NCMHCE Test

The NCMHCE test, formally known as the National Clinical Mental Health Counselor Examination, is a comprehensive and challenging assessment for men and women who wish to enter this exciting and rewarding field of health care. This exam is developed by the National Board for Certified Counselors in consultation with an expert team of test administrators.

The NCMHCE consists of 10 simulations in which candidates must determine a plan of action for a hypothetical scenario. Responses are assessed in terms of two skills: information gathering and decision-making. Test content is divided into three categories: evaluation and assessment, diagnosis and treatment planning, and clinical practice.

The evaluation and assessment domain tests a candidate's knowledge of how to identify precipitating problems of symptoms, conduct mental status exams, conduct comprehensive biopsychosocial assessment histories, and identify individual and relationship functioning. The section on diagnosis and treatment planning covers the integration of client assessment and observational data with clinical judgment to formulate a differential diagnosis, the development of a treatment plan in collaboration with the client, the coordination of a treatment plan with other service providers, and the monitoring of client progress toward goal attainment. The final domain evaluates skills required to succeed in clinical practice, including knowledge of how to determine if services meet client needs, the ability to discuss ethical and legal issues, and understanding the scope of practice parameters.

NCMHCE test scores are mailed approximately six weeks after the exam date. Candidates will receive subscale scores for both information gathering and decision-making, as well as a total score. The NCMHCE test report will also include an indication of the minimum passing scores.

NCMHCE Test

Simulation #1

Debra is a 34-year-old divorced African-American woman residing in a transitional living center for the past 18 months. Reports indicate she is of normal intellectual capacity, and her current level of function is high. You have been called to evaluate her continued eligibility for services in the facility. Her presenting provisional DSM-IV-TR Axis I diagnosis is Bipolar I Disorder, Most Recent Episode Depressed, Severe With Psychotic Features, Mood-Congruent (296.54). There have been at least 3 episodes of depressive decompensation, each time with accompanying psychotic features, over the past 3 years. Her last decompensation episode occurred within the last 60 days and was only resolved after involuntary hospitalization and medication administration.

NOW GO TO SECTION A.

Section A: Initial Information Gathering

Which of the following elements would be important in confirming or revising the presenting DSM-IV-TR Axis I diagnosis?

DIRECTIONS: Select as many as you consider indicated in this section.

1. Educational history.
2. Mental status examination.
3. Current stressors.
4. Frequency and nature of bipolar episodes.
5. Family mental health history.
6. Past/Current medications prescribed.
7. Medications compliance.
8. Current level of functioning.
9. Employment history.
10. Prior and/or current substance abuse.
11. Other psychiatric history.
12. Quality of existing family relationships.

NOW GO TO SECTION B.

Section B: Based on the intake data, identify potential issues to be addressed:

DIRECTIONS: Select as many that seem correct and necessary.

1. Focus on employment needs.
2. Explore and address family relationship issues.
3. Improve the client’s insight into her illness.
4. Explore past symptoms of depression and coping.
5. Address medication noncompliance concerns.

NOW GO TO SECTION C.

Section C: Additional Information Gathering

Which of the additional following elements would be most important in confirming or revising the presenting DSM-IV-TR Axis I diagnosis?

DIRECTIONS: Select as many as you consider indicated in this section.

1. Income history.
2. The Beck Depression Inventory-II.
3. Duration of time between decompensation episodes.
4. Degree of medication noncompliance.
5. Seasonal mood patterns.
6. Suicidal ideation/attempts.
7. Unexplained weight gain or loss.
8. Medical history.
9. Postpartum depression.
10. Religious affiliation/attendance.
11. Traumatic life events.
12. Marital history.

NOW GO TO SECTION D.

Section D: Provisional Diagnosis Formulation

Based on the available information, what would appear to be the most appropriate provisional DSM-IV-TR Axis I diagnosis?

DIRECTIONS: Select the most appropriate primary diagnosis indicated in this section.

1. Posttraumatic Stress Disorder (309.81).
2. Adjustment Disorder, With Mixed Anxiety and Depressed Mood (309.28).
3. Bereavement as “a focus of clinical attention” (V62.82).
4. Major Depressive Disorder, Recurrent, Severe With Psychotic Features (296.34).
5. Bipolar II Disorder (296.89).
6. Brief Psychotic Disorder, With Marked Stressors (298.8).
7. Schizoaffective Disorder (295.70).

NOW GO TO SECTION E.

Section E: Based on the provisional diagnosis, what treatment methods and referrals would be appropriate for Debra?

DIRECTIONS: Select as many as you consider indicated in this Section.

1. Individual Grief Therapy.
2. Family Counseling.
3. Participation in a bereavement support group.
4. Stress Management Counseling.
5. Illness Insight Counseling.
6. Independent Living Education.
7. Medication Compliance Monitoring and Counseling.
8. Cognitive-Behavioral Therapy.
9. Psychiatrist Referral to Evaluate Medication Needs.

NOW GO TO SECTION F.

Section F: Based on the selected treatment modalities, what information and monitoring methods would be appropriate for Debra?

DIRECTIONS: Select as many as you consider indicated in this section.

1. Staff reports of progress in the transitional living program.
2. Mood graph.
3. Completion of homework assignments.
4. Medications monitoring
5. Affective functioning
6. Social interactions
7. Substance abuse monitoring.
8. Energy level.
9. Employment seeking
10. Cognitive functioning

NOW GO TO SECTION G.

Section G: In developing a collaborative treatment plan with the client, which of the following should be included?

DIRECTIONS: Select as many as you consider indicated in this section.

1. Identify the goals of treatment appropriate to the issues being addressed.
2. Decide on the total number of sessions required.
3. Develop the specific objectives to meet the identified goals.
4. Determine the client’s post-counseling housing options.
5. Address confidentiality requirements and limits.


Simulation #2

Frank is a 32-year-old, slender, unemployed, never-married white man, living in a board and care home paid for by his well-to-do and politically well-connected parents. The care home operator brought him in to be seen, claiming that he was “disruptive, impulsive, and threatening.” Further, he seemed to have episodes of unexplained “crazy” behavior, talking to himself, sleeping very little for days and then “crashing,” and being verbally explosive at other times. The care home operator was concerned that he may be potentially dangerous to the other clients in the facility, including both developmentally delayed and frail elderly individuals.

Hygiene and grooming were fair-to-poor (e.g., uncombed hair, disheveled clothing, soiled hands and fingernails, mild body odor). His attire was very adolescent in appearance, ripped jeans, motorcycle boots, black leather vest, “gothic” skull rings, a long wallet chain, studded leather belt and wrist guard.
Frank was angry about having been confronted about his behavior, and did not feel he needed to be seen. He claimed that the board and care home was too restrictive, and that the care operator “had it out for him.” He had little positive to say about anyone in the facility. His eye contact was poor, psychomotor agitation was moderate-to-high, and he seemed to be manipulative and evasive in his overly aggressive verbal responses.

NOW GO TO SECTION A.

Section A: Initial Information Gathering

Which of the following elements would be important in formulating a provisional DSM diagnosis?

DIRECTIONS: Select as many as you consider correct.

1. Residential history.
2. Medical history.
3. Educational history.
4. Interpersonal relationships.
5. Psychiatric history.
6. Substance abuse history.
7. Mood status.
8. Vocational/employment history.

NOW GO TO SECTION B.

Section B: Based on the intake data, identify potential issues to be addressed:

DIRECTIONS: Select as many as seem correct and necessary.

1. Family relationships.
2. Suicidality
3. Anger management.
4. Mood swings.
5. Educational issues.
6. Impulse control.
7. Employment issues.
8. Explore possible substance abuse

NOW GO TO SECTION C.

Section C: Additional Information Gathering

What assessment tools might offer meaningful information on this client?

DIRECTIONS: Select as many as you consider indicated in this Section.

1. The Minnesota Multiphasic Personality Inventory (MMPI-2)
2. The 16 Personality Factor Questionnaire (16PF).
3. Wechsler Adult Intelligence Scale, Fourth Edition (WAIS-IV)
4. Drug Abuse Screening Test (DAST)
5. Beck Depression Inventory-II (BDI-II)
6. Thematic Apperception Test (TAT)

NOW GO TO SECTION D.

Section D: Additional Data Gathering

To better determine the client’s level of function, current behavioral problems, and possible substance abuse, what additional data may be helpful?

DIRECTIONS: Select the most appropriate options provided in this section.

1. Direct interviews with the care home operator and staff.
2. School records review.
3. Collateral contact with the mental health case manager
4. Contact with the client’s neighborhood friends.
5. Collateral contact with the client’s parents.
6. Legal history review.
7. Medical records review.

NOW GO TO SECTION E.

Section E: Based on the information obtained, what provisional diagnosis would be appropriate for this client?

DIRECTIONS: Select the one most appropriate primary diagnosis.

1. Substance-Induced Psychotic Disorder, With Delusions (292.11).
2. Amphetamine Dependence (304.40).
3. Substance-Induced Psychotic Disorder, With Hallucinations (292.12).
4. Intermittent Explosive Disorder (312.34).
5. Attention-Deficit Hyperactivity Disorder NOS (not otherwise specified) (314.9).
6. Narcissistic Personality Disorder (301.81).

NOW GO TO SECTION F.

Section F: Based on the provisional diagnosis, what theoretical approach might work best for this client?

DIRECTIONS: Select as many as you consider indicated in this section.

