Part One

Intake

Client

Age: 25

Sex Assigned at Birth: Female

Gender Identity: Cisgender Female

Pronouns: She/her

Sexual Orientation: Heterosexual

Race/Ethnicity: Asian American

Relationship Status: Single

Setting: Community clinic

Type of Counseling: Individual

Provisional Diagnosis: Panic Disorder, Obsessive-Compulsive Disorder

Presenting Problem: You are the clinical director at a community mental health clinic. Your client is a 25 year-old elementary school teacher who is in her second year of teaching. She is currently in danger of losing her position at the local school district because she has been unable to report to work for the past six months. She states that when she gets on the highway on her way to work, she habitually thinks that she has hit a pedestrian, begins to panic, and races to the next exit so she can circle back around and make sure she did not hurt anyone. Often times as she gets off at the exit, she has the same thought again, and sometimes has to pull over for the panic to subside. She has spent up to eight hours a day circling the same two exits on the highway because she feels that she has to make sure no one has been harmed by her. The client tells you that she knows that it is irrational, but if she does not go back and check, she has a hard time getting through the rest of her day because the thought that she has potentially killed someone consumes her. “I try not to think about it, but I can’t push the thought out of my mind,” she states.

Mental Status Exam: The client shows up to the session ten minutes late, and comes in crying. She apologizes for the late arrival, stating that her taxi service had trouble finding your office. The client holds up her hand and begins to breathe shallowly. her hands shake and she apologizes to you between breaths. After about ten minutes she calms down and continues talking to you. She states that similar episodes happen about four times a day, and even more frequently if the client drives. She is oriented to person, place, and time. Outside of the episode of anxiety, the client’s speech is normal and thought content contains obsessive characteristics.

History of Condition:

The client reports that she has struggled with anxiety for most of her adult life and describes herself as someone who has always felt highly responsible for the safety and well-being of others. During college, she frequently worried about making mistakes in school or accidentally offending people. She recalls rereading important emails multiple times before sending them and often seeking reassurance from friends that she had not done anything wrong. At the time, these behaviors were manageable and did not interfere significantly with her daily life.

Approximately eight months ago, the client noticed a marked increase in anxiety and self-doubt. She began experiencing unwanted intrusive thoughts that something terrible might happen because of her actions or negligence. She reports spending considerable time mentally reviewing events from the day to make sure she had not made a mistake or harmed someone. The client frequently seeks reassurance from trusted individuals and experiences temporary relief when others tell her that her fears are unlikely. However, the relief rarely lasts long before another doubt emerges.

The client reports feeling embarrassed by these symptoms and worries that others would think she is irrational if they knew how much time she spends questioning herself. She states that she has become increasingly isolated from friends and has stopped participating in several recreational activities because she feels emotionally exhausted most of the time.

Relationship History: The client has a boyfriend of three years, who she met in college. Her boyfriend describes her as his “rock,” and states that she is the main reason he gets out of bed in the morning. He went to college on a baseball scholarship, but quit the team his senior year because he couldn’t find the motivation to attend practices. His mood is depressed nearly all day, every day, except for some weeks when he feels “normal.” He has suffered from weight gain and sleep problems over the past year. The client states that she tries to take advantage of those weeks because that’s when she and her boyfriend get to do many of the things they enjoy, but during the depressive episodes they hardly see each other. She hopes that once they get married and start living together she’ll be able to convince him to get some help, or at least get out of bed more often.

Work History: The client states that the client had a great school year last year, however during the first quarter of this school year the client started having episodes in which client believed that she was having a heart attack. Her heart would start beating rapidly and she would begin sweating and trembling. She would walk out of the classroom in the middle of teaching and have to catch her breath in the teachers’ lounge. She states that whenever this happens she feels like she is going crazy and is not in control over her body or her emotions.

Domain: Intake, Assessment and Diagnosis

What client statement disclosed during the session most strongly supports the diagnosis of Panic Disorder?

Domain: Counseling Skills and Interventions

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

Domain: Professional Practice and Ethics

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

Domain: Intake, Assessment, and Diagnosis

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

Domain: Counseling Skills and Interventions

Regarding the client’s struggle while driving on the highway, you decide to introduce a DBT distress tolerance intervention.

Which intervention BEST demonstrates the use of a DBT distraction skill?

Part Two

First session, two weeks after initial intake appointment

The client provides an update about her work situation, stating that the school has found a long-term sub, however the client’s job position is not guaranteed for next year. She expresses a deep desire to get back into the classroom, and back onto the PTA board because she receives a generous stipend for her participation on the board. She states that she has become good friends with some of the parents from the PTA, and some have found her on social media to ask if she is okay. The client tells you that she has a hard time knowing how to answer the parents’ questions because, although she would love to provide them with a timeline for when she’ll be back, she is unsure of how realistic it is that it will be soon. She tells you that he has frequent dreams that she is in her classroom and she feels as though she is at home among the desks, papers, pencil shavings on the floor, and art supplies that she has organized in the cubbies on the wall. “I know my classroom is my happy place,” she says, “The question is whether or not I can make it through all the scariness on the way to actually get there.” You provide the client with psychoeducation about panic attacks and answer the questions she has, specifically focusing on whether or not panic attacks tend to cause fatalities. The client states that her panic worsens when the thought of her dying comes to mind. You normalize the experience and provide factual evidence that panic attacks are not fatal. The client clings to the phrase, “It’s just a thought. It doesn’t mean it’s true.” The client pauses and says, “That's the part I can't wrap my head around. When the thought shows up, it feels completely real. I know I've never actually hit anyone, but in the moment it feels irresponsible not to go back and check. If I don't check, it feels like I'm gambling with someone else's life.” You encourage her to post the phrase somewhere where she can see it at home and in the car. The client thanks you for the suggestion and states that she is hopeful at the end of session.

Domain: Counseling Skills and Interventions

When asking the client, “What did you find most beneficial about the work you did with your past counselors?” what is the PRIMARY purpose of this question?

Domain: Intake, Assessment, and Diagnosis

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

Domain: Counseling Skills and Interventions

The client states, “When the thought shows up, it feels completely real. I know I've never actually hit anyone, but in the moment it feels irresponsible not to go back and check. If I don't check, it feels like I'm gambling with someone else's life.”

Which counselor response would BEST utilize cognitive reframing?

Domain: Intake, Assessment and Diagnosis

Which aspect of the client's presentation most strongly supports the diagnosis of Panic Disorder?

Part Three

Second session, three weeks after the initial intake appointment

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

Domain: Professional Practice and Ethics

Under HIPAA, therapists may generally use or disclose a client's protected health information without a separate authorization for all of the following purposes EXCEPT:

Domain: Counseling Skills and Interventions

Which therapeutic concept is BEST illustrated by the client's statement regarding her boyfriend?

