March 9, 2015

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 Study Guide

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NCMHCE Study Guide
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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.

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.

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

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NCMHCE Study Options

  1. NCMHCE Study Guide 2018: Exam Prep and Practice Questions for the National Clinical Mental Health Counseling Examination NCMHCE (click here)
  2. NCMHCE Secrets Study Guide: NCMHCE Exam Review for the National Clinical Mental Health Counseling Examination (click here)
  3. NCMHCE Flashcard Study System: NCMHCE Test Practice Questions & Exam Review for the National Clinical Mental Health Counseling Examination (click here)
  4. NCMHCE Practice Questions: NCMHCE Practice Tests & Exam Review for the National Clinical Mental Health Counseling Examination (click here)
  5. Official site (click here)