Part One

Client

Age: 56

Sex Assigned at Birth: Female

Gender Identity: Female

Pronouns: She/her

Sexual Orientation: Heterosexual

Race/Ethnicity: African American

Relationship Status: Single

Setting: Agency

Type of Counseling: Individual

Provisional Diagnosis: Bipolar II Disorder

Presenting Problem: You are a mental health counselor working in private practice. A 56-year-old single, black female presents to your office as a self-referral. She reports feeling depressed for the past two weeks, and she is seeking counseling to better understand her moods. She describes her depression as feeling like a heavy weight on her chest. She states she’s having a hard time focusing at work, and she’s not interested in anything other than sleeping. When asked, she states she has felt this way on and off since her mid-twenties. She becomes tearful and states, “I just feel so worthless, sometimes I think I’d rather be dead than deal with these moods.” She tells you she worries that her symptoms might cause her to lose her job, and she finally decided to seek counseling after her boss approached her with concern over her work performance. The client reports that her depressive episodes are often accompanied by a persistent sense of dread. During the current episode, she finds herself repeatedly worrying that she will lose her job, become unable to support herself, and end up alone. She states that she spends much of the day anticipating something bad happening, even when there is no evidence that a problem exists. She describes herself as feeling "keyed up" and reports difficulty sitting still during meetings because of nervous tension. When asked whether anything positive improves her mood, she states, "A little. Lunch with my sister helps for a while."

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

Work History: Client works as an executive at a marketing firm, where she has been employed for 20 years. She is a valued member of the team, though she has been put on disciplinary notice multiple times over the course of her career. Her boss reports that client has a pattern of missing deadlines and calling in sick, but she “always makes up for it” by increasing her productivity afterwards. Client’s co-workers have expressed frustration over her unreliability and inconsistent work performance. When discussing her periods of increased productivity, the client laughs and says, “It's funny because everyone worries about me when I'm depressed, but they never complain when I'm on a roll.” She reports that several times per year she goes through periods lasting four to six days during which she sleeps only three or four hours per night, feels unusually confident, talks more than usual, and takes on multiple projects at work simultaneously. During these periods she feels "unstoppable," spends money impulsively, and frequently begins new romantic relationships. She denies ever being hospitalized for her mood symptoms and states that these periods have never caused severe impairment.

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

Domain: Intake, Assessment, and Diagnosis

Which detail from Part One provides the strongest support for a diagnosis of Bipolar II Disorder rather than Major Depressive Disorder?

Domain: Intake, Assessment, and Diagnosis

Based on the information presented in Part One, which DSM-5 specifier would be MOST appropriate to consider for this client's Bipolar II Disorder?

Domain: Intake, Assessment, and Diagnosis

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

Domain: Counseling Skills and Interventions

Regarding the client’s ‘tearful’ statement from the Presenting Problem section, which response BEST demonstrates a reflection of meaning?

Domain: Professional Practice and Ethics

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

Part Two

The client returns to counseling reporting that her mood has remained low throughout most of the week. She states that she has continued to worry about her job performance and frequently finds herself imagining worst-case scenarios. "If I miss one more deadline, they're probably going to fire me," she says. When asked what evidence supports this belief, she acknowledges that her supervisor recently expressed concern but has not discussed termination. She then adds, "I know you're probably sitting there thinking I'm a terrible employee too."

You ask the client what leads her to believe that. She shrugs and says, "I don't know. When people hear about my moods, they usually end up disappointed in me eventually."

You explore the connection between the client's thoughts, emotions, and behaviors. Together, you identify a recent situation at work in which she assumed her supervisor was upset with her. You write down the situation, the automatic thoughts that occurred, the emotions she experienced, evidence supporting and contradicting her assumptions, and a more balanced alternative thought. As the discussion progresses, the client acknowledges that she often treats her fears as facts before examining the available evidence.

Before ending the session, you assign the client a homework exercise. You ask her to complete a similar worksheet to the one you just completed together each time she notices a significant shift in mood or catches herself predicting a negative outcome. You explain that the goal is not to force positive thinking, but rather to slow down and evaluate whether her conclusions are supported by the available evidence.

As the session concludes, the client says, "You know, you're a lot more patient with me than most people. I keep waiting for you to get frustrated and tell me to get my act together." You thank her for sharing that observation and invite her to say more about what she expects from people when they learn about her struggles.

Domain: Counseling Skills and Interventions

Which Cognitive Behavioral Therapy technique did you primarily utilize during this session?

Domain: Counseling Skills and Interventions

What would you MOST hope the client learns from the homework assigned in Part Two?

Domain: Counseling Skills and Interventions

The client's statement near the end of the session is a classic example of:

Domain: Counseling Skills and Interventions

Which intervention would be MOST appropriate for helping this client manage Bipolar II Disorder?

Part Three

Second session, six weeks after the intake session

Client arrives on time for session with continued low affect. She states that her sister has been supportive by calling to check on her often. She reports feeling guilty for being “such a burden.” Client pauses and says, "My sister probably thinks I'm selfish. Honestly, if I were her, I'd probably be tired of me by now." When asked whether her sister has ever said that, client replies, "No, but I can tell." You acknowledge that client’s sister seems to care deeply for her, and you ask client for evidence that she is being a burden. Client concedes that her sister has never told her she is a burden, and she has always been willing to help when the client is feeling down. Given this, you ask her to consider whether her feeling of guilt is appropriate, and client replies, “No, I guess not.” You ask her to reframe her original thought to something that more closely fits the facts, and she is receptive. She tells you that she has a habit of throwing her sister to the wayside when she gets into a new relationship, and although the two see each other every day at work, she has a habit of skipping lunch to keep up with the conversation with her partners via text and private message. He sister has expressed her sadness in the past, but your client states that there are certain times when it doesn’t mean much to her, and other times when she feels bad for doing that. She has plans to eat dinner at her sister’s apartment after the session, and makes a comment about bringing up this comment to once again apologize to her. She also says the two have plans to travel to Florida next month to see one of her brother’s performances, and she is thinking about disabling her dating apps for the duration of the trip. Client mentions that she will be helping her sister move into a new house next week.

Domain: Counseling Skills and Interventions

From a Positive Psychology perspective, which response would BEST help the client recognize an existing strength within her support system?

Domain: Counseling Skills and Interventions

The client states, “My sister probably thinks I'm selfish. Honestly, if I were her, I'd probably be tired of me by now.”

Which cognitive distortion is MOST evident in the client's statement?

Domain: Counseling Skills and Interventions

From a CBT perspective, why would you ask the client for evidence that she is being a burden to her sister?

Domain: Counseling Skills and Interventions

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

Part One

Client

Age: 16

Sex Assigned at Birth: Male

Gender Identity: Male

Pronouns: He/him

Sexual Orientation: Heterosexual

Race/Ethnicity: Latino American

Relationship Status: Single

Setting: School clinic

Type of Counseling: Individual

Provisional Diagnosis: Adjustment Disorder (With disturbance of conduct)

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

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

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

Living Situation: The client lives with both of his parents and three younger siblings. The parents told the family they would be getting a divorce five weeks ago, and the client was completely caught off guard because he thought the parents had a decent relationship. When discussing the divorce, the client states, "Nobody asked for my opinion. Everyone keeps telling me what's happening, but nobody seems to care how this affects me." After that conversation, once the younger siblings had gone to bed, they explained to him that the reason for the divorce is because his dad was unfaithful to his mom. The client states that, although the parents are getting divorced, both of them are still living in the home due to financial reasons. The client states that he feels uncomfortable at home, especially since he has to keep a secret from his younger siblings.

