, you notice an urge to challenge the accuracy of his conclusions. At the same time, you are concerned that directly disputing the beliefs this early in treatment could damage rapport and reduce the client's willingness to continue counseling.

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Domain: Counseling Skills and Interventions

As the client describes the hidden messages he believes the political candidate is sending him, you notice an urge to challenge the accuracy of his conclusions. At the same time, you are concerned that directly disputing the beliefs this early in treatment could damage rapport and reduce the client's willingness to continue counseling.

What is the MOST appropriate counselor response at this stage of treatment?

Domain: Counseling Skills and Interventions

During the session, you ask the client, "What do others in your family and your community think is causing your problem?"

What is the PRIMARY purpose of asking this question?

Domain: Core Counseling Attributes

During an initial intake session, you review a client's paperwork and notice that the client identifies their gender identity as non-binary. Which of the following would be the MOST appropriate counselor response?

Domain: Professional Practice and Ethics

Which of the following is not an accepted practice for when counseling records are being audited by a third-party?

Part Three

Second session, three weeks after the initial appointment

Client comes in to session distraught and confused over a restraining order that client received after client approached the political candidate at a rally in town. The client was escorted away by security after refusing to leave the candidate's personal space. The client expresses confusion about all of the signs that client has seen in recent months and wonders why the politician would "publicly reject him." You make a list of all of the signs the client has interpreted as direct communication. The client ranks each item on a likert scale of how likely a person is to contact another person by that means of communication, however the client shows an extreme lack of insight by indicating that all of the means of communication are very probable and typical. You help the client go through the list using other criteria, such as whether the client has previously witnessed another person using such means to communicate with others. The client becomes slightly agitated, asking you to "just listen for once," and "entertain the possibility that you potentially don't know anything." There is a moment of silence in the session before you apologize to the client for offending him and explain that it is your job to help him entertain all potential possibilities. He thanks you for the apology and discusses how he plans to tell his wife about the restraining order. He tells you he hopes his work doesn't find out because he tries to avoid being the subject of any type of gossip among his coworkers. You discuss with the client potential consequences of breaching the restraining order, to which the client responds "I would never put my career in danger, and I now see that she wants our communication to be one sided. I'll watch the news tonight to see what else she has to say."

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Domain: Counseling Skills and Interventions

During the session, the client becomes agitated and states, "Just listen for once," and "entertain the possibility that you potentially don't know anything." After a brief silence, the counselor apologizes for offending the client and explains that it is the counselor's role to help the client consider multiple possibilities. What counseling intervention is the counselor MOST clearly demonstrating?

Domain: Counseling Skills and Interventions

The client reports feeling confused and distressed after receiving a restraining order from the political candidate. He states, "I don't understand. After all the signs she's been sending me, why would she publicly reject me?"

What would be the MOST appropriate counselor response at this point in the session?

Domain: Intake, Assessment, and Diagnosis

The Scale utilized in Part Three is intended to:

Domain: Core Counseling Attributes

Which of the following is a key characteristic of an empathic attunement response?

Age: 13

Sex: Male

Gender: Male

Sexuality: Heterosexual

Ethnicity: Latino American

Relationship Status: Single

Counseling Setting: School Counseling

Type of Counseling: Individual

Diagnosis: Disruptive Mood Dysregulation Disorder

Presenting Problem: You are a counselor in a school setting. During the initial counseling session, a 13-year-old boy is sent to your office after receiving a disciplinary referral. The client states that he hates school and that "homework sucks!" His teacher reports that he frequently talks back in class, refuses to follow directions, and becomes argumentative when corrected. His grades have steadily declined over the past year, and he is currently struggling in all of his classes. School staff report that he appears angry much of the day and has been involved in several verbal altercations with peers, including two recent physical fights.

The client states that most teachers "pick on him" and that other students are constantly trying to start problems. He reports feeling frustrated nearly every day and says that when he gets angry, it feels like "everyone expects me to just get over it."

Mental Status Exam: The client presents as angry and frustrated. He is appropriately dressed and groomed. He is somewhat cooperative but maintains little eye contact throughout the interview. Affect is constricted and mood appears irritable. At several points he sighs heavily and responds with one-word answers. Thought processes are logical and goal directed. He denies suicidal ideation, homicidal ideation, hallucinations, and self-harm behaviors. He is alert and oriented to person, place, and time.

Social History: The client reports struggling socially since entering middle school. He states that the school year started out well, but midway through the previous semester he began spending time with a girl he liked. Another boy at school was also interested in her. According to the client, the other student was very popular and became angry that the client was "hitting on his girl."

The other student began making fun of the client on Instagram and encouraged other students to post negative comments. The client states that he tried to ignore the posts at first, but eventually confronted the student during recess. The confrontation escalated into a physical fight. Because the client threw the first punch, he received a three-day suspension.

Following the suspension, the girl's parents instructed her to stop spending time with him because they believed he was a bad influence. The client states, "That loser was so lame. She would have been much better off with me anyway." Despite saying this, he becomes noticeably quieter when discussing the situation and admits that he has not spent much time with friends since then.

School History: Teachers report that the client is capable of completing grade-level work when he applies himself. His cumulative academic record shows average grades throughout elementary school and the beginning of middle school. During the past year, however, he has accumulated multiple disciplinary referrals for arguing with teachers, leaving class without permission, and disrupting instruction. Several teachers report that his mood appears to shift rapidly from calm to highly irritable, often in response to relatively minor frustrations.