Domain: Intake, Assessment, and Diagnosis

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

Domain: Professional Practice and Ethics

During treatment, you learn that a close family member has experienced a serious medical emergency. You will need to be out of the office for approximately six weeks and will be unable to provide counseling services during that time. The client is disappointed by the news and expresses concern about managing her anxiety without regular sessions.

What is the MOST ethical course of action?

Part One

Intake

Client

Age: 12

Sex Assigned at Birth: Female

Gender Identity: Cisgender Female

Pronouns: She/her

Sexual Orientation: Heterosexual

Race/Ethnicity: African American

Relationship Status: Single

Setting: School Counseling

Type of Counseling: Individual

Provisional Diagnosis: Specific Learning Disorder (Written Expression)

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

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

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

History of Condition:

The client reports that writing assignments have felt more difficult than other schoolwork for as long as she can remember. She states that she often knows what she wants to say but struggles to organize her thoughts into sentences and paragraphs. Written assignments take her much longer to complete than they do for her classmates.

The client recalls becoming frustrated with writing in elementary school. Teachers often noted that she participated well in class discussions and understood the material, yet her written work did not reflect the knowledge she demonstrated verbally. Despite putting significant effort into homework, her writing performance has remained below expectations.

Since moving to her new school, the client's difficulties have become more noticeable because written assignments are longer and more frequent. She reports spending hours on essays and often becomes tearful before turning them in. On days when major writing assignments are due, she frequently complains of stomachaches and asks to stay home from school.

The client states that she enjoys reading and generally performs adequately on tests. However, when asked to write essays or organize ideas into paragraphs, she becomes overwhelmed and doubts her abilities. She states, “Sometimes I look at a blank page and feel like my brain just freezes.”

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

Domain: Professional Practice and Ethics

Which statement best describes the primary purpose of the informed consent process?

Domain: Intake, Assessment, and Diagnosis

Based on the information presented in Part One, which diagnosis would be LEAST supported by the available information and therefore warrant the lowest priority for further assessment?

Domain: Core Counseling Attributes

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

Domain: Counseling Skills and Interventions

The client tears up as she discusses her struggles with writing assignments and says, “I guess I'm just not very smart.”

How would you BEST respond with empathic attunement?

Domain: Professional Practice and Ethics

Three weeks after the initial intake session, the client's grandmother calls you before the school day begins. She reports that the client spent several hours crying the night before while working on a writing assignment and begged not to attend school the next morning. The grandmother asks you not to tell the client that she called because she is afraid the client will be embarrassed.

What is the MOST ethical course of action?

Part Two

First session, two weeks after the intake session

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

Domain: Intake, Assessment, and Diagnosis

The counselor says, “It sounds like your stomach is trying to tell us something. If it could speak, what do you think it would say?” Which theoretical orientation is MOST reflected in this intervention?

Domain: Assessment and Diagnosis

The client has reported difficulty adjusting to a recent move across the country, ongoing comparisons to her high-achieving brother, academic struggles, and support from friends she has made through band and art club. You would like to better understand the relationships and environmental systems that influence the client's functioning.

Which assessment tool would be MOST appropriate?

Domain: Counseling Skills and Interventions

Which counselor response would be MOST appropriate regarding the client’s statement at the close of Part Two?

Domain: Core Counseling Attributes

Which two states must match in a congruent counselor?

Part Three

Second session, eight weeks after the intake session

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

Domain: Core Counseling Attributes

The client states, “I'll be so embarrassed if she calls my teacher.” Which response best demonstrates a nonjudgmental counseling response?

Domain: Counseling Skills and Interventions

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

Domain: Intake, Assessment, and Diagnosis

Which of the following assessments utilizes unstructured data gathering?

Domain: Core Counseling Attributes

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

Part One

Intake

Client

Age: 68

Sex Assigned at Birth: Male

Gender Identity: Cisgender Male

Pronouns: He/him

Sexual Orientation: Heterosexual

Race/Ethnicity: White

Relationship Status: Divorcing

Setting: Agency

Type of Counseling: Individual

Provisional Diagnosis: Major Depressive Disorder

Presenting Problem:

Client is a 68-year-old White male who presents to counseling at the urging of his primary care physician after losing nearly 30 pounds over the past four months. Client states, “I don't know why everyone is making such a big deal about my weight. People lose weight all the time.” When asked about current stressors, he quickly shifts the conversation to his pending divorce. “I don't care that I'm getting divorced,” he says. “She was annoying anyway. She was crazy. All I ever did was provide for her.” As the session continues, however, he acknowledges spending much of the day thinking about the divorce and admits that he frequently calls his wife after drinking to “put her in her place.” He reports that most of his friends have distanced themselves from him during the separation and that nearly everyone has sided with his wife. “Thirty years together and somehow I'm the villain,” he says bitterly.

Mental Status Exam:

Client presents as well groomed and professionally dressed, though he appears tired and older than his stated age. His affect is constricted and predominantly irritable. Throughout the session he alternates between anger, sarcasm, and moments of visible sadness. At one point he stares at the floor for several seconds before responding to a question. Speech is coherent and goal directed. He is alert and oriented to person, place, time, and situation. Client reports sleeping only three to four hours per night and often lies awake replaying arguments with his wife. He states that food has become “more of a chore than anything” and admits that he often skips meals without noticing. He reports increased alcohol consumption over the past several months to “take the edge off.” Client endorses passive suicidal ideation, stating, “Sometimes I wonder what the point of all this is,” but denies intent or plan, explaining that he would never do that to his children or future grandchild.

Family History:

The client and his wife were married for 30 years and have two adult children. Their daughter is getting married in a few months and recently announced that she is expecting her first child. Their son recently came out as gay. The client states that he loves both of his children but acknowledges that he has never been particularly emotionally close with them. He describes himself as a provider rather than a nurturer. Since the separation, communication with both children has become strained. He believes they unfairly blame him for the divorce and admits he has considered skipping his daughter's wedding because he does not want to be around extended family members who may judge him.

Work History:

The client has worked as an attorney in solo private practice for more than 35 years. He describes himself as highly successful and states, “I tried working in a group practice, but those other lawyers just don't have the juice I have.” Recently, however, he has noticed increasing difficulty concentrating on legal documents and preparing for court appearances. He reports feeling mentally exhausted by the end of the day and admits that his motivation has declined significantly. He also acknowledges frequent turnover among his staff, whom he describes as “people who can't keep up.” Despite his complaints about employees, he notes that several long-term staff members resigned shortly after news of the divorce became public.