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

Domain: Intake, Assessment, and Diagnosis

Although Adjustment Disorder with disturbance of conduct is the most appropriate diagnosis, which additional diagnosis should be carefully ruled out given the client's recent behaviors?

Domain: Counseling Skills and Interventions

The client states, “Nobody asked for my opinion. Everyone keeps telling me what's happening, but nobody seems to care how this affects me.”

From a Reality Therapy perspective, which response would BEST help build therapeutic alliance?

Domain: Counseling Skills and Interventions

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

Domain: Professional Practice and Ethics

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

Domain: Intake, Assessment, and Diagnosis

You elect to utilize the Cultural Formulation Interview (CFI) to better understand the client's experience.

Which question would be MOST consistent with the goals of the Cultural Formulation Interview?

Part Two

First session, one week after the initial intake session

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

Domain: Intake, Assessment, and Diagnosis

The counselor decides to complete a genogram with the client. What would be the PRIMARY purpose of this intervention?

Domain: Counseling Skills and Interventions

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

Domain: Treatment Planning

When developing a treatment plan for this client, which factor should MOST influence the selection of counseling goals?

Domain: Counseling Skills and Interventions

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

Part Three

Second session, two weeks after the initial intake session

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

Domain: Professional Practice and Ethics

Which of the following statements regarding informed consent is LEAST accurate?

Domain: Treatment Planning

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

Domain: Treatment Planning

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

Domain: Professional Practice and Ethics

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

Part One

Client

Age: 42

Sex Assigned at Birth: Male

Gender Identity: Male

Pronouns: He/him

Sexual Orientation: Heterosexual

Race/Ethnicity: Asian American

Relationship Status: Single

Setting: Private Practice

Type of Counseling: Individual

Provisional Diagnosis: Agoraphobia

Presenting Problem: You are a therapist in private practice and receive a referral from a colleague for a 42-year-old, Heterosexual, single, Asian American, male. Your colleague informs you that the client is experiencing “severe anxiety in elevators” and that they do not have appropriate training to treat his presenting condition. During your initial evaluation, you learn that the client is the Marketing Advisor for a social media firm and works on the 11th floor of a large office building. Due to an intense fear of elevators, client stated that he takes the stairs daily to his office and is often late for important meetings. Upon further inquiry, client shared, “it’s not just elevators that I won’t go in. I will not take the bus or train because they get overly crowded and I feel like I can’t move or breathe.” Client reported that when he has been “forced” to use public transport or elevators in the past, he begins shaking uncontrollably with intense chest pain and a racing heart. Client endorsed, “I have a few close friends that want me to meet them in the city for drinks after work, but I won’t do it. It’s really starting to cause a strain in my friendships.” As the client discusses turning down invitations from friends, he becomes visibly emotional. Looking down at the floor, he says, "The worst part is that people think I'm just making excuses. They don't understand how trapped I feel. Sometimes I watch my friends having fun without me and wonder if this is just going to be the rest of my life."

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

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

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

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

Domain: Professional Practice and Ethics

The client expresses concern that coworkers, friends, or family members may discover what he discusses in counseling. You review the confidentiality provisions that were discussed during informed consent and explain the circumstances under which information may and may not be disclosed.

What is the PRIMARY ethical purpose of this discussion?

Domain: Intake, Assessment, and Diagnosis

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

Domain: Counseling Skills and Interventions

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

Domain: Counseling Skills and Interventions

The client states, “The worst part is that people think I'm just making excuses. They don't understand how trapped I feel. Sometimes I watch my friends having fun without me and wonder if this is just going to be the rest of my life.”

Which response BEST demonstrates empathic attunement?

Domain: Counseling Skills and Interventions

As counseling progresses, you become curious about whether cultural factors may influence the client's experience of anxiety and help-seeking behaviors.

Which of the following would be the MOST culturally responsive approach?

Part Two

Client presents to session a few minutes late in appropriate attire. He reports that he recently began working remotely due to the COVID-19 pandemic and admits that part of him feels relieved. "For the first time in years, I don't have to think about elevators or public transportation every day," he says. He continues to fidget with his pen and frequently glances at the clock. Initially, he appears hesitant to engage in treatment and questions whether now is the right time to work on his anxiety.

Using supportive reflection and summarizing, you explore the pros and cons of postponing treatment. The client acknowledges that working from home has reduced his anxiety, but he also worries that avoiding elevators and public transportation for an extended period may make his fears worse. "Eventually I'm going to have to go back to the office," he says. "I'd rather start working on this now than wait until it's a crisis."

You discuss treatment expectations and begin developing a hierarchy of feared situations. The client reports that he can tolerate standing inside an elevator for approximately 30 seconds if the doors remain open. He states that riding a crowded train would be nearly impossible at this point. He also reports feeling somewhat more comfortable in vehicles when he is driving rather than riding as a passenger. Together, you identify several situations that produce mild, moderate, and severe anxiety.

Before ending the session, you discuss the role of gradual exposure in treatment. The client agrees that his long-term goal is to ride elevators and public transportation without significantly disrupting his work, friendships, and daily life. He expresses willingness to begin with smaller steps before attempting more challenging situations.

Domain: Treatment Planning

Based on the information presented in Part Two, what would be the MOST appropriate short-term treatment goal?

Domain: Intake, Assessment, and Diagnosis

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

Domain: Counseling Skills and Interventions

At the beginning of the session, the client expresses relief that working remotely allows him to avoid elevators and public transportation. He also questions whether now is the right time to address his anxiety. Later, he acknowledges that continued avoidance may worsen his fears and agrees to begin exposure-based treatment.

The client's initial presentation is BEST described as:

Domain: Core Counseling Attributes

A counselor tells a client, “You can tell me anything, and I won’t think any less of you.”

What is the PRIMARY purpose of this statement?

Part Three

Second session, three weeks after first session

During your previous session, client made progress in practicing deep breathing techniques when he begins to feel his chest pounding and palms sweaty. He demonstrates this skill to you today and throughout the session as he becomes anxious when processing his fear of returning to work and seeing his friends again. Client reflected, “After work I’ll just play video games and lose track of time. It makes me forget about the isolation.” As you explored in the previous session, client noted that he walked to the bus station and only began to feel anxious when he saw passengers get off. You ask what made him nervous about the people getting off. He talked about the different individuals he saw riding the bus. There was a mother who was holding both of her toddler’s hands as she walked behind him. She allowed him to feel like he was walking independently. Your client states that he thought this was sweet, and nothing to feel nervous about. He then discussed an older couple he saw who was dressed in very nice clothes and how he wondered where they were headed dressed up so nice. Then, he noticed a male nurse get off the bus. “Everyone is just headed somewhere. The bus is like a little representation of the whole world all wrapped up into a neat package. I’m always thinking about marketing, you know. Everyone has their own opinions, style, and preferences. There’s just a lot of information there inside a bus. It’s a lot to take in.” After describing the people getting off the bus, the client pauses and says, "I guess what bothers me is that everyone else seems to know where they're going. They just get on and off without thinking about it. Meanwhile, I spend all my energy worrying about whether I can handle it." He endorsed that he used to get anxious by simply the thought of public transportation and noted this is gradually improving. He then laughed and shared, “Oh, but don’t think I’m even close to ready to work on elevators yet. Or crowds. I’m not there yet.” You highlighted client’s progress and scheduled a session for next week.

Domain: Counseling Skills and Interventions

A counselor plans to use systematic desensitization to help a client reduce anxiety associated with a specific phobia. Before beginning gradual exposure to items on the anxiety hierarchy, what should the counselor do FIRST?

Domain: Counseling Skills and Interventions

After describing the people he observed at the bus station, the client states, “Everyone else seems to know where they're going. They just get on and off without thinking about it. Meanwhile, I spend all my energy worrying about whether I can handle it.”