1. Person-Centered Therapy.
2. Cognitive-Behavioral Therapy.
3. Freudian Therapy.
4. Gestalt Therapy.
5. Adlerian Therapy.
6. Existential Therapy.

NOW GO TO SECTION G.

Section G: Based on the provisional diagnosis, what interventions and referrals might work best for this client?

DIRECTIONS: Select as many as you consider indicated in this Section.

1. Referral to a 12-step recovery and maintenance program.
2. Thought stopping.
3. Urine drug testing.
4. A combination of group and individual sessions.
5. Dream analysis.
6. Empathy.


Simulation #3

Lisa is a 14-year-old white female adolescent, brought in by her parents for oppositional behavior. She is the oldest of 4 children. The father describes her as routinely defiant, argumentative, frequently truant from school, and regularly sneaking out at night to “go places with her friends.” School teachers report frequent absences, noncompliance with homework, often distracted and poor attention to instruction, and disrespectful behavior toward authority figures (teachers and other school staff). Increasingly angry at any efforts to control her behavior, the daughter has taken to aggressive and even vindictive retaliation (e.g., scoring the paint on the automobile if they refuse to drive her places; breaking the glass in her bedroom window if locked shut; stealing money when denied requested funds). Her parents feel they have “done everything” to keep her attending school, staying in at night, and treating them and others respectfully. The daughter feels that the parents are overly strict, domineering, and refusing to “let her be herself and grow up the way she wants.” They are seeking further counsel and advice.

NOW GO TO SECTION A.

Section A: Initial Information Gathering

What intake information should be obtained and assessed to formulate a provisional DSM-IV-TR diagnosis?

DIRECTIONS: Select as many as you consider indicated in this section.

1. Any history of learning disabilities.
2. Length of time the problematic behaviors have persisted.
3. Any history of drug use/abuse.
4. Major disruptive changes in the home.
5. Nature of her relationship with friends.
6. Any history of fighting.
7. Any history of cruelty or bullying others.
8. Changes in sleeping patterns.
9. Length of absences when “sneaking away.”
10. Any history of stealing.
11. Any history of lying to specific advantage (“cons” others).
12. Excessive consumption of caffeine or sugar.
13. Major weight gain or loss.
14. Problems paying attention and/or coping with distractions.
15. Any history of fire-setting.

NOW GO TO SECTION B.

Section B: Based on the intake data, identify early issues that need to be addressed:

DIRECTIONS: Select as many as seem correct and necessary:

1. Focus on improving academic performance.
2. Address parent-child conflicts.
3. Explore possible sexual abuse.
4. Refer for learning disabilities testing.
5. Assist in creating an in-home behavior management plan.
6. Formally evaluate for symptoms of ADHD.
7. Increase respectful behavior toward figures of authority.
8. Educate the parents on reporting runaway concerns.

NOW GO TO SECTION C.

Section C: Additional Information Gathering

What assessment tools might offer meaningful information on this client?

DIRECTIONS: Select as many as you consider indicated in this section.

1. The Scholastic Aptitude Test.
2. The Behavioral Assessment Rating Scales.
3. Rorschach testing.
4. Conners ADHD Rating Forms.
5. The Child and Adolescent Needs and Strengths (CANS) functional assessment tool.
6. The Bender-Gestalt II.

NOW GO TO SECTION D.

Section D: Additional Data Gathering

To better determine the client’s level of function, what additional data may be helpful?

DIRECTIONS: Select the most appropriate options provided in this section.

1. Evaluate the quality of current peer relationships.
2. Review school records.
3. Seek collateral contact with a school counselor.
4. Complete a mental status evaluation.
5. Review diet and exercise patterns.
6. Initiate drug testing.
7. Determine if the parents feel the teen’s behavior is beyond control.
8. Explore the teen’s capacity to cope with the new baby in the home.

NOW GO TO SECTION E.

Section E: Provisional Diagnosis Formulation

Based on the available information, what would appear to be the most appropriate primary provisional DSM-IV-TR Axis I diagnosis?

DIRECTIONS: Select the most appropriate primary diagnosis indicated in this section.

1. Adjustment Disorder With Mixed Disturbance of Emotions and Conduct (309.4).
2. Attention-Deficit/Hyperactivity Disorder, Predominantly Inattentive Type (314.00).
3. Conduct Disorder, Adolescent-Onset Type (312.82).
4. Oppositional Defiant Disorder (313.81).
5. Disruptive Behavior Disorder NOS (312.9).
6. Sexual Abuse of Child (V61.21).

NOW GO TO SECTION F.

Section F: Identify appropriate short-term goals for this client.

DIRECTIONS: Select as many as you consider indicated in this section.

1. Placing the teen in a residential treatment center.
2. Exploring childhood memories.
3. Educating the parents in behavior modification techniques.
4. Improving school grades.
5. Introducing better patterns of parent-child communication.
6. Referring the case to Child Protective Services to explore possible sexual abuse.

NOW GO TO SECTION G.

Section G: Identify appropriate treatment outcomes for this client.

DIRECTIONS: Select as many as you consider indicated in this section.

1. Decreased verbal disrespect toward authority figures.
2. Better study habits.
3. Improved peer relationships.
4. Decreased incidents of truancy.
5. Increased exercise and intake of nutritional food.
6. Decreased incidents of leaving or failing to return home.
7. Reduced occurrences of property damage and theft.

NOW GO TO SECTION H.

Section H: Identify various interventions that would be appropriate.

DIRECTIONS: Select as many as you consider indicated in this section.

1. Role play.
2. Challenging negative thoughts.
3. Contracting.
4. Guided imagery.
5. Positive reinforcement.
6. Resolving unfinished business.

NOW GO TO SECTION I.

Section I: Identify the optimum theoretical approach for this situation.

DIRECTIONS: Select as many as you consider indicated in this section.

1. Psychoanalysis.
2. Transactional analysis.
3. Cognitive therapy.
4. Reality therapy.
5. Behavioral modification.


Simulation #4

Julie is a 20-year-old Asian college student. She is enrolled in a demanding premedical course of study. Her parents feel strongly that she should become a physician, but the rigorous curriculum has been taxing her capacity. Consequently her grade point standing may not be adequate to ensure later medical school admission. She would prefer to become a nurse, but her father will not accept this alternative. A roommate brought her into the University Counseling Center, concerned because she has lost a great deal of weight. Julie, however, does not feel concerned about her weight loss and feels she looks just fine. Over the last semester or two, her weight has fallen from 118 lb to 84 lb on her small-built 5 ft 5 in frame. Consulting a weight-height chart, her roommate notes that a medically healthy weight for a woman of her build is 117 to 130 lb. The roommate is concerned.

NOW GO TO SECTION A.

Section A: Initial Information Gathering

What intake information should be obtained and assessed to formulate a provisional DSM-IV-TR diagnosis?

DIRECTIONS: Select as many as you consider indicated in this section.

1. Employment history and current situation.
2. Past and current eating patterns and appetite.
3. Presence or absence of “binge and purge” episodes.
4. Educational goals.
5. Feelings about her weight.
6. Self-esteem and weight relationships.
7. Number and order of siblings in family of origin.
8. Any use of laxatives or diet pills.
9. Psychosocial stressors.
10. Irregular eating rituals.

NOW GO TO SECTION B.


Section B: Based on the intake data, identify the psychosocial and/or environmental stressors that should appear on the client’s DSM-IV-TR Axis IV:

DIRECTIONS: Select as many as seem correct and necessary.

1. Economic problems.
2. Occupational problems.
3. Educational problems.
4. Socio-environmental problems.
5. Primary support group problems
6. Health care access problems.

NOW GO TO SECTION C.


Section C: Provisional Diagnosis Formulation

Based on the available information, what would appear to be the most appropriate primary provisional DSM-IV-TR Axis I diagnosis?

DIRECTIONS: Select the most appropriate primary diagnosis indicated in this Section.

1. Eating Disorder NOS (307.50).
2. Anorexia Nervosa, Restricting Type (307.1).
3. Anorexia Nervosa, Binge Eating/Purging Type (307.1).
4. Bulimia Nervosa, Non-purging Type (307.51).
5. Bulimia Nervosa, Purging Type (307.51).
6. Adjustment Disorder With Mixed Disturbance of Emotions and Conduct (309.4).

NOW GO TO SECTION D.


Section D: Decision Making

Identify the services you can provide to help the client:

DIRECTIONS: Select the most appropriate options provided in this section.

1. Body dysmorphic/body image education.
2. Hospitalization.
3. Healthy eating education.
4. Eating disorder medications.
5. Counseling regarding locus of control issues.

NOW GO TO SECTION E.


Section E: Based on the information obtained, identify appropriate short-term treatment goals for this client.

DIRECTIONS: Select the short-term treatment goals indicated.

1. Increased self-esteem.
2. Awareness of repressed memories.
3. Meaningful and sustained weight gain.
4. New recreational activities.
5. Recognition of the need to control in anorexia.
6. Eliminate binging behaviors.

NOW GO TO SECTION F.


Section F: Identify potential effective treatments

DIRECTIONS: Select as many as you consider indicated in this section.

1. Abreaction.
2. Reality testing.
3. Engage prior effective coping skills.
4. Confrontation.
5. Keep a food diary.
6. Positive self-talk training.
7. Relaxation training.
8. Social skills training.

NOW GO TO SECTION G.


Section G: Following a successful course of counseling (the client’s weight moves into the healthy range), identify optimal ways to monitor client progress following therapy.

DIRECTIONS: Select as many as you consider indicated in this section.