Current Living Situation:

The client's divorce attorney suggested that the couple remain in the marital home during the divorce proceedings to simplify the division of assets. However, the client's wife stated that she could no longer tolerate the tension in the home and moved out shortly after divorce papers were filed. The client does not know where she currently lives and insists that he does not care, although he frequently speculates about who she may be spending time with. He reports spending most evenings alone in the house watching television or sitting in silence. During the session, a tear forms in his eye as he describes the empty spaces on the walls where family photographs and decorations once hung. He states that the house feels “hollow” and describes it as a museum of a life that no longer exists. Although he quickly laughs off the comment, he quietly adds, “I never realized how much noise one person made until she wasn't here anymore.”

Domain: Intake, Assessment, and Diagnosis

During the intake process, you gather information about the client's coping strategies, trauma history, physical health habits, family relationships, educational background, and legal history. What are you primarily conducting?

Domain: Intake, Assessment, and Diagnosis

Based on the information presented in Part One, which additional diagnosis would be MOST important to consider during the assessment process?

Domain: Intake, Assessment, and Diagnosis

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

Domain: Counseling Skills and Interventions

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

Domain: Intake, Assessment, and Diagnosis

Based on the information presented in Part One, which aspect of the client's presentation provides the strongest support for the diagnosis of Major Depressive Disorder?

Part Two

First session, 2 weeks after intake session

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

Domain: Treatment Planning

You would like to establish a baseline measure and monitor whether the client's depressive symptoms improve over the next three months of treatment. Which assessment would provide the most clinically useful information for evaluating treatment effectiveness?

Domain: Core Counseling Attributes

During a session, your client expresses anger and disappointment about his son's recent disclosure that he identifies as gay. As the session progresses, you notice yourself becoming irritated and emotionally reactive. Later, you realize that your responses became shorter and less exploratory than usual.

Which practice would BEST help increase your self-awareness during future counseling sessions?

Domain: Counseling Skills and Interventions

How would you BEST respond with a reflection of meaning to the client’s statement about his self-identity in Part Two?

Domain: Counseling Skills and Interventions

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

Part Three

Second session, 4 weeks after the intake session

While you are in this session, your client asks if you have any pain killers as his back is killing him and he forgot to take anything. When questioned on how long this has been going on, he responds, about 4 weeks. He states, “I guess all of this laying around with no exercise is not doing me any good, but I just don’t feel like doing anything!” The client sighs and stares at the floor. “Honestly, I don't see much changing. Every day feels pretty much the same. I go to work, come home, drink a little, watch television, and go to bed. Sometimes I wonder what the point of making plans is when there's nothing to look forward to anyway.” You decline to provide medication and remind client of your scope of practice. He tells you that his mom’s therapist used to prescribe her medication and would even give her samples from the office’s supply. “I guess you’re not the same kind of therapist that mom had,” he goes on, “You know, I didn’t trust therapists for the longest time. They kept mom drugged up, you know? I never felt like I was really talking to her. So, when my doctor told me to come see you, I didn’t feel right about it.” You thank the client for sharing that information with you, and you take time to review the client’s goals. You discuss your type of licensure, and state that if the client would like to have a consultation about medication, that he is welcome to discuss this with a prescriber. The client insists that he does not need medication, nor does he want someone telling him what to do with his body. You empathize with the client and discuss the session’s homework assignment and its potential benefits. You assign the client a thought record worksheet as homework to complete for the next session.

Domain: Treatment Planning

As you begin developing the client's treatment plan, which source of information should receive the greatest priority when establishing counseling goals and interventions?

Domain: Professional Practice and Ethics

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

Domain: Counseling Skills and Interventions

As treatment progresses, the client makes the following statement:

“I failed as a husband, everyone seems to be against me, and honestly I don't see much reason to think things are going to get better.”

Which cognitive therapy concept is MOST clearly illustrated by the client's statement?

Domain: Counseling Skills and Interventions

The client states that he wants to feel better and reconnect with friends, but he spends most evenings drinking, watching television, and going to bed early. Which response would BEST develop discrepancy and move the client toward change?

Part One

Intake

Client

Age: 71

Sex Assigned at Birth: Male

Gender Identity: Cisgender Male

Pronouns: He/him

Sexual Orientation: Heterosexual

Race/Ethnicity: African American

Relationship Status: Widowed

Setting: Private practice

Type of Counseling: Individual

Provisional Diagnosis: Post-Traumatic Stress Disorder

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

Mental Status Exam: Client presents in therapy with anxious mood and oscillates between tearful and blunted affect. He endorses symptoms of intrusive memories, difficulty concentrating, nightmares, and flashbacks. He tearfully recalls a moment three years ago where has driving to work and almost crashed into a fence because he thought he was a child again. The client pauses and describes occasional episodes that occur when discussing his childhood trauma. “Sometimes it feels like I'm watching myself from across the room, like I'm observing somebody else's life instead of my own,” he explains. He states that the sensation usually lasts a few minutes and is most likely to occur after a nightmare or during conversations about his childhood. He reports that the experience is unsettling but recognizes that it is a feeling rather than reality. He becomes emotionally disengaged when exploring his childhood trauma and notes, “Maybe this isn’t for me. I can just pop an Ambien and take a shot of whiskey to sleep.” He denies suicidal or homicidal ideation.

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

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

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

Domain: Intake, Assessment, and Diagnosis

When completing a biopsychosocial assessment, which of the following would generally be classified within the biological domain rather than the psychological domain?

Domain: Intake, Assessment, and Diagnosis

Which diagnostic feature is MOST clearly reflected by the client's description of the occasional episodes that occur when discussing his childhood trauma found in Part One?

Domain: Intake, Assessment, and Diagnosis

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

Domain: Counseling Skills and Interventions

Based on the client's statements in the Presenting Problem, which response would BEST begin building a therapeutic alliance?

Domain: Professional Practice and Ethics

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

Part Two

First session, 3 weeks after the intake appointment

The client arrives on time for session and reports that his nightmares have continued, although he has begun keeping a journal beside his bed as discussed during the previous session. He explains that writing down portions of the dreams helps him remember them less throughout the day. He reports one particularly difficult nightmare in which he was back in his childhood bedroom. He woke up disoriented and spent several minutes checking the locks on his doors before realizing he was safe in his own home.

You spend time reviewing the relationship between trauma, avoidance, and PTSD symptoms. The client listens attentively but becomes visibly uncomfortable when discussing his childhood. At one point he states, “Part of me wants to talk about all of this because I'm tired of carrying it around. Another part of me thinks the best thing to do is leave it alone.” He explains that throughout his military career he learned to push difficult emotions aside and focus on the task at hand. “That's how I survived,” he says. “The problem is that now I'm retired, the house is quiet, and all of these memories seem louder than they used to be.”

As the session progresses, the client notices that he is gripping the armrests of his chair. You help him slow his breathing and orient to the present moment by identifying objects in the room. After a few minutes, his anxiety decreases. Before the session ends, he states, “I guess a part of me is worried that if I start talking about this stuff, it's going to get worse before it gets better.”