Which response BEST reflects the client's feelings?

Domain: Intake, Assessment, and Diagnosis

The term Psychasthenia is associated with which assessment instrument?

Domain: Intake, Assessment, and Diagnosis

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

Part One

Client

Age: 26

Sex Assigned at Birth: Female

Gender Identity: Female

Pronouns: She/her

Sexual Orientation: Heterosexual

Race/Ethnicity: Asian American

Relationship Status: Single

Setting: Agency

Type of Counseling: Individual

Provisional Diagnosis: Generalized Anxiety Disorder

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

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

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

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

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

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

Domain: Intake, Assessment, and Diagnosis

Which of the following symptoms is NOT included among the DSM-5 diagnostic criteria for Generalized Anxiety Disorder?

Domain: Counseling Skills and Interventions

During the intake, you notice that the client becomes visibly irritated whenever questions focus on her background or family relationships.

Which response would be MOST appropriate at this stage of counseling?

Domain: Professional Practice and Ethics

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

Domain: Counseling Skills and Interventions

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

Domain: Counseling Skills and Interventions

You elect to utilize Cognitive-Behavioral Therapy (CBT) to help address the client's chronic worry, fear of being judged by others, and avoidance of job applications and public situations.

Which of the following is NOT commonly associated with Cognitive-Behavioral Therapy?

Part Two

First session one week after initial intake:

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

Domain: Treatment Planning

Which of the following would be the MOST appropriate long-term treatment goal for a client diagnosed with Generalized Anxiety Disorder?

Domain: Counseling Skills and Interventions

Regarding the client’s reluctance to try the worry coping cards, which response would BEST develop discrepancy and move the client toward change?

Domain: Core Counseling Attributes

What insight would you MOST hope the client gains from this homework assignment?

Domain: Counseling Skills and Interventions

Your client recently applied for three jobs and was invited to interview with two of them. When you point out that receiving interview invitations from most of the positions she applied for is a positive outcome, she responds, “That doesn't count. I'm sure they only called me because no one else applied.”

Which cognitive distortion is MOST evident in the client's response?

Part Three

Second session three weeks after initial intake:

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

Domain: Professional Practice and Ethics

During treatment, you become aware that your own racial biases and stereotypes are negatively influencing your reactions to the client. You notice increasing frustration when she reports that she did not complete her therapy homework assignments. What is the MOST appropriate course of action?

Domain: Professional Practice and Ethics

What is the MOST appropriate response?

Domain: Core Counseling Attributes

When the client states, "I felt like everyone was staring at me on the bus today," which response BEST demonstrates a nonjudgmental stance?

Domain: Counseling Skills and Interventions

During the session, the client reports that she completed the homework assignment and noticed a recurring pattern. Whenever she rode the bus, entered a store, or thought about applying for a job, she frequently had thoughts such as, "Everyone is looking at me," "They're judging me," or "Something bad is going to happen." She states, "I never realized how often I think those things."

Based on the client’s report, what would be the MOST appropriate next step?

Part One

Client

Age: 14

Sex Assigned at Birth: Male

Gender Identity: Male

Pronouns: He/him

Sexual Orientation: Heterosexual

Race/Ethnicity: White

Relationship Status: Single

Setting: Agency

Type of Counseling: Individual

Provisional Diagnosis: ADHD

Presenting Problem: You are a counselor working in private practice and specializing in child and adolescent mental health. A 14-year-old White male presents to your office upon referral from his high school counselor. He arrives 10 minutes late, explaining he rode his bike and didn’t consider the distance to your office. He reports feeling sad and worthless after his girlfriend of 2 months dumped him. When you ask for additional details, he doesn’t seem to hear you. He stands up to examine a painting of a sunflower field hanging on your wall. The client comments that he enjoys the calming atmosphere of your office. When you return to the subject of his break-up, he laments that he can’t seem to do anything right. He reports other people, including his ex-girlfriend, call him unreliable and selfish. He worries about being perceived this way and asks for your help. The client becomes quiet for a moment and looks down at the floor. "The thing is, I really did care about her," he says. "I know I forgot stuff and got distracted, but I wasn't trying to be selfish. I keep replaying everything she said and wondering if maybe everybody sees me that way. Sometimes it feels like no matter how hard I try, I just disappoint people." He shrugs and adds, "I don't know... maybe there's just something wrong with me."

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

Family History: The client lives with both parents and a younger sister. His parents describe him as a bright and caring child who has always struggled with organization and follow-through. Beginning in elementary school, teachers frequently reported that he would forget assignments, lose materials, and appear to be daydreaming during class. Parent-teacher conferences often focused on his inconsistent performance, with teachers commenting that he seemed capable of doing much better than his grades reflected.

The client's parents also recall that he was constantly in motion as a child. He frequently left his seat during meals, interrupted conversations, and had difficulty waiting his turn during games and family activities. His mother remembers receiving notes from teachers about excessive talking and blurting out answers before being called on. Although these behaviors have improved somewhat with age, the client continues to interrupt others unintentionally and often finishes people's sentences before they are done speaking.

The family reports frequent conflict surrounding chores and responsibilities. The client often begins tasks but becomes distracted and moves on to something else before finishing. His father states, "It's not that he refuses to help. He just gets sidetracked and forgets what he was supposed to be doing." The client acknowledges that he becomes frustrated when people assume he is being lazy or irresponsible, explaining that he often intends to complete tasks but loses track of time or becomes distracted by something else.

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

Domain: Core Counseling Attributes

Regarding the client’s statements about his break-up found in Part One, which response BEST demonstrates empathic attunement?

Domain: Intake, Assessment, and Diagnosis

During the mental status examination, which present focused statement would MOST strongly support the diagnosis of ADHD?

Domain: Intake, Assessment, and Diagnosis

Based on the information provided in Part One, which DSM-5-TR presentation of ADHD is MOST consistent with the client's symptoms?

Domain: Intake, Assessment, and Diagnosis

Although ADHD appears likely, you would like additional information regarding the client's attention, impulsivity, and executive functioning across multiple settings.

Which assessment would be MOST appropriate?

Domain: Professional Practice and Ethics

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

Part Two

First session, three weeks after the intake session

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

Domain: Counseling Skills and Interventions

You elect to utilize a Gestalt approach while building rapport with the client. As he talks excitedly about video games, movies, and the girl he met at the skate park, you notice that he is tapping his foot rapidly, speaking without pause, and frequently looking around the room.

Which response would BEST reflect a Gestalt approach?

Domain: Intake, Assessment, and Diagnosis

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

Domain: Intake, Assessment, and Diagnosis

You are utilizing the services of an interpreter to perform an intake interview with a client from Mexico. You ask the client:

"People often understand problems in their own way, which may be similar or different to how professionals might describe the problem. How would you describe the problem?"

What is the PRIMARY purpose of this question?

Domain: Professional Practice and Ethics

Which of the following statements regarding a client's authorization for the release of confidential information is correct?