1. Offer follow-up telephone consultations if/as requested by the client.
2. Have the roommate report on the client’s ongoing maintenance and progress.
3. Request daily telephone reports from the client.
4. Taper off the frequency of office visits until no longer needed.


Simulation #5

Joseph is a 26-year-old African-American man who returned from an 18-month tour of duty in an active war zone in the Middle East. He had been trained and served as a combat paramedic. He is a married college graduate with a young child. He did not reenlist upon his return, and instead obtained work at a local fire department as a paramedic. He made an appointment to see you, but did not disclose his reason at that time.

NOW GO TO SECTION A.

Section A: Initial Information Gathering

Indicate the questions that would be appropriate to ask in determining the client’s reason for seeking help.

DIRECTIONS: Select as many as you consider correct.

1. Who told you to see a counselor?
2. Why have you come in today?
3. Do you feel you have problems?
4. Can you describe your problem for me?
5. What do you hope to accomplish through therapy?
6. Are you willing to complete assignments between sessions?

NOW GO TO SECTION B.

Section B: Identify the least useful information to provide the client during an intake session:

DIRECTIONS: Select the information least likely to be helpful to the client at intake.

1. A review of confidentiality boundaries.
2. A summary of the purpose of counseling.
3. The therapist/counselor’s private personal biases.
4. A summary of this first working (intake) session.
5. The need for client commitment to the counseling process.

NOW GO TO SECTION C.

Section C: Diagnostic Formulation

Identify the most likely diagnosis, given the available information:

DIRECTIONS: Select the single most likely diagnosis in this situation.

1. Adjustment Disorder With Mixed Disturbance of Emotions and Conduct (309.4).
2. Substance-Induced Anxiety Disorder (292.89).
3. Posttraumatic Stress Disorder (309.81).
4. Acute Stress Disorder (308.3).
5. Generalized Anxiety Disorder (300.02).
6. Intermittent Explosive Disorder (312.34).

NOW GO TO SECTION D.

Section D: Clinical Response

The client is charged with battery for striking out at another. If a court order is issued for the counseling records, indicate the best response:

DIRECTIONS: Select the single most appropriate option provided in this section.

1. Direct the client to respond to the court order.
2. Disclose client information to a colleague to obtain helpful advice.
3. Have the client sign an information release for the spouse, and have her respond.
4. Inform the client of confidentiality limits and release the information.
5. Respond to the court personally, indicating possible harm to the client from this disclosure.

NOW GO TO SECTION E.

Section E: Assume that you work in a large counseling center with multiple counselors. One in particular has specific experience and training in PTSD and could provide particularly effective service to this client. However, you feel you would enjoy working with this client and feel that he would connect well with you. Given the situation, indicate the proper disposition of this case in the agency.

DIRECTIONS: Select the one most-appropriate disposition of the case.

1. Continue your work with Joseph, knowing that the client-therapist bond is particularly important.
2. Refer Joseph to the PTSD specialist for the most effective intervention.
3. Try to refer Joseph, and if he declines the referral then continue to work with him out of obligation, in spite of your lack of PTSD experience.
4. Turn Joseph away without any other referral if the PTSD specialist is not available, knowing that your skills in PTSD treatment are inadequate.

Answers

Simulation #1
Section A: Relevance and Initial Information Explored

1. Educational history
NOT INDICATED (-1)
High school graduate, of apparently normal intellectual functioning.

2. Mental status examination
NOT INDICATED (-1)
The formal record indicates “she is of normal intellectual capacity, and her current level of function is high.”

3. Current stressors
INDICATED (+1)
Unemployed and at risk of homelessness. Limited social support (no local family and few apparent friends, largely because the client is very quiet and introverted). Living in a group-style transitional setting. Ongoing issues of mental illness.

4. Frequency and nature of bipolar episodes
INDICATED (+2)
All decompensation episodes have been depressive in nature (i.e., no signs of mania). During the episodes, the client reported feelings of helplessness, hopelessness, hypersomnia, tearfulness, fatigue, poor concentration, and marked anhedonia. Over a period of two or more weeks, the symptoms escalated to include psychotic features (hallucinations, delusions, and intense agitation), resulting in involuntary psychiatric hospitalization. In between episodes, the client has been remarkably stable without apparent mood “coloring” of any kind.

5. Family mental health history
INDICATED (+1)
There is no family history of mental illness, and specifically none indicative of bipolar tendencies.

6. Past/Current medications prescribed
INDICATED (+1)
The client has no history of psychotropic medications use; current medication prescribed is lithium carbonate.

7. Medications compliance
INDICATED (+2)
The client is persistently noncompliant with her medications.

8. Current level of functioning
NOT INDICATED (-1)
The formal record indicates “her current level of function is high.”

9. Employment history
NOT INDICATED (-1)
The client resides in a transitional living residence and is unemployed. Past employment has involved clerical and house-cleaning jobs.

10. Substances of abuse
NOT INDICATED (-1)
The client has no past or current substance abuse.

11. Other psychiatric history
INDICATED (+1)
The client has no other known history of a psychiatric nature.

12. Quality of existing family relationships.
NOT INDICATED (-2)
The client has family who live on the opposite coast of the nation, and she has little contact with them.

RESPONSE DEVELOPMENT:
The client has been given a provisional Bipolar I Disorder diagnosis. However, relevant criteria for this diagnosis require at least one manic episode or mixed mania and depression. However, the record indicates the client has had only depressive symptoms evident during decompensation. Cyclothymic Disorder can be ruled out, as it is characterized by only mild depression and also requires evidence of hypomania; the client has had severe depressive symptoms, sufficient to induce “psychotic features,” and has exhibited no mania. Bipolar II is a possible diagnosis, although the requisite “at least one hypomanic” episode appears to be lacking. The absence of substance abuse further suggests endogenous rather than exogenous factors. Finally, the lack of any family bipolar history is noteworthy, as two-thirds of all individuals with a bipolar diagnosis have a family history of the disorder. Certainly the provisional diagnosis warrants further investigation.

Section B: Relevance of Potential Information to Be Addressed:

1. Focus on employment needs.
NOT INDICATED (-1)
The client is currently in a stable living situation, and staff at the transitional living center are charged with addressing the client’s employment status.

2. Explore and address family relationship issues.
NOT INDICATED (-1)
No family issues have been presented, thus assume there are none.

3. Improve the client’s insight into her illness.
INDICATED (+2)
The client is described as noncompliant with medications, and she has had repeated episodes of decompensation. She is clearly in need of education regarding her illness and its effects, the role of medications, how to head off impending episodes, decompensation, and coping skills.

4. Explore past symptoms of depression and coping.
INDICATED (+1)
The client describes classic symptoms of depressive decompensation lasting more than two weeks, and she is in need of better coping skills, including medication compliance.

5. Address mediation noncompliance concerns.
INDICATED (+2)
Of primary concern, given the provisional diagnosis, is medication compliance.

Section C: Element Relevance and Secondary Information Obtained
1. Income history.
NOT INDICATED (-1)
The client has no current income, but is in a stable total-care living situation.

2. The Beck Depression Inventory-II.
NOT INDICATED (-2)
The client is not currently in a decompensated state; this evaluation for depression is not indicated.

3. Duration of time between decompensation episodes.
INDICATED (+1)
It is revealed that the client has annual episodes of decompensation, with remarkable stability between episodes. Decompensation is brief, and tends to be quickly resolved by involuntary hospitalization and medication administration.

4. Degree of medication noncompliance.
INDICATED (+2)
The client is totally noncompliant with medications throughout all periods between decompensation episodes, and cannot be legally forced to comply.

5. Seasonal mood patterns.
INDICATED (+1)
The client’s episodes of decompensation occur only during the last two weeks of August each year, suggesting a late-summer seasonal pattern.

6. Suicidal ideation/attempts.
INDICATED (+1)
The client denies ever having attempted suicide, and denies ideation with any real intent (e.g., transient thoughts but absent any element of planning).

7. Unexplained weight gain or loss.
INDICATED (+1)
No significant weight loss or gain has been reported.

8. Medical history.
INDICATED (+1)
The client has been medically evaluated. No history of head trauma, hormone imbalance, seizures, or other relevant disorders.

9. Postpartum depression.
INDICATED (+2)
The client is gravida 2, para 2 (no spontaneous or therapeutic abortion history), and denies any problems with postpartum depression.

10. Religious affiliation/attendance.
NOT INDICATED (-1)
No issues regarding religiosity have been identified.

11. Traumatic life events.
INDICATED (+2)
Upon careful interview the client admits she was the driver of the vehicle in which her two children were killed, when struck by a drunk driver, in August 3 years ago.

12. Marital history.
NOT INDICATED (-1)
No issues of a marital nature have been identified. However, the divorce did occur shortly after the death of the children.

RESPONSE DEVELOPMENT:

Duration of time between decompensation episodes is significant as the average number of bipolar episodes is 8 to10 over a lifetime, and this client is experiencing episodes at least annually. Issues of medication noncompliance are significant, as most individuals with bipolar disorder will tend toward symptoms of depression and/or mania when not medicated. This client, however, manages well for extended periods with no mood “coloring” in spite of the absence of medications. The seasonal nature of the client’s episodes (summertime only) is significant, as many individuals with bipolar disorder have seasonal variations (e.g., particularly depressive symptoms in the fall). The absence of postpartum depression is meaningful, as bipolar disorder is triggered by pregnancy and postpartum mood changes in up to 25% of diagnosed women. In summary, the client’s decompensation frequency is higher than would be expected, stability off of medications is far better than would be expected (i.e., no mood “coloring” at all), the condition was not triggered nor exacerbated by pregnancy, there is no family history, as would be common, and the periods of onset are far too specific (i.e., limited to the last 2 weeks in August) than could be explained by a diagnosis of Bipolar I Disorder alone.