Domain: Counseling Skills and Interventions

The client states, “Part of me wants to talk about all of this because I'm tired of carrying it around. Another part of me thinks the best thing to do is leave it alone.”

Which counselor response would BEST facilitate exploration of the client's ambivalence?

Domain: Treatment Planning

Based on the client's presentation in Part Two, which treatment goal would be MOST appropriate at this stage of counseling?

Domain: Intake, Assessment, and Diagnosis

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

Domain: Intake, Assessment, and Diagnosis

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

Part Three

Second session, one week after first session

Client arrives ten minutes late to the session. You smell alcohol on his breath, and he expresses that he woke up late after ten whiskey shots the night before. He frequently spends time at the local Veterans of Foreign Wars club that is located about two blocks away from his home. He tells you that many of his friends spend time there, and he is grateful for the connection. He states that he normally doesn’t drink that much whiskey, but a newlywed couple was celebrating their marriage, and they bought shots for everyone at the bar. He tells you that the men at the bar all have a certain understanding about what topics they can talk about in public, and which ones they should refrain from talking about, and for the most part the conversation at the club is about mundane topics such as cars, civilian jobs, and family. His friend, Walt, a Vietnam veteran, often talks about his three dogs’ personalities, and once he even brought the pups to the bar with him to show them off to everyone. Your client tells you he isn’t really a dog person, but was entertained by the amount of energy the dogs had that day. After the introduction and small talk about last night’s endeavors, he selects a seat by the door and makes intermittent eye contact. He expresses that he is not sure therapy will work and that the nightmares are so intense that he will do anything to silence them. You provide space for client to explore his concerns about therapy, including his underlying fear that he will live with the nightmares and flashbacks for the rest of his life. You gently provide psychoeducation regarding trauma treatment and create a “triggers” list together to remind client to practice his grounding and deep breathing techniques before sleep. As the client discusses his years in the military, he comments that most civilians cannot understand what people like him have been through. He then looks directly at you and asks, “Have you ever experienced anything remotely like this? Or are you just reading about it in textbooks?” You notice yourself feeling slightly defensive and briefly wonder whether the client is questioning your competence. As the session comes to a close, the client pauses near the doorway and says, “I guess if I really thought this was completely hopeless, I probably wouldn't have bothered coming back.”

Domain: Counseling Skills and Interventions

The client states that he is unsure therapy will work and worries that he may have nightmares and flashbacks for the rest of his life.

How would you use a cognitive reframe to respond to the client's statement?

Domain: Core Counseling Attributes

You notice feeling defensive after the client questions whether you can understand his experiences.

How should you BEST manage this reaction?

Domain: Counseling Skills and Interventions

A counselor is teaching a client anxiety-management strategies and explains that some responses activate the parasympathetic nervous system, making it difficult for the body to maintain a heightened anxiety response.

Which of the following is MOST physiologically incompatible with anxiety?

Domain: Core Counseling Attributes

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

Part One

Intake

Client

Age: 11

Sex Assigned at Birth: Male

Gender Identity: Cisgender Male

Pronouns: He/him

Sexual Orientation: Heterosexual

Race/Ethnicity: White

Relationship Status: Single

Setting: School clinic

Type of Counseling: Individual

Provisional Diagnosis: Adjustment Disorder (With anxiety)

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

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

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

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

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

Domain: Intake, Assessment, and Diagnosis

Which piece of information from the client's history most strongly supports the diagnosis of Adjustment Disorder with Anxiety?

Domain: Counseling Skills and Interventions

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

Domain: Counseling Skills and Interventions

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

Domain: Professional Practice and Ethics

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

Domain: Counseling Skills and Interventions

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

Part Two

First session, two weeks after intake

After a bit of coaxing, the client agrees to sit with you for a session after school. He says he’d rather be home and appears restless when he’s talking about his father picking him up from school on time. You provide him with age-appropriate psychoeducation about worry and anxiety and demonstrate with him how to become aware of his breathing. The main source of psychoeducation comes from a children’s book that you purchased at a recent therapy convention held by your state’s licensure board. At the convention, you stopped at a booth run by a business called Mindfulness for Kids, and knew this book would be an asset for your clients. The person running the stand asked you if you would be interested in their newsletter as well, which you have found helpful. In session, you pull it off the shelf and encourage the client to feel the smooth cover, listen to the whooshing of the pages as he flips them, and notice the textures he feels on the pages that have fabric, feathers, and sandpaper pasted to them. The last page of the book includes a guided meditation exercise that you read to the client as he notices the temperature of the air he inhales versus the temperature of the air he exhales. Together, you practice deep-belly breaths and teach him how to count as he exhales. He says he will try to do these exercises when he feels nervous at school and at home. Before leaving the session, the client asks whether his father has arrived yet. When you tell him that his father is expected in a few minutes, he visibly relaxes. He then admits that several times during the school week he has asked his teacher if he can call home because he worries that something bad might happen to one of his parents while he is at school. He says that he knows the worries are "probably silly," but he cannot stop thinking about them once they start.

Domain: Intake, Assessment, and Diagnosis

Which intervention would be MOST consistent with a Logotherapy approach when working with this client's anxiety?

Domain: Intake, Assessment, and Diagnosis

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

Domain: Intake, Assessment, and Diagnosis

Based on the information currently available, which diagnosis would be MOST important to assess further as a potential comorbid condition?

Domain: Core Counseling Attributes

The client expresses concern that his father may not arrive on time to pick him up after the session. You respond, “I know you’re concerned about your dad picking you up on time. Would it help if we called him after the session is over?”

What is the PRIMARY purpose of this response?

Part Three

Second session, two weeks after first session

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

Domain: Professional Practice and Ethics

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

Domain: Treatment Planning

The client reports that the breathing exercises have been somewhat helpful when he feels nervous at school. As you begin discussing treatment goals, which question would BEST help the client identify a meaningful and measurable goal for counseling?

Domain: Treatment Planning

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

Domain: Counseling Skills and Interventions

Based on the Part Three narrative, which response BEST demonstrates a reflection of meaning?

BREAK TIME! Look at your clock and take a 15 minute break. The exam clock will not stop but your start time on this exam 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

Intake

Client

Age: 14

Sex Assigned at Birth: Female

Gender Identity: Cisgender Female

Pronouns: She/her

Sexual Orientation: Heterosexual

Race/Ethnicity: Latina American

Relationship Status: Single

Setting: School clinic

Type of Counseling: Individual

Provisional Diagnosis: Anorexia Nervosa

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

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

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

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

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

Social History:

The client reports that she used to enjoy spending time with friends after school and participating in dance activities at a local community center. Over the past year, however, she has become increasingly socially withdrawn. Although she still attends school regularly, she often avoids social gatherings that involve food, such as birthday parties, sporting events, and family celebrations. She reports making excuses to leave early or telling friends that she already ate before arriving.