Part Three

Second session, six weeks after the intake session

Client paces your office while describing an argument he had with his mother. He states she came home from a parent-teacher conference and yelled at him for failing 3 classes. His mom also expressed to him that she is embarrassed because the school counselor told her that he is in danger of failing a grade, and she has tried everything to prevent this. “Why can’t you just pay attention? School is your one responsibility!” the client exclaims in a mocking tone. He tells you he has heard the same thing year after year, and he hasn’t failed a grade yet. He speculates that everyone is just trying to scare him. Client defends himself to you, stating he wants to do better but he can’t focus on studying. He reports he was rejected by the girl at the skate park, and his friends seem annoyed by him lately. He tells you he feels like a failure and wonders, “What’s wrong with me?” The client continues, "Maybe my mom is right. Maybe I really am just lazy. Everyone else seems able to remember things and stay on top of their responsibilities. I keep messing things up. If I can't even get through school without all these problems, I don't know how I'm ever going to be successful." You summarize client’s complaints and validate his feelings of distress. You normalize the feelings of rejection he is experiencing and briefly share that you remember feeling disappointed and questioning yourself after being rejected by someone you liked when you were younger. You explain that, although the situation eventually became easier to understand, it felt very painful in the moment. You then redirect the conversation back to the client's experience and ask what the rejection has meant to him. He asks you follow up questions about how you handled the rejection and what your opinion is of a conversation that he had with the girl in question via text. He expresses relief that someone understands and throws himself into the chair opposite yours.


Domain: Professional Practice and Ethics
Why was the counselor's use of self-disclosure in this situation most appropriate?

Domain: Counseling Skills and Interventions

After discussing his recent struggles, the client states:

"Maybe my mom is right. Maybe I really am just lazy. Everyone else seems able to remember things and stay on top of their responsibilities. I keep messing things up. If I can't even get through school without all these problems, I don't know how I'm ever going to be successful."

Which cognitive distortion is MOST evident in the client's statement?

Domain: Counseling Skills and Interventions

Which of the following statements regarding distance counseling is FALSE?

Domain: Counseling Skills and Interventions

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

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

Client

Age: 16

Sex Assigned at Birth: Female

Gender Identity: Female

Pronouns: She/her

Sexual Orientation: Heterosexual

Race/Ethnicity: White

Relationship Status: Single

Setting: Agency

Type of Counseling: Individual

Provisional Diagnosis: Bulimia Nervosa

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

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

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

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

History of Condition: The client reports that approximately four months ago she began following several fitness and nutrition influencers on social media. Around that time, she became increasingly concerned about her weight and started comparing her appearance to other girls at school. She reports spending considerable time looking at photos of herself and frequently asking friends whether she looks overweight.

The client admits that she often feels out of control around food. Several times per week, she eats large quantities of food in a short period of time, usually when she is home alone after school. She reports consuming multiple servings of snack foods, cereal, leftovers, and desserts during these episodes. Afterwards, she feels ashamed and worries that she will gain weight. To compensate, she frequently induces vomiting and sometimes exercises for extended periods at the gym. She states, "I know it's not healthy, but I feel like I have to undo the damage."

The client reports that despite her efforts to lose weight, her weight has remained relatively stable over the past several months. She becomes visibly uncomfortable when discussing her current weight and repeatedly asks whether her height and weight would be considered "fat." She denies any history of significantly low body weight and reports that her menstrual cycle has remained regular.

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

Domain: Counseling Skills and Interventions

During the initial session, the counselor wants to establish rapport while remaining consistent with the principles of Reality Therapy. Which response would be MOST appropriate?

Domain: Intake, Assessment, and Diagnosis

Which of the following is NOT one of the seven stages identified in Roberts' Seven-Stage Crisis Intervention Model?

Domain: Professional Practice and Ethics

A counselor wants to routinely monitor the quality of the therapeutic relationship and identify potential alliance ruptures before they negatively affect treatment outcomes.

Which assessment would be MOST appropriate?

Domain: Intake, Assessment, and Diagnosis

Which diagnosis would be the MOST important differential diagnosis to rule out when evaluating this client?

Domain: Treatment Planning

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

Part Two

First session, two weeks after initial intake session

The client comes to your office after school with a large convenient store soda. She expresses feeling stressed out lately and tells you about her recent frustration with her father. He is often critical of her and compares her to her sisters. A few days before, he told her that he was disappointed in her most recent report card, because she received a B in English. She expresses anger and shame connected to this and doesn’t understand why he isn’t pleased with all the A’s she received. You ask what she does when she feels stressed, and she reports that sometimes she eats more than she probably should. She often goes through a drive-through on her way home from school, eats a full meal and then eats dinner with her parents. She also has a secret stash of snacks she keeps hidden in her room. She expresses that she has a habit of eating salty foods in the middle of the night and early in the morning right before she has to wake up for school. She tells you that she started eating potato chips, but one night her mom came in because she heard all of the noise the client was making with the bag. When the client heard her mom coming, she quickly stashed the bag under the covers and acted like she was sleeping. Ever since then, she has opted for snacks in quieter containers, and the only chips she eats are the wavy ones that come in a cardboard tube. She also has eaten cupcakes late at night because those are considered to be a quiet snack as well. She tells you that you’re the only one that knows about this, and she doesn’t want her parents to know about the stress eating. The client hesitates for a moment and then says, "Sometimes I feel so guilty afterward that I wish I could just erase it." When you ask what she means, she looks away and shrugs. "I don't know. Sometimes after I eat a lot, I go to the bathroom for a while. I just feel disgusting after." She quickly adds, "It's not every time or anything. I can usually make up for it by working out." She appears nervous after sharing this information and asks, "You're not going to tell my parents, are you?" You empathize with the difficulty of trying to live up to her parents’ expectations.

Domain: Intake, Assessment, and Diagnosis

After disclosing that she sometimes spends extended periods in the bathroom after eating and worries that you will tell her parents, what would be the MOST appropriate response?

Domain: Treatment Planning

Which of the following is MOST likely to function as a barrier to successful treatment outcomes?

Domain: Counseling Skills and Interventions

The client reports feeling hurt and ashamed when her father compares her to her sisters and criticizes her academic performance.

Using an Acceptance and Commitment Therapy (ACT) approach, which response would be MOST appropriate?

Domain: Core Counseling Attributes

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

Part Three

The client arrives on time for session wearing athletic clothing and carrying a large water bottle. She reports that things at home have been "about the same" and states that her father continues to compare her academic performance and accomplishments to those of her sisters. She says she recently received a 95% on a biology exam and was disappointed when her father responded by asking why she had missed the remaining five percent.

You review the food and mood records the client completed between sessions. She reports that she became more aware of situations that trigger overeating. The client identifies criticism, arguments with her parents, and feelings of loneliness as common triggers. She states that she often feels overwhelmed by these emotions and immediately begins thinking about food. She reports several episodes during which she consumed large amounts of food in a short period of time and felt unable to stop eating once she started.

The client also discloses that she has continued to induce vomiting after some binge-eating episodes. She states that she feels temporary relief afterward but quickly begins feeling guilty and ashamed. "I know it doesn't really solve anything," she says, "but in the moment it feels like the only way to undo what I did."

As the session progresses, the client becomes tearful while discussing her relationship with her sisters. She states that she often feels like the "disappointment" of the family and worries that she will never measure up to their accomplishments. When asked how she would describe herself apart from her appearance, grades, or athletic ability, she pauses for several moments before saying, "I honestly don't know."

You explore the connection between the client's thoughts, emotions, and eating behaviors. Together, you identify several harsh self-critical thoughts that frequently occur before binge-eating episodes. You also discuss how efforts to avoid feelings of shame and inadequacy may unintentionally maintain the cycle of bingeing and purging. Before the session ends, you assign a values clarification exercise in which the client is asked to identify qualities she would like to embody regardless of her weight, appearance, or academic performance.

Domain: Professional Practice and Ethics

You receive a subpoena requesting records regarding a former client. Which portion of the record generally receives the greatest level of protection from disclosure and is typically maintained separately from the client's clinical record?

Domain: Counseling Skills and Interventions

Regarding the client’s statements regarding her response to common triggers, which response is the BEST example of a reflection of content?

Domain: Core Counseling Attributes

At the end of the session, you assign the client a values clarification exercise in which she is asked to identify qualities she would like to embody regardless of her weight, appearance, or academic performance.