Section D: Relevance and Diagnostic Formulation.

1. Posttraumatic stress disorder.
INDICATED (-1)
The client meets PTSD criteria during episodes of decompensation, but lacks sufficient features for a full diagnosis of PTSD (primarily because of her success in blocking out the event outside the time immediately surrounding the “anniversary date” of the loss).

2. Adjustment Disorder, With Mixed Anxiety and Depressed Mood, chronic.
NOT INDICATED (-1)
DSM-IV-TR specifies that the diagnosis of an adjustment disorder may not be given in situations related to bereavement, and cannot persist longer than 6 months. The client appears to have specific issues surrounding the loss of her children, and the problem has episodically resurfaced over the past 3 years.

3. Bereavement as “a focus of clinical attention.”
NOT INDICATED (-1)
As indicated at the top of page 5 of the DSM-IV-TR, V codes represent things that are the focus of clinical attention but are not considered disorders. Given the severity and recurrent nature of this case, a V code would not be diagnostically sufficient.

4. Major Depressive Disorder, Recurrent, Severe With Psychotic Features.
INDICATED (+3)
The client has key features of depression, including feelings of helplessness, hopelessness, hypersomnia, tearfulness, fatigue, poor concentration, and marked anhedonia, eventually progressing to include psychotic features. Symptoms persisted for more than 2 weeks and only resolved with hospitalization and medication.

5. Bipolar II Disorder
NOT INDICATED (-1)
Requires at least 1 episode of hypomania in addition to an episode of Major Depression.

6. Brief Psychotic Disorder, With Marked Stressors
NOT INDICATED (-1)
The DSM-IV-TR notes that this diagnosis is only appropriate where disturbance is not better accounted for by a Mood Disorder, With Psychotic Features. The client’s marked depressive symptoms more accurately fit Mood Disorder criteria.

7. Schizoaffective Disorder
NOT INDICATED (-1)
For this diagnosis, there must have been an uninterrupted period of illness (the client’s symptoms completely resolve between episodes), and psychotic features must have persisted in the absence of prominent mood symptoms (the client’s mood symptoms persisted during psychosis).

RESPONSE DEVELOPMENT:

The client’s history is positive for a profoundly traumatic life event: the death of her 2 children, in August, 3 years prior (coinciding with the onset of decompensation episodes). This history suggests PTSD, and/or Major Depression, recurrent, severe, with psychotic features. The client lacks sufficient features for a full diagnosis of PTSD (primarily because of her success in blocking out the event outside the time immediately surrounding the “anniversary date” of the loss), although some features are present. The DSM-IV-TR V code of V62.82 (bereavement) is inadequate, because it refers solely to issues of bereavement that are a focus of clinical attention, without addressing the severity of the problem (while a diagnosis for complicated, prolonged, traumatic, or atypical grief is being considered for DSM-V). This leaves Major Depression, recurrent, severe, with psychotic features, with full interepisode recovery, as a full remission was attained between the mood disturbance episodes.

Section E: Treatment Approach Relevance and Selection.

1. Individual Grief Therapy.
INDICATED (+2)
All signals are that the client has unresolved grief issues urgently in need of address. Worden (1991) indicates that “grief counseling” addresses uncomplicated or normal grief, while grief therapy utilizes specialized techniques to address abnormal or complicated grief: (1) prolonged grief; (2) grief manifested through somatic or behavioral symptoms; or (3) an exaggerated grief response.

2. Family Counseling.
NOT INDICATED (-2)
No family involvement described; must assume there are no relevant issues.

3. Participation in a bereavement support group.
INDICATED (+1)
The client’s history suggests great fragility, and support group settings are generally insufficiently structured to ensure this client’s best interests. After progress in one-on-one sessions, group work may well be indicated.

4. Stress Management Counseling.
INDICATED (+1)
The client clearly has not coped well with the stressors surrounding her loss. This approach may be useful in conjunction with grief counseling.

5. Illness Insight Counseling.
INDICATED (+2)
The client is greatly in need of illness insight counseling, both to understand what is occurring in her life, and to more fully ensure treatment compliance.

6. Independent Living Education.
NOT INDICATED (-2)
All indications are that this previously married mother of two was functioning well prior to the traumatic loss of her children. There is no indication that she is in need of education regarding independent living skills.

7. Medication Compliance Monitoring and Counseling.
INDICATED (+2)
The constellation of symptoms described strongly suggests the need for psychiatric medications, and counseling and compliance monitoring to this end is particularly important.

8. Cognitive-Behavioral Therapy.
INDICATED (+2)
This technique is most useful in situations where understanding (of illness) and behavioral change (medication compliance) are required.

9. Psychiatrist Referral to Evaluate Medication Needs.
INDICATED (+2)
Given the scenario presented, it is highly likely that this client will need medication support, and prompt follow-up with a psychiatrist is essential.

Section F: Information and Monitoring Methods Relevance and Selection.
1. Staff reports of progress in the transitional living program.
NOT INDICATED (-1)
Transitional living activities and progress are not a substantial measure of grief work and progress.

2. Mood graph
INDICATED (+2)
Tracking mood on a graph aids in determining the client’s level of depression, as well as progress being made in coping, etc.

3. Completion of homework assignments.
INDICATED (+1)
This serves as a measure of compliance and motivation. Approaches may include 1) journaling, 2) bibliotherapy (reading assignments), 3) memorialization.

4. Medications monitoring
INDICATED (+2)
Pill counts and therapeutic blood levels (where indicated)

5. Affective functioning
INDICATED (+1)
The client’s affective presentation should signal any upcoming relapse and should be followed closely.

6. Social interactions
INDICATED (+1)
The client has been described as quiet and introverted, which may predispose relapse. Thus, careful monitoring of social interactions is important.

7. Substance abuse monitoring
NOT INDICATED (-1)
No issues of substance abuse have been identified.

8. Energy level.
INDICATED (+1)
Increasing fatigue, apathy, and listlessness may signal a relapse and should be followed closely.

9. Employment seeking
NOT INDICATED (-1)
This is a component of the facility’s program, and is largely unrelated to the current issues being addressed.

10. Cognitive functioning
INDICATED (+1)
The client struggled with poor concentration and distractibility during past periods of decompensation. This should also be carefully monitored.

Section G: Treatment Plan Development Options – Relevance and Selection.
1. Identify the goals of treatment appropriate to the issues being addressed.
INDICATED (+2)
Shared efforts to identify the goals of treatment will elicit client buy-in to the process and outcomes of the therapeutic experience.

2. Decide on the total number of sessions required.
NOT INDICATED (-1)
While a general counseling course may be parsed if requested by the client, no effort should be made to delimit this important experience at the outset.

3. Develop the specific objectives to meet the identified goals.
INDICATED (+2)
Identification of the steps to goal achievement deepens client commitment and overall clarity of necessary steps and expectations.

4. Determine the client’s post-counseling housing options.
NOT INDICATED (-2)
This issue is being addressed by the transitional living program, and is not germane to the counseling issues being addressed.

5. Address confidentiality requirements and limits.
INDICATED (+1)
Every client needs to know the scope and limits of confidentiality in the context of counseling, and it should be addressed at the outset of the counseling experience.

SCORING: (Max = maximum possible; MPL = minimum passing level)

1A. Max 8; MPL 5
1B. Max 5; MPL 3
1C. Max 11; MPL 8
1D. Max 3; MPL 1
1E. Max 12; MPL 8
1F. Max 9; MPL 6
1G. Max 5; MPL 3

Simulation #2

Section A: Relevance and Initial Information Obtained

1. Residential history.
INDICATED (+1)
The client has lived in various group homes and board and care settings since late adolescence, based on behavioral problems and the presumptive presence of “some sort of mental illness.” He had often been evicted because of disruptive and aggressive behavior. He does not get along well with his parents, and states that they would not allow him back into their home.

2. Medical history.
INDICATED (+1)
No information relevant to a diagnosis was obtained. No reported history of head trauma, neurological disorders, endocrine (including thyroid) disorders, and no metabolic issues. Client is a chronic 3-pack/day smoker.

3. Educational history.
NOT INDICATED (-1)
Not relevant to formulating a DSM diagnosis. However, the client dropped out of high school in his junior year.

4. Interpersonal relationships.
INDICATED (+1)
An only child, he was functionally estranged from his parents, who nevertheless support him. All reported friendships were with adolescents and others much younger than him. Age-appropriate relationships were typically transient and problematic because of the client’s demanding nature.

5. Psychiatric history.
INDICATED (+2)
At least 1 prior psychiatric hospitalization for “schizophrenic-like” behavior, with suspicions of substance-induced psychosis (blood testing was positive for methamphetamine abuse). This hospitalization became the basis for his subsequent admissions to board and care homes. It also resulted in the assignment of a mental health case manager, largely serving only to relocate him to new living settings following his frequent evictions, and to manage his money

6. Substance abuse.
INDICATED (+2)
Client admits remote history of amphetamine use, but denies any current use.

7. Mood status.
INDICATED (+1)
The client is often agitated, angry, and mercurial. Similar features evident during intake.

8. Vocational/employment.
NOT INDICATED (-2)
Not germane to the diagnostic process; client has no special skills or training. He has never been employed.