The client states that most of her closest relationships now occur online. She communicates daily with members of several weight-loss and body-image forums, many of whom she has never met in person. She describes the online community as “the only place where people understand me.” She reports receiving praise from group members when she loses weight and criticism when she gains weight or eats foods that are considered unhealthy by the group. The client states that she has hidden multiple social media accounts from her parents because she fears they would force her to stop participating in the communities. When asked how she would feel if she lost access to these groups, she becomes visibly anxious and states, “They’re the only people who don't constantly tell me that something is wrong with me.”

Domain: Core Counseling Attributes

The client hesitates and states, “There are some things I don't think I can tell you right now.”

Which response would BEST promote trust and psychological safety in the counseling relationship?

Domain: Intake, Assessment, and Diagnosis

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

Domain: Treatment Planning

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

Domain: Counseling Skills and Interventions

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

Domain: Intake, Assessment, and Diagnosis

The client reports spending up to three hours per day interacting with online communities that praise starvation and extremely low body weight. She states that members of the group require daily weigh-ins, photographs of meals, and body pictures. The client describes the community as supportive and protective of her participation in it.

From a clinical perspective, what is the MOST important significance of this information?

Part Two

First session, one week after the initial intake session

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

Domain: Intake, Assessment, and Diagnosis

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

Domain: Counseling Skills and Interventions

Which of the following is considered an affective technique?

Domain: Core Counseling Attributes

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

Domain: Core Counseling Attributes

Regarding the client's comment about her online community from Part Two, which response BEST demonstrates empathic attunement?

Part Three

Second session, two weeks after the initial intake session

The client's mother checks in with you during the first ten minutes of the session and expresses cautious optimism about the counseling process. She shares that the client recently told her she was looking forward to coming to counseling and has begun eating a few additional foods. “I know it’s not much,” she whispers while glancing toward the waiting room door, “but she ate crackers three different days this week. That’s more than she would have done a month ago.” You acknowledge the importance of these small changes while continuing to express concern about the seriousness of the client’s medical condition. You encourage the mother to contact an agency that provides intensive outpatient treatment and eating disorder support groups. The mother agrees and states that she will make the call while waiting for the session to conclude.

When the client enters the office, she appears irritated. She explains that several friends have recently approached her about her weight and eating habits. She pulls a folded note from her backpack and shows it to you. The note was written by a friend who expressed concern about the client's health and encouraged her to seek help. The client rolls her eyes and says, “Now my friends are doing it too. Everyone thinks they know what's best for me.”

You ask the client to make a list of comments she has received about her weight from both people in her daily life and members of her online communities. Together, you compare the lists. The client notices that the comments from friends, family members, teachers, and medical professionals generally focus on concern for her wellbeing, whereas many of the comments from online community members include criticism, pressure to lose additional weight, or praise for extreme restriction. When you ask what she makes of that difference, she becomes quiet and shrugs. “I don't know,” she says. “I guess I never really thought about it that way.”

You provide a nonjudgmental environment as the client explores these conflicting messages. Although she continues to show limited insight regarding the severity of her condition, she acknowledges that she feels less defensive talking with you than she does with many of the adults in her life.

Domain: Counseling Skills and Interventions

The client appears frustrated after discussing the growing number of people who have expressed concern about her weight. She sighs and says, “Everyone thinks they know what's best for me.”

Regarding the client's comment about her friends found in Part Three, which response would BEST strengthen the therapeutic alliance at this point?

Domain: Intake, Assessment, and Diagnosis

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

Domain: Counseling Skills and Interventions

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

Domain: Professional Practice and Ethics

The client continues to demonstrate minimal insight into the severity of her eating disorder. She weighs 98 pounds at 5'6", has not menstruated for approximately one year, and remains strongly connected to online communities that encourage starvation and extreme weight loss. Although she has recently added a few foods to her diet, her parents are considering intensive outpatient treatment.

At this point, what would be the MOST appropriate reason to seek supervision or consultation?

Part One

Intake

Client

Age: 22

Sex Assigned at Birth: Male

Gender Identity: Cisgender Male

Pronouns: He/him

Sexual Orientation: Homosexual

Race/Ethnicity: White

Relationship Status: Single

Setting: College Clinic

Type of Counseling: Individual

Provisional Diagnosis: Schizophreniform Disorder

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

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

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

Additional Clinical Observation: As the session progresses, the client becomes increasingly suspicious when you ask questions about his daily routine and class attendance. He leans back in his chair and states, “You sound just like my parents. They always ask questions like that when they're trying to catch me doing something wrong. I knew this counseling thing wasn't really about helping me. It's about getting information.”

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

Domain: Counseling Skills and Interventions

During the session, the client describes spending hours documenting license plate numbers, avoiding the teaching assistant, and monitoring his surroundings because he believes people are watching him. He appears tired and anxious as he discusses these experiences.

Which response would BEST help establish a therapeutic alliance?

Domain: Professional Practice and Ethics

Which of the following does NOT reflect accepted ethical standards regarding counselors' use of social media?

Domain: Professional Practice and Ethics

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

Domain: Intake Assessment and Diagnosis

Regarding the information disclosed in the Additional Clinical Observation of Part One, which counseling concept is BEST illustrated by the client's response?

Domain: Intake, Assessment, and Diagnosis

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

Part Two

First session, one week after the original intake

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

Domain: Core Counseling Attributes

As the client is showing you drawings and notes about the Motrax, which response best demonstrates genuineness while maintaining an appropriate therapeutic stance?

Domain: Core Counseling Attributes

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

Domain: Counseling Skills and Interventions

Regarding the client’s statements about the psychiatry referral from Part Two, which response is MOST consistent with a motivational interviewing approach?

Domain: Intake, Assessment, and Diagnosis

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

Part Three

Second session, two weeks after the original intake

The client comes to session very upset because he just received a document stating that he is in danger of failing this semester since he has not reported to class once. “See? I knew this was what they were out to do!” he yells. The client wonders about your involvement with his parents’ plan, and you review with him the rules regarding confidentiality that you discussed during the intake session. During the session, the client mentions that his parents have been calling him repeatedly and asking about counseling. Later that afternoon, after the client leaves, his mother calls the clinic. She states that she has noticed her son covering mirrors in the home and staying awake all night watching the driveway. She asks whether he has discussed these behaviors in counseling and wants to know what he has been telling you during sessions. She sounds worried and asks if there is anything she should be doing to help him. You work to strengthen the therapeutic alliance and logically reason with the client so that he knows that you are working in his best interest. He shows you an email from his roommate expressing concern for him. At the end of the email, his roommate reminds him that he is always available to talk or to help him study. Your client expresses that he is suspicious of his roommate’s phrasing, accusing the roommate of looking through his mail: “How would he know I need help with school? He had to have seen this notice I got about almost failing. No one in this world is willing to give me privacy, and I’m getting sick of it!” You encourage the client to continue with the improvement plan he was given, which includes going to the psychiatrist appointment that is scheduled for the following day. You answer the questions he has about what to expect from the psychiatrist and reassure him that neither you nor the psychiatrist wants to see him fail, and that both of you are working to help him get back on track with his education.