What insight do you hope the client gains from completing this homework?

Domain: Counseling Skills and Interventions

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

Part One

Age: 42

Sex: Female

Gender: Female

Sexuality: Heterosexual

Ethnicity: Latina American

Relationship Status: Married

Counseling Setting: Agency

Type of Counseling: Individual

Diagnosis: Major Depressive Disorder, Recurrent, Moderate

Presenting Problem: You are a mental health counselor in a community mental health agency. A 42-year-old Latina American female presents for an intake assessment due to worsening depression affecting her work and family relationships. For the past month, she has struggled to complete routine tasks, cries frequently, and has become increasingly withdrawn from family members. Her spouse and adult daughters encouraged her to seek counseling because she appears sad most days and isolates herself. She reports feeling overwhelmed by responsibilities and states, “Everything feels harder than it used to.”

Mental Status Exam: Client presents with disheveled appearance and poor hygiene. She is tearful at times and otherwise maintains a flat affect. She avoids eye contact and speaks in a soft, slowed manner. Client reports difficulty sleeping, diminished appetite, low energy, and poor concentration. She endorses fleeting suicidal ideation without plan or intent and denies any history of suicide attempts or self-harm. She is oriented to person, place, time, and situation.

Family History: The client has been married for twenty years and has two adult daughters, ages 19 and 21. Her mother died approximately two years ago and her father died eighteen months later. She reports that her current symptoms are more severe than the grief she experienced following either loss. She has not spoken to her two older siblings for over a year due to family conflict. The client believes her father struggled with depression, although he was never formally diagnosed.

History of Condition: The client reports that approximately one month ago she experienced a significant decline in mood and motivation. She has difficulty getting out of bed, cries frequently, has lost interest in previously enjoyable activities, and struggles to complete daily responsibilities. She reports feeling hopeless about the future, guilty about her declining work performance, and increasingly detached from her family.

The client reports a similar depressive episode six years ago following the death of a close friend. At that time, she experienced persistent sadness, social withdrawal, fatigue, and impaired work functioning. The symptoms gradually resolved over several months, and she returned to her usual level of functioning until her current episode began.

Legal History: The client stopped speaking to her siblings because of disputes regarding their parents’ estate. Probate proceedings remain ongoing. She reports feeling saddened by the loss of these relationships but lacks the motivation to become involved in the process herself. “I don’t really care what happens to all their stuff,” she says with a sigh.

Work History: Client has been employed as a paralegal for the past five years. She reports previously enjoying her work and taking pride in being dependable. During the past month, however, she has become increasingly disinterested in her job and struggles to complete assignments on time. She was recently placed on a performance improvement plan due to lateness, missed deadlines, and careless mistakes that resulted in client complaints. She reports spending long periods staring at her computer screen without making progress on assignments.

Domain: Professional Practice and Ethics

The client asks whether they are entitled to review or obtain a copy of their counseling records. What is the MOST appropriate response?

Domain: Treatment Planning

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

Domain: Intake, Assessment, and Diagnosis

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

Domain: Intake, Assessment, and Diagnosis

Which aspect of the client's work history most strongly supports a diagnosis of Major Depressive Disorder, Recurrent, Moderate?

Domain: Treatment Planning

You are counseling a different client who has relapsed on cocaine for the second time since beginning treatment six weeks ago. The client arrives visibly distressed and states, “I really want to stop using, but nothing seems to be working.”

Based on the information provided, which level of care would be MOST appropriate to recommend at this time?

Part Two

First session one week after initial intake:

Client arrived for session disheveled with flat affect and little eye contact. She reported she was fired from her job because she was late for work three times this past week due to her inability to sleep at night. During session, you focused on building rapport, establishing trust by providing empathy and support to the client through active listening. You asked about goal setting. The client reported she wants to learn ways to cope with recent losses, manage irritability, and improve communication with family members. When you ask her what she has lost, she gets irritated and asks if you didn’t listen to her at all last session or this one. “I’ve lost my parents, my siblings, and now my job,” she says through clenched teeth. You apologize for your lack of awareness in an attempt to repair this rupture in the therapeutic alliance. After you apologize for overlooking the significance of the client's losses, the client sits quietly for several moments. She then says, "You know, this is exactly why I didn't want to come to counseling in the first place. People always say they're listening, but nobody really pays attention." She looks away and folds her arms across her chest. You notice yourself feeling defensive and wanting to explain that you have only met with her twice and are still learning important details about her history. Before you respond, the client adds, "Maybe you're just like everyone else. Maybe talking about this stuff doesn't help anyway." Your client seems somewhat willing to reengage in the session despite feeling shut down and irritable. She tells you that she would go on medication, but she has read about terrible side effects that she doesn’t want to deal with. She says that she has spent a lot of time researching antidepressants, and despite having numerous conversations with her doctor, she is unwilling to take them. You listen to her with empathy and demonstrate unconditional positive regard. The client continues to have a flat affect throughout your conversation. As a calming technique, you taught and practiced diaphragmatic breathing.

Domain: Intake, Assessment, and Diagnosis

A counselor is conducting a comprehensive assessment for suspected Major Depressive Disorder. Which of the following instruments would be LEAST useful for directly assessing depressive symptoms?

Domain: Treatment Planning

After discussing recent stressors, you ask the client what she hopes to accomplish through counseling. She reports wanting to learn ways to cope with recent losses, manage irritability, and improve communication with family members.

What is the PRIMARY purpose of exploring these goals at this stage of treatment?

Domain: Counseling Skills and Interventions

As the client questions whether you have been listening and expresses doubt about counseling, what is the MOST appropriate response?

Domain: Core Counseling Attributes

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

Part Three

Client arrived for session disheveled with flat affect. You aren't sure if it's just a coincidence, but she is wearing the exact same outfit that she wore at her appointment last week. It was Pink brand sweatpants with a dark blue T-shirt and a long white sweater. Her socks have little avocados printed on them, and they can be seen when she crosses her legs during the session. You consider asking about her self-care but decide to continue monitoring the situation before drawing conclusions.

The client maintained eye contact throughout the session and reported that she has been using diaphragmatic breathing during the past week to help manage her mood. She states, “I still feel sad most of the time, though.” When discussing the loss of her job, she becomes tearful and says, “Getting fired was embarrassing, but honestly it just confirmed what I've been thinking for a while. Everyone else seems able to handle life, and I can't even keep a job. Maybe I'm just not the kind of person who can get things together.”

You provide psychoeducation regarding the connection between thoughts, feelings, and behaviors. The client reports that she often stays in bed for long periods of time because she feels there is no point in trying. She acknowledges that the more she withdraws from others, the worse her mood becomes. You introduce a mood chart and ask her to track her mood each day. Toward the end of the session, you teach and practice progressive muscle relaxation.

Domain: Counseling Skills and Interventions

During the second session, the counselor teaches the client Progressive Muscle Relaxation (PMR) to help reduce physiological tension and improve emotional regulation. For which of the following diagnoses would this intervention likely be LEAST central to treatment planning?

Domain: Intake, Assessment, and Diagnosis

You introduce a mood chart and ask the client to track her mood each day between sessions.

What is the PRIMARY purpose of assigning this activity?

Domain: Counseling Skills and Interventions

Regarding the client’s statements about her job loss, which response is the BEST example of a reflection of meaning?