Family History: The client currently lives with his grandmother. His parents are in the middle of a contentious divorce and have been living separately for nearly a year. The client has four siblings, including two younger brothers and two older sisters. He reports frequent arguments with his younger brothers and states that they "never leave him alone." His grandmother reports that he often yells, slams doors, and becomes verbally aggressive when asked to complete chores or homework.

The client states that he misses the way things used to be before his parents separated. Although he denies feeling sad, his grandmother reports that he spends much more time alone in his room than he did in previous years. She also reports that his temper has become noticeably worse since the divorce began.

History of Condition: According to both the client and his grandmother, the client has experienced frequent temper outbursts for the past several years. These episodes occur both at school and at home and are often triggered by situations in which he feels criticized, rejected, or treated unfairly. His grandmother reports that his irritability is present most days, even when he is not actively upset. She states, "It feels like he's always angry about something."

The client acknowledges that he gets angry more easily than other people his age but believes others are usually responsible for causing the problem. He reports that after an outburst he often regrets what he said or did but struggles to control himself in the moment.

Domain: Counseling Skills and Interventions

The client reports that everyone at school is against him and that most of his fights started because other people provoked him.

Which response would BEST use a CBT approach while also strengthening the therapeutic alliance?

Domain: Intake, Assessment, and Diagnosis

During the initial assessment, which of the following pieces of information would provide the strongest support for the diagnosis of Disruptive Mood Dysregulation Disorder (DMDD)?

Domain: Professional Practice and Ethics

While attending a professional conference, you have lunch with a colleague who is a licensed counselor. During the meal, you observe the colleague consume several alcoholic beverages and begin slurring some words. The colleague mentions that they are scheduled to conduct a counseling session with a client immediately after lunch.

What is the MOST appropriate initial course of action?

Domain: Treatment Planning

Based on the client's presenting concerns and diagnosis, which of the following would be the MOST appropriate short-term goal?

Domain: Intake, Assessment, and Diagnosis

During the intake session, the client becomes tearful while discussing recent losses and states, "Sometimes I wonder if things would be easier if I just disappeared." What is the MOST appropriate counselor response?

Part Two

First session, 3 weeks after intake session

The client arrives for the next session appearing irritated and immediately states that he got into another fight earlier that morning and that "it wasn't my fault." As the session progresses, the client struggles to discuss his emotions directly and provides brief responses to several questions.

Recognizing his reluctance to engage in traditional talk therapy, you invite him to participate in an activity. You provide magazines and ask him to create a collage using pictures that represent things that are important to him, things he enjoys, and things he hopes to do in the future. As he works, the client becomes noticeably more engaged and begins talking about the images he selected, including cars, computers, and favorite foods.

The client spends considerable time discussing cars and explains that he used to enjoy watching his father work on the family vehicle. He becomes quieter when discussing his father's absence and states that he misses spending time with him. You reflect the significance of these experiences and affirm his interest in automotive mechanics. Together, you explore how this interest could potentially translate into participation in the high school's automotive program. You also discuss how developing better emotional regulation skills could help him reach goals that require responsibility, trust, and safe use of equipment.

Domain: Treatment Planning

The client leaves the session excited about the possibility of someday working in automotive mechanics. You would like to build on this interest and increase his motivation to remain engaged in counseling.

Which intervention would be MOST appropriate?

Domain: Core Counseling Attributes

What was the PRIMARY purpose of the collage activity used during the session?

Domain: Counseling Skills and Interventions

Based on the client's diagnosis of Disruptive Mood Dysregulation Disorder and his tendency to blame others for conflicts, which intervention would be MOST appropriate to help reduce his emotional outbursts and improve self-regulation?

Domain: Core Counseling Attributes

______ is discrimination against people with disabilities.

Part Three

Second session, 5 weeks after the intake session

Client arrives for the next session stating "why do I have to come here all the time? I didn't do anything!" You use your calm voice, modeling how much you care about him and tell him that you are here to help him. During this session you continue to work on goals to help him have better behavior at school. You ask him how his week went at school. Client discloses that he had another "run in" with the "loser" who was involved in the client's prior three day suspension for fighting. This time, the client was in the bathroom when the other boy started teasing him about his jacket. "He thinks he is so cool because he wears H&M. But that doesn't mean he's cool, it just means his parents are loaded. So I called him a 'spoiled little rich boy' and left", client states. You affirm the client for not allowing himself to get pulled into another fight and comment on how much progress he is making, specifically highlighting his increased ability to control his temper and to consider adverse consequences. "I'm so glad that you had the smarts to just walk away. It would have been a real drag to let yourself get manipulated into another suspension", you say.

Before ending the session, you assign the client a homework exercise. You ask him to intentionally use a "walk away and cool down" strategy at least one time during the upcoming week when he notices himself becoming angry. You explain that he does not need to avoid problems forever, but instead should practice taking a brief break before deciding how he wants to respond. You ask him to be prepared to discuss the experience during the next session.

Domain: Core Counseling Attributes

How would you best respond to the client's bathroom statement in Part Three using a reflection of feeling?

Domain: Intake, Assessment, and Diagnosis

Which of the following findings would MOST strongly indicate that a diagnosis of Disruptive Mood Dysregulation Disorder (DMDD) is inappropriate?

Domain: Counseling Skills and Interventions

What is the PRIMARY purpose of assigning the "walk away and cool down" homework exercise?

Domain: Treatment Planning

After six months of counseling, the client has not been involved in a physical fight for three months. His teachers report improved classroom behavior, his grades have improved, and his grandmother reports fewer arguments at home. The client states, "I still get mad sometimes, but now I usually know what's setting me off before I blow up." You and the client agree that his treatment goals have largely been achieved.

Which counselor response would be MOST appropriate during the termination process?