Domain: Professional Practice and Ethics

Regarding the mother’s phone call as disclosed in Part Three, what is the MOST appropriate response?

Domain: Counseling Skills and Interventions

The client repeatedly attributes his academic difficulties and emotional distress to the actions of his parents, university staff, and the teaching assistant. From a motivational interviewing perspective, which response would BEST encourage a more internal locus of control?

Domain: Professional Practice and Ethics

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

Domain: Counseling Skills and Interventions

The client states, “How would he know I need help with school? He had to have seen this notice I got about almost failing. No one in this world is willing to give me privacy, and I’m getting sick of it!”

Which response BEST demonstrates a reflection of content?

Part One

Intake

Client

Age: 11

Sex Assigned at Birth: Male

Gender Identity: Cisgender Male

Pronouns: He/him

Sexual Orientation: Heterosexual

Race/Ethnicity: Asian American

Relationship Status: Single

Setting: Community Clinic

Type of Counseling: Individual

Provisional Diagnosis: Specific Phobia (Animal Type – Dogs)

Presenting Problem: Client is an 11-year-old Asian American male brought to counseling by his mother due to concerns regarding increasing social withdrawal and oppositional behavior. During the intake session, the client appears shy and frequently allows his mother to answer questions for him. His mother reports that over the past six months he has become increasingly resistant to leaving the house and often argues with family members when asked to participate in neighborhood activities. She notes that he frequently refuses invitations to play with friends and appears distressed when family activities involve spending time outdoors. His mother states that these behaviors are very different from how he behaved previously and asks for help understanding what has changed.

History of Condition: Upon further exploration, the client's mother recalls an incident approximately eight months ago when the client was walking home from a friend's house. A large dog escaped from a fenced yard and ran toward him barking loudly. Although the dog never bit him, it knocked him to the ground and scratched his arm while jumping on him. Several adults intervened and pulled the dog away. The client sustained only minor injuries, but afterward became fearful of walking near dogs.

Initially, the family assumed the fear would fade with time. Instead, the client began crossing streets to avoid dogs, refusing to walk past houses where dogs lived, and asking his parents for reassurance whenever he heard barking. Over time, his fear generalized to nearly all dogs regardless of size, breed, or whether they were restrained. He now avoids parks, neighborhood gatherings, sporting events, and other situations where dogs might be present. The client acknowledges that he knows many dogs are friendly, but states that he feels unable to control his fear when he sees one.

Family History: Client was born in Korea and immigrated to the United States with his parents when he was two years old. He currently lives with both parents and his 8-year-old sister in a suburban neighborhood. The family generally describes their relationships as close and supportive. Client's father experiences occasional anxiety during periods of work-related stress. No additional significant family mental health history is reported.

Academic History: Client has historically performed well academically. He currently maintains an A average and is described by teachers as polite, conscientious, and highly motivated. His favorite subjects are math and science, and he hopes to become an engineer one day.

Health History:

When the client was two months old, he was diagnosed with Tubular Renal Acidosis, a kidney disorder that temporarily affected his growth and required frequent medical monitoring during infancy. Following successful treatment, his health stabilized and he was discharged from specialty care by age two and a half. Other than this early medical issue, his developmental history is unremarkable.

Domain: Counseling Skills and Interventions

Based on the information revealed during the intake session, which response would be MOST consistent with a Solution-Focused Brief Therapy (SFBT) approach?

Domain: Professional Practice and Ethics

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

Domain: Intake, Assessment, and Diagnosis

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

Domain: Intake, Assessment, and Diagnosis

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

Domain: Counseling Skills and Interventions

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

Part Two

First session, three weeks after the intake session

The client arrives on time for his follow-up session accompanied by his mother. She immediately begins discussing a recent family camping trip. She reports that although the client was excited while preparing for the trip, his mood changed dramatically upon arrival at the campsite. According to his mother, several nearby families had dogs with them. The client refused to leave the vehicle and remained inside for several hours despite repeated encouragement from his parents. He eventually exited the car after dark when most of the campers and dogs had returned to their cabins.

For the remainder of the weekend, the client spent most of his time indoors reading books, playing handheld video games, and avoiding common areas where dogs might be present. His mother expresses frustration and concern because she believes the fear is beginning to interfere with normal family activities.

You spend the first portion of the session alone with the client building rapport. He enthusiastically discusses his favorite books, anime series, and action movies. You ask him which characters he identifies with and which characteristics he admires. He enjoys describing brave and intelligent characters who overcome difficult challenges. You invite him to draw several of these characters and write words that describe them. He appears proud of his artwork and states that he wants to hang the drawings in his bedroom.

Later in the session, you transition back to discussing the camping trip. The client acknowledges that he spent most of the weekend avoiding situations where he might encounter dogs. He explains that whenever he sees a dog, even from a distance, his heart races and his stomach feels sick. He states that he immediately begins looking for ways to escape. You ask what he imagines might happen if he stayed near a dog. After a long pause, he replies, “I know it sounds dumb, but I always think they're going to run at me again.”

You normalize his reaction and provide age-appropriate psychoeducation about fear responses. Together, you begin discussing how fears sometimes grow stronger when people repeatedly avoid the things that scare them. As the session concludes, the client agrees to invite his mother back into the room so that the three of you can begin discussing ways to help him gradually face situations involving dogs.

Domain: Treatment Planning

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

Domain: Counseling Skills and Interventions

At what point in therapy would a counselor be MOST likely to utilize the pie technique?

Domain: Counseling Skills and Interventions

Which intervention would MOST directly address the client's Specific Phobia (Animal Type)?

Domain: Counseling Skills and Interventions

Which intervention would BEST help the client understand the relationship between his fear and these reactions?

Domain: Counseling Skills and Interventions

Which response BEST demonstrates empathic attunement?

Domain: Counseling Skills and Interventions

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

Domain: Counseling Skills and Interventions

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

Domain: Intake, Assessment, and Diagnosis

Based on the information gathered throughout treatment, how would you rate the severity of the client's Specific Phobia (Animal Type)?

Part One

Intake

Client

Age: 44

Sex Assigned at Birth: Female

Gender Identity: Cisgender Female

Pronouns: She/her

Sexual Orientation: Heterosexual

Race/Ethnicity: White

Relationship Status: Married

Setting: Agency

Type of Counseling: Individual

Provisional Diagnosis: Somatic Symptom Disorder

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

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

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

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

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

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

Domain: Intake, Assessment, and Diagnosis

You would like to obtain a broad screening of symptoms across multiple DSM-5 domains in order to identify areas that may warrant further assessment. Which assessment would be MOST appropriate?