Domain: Core Counseling Attributes

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

Part One

Client

Age: 13

Sex Assigned at Birth: Male

Gender Identity: Male

Pronouns: He/him

Sexual Orientation: Heterosexual

Race/Ethnicity: White

Relationship Status: Single

Setting: School Counseling

Type of Counseling: Individual

Diagnosis: Specific Learning Disorder (Written Expression), Oppositional Defiant Disorder

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

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

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

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

History of the Condition: For the past eight months, parents and teachers have noticed the client being increasingly angry, argumentative, and resentful. The client states that nothing significant happened eight months ago and says that he “just decided not to take anyone's crap anymore.” He reports that he is tired of being criticized for his grades and believes most adults assume he is lazy or stupid.

Teachers report that the client frequently argues with adults, refuses to comply with classroom requests, deliberately annoys peers, and blames others when conflicts occur. At home, his mother and her boyfriend report that he often ignores instructions, talks back, and becomes verbally hostile when asked to complete chores or homework.

Despite these difficulties, the client attends a local secular youth center three afternoons per week. The center offers recreational activities, video game tournaments, art projects, and access to a bicycle repair workshop. Staff members describe the client as respectful, cooperative, and helpful. He rarely argues with staff and has volunteered to help younger children learn how to repair bicycles. The client states that he likes the youth center because “nobody there acts like they're better than me,” and he feels accepted by the staff. He reports that he has never been suspended or disciplined at the center.

Domain: Intake, Assessment, and Diagnosis

Which of the following findings would most appropriately be documented under the Thought Content section of a Mental Status Examination?

Domain: Intake, Assessment, and Diagnosis

Based on the information gathered during intake, which statement provides the STRONGEST support for a diagnosis of Oppositional Defiant Disorder?

Domain: Intake, Assessment, and Diagnosis

Based on the staff description of the client’s behavior at the youth center from Part One, What is the MOST appropriate interpretation of this information?

Domain: Counseling Skills and Interventions

The client states:

"Teachers always think I'm the problem. My mom's boyfriend thinks I'm a screw-up. Everybody already has their mind made up about me before I even say anything."

If you were working from a psychodynamic therapy model, which response would BEST help build the therapeutic alliance?

Domain: Intake, Assessment, and Diagnosis

Based on the information provided, which severity specifier is MOST appropriate for the client's Oppositional Defiant Disorder?

Part Two

First session, one week after the initial intake session

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

Domain: Treatment Planning

The counselor begins developing a treatment plan with the client. Which of the following goals would be the MOST appropriate initial treatment goal?

Domain: Core Counseling Attributes

What response BEST demonstrates genuineness to this client?

Domain: Counseling Skills and Interventions

After the client states, “You're probably just going to tell me I need to make better choices like everyone else,” what is MOST likely occurring between you and the client?

Domain: Counseling Skills and Interventions

The client states that teachers, administrators, and family members already have negative opinions about him and that nobody is interested in hearing his side of the story.

From a transtheoretical perspective, how could you use an amplified reflection to encourage further exploration?

Part Three

The client comes into session in a much better mood than last session as evidenced by providing more eye contact, voluntarily offering information, and asking follow-up questions. You ask the client if he has thought about any goals he would like to work on in counseling, and he states that he is sick of feeling stupid and wants to stop thinking that way. He says that if he were not so stupid, maybe he would not be in so many people's spotlights all the time.

You explore his writing difficulties and encourage him to explain in detail what he finds most frustrating. The client reports that he often knows what he wants to say but cannot get the words onto paper. He states that he becomes angry when teachers assume he is not trying. You normalize his experiences and explain the difference between having a learning disability and being unintelligent. You refer him to an intervention specialist who has training in writing and language deficits.

The client asks whether you would be willing to talk with his mother and her boyfriend about some of the goals discussed in counseling because they are the two people who make him feel the dumbest. You spend part of the session discussing how he would like that conversation to go and what information he would and would not feel comfortable sharing. You also ask whether he would like to be present for the conversation, but he declines.

The client then talks about his older brother and states that he believes his mother's boyfriend makes his brother feel stupid as well. “At least his grades aren't as bad as mine,” the client mutters. A few moments later he becomes quiet and says, “I don't think my mom's boyfriend realizes how much the stuff he says sticks with me. When he calls me lazy or says I'm not trying hard enough, I start thinking maybe he's right.” He shrugs and adds, “If the people who know me best think I'm dumb, maybe I really am.”

The client asks whether you are going to tell his mother and her boyfriend everything that was discussed during the session. He specifically states that he does not want them to know about some of the things he said regarding feeling stupid because he is worried they will become angry or use it against him during future arguments.

You discuss the limits of confidentiality and explain that you would like to collaborate with him regarding any information that is shared. Before the session ends, you assign the client homework. You ask him to keep a record of situations during the week in which he notices himself thinking negative things about his intelligence or abilities. For each situation, you ask him to write down what happened, what he told himself, and whether there might be another explanation for the situation. The client agrees to try the assignment and asks when he will see you again.

Domain: Professional Practice and Ethics

The client asks whether you are going to tell his mother and her boyfriend everything that was discussed during the session.

What is the MOST appropriate response?

Domain: Professional Practice and Ethics

All of the following are potential ethical concerns related to a therapist maintaining a professional social media page EXCEPT:

Domain: Counseling Skills and Interventions

The client states:

"If the people who know me best think I'm dumb, maybe I really am."

Which response is the BEST example of a reflection of meaning?

Domain: Core Counseling Attributes

What is the PRIMARY purpose of this homework assignment from Part Three?

Part One

Client

Age: 66

Sex Assigned at Birth: Female

Gender Identity: Female

Pronouns: She/her

Sexual Orientation: Heterosexual

Race/Ethnicity: White

Relationship Status: Married

Setting: Agency

Type of Counseling: Individual

Provisional Diagnosis: Hoarding Disorder

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

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

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

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

Domain: Core Counseling Attributes

If at some point the client and her husband requested assistance with conflict resolution skills, which of the following would be LEAST consistent with the goals of conflict-resolution counseling?

Domain: Intake, Assessment, and Diagnosis

Which question would BEST help assess the client's level of insight regarding her hoarding behaviors?

Domain: Intake, Assessment, and Diagnosis

From a Rational Emotive Behavior Therapy (REBT) perspective, what would be the MOST important focus of treatment for this client?

Domain: Professional Practice and Ethics

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

Domain: Professional Practice and Ethics

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

Part Two

First session, two weeks after intake

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

Domain: Treatment Planning

During the session, you and the client collaboratively explore resources that may support her treatment goals and reduce the impact of her hoarding behaviors.

Which of the following resources would be LEAST appropriate to include in the treatment plan at this time?

Domain: Intake, Assessment, and Diagnosis

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

Domain: Counseling Skills and Interventions

Based on the client's presenting concerns and diagnosis, which intervention approach would be MOST appropriate to emphasize in treatment?

Domain: Professional Practice and Ethics

You consider referring the client to a support group for individuals who struggle with hoarding. Which of the following is NOT typically considered an element of effective group termination?

Part Three

During your first session, the client made progress in accepting help and working with the case managers at the community agency to clean her home. She established a plan with her husband that he will move home in two weeks. She expresses that she donated some of her belongings to Goodwill and has utilized the thought-stopping techniques learned in counseling when she has the urge to spend money at an estate sale.

Although she enjoys going to estate sales on the weekends, she has developed a plan with her husband to go to other places to pass the time on Saturday afternoons when she would typically attend one. She tells you that going to estate sales was a good socialization activity for her, so they are coming up with ideas that will not only take up time but also involve interacting with others. She states that one of the ideas on the table is to join a bowling league or volunteer together at a homeless shelter because volunteers are needed to serve lunch and dinner.

The client reports that she recently filled three large boxes with items to donate. She becomes tearful while discussing the experience and says, “I know it was the right thing to do, but after the boxes left the house, I sat in my chair and cried. Some of those things had been with me for decades. Part of me feels proud that I did it, but another part of me feels like I lost old friends.” She pauses for several seconds before adding, “Sometimes I worry that if I keep getting rid of things, there won't be much left of my story.”

You reflect upon the progress the client has made in treatment and encourage her to utilize referrals for a support group and continue practicing cognitive reframing techniques. The client states that she is optimistic about finding new ways to spend her time while also acknowledging that change has been more emotionally difficult than she expected.

Domain: Counseling Skills and Interventions

Which of the following would be the BEST example of a paradoxical intervention for this client?

Domain: Core Counseling Attributes

Regarding the client’s statements about donating some of her possessions, which response BEST demonstrates empathic attunement?

Domain: Counseling Skills and Interventions

You are considering referring the client to a 12-step support group for individuals struggling with hoarding behaviors. Which of the following is NOT one of the traditional principles or steps found within a 12-step recovery program?

Domain: Counseling Skills and Interventions

The client reports that she previously spent most Saturday afternoons attending estate sales. Because these outings often led to acquiring additional possessions, she and her husband developed a plan to replace estate sales with alternative activities such as joining a bowling league or volunteering at a homeless shelter.

The intervention of scheduling these alternative activities is an example of:

Part One

Client

Age: 48

Sex Assigned at Birth: Female

Gender Identity: Female

Pronouns: She/her

Sexual Orientation: Heterosexual

Race/Ethnicity: Latina American

Relationship Status: Single

Setting: Community clinic

Type of Counseling: Individual

Provisional Diagnosis: Histrionic Personality Disorder

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

Mental Status Exam: The client comes to session wearing revealing clothing. At one point she takes a hair tie out of her hair and seductively flips her hair. She looks at you flirtatiously and fishes for compliments by stating, “You know, so many people have told me I have the kind of hair you see in shampoo commercials.” When you don’t respond with a compliment, she frantically begins talking about her accomplishments as a multi level marketing representative. You notice her demeanor and emotions change as the conversation goes from topic to topic. The client is oriented to person, place, and time. As the session continues, the client comments that she is glad her physician referred her to a counselor because “most therapists are boring.” She smiles and tells you, “You seem different. I can tell we're going to have a special connection.” A few minutes later, she asks whether you are married and states that your partner must be “very lucky.” When you redirect the conversation back to her concerns about the breakup, she laughs and says, “You're good at avoiding compliments.”

Relationship History: The client has dated men of all backgrounds, and the client boasts that she has had over 100 sexual partners. She tells you that she stays in touch with many of them, but has never had a serious relationship. She tells you that her parents disapprove of her relationship habits, and they expressed their disdain for the way client has dated others since the client was in her first year of high school. The client tells you that she finds dating to be very exciting, and she considers herself a social butterfly. You ask the client how she feels about all of these surface-level relationships, and she states that it’s good to have someone to talk to all the time. “I look at it as I have the world’s largest support system, and now I get to add you to the list!” she exclaims. The client reports that she often develops strong feelings for people shortly after meeting them. She states that she frequently describes new friends and romantic interests as her “best friend” or “soulmate” within days or weeks of meeting them. However, she struggles to explain what she likes about these individuals beyond saying that they are “amazing” or “special.” She reports becoming upset when she feels ignored and admits that she sometimes exaggerates stories or emotions to capture people's attention. She denies a history of self-harm, suicide attempts, chronic feelings of emptiness, intense anger, or fears that others will abandon her if she does not maintain constant contact with them.

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

Domain: Professional Practice and Ethics

Regarding the client’s flirtatious comments as reported in the Mental Status Exam, what is the MOST appropriate counselor response?

Domain: Treatment Planning

From an Object Relations perspective, what would be the MOST important focus of treatment for this client?

Domain: Intake, Assessment, and Diagnosis

You would like to obtain a relatively quick overview of symptoms across multiple mental health domains during an intake assessment. Which of the following instruments would be the BEST choice?

Domain: Counseling Skills and Interventions

The client states:

"My friends all have successful careers, families, and great lives. Meanwhile, I've barely accomplished anything worthwhile. Nothing I've done really counts."

Which cognitive distortion is MOST clearly demonstrated by this statement?

Domain: Intake, Assessment, and Diagnosis

Which diagnosis would be MOST important to rule out when evaluating this client's presentation?

Part Two

FIrst session, two weeks after the initial intake session

Client comes to session and places a gift bag on your desk. You explain to the client that due to your agency’s policy you are unable to accept gifts, and the client begins to sob and gesture wildly about your ungratefulness. You ask the client to identify her feelings, and all she will say is that you have ripped her heart out. At one point she sits on the floor. You state, “It sounds like gifts are important to you.” She gets up, gets her phone out, and starts excitedly showing you gift bags that she made for her team of employees. She tells you that she has been in the multi level marketing world for nearly her whole adult life, but the company she works with now has been her best experience yet. She started out selling makeup out of catalogs, and then she moved into health products. Now she sells beauty products. “I don’t allow any Ugg-os on my team. You definitely have to look the part if you want to sell products like these. No one wants to see you go live on social media if you’re not put together. That’s not going to inspire anyone to join your team,” she advises. She discusses all of the awards her team has won over the years, and how they will be going on a company-wide conference on a cruise ship this summer as a part of heir incentive to keep growing their team. She states that she throws an event every quarter in which she requires her staff to dress up and come to an awards banquet that she emcees. “They look good, but I look better,” she says to you with a wink. You discuss boundaries with the client, and she mocks you with a laugh. Near the end of the session, the client excitedly tells you that she uses social media to promote her business and maintain relationships with current and former team members. She states that she looked you up online after the intake session and found your professional social media page. She reports that she sent you a friend request and left a public comment underneath one of your posts that read, “So excited to be working with the best counselor in town!” She asks whether you saw the comment and says that she plans to tag you in a post after her next appointment because she wants her followers to know how much counseling is helping her.

Domain: Professional Practice and Ethics

Regarding the client’s social media comments from Part Two, what is the MOST appropriate response?

Domain: Intake, Assessment, and Diagnosis

Given this client's diagnosis and presenting concerns, which of the following would be LEAST appropriate as a long-term treatment goal?

Domain: Intake, Assessment, and Diagnosis

Which behavior described in Part Two provides the STRONGEST support for the diagnosis of Histrionic Personality Disorder?

Domain: Treatment Planning

Cultural safety is primarily concerned with awareness of:

Part Three

Second session, five weeks after the initial intake session

The client comes to session and states, “I could die from sadness.” You ask the client to go into more detail about what she is feeling, and all she will say is “Life is a tragedy.” She discusses a family conflict over the weekend in which she attended her niece’s birthday party, but got agitated when it was time for the child to open her gifts. Her brother and his wife were throwing the party, and the client was fixing herself a plate when the parents of the birthday girl announced that they would be opening gifts. The client states that she left her plate of food on the table and insisted upon going over and having the birthday girl sit on her lap while she was opening presents. The client states that she wanted to be in the pictures so that everyone on social media would know what a good aunt she is. Her sister-in-law got angry, and asked the client to sit in the circle with the rest of the family. Your client states she felt so rejected that she began to cry, and could not control herself. She locked herself in the only bathroom in the house because she was too embarrassed to come out. She eventually left without saying anything to anyone, and is unsure if she will go to another family gathering. She discusses not being able to stay at the party and wondering what upset her so much. You make a list with the client about times when she felt a similar way and help her identify patterns in the events. As you and the client review the list of similar situations, she notices that many of the events involve feeling ignored, excluded, or overshadowed by someone else. She becomes quiet for a moment and then says, “I never thought about it before, but maybe it's not really the event itself. Maybe it's that I can't stand feeling invisible.” She pauses and then quickly adds, “But honestly, who wants to be invisible?”