RESPONSE DEVELOPMENT:
The client is a 32-year-old adult with a history of substance abuse, disruptive, angry behavior, poor impulse control, moodiness, and possible psychotic behavior. He has poor educational achievement, negligible independent living skills, no vocational skills, and no employment history. Prior psychiatric hospitalization suggests the presence of mental illness. However, it is unclear whether presenting symptoms at the time of hospitalization were due to substance abuse or an underlying psychiatric condition. The care operator reports episodic symptoms of “talking to himself” that suggest attention to internal stimuli. However, these symptoms could also reflect ongoing substance abuse, as could his alternating episodes of insomnia and hypersomnia.

Section B: Relevance of Potential Information Needing to be Addressed:

1. Family relationships.
NOT INDICATED (-1)
The client is an only child and is long estranged from his parents. This is not a pressing issue.

2. Suicidality
NOT INDICATED (-1)
There is no indication of depression, grief, or overt self-harm intent.

3. Anger management.
INDICATED (+2)
By all reports and presentation the client has anger management issues requiring address.

4. Mood swings.
INDICATED (+1)
Reports indicate that the client has frequent mood swings that compromise his ability to cope with relationships and other emotional issues (e.g., anger).

5. Educational issues.
NOT INDICATED (-1)
While it would be positive for the client to complete his high school education, it is not a pressing or relevant issue requiring address.

6. Impulse control.
INDICATED (+2)
By reports and presentation the client appears to have very poor impulse control.

7. Employment issues.
NOT INDICATED (-1)
The client has no employment history. However, his living situation appears stable (outside of behavioral issues) and employment concerns do not need current address.

8. Explore possible substance abuse.
INDICATED (+2)
The client’s mental health symptoms could be explained by ongoing substance abuse, which needs to be explored further and then addressed if confirmed.

Section C: Relevance of Proposed Assessment Tools:

1. The Minnesota Multiphasic Personality Inventory (MMPI-2)
INDICATED (+1)
This widely used, well-validated personality instrument could provide objective insights into this client’s personality, but it may be difficult to administer to an individual with limited tolerance and impulse control.

2. The 16 Personality Factor Questionnaire (16PF).
INDICATED (+2)
This internationally used and well-validated multiple-choice personality questionnaire measures 16 primary traits, along with 5 higher-level “second-order” traits. The test is useful in predicting a wide variety of behaviors; most particularly for this case includes cognitive style, empathy and interpersonal skills, conscientiousness, self-esteem, frustration tolerance, and coping patterns.

3. Wechsler Adult Intelligence Scale, Fourth Edition (WAIS-IV)
NOT INDICATED (-2)
There is no information nor presentation pattern to suggest diminished cognitive capacity.

4. Drug Abuse Screening Test (DAST)
NOT INDICATED (-1)
There are suspicions of drug abuse, but the client denies such use. As a self-report instrument, this test is of no immediate value.

5. Beck Depression Inventory-II (BDI-II)
NOT INDICATED (-1)
The client is reportedly moody, but the primary emotion displayed is anger as opposed to depression.

6. Thematic Apperception Test (TAT)
INDICATED (+1)
This projective assessment tool may aid in uncovering useful unconscious material with this client.

Section D: Options Relevance and Findings.

1. Direct interviews with the care home operator and staff.
INDICATED (+2)
The operator has described the client as disruptive, impulsive, and threatening, with episodes of unexplained “crazy” behavior, talking to himself, sleeping very little for days and then “crashing,” and being verbally explosive at times. Other facility staff offered similar supporting views

2. School records review.
NOT INDICATED (-2)
The client is 32 years of age and left school between 16 and 17 years of age. These records would be difficult to obtain (the client is unlikely to release them), and would offer only very remote history.

3. Collateral contact with the mental health case manager.
INDICATED (+2)
The mental health case manager, citing a client information release, notes that the client has had considerable behavioral problems for some years (evicted from more than 20 care homes). He confirms ongoing substance abuse (“I pulled needles out of his clothes last week, and if I don’t use a payee service to manage his money, he spends it all on methamphetamines). He also seconds the suspicions that the client’s “mental health” issues are actual a direct result of his drug use, as the client tends to display psychotic features only when using drugs.

4. Contact with the client’s neighborhood friends.
NOT INDICATED (-1)
The client tends to associate only with minors. Friends and neighbors reveal the client has issues of confidentiality and other potential legal pitfalls.

5. Collateral contact with the client’s parents.
NOT INDICATED (-1)
The client specifically indicates that he is estranged from them. Reports indicate that the politically well-placed parents have “pulled strings” to secure mental health services for their son, and that they are very defensive of him to the point of covering and denying his behavior.

6. Legal history review.
INDICATED (+2)
Local law enforcement records indicate that the client has repeatedly been picked up for possession/purchase of methamphetamine. He was not prosecuted, however, as he was seen as a mental health client and was relinquished for psychiatric care.

7. Medical records review.
INDICATED (+2)
The client has had repeated emergency department visits at the local county hospital, having been brought in by law enforcement for “bizarre behavior” and being under the influence on numerous occasions, most recently within the last 30 days. Records indicate positive laboratory testing for amphetamines, and that his psychotic behavior and hallucinations (formication) typically cleared as soon as the intoxication had passed.

RESPONSE DEVELOPMENT:
The client has a positive ongoing history of drug abuse (methamphetamine, by report), which appears to be his primary mental health issue. With the case manager’s description of syringes and needles in the client’s personal affects, it appears that intravenous drug abuse is a primary concern.

Section E: Element Relevance and Diagnostic Formulation

1. Amphetamine-Induced Psychotic Disorder, With Delusions (292.11).
NOT INDICATED (-1)
There is no report of delusions when the patient was in a substance-induced psychotic state.

2. Amphetamine Dependence (304.40).
NOT INDICATED (-2)
There is no report of substance withdrawal symptoms; rather, the client appears to abuse methamphetamine recreationally (likely because his funds do not allow for more extensive abuse).

3. Amphetamine-Induced Psychotic Disorder, With Hallucinations (292.12).
INDICATED (+3)
This would be the proper primary diagnosis. Clinical laboratory testing confirms that the client has abused amphetamines in the past. The substance was reportedly methamphetamine (an amphetamine-class drug). Psychotic behavior with hallucinations (formication) was medically documented as well.

4. Intermittent Explosive Disorder (312.34).
NOT INDICATED (-2)
The DSM indicates that the behavioral criteria for this diagnosis must not be met by “a general medical condition or substance use, including medications and drugs of abuse.”

5. Attention-Deficit Hyperactivity Disorder NOS (314.9).
NOT INDICATED (-1)
While the client does appear to be impulsive and easily agitated, the substance abuse may well be the primary cause of his erratic and hyperactive behavior, insomnia, etc.

6. Narcissistic Personality Disorder (301.81).
NOT INDICATED (-2)
This client clearly has features of narcissism, among other possible personality disorder traits. However, it is NEVER appropriate to produce an Axis II diagnosis early in a clinical course, absent a substantial preponderance of relevant supporting evidence. Until all Axis II issues are clear, a clinician should enter 799.9: Axis II diagnosis is deferred or pending more information.

RESPONSE FORMATION
The current provisional DSM-IV-TR Axis I diagnoses for this client would be:
1. Amphetamine Abuse (episodic) (primary) (305.7).
2. Amphetamine-Induced Psychotic Disorder, With Hallucinations (by prior history) (292.12).
3. Nicotine Dependence (305.10).

Section F: Element Relevance and Commentary
1. Person-Centered Therapy.
NOT INDICATED (-1)
This approach works well for situational disorders or self-esteem issues, but it is not ideal for substance abuse problems.

2. Cognitive-Behavioral Therapy.
INDICATED (+2)
This approach is ideal for substance abuse treatment; it can be readily focused on relapse prevention strategies.

3. Freudian Therapy.
NOT INDICATED (-1)
This therapeutic approach is best suited to short-term interventions around depression and anxiety, and long-term therapy with dissociative disorders and personality disorders.

4. Gestalt Therapy.
NOT INDICATED (-1)
This approach is appropriate for individuals coping with stressors of a more minor nature, as opposed to a substance abuse issue.

5. Adlerian Therapy.
NOT INDICATED (-1)
The Adlerian approach is well suited to marital concerns, parent-child conflicts, acting out, and other emotive issues in otherwise healthy clients, but not for substance abuse problems.

6. Existential Therapy.
NOT INDICATED (-1)
This approach works best for individuals coping with anxiety or depression, but not for substance abuse

Section G: Element Relevance and Commentary

1. Referral to a 12-step recovery and maintenance program.
INDICATED (+2)
This is ideal for treating a client with a substance abuse problem.

2. Thought stopping.
INDICATED (-1)
This intervention can be helpful for overcoming substance abuse problems, as well as for assisting a client to gain better control over inappropriate, negative, and/or aggressive thoughts and emotions.

3. Urine drug testing.
INDICATED (+2)
An important part of substance abuse treatment.

4. A combination of group and individual sessions.
INDICATED (+1)
Combined individual and group therapy can be more effective in treating substance abuse.

5. Dream analysis.
NOT INDICATED (-2)
Not indicated in the treatment of substance abuse, but may be helpful in addressing potentially contributing factors (e.g., stress related to repressed memories, conflicts).

6. Empathy.
NOT INDICATED (-1)
This therapeutic approach is often too passive for the accountability-oriented requirements of substance abuse treatment.