Domain: Treatment Planning

Given the client's diagnosis of Somatic Symptom Disorder and her extensive preoccupation with physical symptoms, which of the following would be the MOST appropriate long-term therapeutic goal?

Domain: Intake, Assessment, and Diagnosis

Which detail from the client's history MOST strongly supports the diagnosis of Somatic Symptom Disorder?

Domain: Professional Practice and Ethics

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

Domain: Counseling Skills and Interventions

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

Part Two

First session, two weeks after the initial intake

The client comes to session with a list of questions she has for you about treatment. She expresses frustration that doctors have come to the conclusion that her pain is just a “mind game,” and wonders how you can help. You help the client set goals for your time together. You discuss her diagnosis and normalize her experience, as well as answer additional questions she has. You begin to make a timeline of events with her and discuss significant life events. As she discusses her miscarriages and her daughter leaving for college, she repeatedly insists that these events no longer affect her. However, she becomes visibly tearful each time the topics arise and quickly redirects the conversation back to her physical symptoms. She states that her daughter has not disclosed any information about potential college romances, and she admittedly feels nervous that her daughter will soon experience her first heartbreak, as the client did in college. She tells you that she had numerous conversations with her daughter from the time she was sixteen about not jumping into relationships too quickly because the other person might not be as invested as one thinks. She compares her marriage to that past relationship, and states that she is glad the two broke it off in college because she is in a better place, and her house is bigger than her ex’s house anyways. She talks about the freedoms of being a stay at home mom, and expresses gratitude for her husband’s success. She abruptly asks for a copy of her treatment plan so she can add it to the accordion folder she is carrying with her other medical files. You explain that the treatment plan will be finalized next session and you can print it out for her then. You build rapport with the client by asking follow up questions and providing unconditional positive regard.

Domain: Counseling Skills and Interventions

Regarding the client’s reaction to discussing her miscarriages and her daughter leaving for college found in Part Two, from a cognitive-behavioral perspective, which response would BEST inspire the client toward change?

Domain: Treatment Planning

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

Domain: Counseling Skills and Interventions

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

Domain: Core Counseling Attributes

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

Part Three

Second session, three weeks after the initial intake

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

Domain: Professional Practice and Ethics

You would like to monitor the quality of the therapeutic relationship and identify any concerns that could interfere with treatment.

Which question would be MOST appropriate?

Domain: Assessment and Diagnosis

You elect to construct a genogram with this client.

What information would you MOST hope to gain from this intervention?

Domain: Counseling Skills and Interventions

The client states, “It's strange. For the first time in a long time, I forgot about my pain while we were talking about baking.” You recognize an opportunity to help the client examine the belief that her pain completely controls her life. Which response would be MOST appropriate from a cognitive-behavioral perspective?

Domain: Counseling Skills and Interventions

You also provide substance abuse counseling for your agency. Which of the following pairs of factors has historically posed the greatest challenge to successful substance abuse treatment outcomes?

Part One

Intake

Client

Age: 15

Sex Assigned at Birth: Male

Gender Identity: Cisgender Male

Pronouns: He/him

Sexual Orientation: Heterosexual

Race/Ethnicity: African American

Relationship Status: Single

Setting: School clinic

Type of Counseling: Individual

Provisional Diagnosis: Oppositional Defiant Disorder

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

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

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

Legal History: Last summer, the client's aunt enrolled him in a local juvenile diversion program after several incidents involving shoplifting allegations and disorderly conduct in the neighborhood. As part of the program, he was required to attend meetings with probation officers, community volunteers, and local law enforcement personnel. The client completed the program requirements but reports that he did not find the experience helpful.

When discussing the program, he states, “Everybody kept acting like they wanted to help me, but nobody actually cared what I had to say. They already decided who I was before I walked through the door.” He recalls one probation officer praising him for attending all of the required meetings. The client responded by shrugging and telling the officer it didn't matter because nobody expected him to do anything good anyway. The client goes on to say, “Adults always talk about giving people chances, but they don't really mean it. Once people think you're trouble, that's all they see.” When asked how he felt after completing the program, he responds, “What's the point? They'll just be waiting for me to mess up again.”

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

Domain: Professional Practice and Ethics

You begin reviewing informed consent with the client and his aunt. Which of the following statements is NOT consistent with current ethical guidelines regarding informed consent?

Domain: Intake, Assessment, and Diagnosis

Based on the information revealed in Part One, which detail MOST directly reflects a core symptom of Oppositional Defiant Disorder?

Domain: Counseling Skills and Interventions

Based on the client’s statements in the Legal History section of Part One, which response BEST demonstrates a reflection of meaning?

Domain: Counseling Skills and Interventions

From a Motivational Interviewing perspective, how could you use shifting focus to help the client explore his role in the situations he describes?

Domain: Intake, Assessment, and Diagnosis

You would like to obtain a more comprehensive assessment of the client's behavioral, emotional, and social functioning across multiple settings. Which assessment instrument would be MOST appropriate?

Part Two

First session, one week after the initial intake session

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

Domain: Counseling Skills and Interventions

Based on the Part Two narrative, which question would be MOST effective for continuing to build rapport at this stage of the counseling relationship?

Domain: Counseling Skills and Interventions

Which intervention would be MOST appropriate for addressing the client's symptoms of Oppositional Defiant Disorder?

Domain: Core Counseling Attributes

A counseling student asks a supervisor how to remain open and accepting when working with clients whose values and life choices differ significantly from their own. The supervisor replies:

"Your goal is to understand the client's perspective without evaluating it as right or wrong. Listen with curiosity and seek to understand how the client experiences the situation before deciding what interventions might be helpful."

Which counseling skill is BEST illustrated by the supervisor's response?

Domain: Treatment Planning

You help the client distinguish between factors that are within his control and factors that are outside of his control. You then assist him in selecting a small behavioral goal for the upcoming week.

What is the PRIMARY insight you hope the client gains from this exercise?

Part Three

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

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

Domain: Treatment Planning

The counselor helps the client sort concerns into two categories: factors he can control and factors he cannot control. What treatment-planning objective is this intervention most directly intended to support?

Domain: Counseling Skills and Interventions

What are the four processes of Motivational Interviewing?

Domain: Intake, Assessment, and Diagnosis

You become concerned that a client may be at risk for suicide and want to conduct an initial assessment of safety.

Which of the following would be MOST appropriate?

Domain: Treatment Planning

As treatment progresses, the client begins consistently completing homework assignments, demonstrates fewer conflicts with authority figures, and follows through on goals he has established for himself. You begin thinking about eventual termination.

Which factor would provide the STRONGEST indication that the client is approaching readiness for termination?