Domain: Counseling Skills and Interventions

What is the MOST important therapeutic insight reflected in the client’s statement about feeling invisible?

Domain: Counseling Skills and Interventions

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

Domain: Professional Practice and Ethics

You are supervising a counseling intern. The principle of due process in clinical supervision includes all of the following except:

Domain: Treatment Planning

Which of the following would NOT be considered a psychotherapist-initiated interruption of treatment?

Part One

Client

Age: 15

Sex Assigned at Birth: Male

Gender Identity: Male

Pronouns: He/him

Sexual Orientation: Heterosexual

Race/Ethnicity: Native American

Relationship Status: Single

Setting: Community clinic

Type of Counseling: Individual

Provisional Diagnosis: Acute Stress Disorder

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

History of Condition: Client presents to your intake session carrying a sketchbook. You notice that he is trembling, and you offer him a stress ball to self-soothe during your session. He tearfully shares that his best friend found a gun and shot himself back home on the reservation, “I feel so guilty! I knew he was in trouble because he was using drugs and getting high! I should have gone over to his house!” He presents with symptoms of anxiety, difficulty concentrating, irritability, and hopelessness. He reports that he will never be able to walk by his friend’s home again and expresses intense sleep disturbances, “I’ve barely slept in the last week. I can’t even paint.” Client presents with dark circles under his eyes and denies suicidal and homicidal ideation. As the client talks about his friend, he becomes visibly distressed and begins staring at the floor. He reports that several times over the past week he has suddenly felt as though he were back on the reservation hearing people talk about what happened. He states that he tries not to think about his friend and has avoided responding to text messages from mutual friends because discussing the suicide feels overwhelming. When his uncle suggested attending a community memorial, the client initially refused because he did not want to be reminded of the event. He reports that when thoughts of his friend come up, he often opens his sketchbook and begins drawing scenes from nature because it is one of the few activities that helps him feel calmer. He shares several drawings of mountains, rivers, and eagles and says, “When I'm drawing, it's the only time my head slows down.”

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

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

Domain: Intake, Assessment, and Diagnosis

Which of the following additional findings would be MOST likely to rule out a diagnosis of Acute Stress Disorder?

Domain: Intake, Assessment, and Diagnosis

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

Domain: Counseling Skills and Interventions

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

Domain: Counseling Skills and Interventions

A client presents with symptoms consistent with Acute Stress Disorder one week after witnessing a traumatic event. Which of the following interventions has the strongest evidence base for reducing trauma-related symptoms and preventing longer-term impairment?

Domain: Intake, Assessment, and Diagnosis

Which factor disclosed during the intake assessment appears to be the client's strongest protective factor?

Part Two

First session, two weeks after intake

Client arrives to session 15 minutes late with dark circles under his eyes, “I’m sorry I was late. I still cannot sleep. I feel so sad and hopeless all the time.” During the intake session, you learn about client’s friend that passed away and the close bond they shared. Client reveals that he was like a “brother to me” and feels hopeless about the future. He reflects that he is unsure if he will ever be able to paint again if he cannot sleep or stop trembling to pick up a paint brush. He begins shaking uncontrollably and appears detached as he stairs out the window with a blank gaze. You utilize “here-and-now” techniques to support him in returning to the moment and teach a mindfulness exercise that he can practice daily. You originally encourage him to close his eyes during the mindfulness activity, and the client gives you mixed feedback after the intervention ends. He states that closing his eyes reminds him of his sleeping troubles, and he sees unpleasant images when he tries to connect with the guided imagery you mention. You ask the client if it would be okay to try the exercise again, this time with his eyes open, with his gaze fixed on the carpet in front of him. He expresses willingness to do so, and the second time he reports that he felt more comfortable and grounded. You ask him to imagine that he has tree roots growing out of the soles of his feet, and every time he inhales he is pulling the air from the tips of the roots, and when he exhales he is sending the air back down, deep into the earth. He states that this is his favorite activity yet. As homework, you encourage him to try the technique when he paints and before bed to promote relaxation and healing. Before the session ends, you ask the client whether there are any cultural traditions, ceremonies, or spiritual practices within his tribe that have helped him or his family cope with loss in the past. The client tells you that several elders have invited him to participate in a community healing ceremony that includes prayer, drumming, and storytelling, but he has been hesitant to attend because he feels emotionally numb. He also shares that his grandfather taught him that nature has always been a source of healing and that sitting near the river has helped him feel connected to his ancestors. You thank him for sharing this with you and ask whether he would like to explore ways to incorporate these cultural practices into his healing process. The client nods and says, "I think my friend would have wanted that."

Domain: Counseling Skills and Interventions

The client tells you that tribal elders have invited him to participate in a community healing ceremony but that he has been reluctant to attend. What is the MOST culturally responsive counselor intervention?

Domain: Counseling Skills and Interventions

You assign the client homework to practice the grounding exercise while painting and before going to bed each night. Which therapeutic insight would be the MOST important for the client to develop through this assignment?

Domain: Intake, Assessment, and Diagnosis

Distractibility, excessive talkativeness, and flight of ideas may all be observed during which of the following conditions?

Domain: Core Counseling Attributes

A therapy group has begun demonstrating increased trust and cohesion. Members openly support one another, attendance has become more consistent, and participants express concern when another member misses a session.

As the group continues to develop cohesiveness, which of the following is MOST likely to occur next?

Part Three

Before the session, you provide the client's uncle with an update regarding the client's progress and treatment goals. The client's uncle apologizes for needing to discontinue counseling because of financial hardship.

The client tells you he is scared about ending therapy. His uncle explained the night before that he had to choose between paying for counseling or having enough money for gasoline and groceries. The client's birthday is in two months, and he hopes his father sends money as he usually does, although it is never guaranteed. Even then, he says the money will likely be used for household expenses.

The client states that his uncle feels terrible about ending counseling because he can tell it has been helping. The client says, "I don't want to go back to feeling the way I did after my friend died." He reports that some days are better than others but still experiences occasional intrusive memories and hopelessness. His sleep has improved because he practices the grounding exercise before bed, and he has started painting again. He adds, "When I stop painting or quit doing the breathing exercise, everything starts feeling heavier again."

Together, you develop a relapse-prevention plan by identifying warning signs that his symptoms are worsening, including isolating from family, avoiding painting, poor sleep, and withdrawing from friends. You also identify coping strategies such as grounding, painting, spending time in nature, talking with his uncle, and participating in community cultural activities. You explain that if these strategies stop helping or his symptoms worsen, he should seek additional support.

Because treatment is ending due to financial hardship rather than clinical readiness, you provide referrals to the agency's free trauma and grief support group, counselors who offer sliding-scale services, and additional community resources.

As the session comes to a close, the client becomes tearful and says, "I'm afraid people will forget about my friend...and maybe about me too." You sit quietly with him for a moment.

The client then hands you a small painting of a horse. "I painted a picture of my friend too," he says, "but I want to keep that one. This one is for you. I just wanted you to know you helped me start painting again."

Domain: Professional Practice and Ethics

The client's uncle can no longer afford counseling. What is the MOST appropriate ethical course of action?

Domain: Counseling Skills and Interventions

The primary purpose of developing the relapse-prevention plan was to help the client:

Domain: Professional Practice and Ethics

At the end of the session, the client gives you a small painting of a horse that he created and says, "I just wanted you to know you helped me start painting again."

What is the MOST appropriate response?

Domain: Core Counseling Attributes

The client becomes tearful and says, "I'm afraid people will forget about my friend...and maybe about me too."

Which response best demonstrates empathic attunement?