SCORING: (Max = maximum possible; MPL = minimum passing level)

2A. Max 8; MPL 5
2B. Max 7; MPL 4
2C. Max 4; MPL 2
2D. Max 8; MPL 5
2E. Max 3; MPL 2
2F. Max 2; MPL 1
2G. Max 5; MPL 3

Simulation #3

Section A: Element Relevance and Initial Information Obtained

1. Any history of learning disabilities.
INDICATED (+1)
Learning disabilities could relate to misbehavior in school, poor attention to educational tasks, easy distractibility, and even behavioral problems. Testing may be needed. However, the parents deny any past learning problems. The teen’s past academic record was quite good.

2. Length of time the problematic behaviors have persisted.
INDICATED (+3)
The parents report the problems have been pronounced and problematic for the last 8 to 9 months. This information is essential for some diagnoses.

3. Any history of drug use/abuse.
INDICATED (+1)
While no specific mention was made of drug use, early experimentation could contribute to the problems noted. At present, both the teen and the parents deny this.

4. Major disruptive changes in the home.
INDICATED (+2)
The parents experienced a later-life “surprise pregnancy,” and the baby is now about 6 months old. The parents admit that the mother has been more tired and less consistent in parenting since the birth of the child, and also began making more frequent requests for assistance from the teen daughter near the conclusion of the pregnancy and since the birth of the baby.

5. Nature of her relationship with friends.
INDICATED (+2)
The parents note, and the teen admits to a major change in friends. The child is involved with an older, rougher “high school” crowd. When confronted the daughter admits to “seeing” a 19-year-old man who lives where this crowd often gathers. She refuses to address whether or not she is sexually active with the man.

6. Any history of fighting.
INDICATED (+1)
Parents and the teen deny any fighting with others.

7. Any history of cruelty or bullying others.
INDICATED (+1)
No relevant history.

8. Changes in sleeping patterns.
NOT INDICATED (-1)
No problems mentioned or noted.

9. Length of absences when “sneaking away.”
INDICATED (+1)
The parents are aware of 2 occasions when their daughter did not return home from school until the next day.

10. Any history of stealing.
INDICATED (+1)
The parents and the teen deny any such history.

11. Any history of lying to specific advantage (“cons” others).
INDICATED (+1)
The teen has frequently lied to gain advantage, principally to escape responsibilities in the home, avoid school and homework, and be with friends.

12. Excessive consumption of caffeine or sugar.
NOT INDICATED (-2)
While this could be minor issue, it is not diagnostically relevant.

13. Major weight gain or loss.
NOT INDICATED (-2)
This is not relevant from the material presented.

14. Problems paying attention and/or coping with distractions.
INDICATED (+1)
Reports of poor attention and being easily distracted have been noted by the teen’s teachers. However, the parents report that this was never any problem until the current school year when the problematic behaviors began.

15. Any history of fire-setting.
INDICATED (+1)
A necessary to “rule out” certain diagnoses.

RESPONSE DEVELOPMENT:
From the information provided the teen does not fully meet criteria for a diagnosis of “Conduct Disorder” (lacks the core sociopathic-like features). Learning disabilities do not appear to be likely, nor does the teen appear to meet the essential features of Attention-Deficit/Hyperactivity Disorder (the history of poor attention and distractibility appears to be only of recent origin, and falls short of the more graphic, impulsive, and pronounced qualities found in an ADHD diagnosis). Recent events in the home (the unexpected late-life birth) complicate the picture somewhat. What is clear, however, is that the teen is contentious, argumentative, disrespectful of authority figures, frequently truant from school, suffering academically, episodically absent from the home without permission, and dishonest to achieve specific problematic goals (to avoid school, homework, in-home responsibilities) and to be with friends. She appears also to be involved with a young man 5 years her senior, perhaps even sexually.

Section B: Element Relevance of Potential Information to Be Addressed:

1. Focus on improving academic performance.
NOT INDICATED (-2)
Other behavioral problems and basic school attendance must be addressed and stabilized before it would be possible to effectively address primary academic performance.

2. Address parent-child conflicts.
INDICATED (+3)
This is a priority issue that must be addressed promptly, and must closely involve the parents.

3. Explore possible sexual abuse.
INDICATED (+3)
Given the teen’s admission of “seeing” a young man 5 years her senior, it is reasonable to suspect sexual activity. This must be addressed immediately.

4. Refer for learning disabilities testing.
NOT INDICATED (-2)
The teen’s academic history is not problematic. Rather, it is only her recent academic performance that has been poor. Thus, it is not reasonable to presume the need for further evaluation in this regard.

5. Assist in creating an in-home behavior management plan.
INDICATED (+2)
It would appear that the parents have not produced a behavioral management plan involving rewards and consequences. This must be undertaken early on to begin to ward off further behavioral deterioration and the need for more serious steps.

6. Formally evaluate for symptoms of ADHD.
NOT INDICATED (-1)
While the teen’s current teachers have noted issues of poor attention and easy distractibility, there is no history of problems of this nature. In fact, the teen’s past academic performance was reportedly very good (the parents note she qualified to participate in “gifted” educational programs in the past).

7. Increase respectful behavior toward figures of authority.
INDICATED (+2)
It is important that the teen’s negative thought patterns regarding authority figures will need to be addressed, challenged, and modified to reduce the incidences of disrespectful behavior in the home and at school.

8. Educate the parents on reporting runaway concerns.
INDICATED (+2)
The parents will need to learn how to access the juvenile justice system, and obtain additional support in order to stop the teen’s early evidence of runaway tendencies (absent overnight at least twice, returning only after school the next day).

Section C: Relevance of Proposed Assessment Tools:

1. The Scholastic Aptitude Test.
NOT INDICATED (-1)
Reports indicate that the teen’s academic capacity is more than adequate. The issues are behavioral, rather than aptitude- or capacity- based.

2. The Behavioral Assessment Rating Scales.
INDICATED (+3)
There are a variety of well-validated behavioral assessment tools that are appropriate for use in the home and at school. By using a standardized assessment tool, everyone involved can carefully follow the teen’s progress and rate of improvement, and can adjust interventions and consequences accordingly.

3. Rorschach testing.
NOT INDICATED (-2)
This projective tool looks at personality issues, and is not particularly useful for adolescent behavioral problem evaluation.

4. Conners ADHD Rating Forms.
NOT INDICATED (-1)
Although some mention of distractibility and poor attention was made by some teachers, the teen has no longstanding history of inattentive, hyperactive, distracted, and impulsive behavior of sufficient magnitude to warrant early evaluation.

5. The Child and Adolescent Needs and Strengths (CANS) functional assessment tool.
INDICATED (+3)
This tool can offer broad evaluation of both deficits and strengths in an adolescent, aiding the clinician to target key problems and capitalize on key strengths.

6. The Bender-Gestalt II.
NOT INDICATED (-2)
Based on the information provided, it does not appear that a neurological assessment tool would provide any particular insights or benefits.

Section D: Options Relevance and Findings:

1. Evaluate the quality of current peer relationships.
INDICATED (+3)
Further evaluation revealed that this teen has been primarily associating with older high school adolescents, causing her to strive to prematurely “grow up” and inappropriately introducing her to more mature issues that she is not prepared to properly handle.

2. Review school records.
NOT INDICATED (-1)
Ample information is available by direct interview of the parents and teachers. If the primary concern were related to learning disabilities, a records review might be more meaningful.

3. Seek collateral contact with a school counselor.
INDICATED (+2)
A school counselor can be an important source of additional information, as well as a key participant in any behavioral change plan.

4. Complete a mental status evaluation.
NOT INDICATED (-2)
There is no indication that this teen has neurological processing deficits. She presents as oriented to person, place, time, and situation, and has no evidence or complaint of hallucinations or delusions, nor complaints of impaired memory or cognitive function.

5. Review diet and exercise patterns.
NOT INDICATED (-1)
Nothing presented suggests issues of a dietary or physiological nature.

6. Initiate drug testing.
NOT INDICATED (-1)
There is, as of yet, no evidence of drug use or abuse.

7. Determine if the parents feel the teen’s behavior is beyond control.
INDICATED (+3)
When questioned, the parents feel that they cannot cope with the teen’s ongoing behaviors, and therefore aggressive and timely intervention will be necessary.

8. Explore the teen’s capacity to cope with the new baby in the home.
INDICATED (+1)
Some information suggests that decreased parental support and increased demands for help were due to the presence of the new baby.

Section E: Element Relevance and Diagnostic Formulation:

1. Adjustment Disorder With Mixed Disturbance of Emotions and Conduct (309.4).
NOT INDICATED (-1)
While there is a new and disruptive change in the home (the birth of the new baby), it is not the primary cause of the teen’s behavioral problems, nor has she cited it as an overwhelming stressor of any kind.

2. Attention-Deficit/Hyperactivity Disorder, Predominantly Inattentive Type (314.00).
NOT INDICATED (-1)
Information already in evidence indicates that this would not be the primary diagnosis for this teen client. Current issues of inattention and distractibility are of recent origin, and do not meet threshold criteria.

3. Conduct Disorder, Adolescent-Onset Type (312.82).
NOT INDICATED (-1)
The key features of this diagnosis are far more serious and longstanding than those in evidence by this teen client. While some features are present (e.g., stealing, damaging property), they are not substantial or serious enough to warrant this diagnosis.

4. Oppositional Defiant Disorder (313.81).
INDICATED (+3)
This teenager has been oppositional and defiant with her parents, teachers, and other authority figures, and is displaying behavior that is impairing her relationships, her academic performance, and her overall well-being and safety.

5. Disruptive Behavior Disorder NOS (312.9).
NOT INDICATED (-1)
The behavior of this teen client is much more than “disruptive” and warrants serious intervention.

6. Sexual Abuse of Child (V61.21).
NOT INDICATED (-1)
While the chances are good that this teenager may be sexually involved with an older individual, this conduct is not the focus of the clinical intervention and would not be the “primary” diagnosis.

RESPONSE FORMATION
The current provisional DSM-IV-TR Axis I diagnoses for this client would be:
1. 313.81 Oppositional Defiant Disorder (primary).
2. V61.21 Sexual Abuse of Child.

Section F: Relevance of Short-Term Goals Identified:

1. Placing the teen in a residential treatment center.
NOT INDICATED (-3)
All other options and intervention avenues should be exhausted before this option would be considered (exception: if the safety of the parents or teen will be profoundly compromised in the current living situation).

2. Exploring childhood memories.
NOT INDICATED (-2)
This approach would not allow for timely address of the serious presenting problems.

3. Educating the parents in behavior modification techniques.
INDICATED (+3)
This is the first and most important step in the intervention process.

4. Improving school grades.
NOT INDICATED (-2)
Academic performance will improve as a matter of course when other behavioral problems are remedied and resolved.

5. Introducing better patterns of parent-child communication.
INDICATED (+2)
Addressing communication patterns will assist in decreasing confrontational, disrespectful, and argumentative encounters between the teen and other authority figures.

6. Referring the case to Child Protective Services to explore possible sexual abuse.
INDICATED (+3)
Every state has laws requiring that even suspicions of child sexual abuse be reported. The allowable age discrepancy between two teens varies, but no state allows a disparity of 5 or more years.

Section G: Treatment Outcomes Relevance and Selection:

1. Decreased verbal disrespect toward authority figures.
INDICATED (+2)
This is an essential goal, both in the home and at school.

2. Better study habits.
NOT INDICATED (-2)
Academic performance will improve as other behavioral issues are resolved.

3. Improved peer relationships.
INDICATED (+2)
It is essential that the teen client reestablish with an appropriate peer group. Continuing to associate with poorly chosen friends who are much older will lead to additional problems.

4. Decreased incidents of truancy.
INDICATED (+2)
Failure to make progress in this area can result in legal action.

5. Increased exercise and intake of nutritional food.
NOT INDICATED (-3)
There have been problems identified related to food and exercise.

6. Decreased incidents of leaving or failing to return home.
INDICATED (+2)
This is an area that will lead to legal intervention if left unaddressed.

7. Reduced occurrences of property damage and theft.
INDICATED (+2)
Continued problems in this area will quickly lead to damaging legal issues.

Section H: Intervention Relevance and Selection:

1. Role play.
INDICATED (+2)
This technique can aid by demonstrating proper methods of communication and conflict resolution.

2. Challenging negative thoughts.
INDICATED (+1)
Inaccurate and unproductive views about the role and nature of authority figures can be improved through this approach.

3. Contracting.
INDICATED (+1)
This technique establishes mutual expectations, benefits/rewards, and consequences, and is especially helpful in a behavioral modification process.

4. Guided imagery.
NOT INDICATED (-2)
This technique is most useful in addressing situations where a client is avoiding or overwhelmed by a difficult or fearful situation or memory.

5. Positive reinforcement.
INDICATED (+3)
This technique is highly effective in situations of behavioral problems, and can be effective in both home and school settings.

6. Resolving unfinished business.
NOT INDICATED (-3)
This technique is used with adults who have past issues that remain unresolved.

Section I: Relevance and Selection of an Optimal Theoretical Approach:

1. Psychoanalysis.
NOT INDICATED (-1)
This approach addresses unconscious conflicts, rather than conscious choices.

2. Transactional analysis.
NOT INDICATED (-1)
This approach does not focus on feelings important to a teenager, and is overly intellectual.

3. Cognitive therapy.
NOT INDICATED (-1)
While this approach could be helpful in this situation, it is not the best option available.

4. Reality therapy.
NOT INDICATED (-1)
This is an approach that could be helpful in this situation, but it is not the best option.

5. Behavioral modification.
INDICATED (+3)
This approach would be optimal in addressing a behavioral disorder.

SCORING: (Max = maximum possible; MPL = minimum passing level)

3A. Max16; MPL 10
3B. Max 12; MPL 8
3C. Max 6; MPL 4
3D. Max 9; MPL 6
3E. Max 3; MPL 2
3F. Max 8; MPL 5
3G. Max 10; MPL 7
3H. Max 7; MPL 4
3I. Max 3; MPL 2

Simulation #4

Section A: Element Relevance and Initial Information Obtained:

1. Employment history and current situation.
NOT INDICATED (-2)
The client’s employment status and past history is not relevant, unless if finances were at the root of her weight loss (i.e., unable to obtain food). In this scenario, resources are adequate to meet food requirements.

2. Past and current eating patterns, appetite, and weight.
INDICATED (+2)
Eating frequency, quantity consumed at any given meal, and any significant weight changes are all relevant in determining a diagnosis.

3. Presence or absence of “binge and purge” episodes.
INDICATED (+1)
She does not now “binge” (eat heavily) and then “purge” (throw up) her food, nor has she done so in the past.

4. Educational goals.
NOT INDICATED (-2)
The client’s education goals are not relevant to the problem being addressed.

5. Feelings about her weight.
INDICATED (+1)
The client acknowledges that maintaining an “ideal” weight is very important to her. She sees weight management as a measure of personal adequacy. She is now at 72% of her expected body weight and experiencing amenorrhea.

6. Self-esteem and weight relationships.
INDICATED (+2)
In her family of origin, weight gain was deeply frowned on. She admits having always been very eager to obtain approval from her parents, and carefully working to keep her weight in control, especially during puberty and late adolescent years. According to her parents (and her mother in particular) excessive weight gain represents “slovenliness,” a lack of self-respect, gluttony, selfishness, poor self-control, and a host of other negative and stereotypic traits and prejudices.

7. Number and order of siblings in family of origin.
NOT INDICATED (-2)
The birth order and number of siblings is unlikely to have any bearing on the presenting problem.

8. Any use of laxatives or diet pills.
INDICATED (+1)
Very relevant. However, the client denies any such use.

9. Psychosocial stressors.
INDICATED (+2)
Psychosocial stressors can contribute to weight issues and reduced self-esteem. The client reports considerable academic stress. Academic (and later professional) achievement is often presented in her family as a measure of acceptability. The client feels great pressure to perform academically in premedical studies, as selected for her by her parents, but is not finding the academic success necessary for subsequent medical school admission.

10. Irregular eating rituals.
INDICATED (+1)
The client admits that she enjoys cooking, but does not enjoy eating. She often cooks “gourmet meals” for family, friends, and others, but cannot enjoy eating the food she cooks.

Section B: Identify the relevant psychosocial and/or environmental stressors that should appear on the client’s DSM-IV-TR Axis IV:

1. Economic problems.
NOT INDICATED (-1)
The client reportedly has stable finances.

2. Occupational problems.
NOT INDICATED (-1)
The client is a student, and is not working. No relevant occupational problems.

3. Educational problems.
INDICATED (+2)
The client is struggling academically to meet threshold grade point standards necessary for later admission to medical school.

4. Socio-environmental problems.
NOT INDICATED (-1)
Her social life and living and educational environments are not yet impaired.

5. Primary support group problems.
INDICATED (+2)
The client’s parents are not accepting of her situation, and will not support her in making academic and career choices better suited to her ambitions, capacity, and life goals.

6. Health care access problems.
NOT INDICATED (-1)
No information suggests that the client has problems with health care service access in any way.

Section C: Relevance and Diagnostic Formulation:

1. Eating Disorder NOS (307.50).
NOT INDICATED (-1)
There is sufficient information to make a more specific provisional diagnosis.

2. Anorexia Nervosa, Restricting Type (307.1).
INDICATED / CORRECT (+3)

3. Anorexia Nervosa, Binge Eating/Purging Type (307.1).
NOT INDICATED (-1)
The client specifically denies binging/purging, and there are no collateral indicators (i.e., Russell sign, dental problems) to suggest otherwise. She does not participate in the misuse of laxatives, diuretics, enemas, or other medications, or excessive exercise.

4. Bulimia Nervosa, Non-purging Type (307.51).
NOT INDICATED (-1)
The client does not exhibit “binge” eating, but rather is restrictive in her overall caloric intake.

5. Bulimia Nervosa, Purging Type (307.51).
NOT INDICATED (-1)
The client does not exhibit “binge” eating, but rather is restrictive in her overall caloric intake. She does not participate in the misuse of laxatives, diuretics, enemas, or other medications, or excessive exercise.

6. Adjustment Disorder With Mixed Disturbance of Emotions and Conduct (309.4).
NOT INDICATED (-1)
While the client is coping with specific stressors (school), the resultant behavior is very explicit and more properly falls within the Eating Disorder category. Thus, this would not be the primary diagnosis, but it could be identified as a secondary problem warranting further clinical attention.

Section D: Options Relevance and Findings:

1. Body dysmorphic/body image education.
INDICATED (+1)
Issues of body image are typically at the heart of anorexia.

2. Hospitalization.
NOT INDICATED (-1)
While the client is thin, there is no indication that her health is threatened. Alternatives, including outpatient treatment, should be explored first, with hospitalization pursued only as a last resort.
3. Healthy eating education.
INDICATED (+1)
The client requires education on eating patterns and food selection to maintain an appropriate body weight.

4. Medications.
INDICATED (+1)
Medications often help in situations of anorexia. They include antipsychotic drugs such as chlorpromazine; antidepressants such as the tricyclics clomipramine and amitriptyline; and cisapride and erythromycin, which can aid in restoring gastric anorexia nervosa has been reported to increase the weight gain in some patients.

5. Counseling regarding locus of control issues.
INDICATED (+2)
The client is cornered between parental wishes and personal capacity and desires. There are also cultural issues that complicate the situation. Individual counseling could help address some of the “need to please” and perceived loss of control issues that appear to be at work in this situation.

Section E: Treatment Goal Relevance and Rationale:

1. Increased self-esteem.
INDICATED (+2)
There is a direct relationship between self-esteem and the disorder.

2. Awareness of repressed memories.
NOT INDICATED (-2)
There is no history of repressed memories or occult psychological trauma.

3. Meaningful and sustained weight gain.
INDICATED (+2)
Changing patterns and practices to facilitate weight gain is crucial.

4. New recreational activities.
NOT INDICATED (-1)
The information gleaned suggests that the client already has a reasonably active and positive social life.

5. Recognition of the need to control in anorexia.
INDICATED (+2)
In this client’s situation, the need to identify avenues through which to assert personal control is crucial.

6. Eliminate binging behaviors.
NOT INDICATED (-1)
There is no history of binging or purging.

Section F: Element Relevance and Commentary

1. Abreaction.
NOT INDICATED (-1)
This psychoanalytical technique involves the expression and release of emotional tension associated with repressed ideas, and has not been determined to be effective for the treatment of eating disorders (though it may be useful for other comorbidities having collateral influence on the disorder).

2. Reality testing.
NOT INDICATED (-1)
Not generally indicated for eating disorders.

3. Engage prior effective coping skills.
INDICATED (+1)
Always a useful approach.

4. Confrontation.
NOT INDICATED (-1)
Efforts are focused on bringing the client back to the pre-disordered level of coping and function. Confrontation is most effective when higher than preexisting levels of functioning are necessary.

5. Keep a food diary.
INDICATED (+2)
A very helpful intervention in this situation.

6. Positive self-talk training.
INDICATED (+1)
Useful for enhancing issues of self-esteem.

7. Relaxation training.
INDICATED (+2)
Can aid in improving the client’s sense of control and self-esteem.

8. Social skills training.
NOT INDICATED (-1)
The client does not exhibit poor social skills.

Section G: Element Relevance and Commentary:

1. Offer follow-up telephone consultations if/as requested by the client.
INDICATED (+2)
This requires a proactive level of self-evaluation the client may not achieve.

2. Have the roommate report on the client’s ongoing maintenance and progress.
NOT INDICATED (-2)
This would be a breach of the proper therapist-client relationship.

3. Request daily telephone reports from the client.
NOT INDICATED (-1)
An overly inflexible and continuous (as opposed to tapering) response to a process of closure.

4. Taper off the frequency of office visits until no longer needed.
INDICATED (+2)
This allows the client to develop increasing levels of autonomous monitoring and independence as desired and needed.

SCORING: (Max = maximum possible; MPL = minimum passing level)

4A. Max 10; MPL 7
4B. Max 4; MPL 3
4C. Max 3; MPL 2
4D. Max 5; MPL 3
4E. Max 6; MPL 4
4F. Max 6; MPL 4
4G. Max 4; MPL 3

Simulation #5

Section A: Element Relevance and Initial Information Obtained

1. Who told you see a counselor?
NOT INDICATED (-2)
Suggests the client is not self-motivated and is disrespectful.

2. Why have you come in today?
INDICATED (+3)
This is a good, open-ended question. The client responds that the fire house supervisor indicated he needed to “get help for his anger.”

3. Do you feel you have problems?
NOT INDICATED (-2)
This question invites a “yes/no” closed answer, and would not elicit important information. It is also disrespectful and overly negative.

4. Can you describe your problem for me?
INDICATED (+3)
This question allows open client expression, and elicits his perspective on the issues of concern. The client states that he has been short-tempered at home and at work. Further questioning reveals that he has ongoing nightmares, unresolved anger, and persistent fatigue after his military service. When he feels overwhelmed, he tends to strike out at others, including his spouse and certain coworkers.

5. What do you hope to accomplish through therapy?
INDICATED: (+2)
This question encourages the client to form ideas of a positive and hopeful nature. The client responds that he just wants to “get over” the problems he developed during his military service.

6. Are you willing to complete assignments between sessions?
NOT INDICATED (-2)
This is not an appropriate intake question, as it will not reveal any purpose in pursuing therapy and may dissuade the client from wanting to engage the process.

Section B: The value and relevance of potential information to share:

1. A review of confidentiality boundaries.
USEFUL (-1)
This is essential information, allowing the client to understand the limits of privacy in the relationship.

2. A summary of the purpose of counseling.
USEFUL (-1)
This information will help the client clarify the benefits and reduce any unrealistic expectations regarding the counseling process.

3. The therapist/counselor’s private personal biases.
NOT USEFUL (+3)
This is not information that would be proper or helpful to provide the client.

4. A summary of this first working (intake) session.
USEFUL (-1)
Providing a summary at the close of the first session can bolster the therapeutic relationship as it addresses goals, problems, progress, and challenges.

5. The need for client commitment to the counseling process.
USEFUL (-1)
Addressing the need for commitment can help bolster proper levels of engagement in the counseling experience, and more quickly lead to therapeutic success.

Section C: Relevance of Diagnosis Options:

1. Adjustment Disorder with Mixed Disturbance of Emotions and Conduct (309.4).
NOT INDICATED (-1)
The stress-related disturbance must not better fit the criteria for another specific Axis I disorder, and this one does.

2. Substance-Induced Anxiety Disorder (292.89).
NOT INDICATED (-2)
There is no indication of substance abuse.

3. Posttraumatic Stress Disorder (309.81).
INDICATED (+3)
The client acknowledges “nightmares” since returning from the war zone. Under further questioning he admits to loss of interest in life, insomnia, “flashback” memories, and feelings of emotional “numbness” toward important relationships and activities. The duration has been longer than 1 month.

4. Acute Stress Disorder (308.3).
NOT INDICATED (-1)
The disturbance must last for a minimum of 2 days and no longer than 4 weeks. This issue has persisted for many months.

5. Generalized Anxiety Disorder (300.02).
NOT INDICATED (-1)
The client’s issues are far too specific for this diagnostic category.

6. Intermittent Explosive Disorder (312.34).
NOT INDICATED (-1)
This diagnosis requires several discrete episodes of aggression that result in serious assaultive acts or destruction of property. To this juncture, the client has not reached this threshold of conduct.

Section D: Options Review and Findings:

1. Direct the client to respond to the court order.
NOT INDICATED (-3)
The therapist is responsible for these records, not the client.

2. Disclose client information to an outside colleague to obtain helpful advice.
NOT INDICATED (-1)
Advice must not involve the disclosure of confidential information to an outside party.

3. Have the spouse sign an information release for the client, and have her respond.
NOT INDICATED (-3)
This is a violation of client confidentiality, and the spouse cannot release the client’s information.

4. Inform the client of confidentiality limits and release the information.
NOT INDICATED (-1)
The client should have been informed of confidentiality limits at the outset of the therapeutic relationship, and this advance disclosure does not necessarily entitle the therapist to release information that may be harmful to the client.

5. Respond to the court personally, indicating possible harm to the client from this disclosure.
INDICATED (+3)
Inform the client in advance of the release, and release only information that is necessary and required.

Section E: Disposition Relevance and Diagnostic Formulation:

1. Continue your work with Joseph, knowing that the client-therapist bond is particularly important.
NOT INDICATED (-1)
NBCC Section B, #10 stipulates that a counselor should not offer a service outside his or her skill, training, or professional capacity. Appropriate alternative referrals should be provided. If the referral is declined, the counselor need not continue to provide services.

2. Refer Joseph to the PTSD specialist for the most effective intervention.
INDICATED (+3)
NBCC Section B, #10 stipulates that a counselor should not offer a service outside his or her skill, training, or professional capacity. Appropriate alternative referrals should be provided. If the referral is declined, the counselor need not continue to provide services.

3. Try to refer Joseph, and if he declines the referral then continue to work with him out of obligation, in spite of your lack of PTSD experience.
NOT INDICATED (-1)
NBCC Section B, #10 stipulates that a counselor should not offer a service outside his or her skill, training, or professional capacity. Where the relationship was already established, the counselor should suggest reasonable referrals. If the referral is declined, the counselor need not continue to provide services.

4. Turn Joseph away without any other referral if the PTSD specialist is not available, knowing that your skills in PTSD treatment are inadequate.
NOT INDICATED (-1)
NBCC Section B, #10 stipulates that a counselor should not offer a service outside his or her skill, training, or professional capacity. Appropriate alternative referrals should be provided. Every counselor should remain familiar with necessary referral sources in order to make quality referrals as needed. If the referral is declined, the counselor need not continue to provide services.

SCORING: (Max = maximum possible; MPL = minimum passing level)

5A. Max 8; MPL 5
5B. Max 3; MPL 2
5C. Max 3; MPL 2
5D. Max 3; MPL 2
5E. Max 3; MPL 2

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Last Updated: 07/28/2014

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