Part One

Intake

Client

Age: 73

Sex Assigned at Birth: Male

Gender Identity: Cisgender Male

Pronouns: He/him

Sexual Orientation: Heterosexual

Race/Ethnicity: African American

Relationship Status: Widowed

Setting: Agency

Type of Counseling: Individual

Provisional Diagnosis: Major Neurocognitive Disorder due to Traumatic Brain Injury

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

Mental Status Exam: Client presents to your initial evaluation in jeans and a sweatshirt, although it is 80 degrees outside. Client selects a seat by the window and expresses, “I like to listen to the birds chirping daily. I’ll just sit here. During the interview, the client repeatedly asks questions that had already been answered earlier in the session. At one point, after discussing counseling goals for several minutes, he pauses and asks, "Wait, did my daughter bring me here today, or did I drive myself?" Later, he asks you to reintroduce yourself because he cannot remember your name despite having been told several times. After you explain your role at the mental health agency, client becomes agitated and expresses that he does not need counseling, “I’ll just go home to my house! I don’t need this crap!” Client does not recall his recent hospitalization and only complains to you of headaches. He denies all symptoms, but after reviewing the hospital reports and conducing your evaluation you observe symptoms of disorientation, difficulty concentrating, short-term memory loss, and difficulty performing daily tasks. According to client’s son, client will leave piles of newspapers on the front stoop for weeks, forgets to turn the stove off, and will leave the sink running for hours.

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

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

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

Domain: Intake, Assessment, and Diagnosis

During the intake interview, a client reports drinking alcohol daily but minimizes the impact it may be having on his life. You would like to administer a brief, four-question screening instrument designed specifically to identify potential alcohol-related problems. Which assessment instrument would be MOST appropriate?

Domain: Intake, Assessment, and Diagnosis

Which piece of information from the intake evaluation provides the strongest evidence supporting the diagnosis of Major Neurocognitive Disorder due to Traumatic Brain Injury?

Domain: Professional Practice and Ethics

You receive a subpoena requesting records related to a former client.

What is the MOST appropriate initial response?

Domain: Counseling Skills and Interventions

From a logotherapy perspective, which statement would BEST help engage this client?

Domain: Intake, Assessment, and Diagnosis

Genograms provide information regarding all but which of the following:

Part Two

First session, two weeks after intake

Client presents to your second session on time after his son brought him in from the assisted living facility. Client appears with flat affect and does not recall the details of your first session. Client has now been sober for three weeks since his hospitalization and you observe slight tremors in his hands. As the session progresses, the client begins discussing his late wife in greater detail. He describes driving her to chemotherapy appointments and helping her with daily tasks when she became too weak to care for herself independently. At one point he laughs and says, “I used to complain about all those appointments, but now I'd give anything to have one more day of taking care of her.”

The statement affects you more than you expect. Several years ago, you served as the primary caregiver for a close family member who died from cancer. As the client continues talking, you notice yourself thinking about your own loss and feeling a strong urge to focus the session on his grief rather than the cognitive and safety concerns that led to his referral. You also find yourself feeling unusually protective of the client and frustrated with his son for pursuing placement in a group home.

You utilize empathetic listening and provide psychoeducation regarding Major Neurocognitive Disorder due to a TBI to support client in understanding his condition. You explore that symptoms may improve with continued abstinence of alcohol intake. He asks if you could call his son in from the waiting room to discuss this information with him because he is having trouble understanding you, and remains visibly upset due to previous topics of conversation. When you walk out to the waiting room, his son is nowhere to be found, so you ask the security guard if he could keep an eye out for him and send him to your office as soon as possible. You go back into your office alone, and find your client staring out the window. He asks you where you went, and just as you were about to answer, his son walks into the room. Your client stands up and says, “Well, it looks like it’s time to go.” You make an arrangement to speak with his son over the phone at a later time to discuss your client’s diagnosis and information that can help the family members who are in a care-taking role. Your client’s son thanks you for your care.

Domain: Intake, Assessment, and Diagnosis

Which concept is BEST illustrated by the counselor's reaction during this session as reported in Part Two?

Domain: Treatment Planning

Research consistently suggests that which factor has the strongest influence on whether clients remain engaged in counseling and follow through with treatment recommendations?

Domain: Treatment Planning

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

Domain: Counseling Skills and Interventions

The client becomes tearful while discussing his late wife and the years he spent caring for her during her cancer treatment. Which response BEST demonstrates empathic attunement?

Part Three

Second session, three weeks after first session

Client arrives approximately ten minutes early for his appointment and is sitting quietly in the waiting room when you greet him. As usual, he asks you to remind him of your name and role at the agency before entering your office. Once seated, he reports that he continues to experience frequent headaches and remains frustrated by his current living situation. He repeatedly asks when he will be able to return home and appears disappointed when you explain that no discharge date has been determined.

As you discuss the possibility of a group home, the client becomes increasingly frustrated. He tells you that he has lived in the same neighborhood for more than forty years and that his church community has been a major part of his life. He explains that several church members checked on him regularly after his wife died and that many of them still call him each week. He worries that moving to a group home will mean losing contact with his church family and the community where he feels known and respected. He states, “People there know who I am. I don't want to just be some old man sitting in a building somewhere.”

You explore these concerns further and learn that the client served as an usher at his church for more than twenty years. He proudly describes helping new members find seats and making sure elderly congregants made it safely into the building. As he discusses these memories, his posture becomes more upright and he smiles for the first time during the session. You reflect that his church appears to have provided him with not only social support, but also a sense of purpose and identity.

The conversation shifts back to treatment planning. You discuss ways he might remain connected to his church community regardless of where he ultimately resides. The client expresses interest in having church members visit him and wonders whether transportation could be arranged so that he could occasionally attend services. You encourage him to discuss these ideas with his case manager and family members.

Toward the end of the session, the client again asks when he will be able to return home. He expresses confusion about why his son is selling the house and states that no one has explained what his living situation will look like six months from now. He asks whether he will be allowed to attend church, who will manage his finances, and whether he will be able to keep personal belongings that remind him of his wife. You explain that many of these questions involve housing, benefits, long-term planning, and community resources. With the client's permission, you offer to coordinate a meeting with his case manager so that these concerns can be addressed in greater detail.

Domain: Core Counseling Attributes

As you continue treatment planning with this client, which cultural consideration would be MOST important to explore based on the Part Three narrative?

Domain: Counseling Skills and Interventions

The client states, “People there know who I am. I don't want to just be some old man sitting in a building somewhere.” Which response BEST reflects the meaning underlying the client's statement?

Domain: Professional Practice and Ethics

Based on the information disclosed in Part Three, what is the PRIMARY benefit of collaborating with the client's case manager in this situation?

Domain: Counseling Skills and Interventions

From a covert conditioning perspective, the tendency to use internal self-statements to reward or punish one's own behavior is most accurately described as: