National Clinical Mental Health Counseling Examination (NCMHCE) — All Questions

Maya, 19, has seen a counselor by video for six sessions for generalized anxiety disorder, the diagnosis given at intake. The counselor is licensed only in the state where Maya grew up. At session 7 Maya says she is moving next week to a university in another state and wants to keep meeting by video from her dorm. She is doing well and asks whether anything needs to change. What should the counselor do FIRST?

• a.End services the day she moves and name a campus center
• b.Switch to text messaging, which is not regulated as counseling
• c.Continue as before; the license travels with the counselor
• d.Check whether the counselor can legally practice in Maya's new state✓

Both codes place telehealth under the law of the client's location as well as the counselor's: NBCC standard 92 requires counselors to follow the legal requirements of the state(s) where counselor and client are located, and ACA H.1.b says clients must know the rules for counseling across state lines. A license does not travel with the counselor. Ending services abruptly the day she moves skips pretermination planning, and changing to text messages does not remove the legal question, because it is still counseling.

Derrick, 34, is court-ordered to 12 counseling sessions after a second DUI; the intake diagnosis is alcohol use disorder, moderate. His probation officer expects attendance reports. At the first meeting Derrick says, 'I just need the paperwork signed. Whatever I say in here stays in here, right?' Before counseling begins, what is the counselor's ethical obligation?

• a.Assure him that everything said in session stays confidential
• b.Explain what will be reported to the court, and to whom, before starting✓
• c.Explain the report's contents when the first one is due
• d.Tell him he cannot refuse services a judge has ordered

ACA A.2.e says that with mandated clients, counselors discuss the required limits of confidentiality and explain what information is shared and with whom before counseling begins. Promising that everything stays confidential is false because attendance reports go to probation. The same standard says a mandated client may still refuse services, and the counselor explains the consequences of refusing; it does not remove that choice. Waiting until the report is due breaks the requirement to inform him first.

Lena and Tomas, married 11 years, seek counseling for constant arguing; neither partner has a diagnosis at intake. The counselor plans to see them together and sometimes individually. In the intake paperwork there is nothing yet about how information one partner shares alone will be handled. Which step should the counselor take at this first joint session?

• a.Tell the couple the counselor will pass along anything relevant it hears in individual sessions
• b.Tell each partner privately that anything shared one-on-one will be kept secret from the other
• c.Decide on a policy after the first individual sessions, once the counselor knows what is shared
• d.Clarify who the client is and agree in writing on handling individual disclosures✓

ACA B.4.b requires counselors in couples and family work to define clearly who 'the client' is, discuss expectations and limits of confidentiality, and document an agreement in writing among all parties. Promising each partner secrecy, or deciding on a policy after secrets have already been disclosed, sets up exactly the conflict the standard exists to prevent. The counselor also cannot simply announce it will pass things along: NBCC standard 37 bars revealing one person's confidences to others without that person's prior written permission.

Mrs. Nguyen, 58, came to counseling for adjustment disorder after immigrating to join her daughter. At the final session she gives the counselor a small hand-embroidered handkerchief and explains that in her family, giving a small gift is how people show respect to a teacher. The gift has little monetary value. What is the MOST appropriate response?

• a.Accept only if a supervisor approves it in writing before the end of the session
• b.Accept the gift but leave it out of the record because it has little monetary value
• c.Weigh the gift's value and meaning, and if it is accepted, document that in her record✓
• d.Decline the gift, because counselors are prohibited from accepting any gifts from clients

ACA A.10.f recognizes that in some cultures small gifts are a token of respect, and asks counselors to weigh the therapeutic relationship, the monetary value, and both the client's and the counselor's motives. NBCC standard 21 allows acceptance when it is culturally appropriate or therapeutically relevant and requires that acceptance be documented. There is no blanket prohibition, and not recording it violates NBCC standard 21. Neither code requires written supervisor approval before a gift can be accepted.

Jordan, 27, is in counseling for persistent depressive disorder, diagnosed at intake, and often talks about feeling alone. After session 5 the counselor finds a friend request from Jordan on the counselor's personal social media account, with a message: 'You're the only one who really gets me.' What should the counselor do?

• a.Accept the request, since refusing could feel like rejection to a lonely client
• b.Block Jordan's account without discussion to avoid encouraging further contact
• c.Accept but keep the connection private and never mention it in sessions
• d.Decline the request and discuss the social media policy with Jordan✓

ACA A.5.e prohibits a personal virtual relationship with a current client, and NBCC standard 114 says this includes connecting with or following clients online. Both codes also require that the counselor's social media policy be part of informed consent (ACA H.6.b; NBCC standard 109), so the respectful response is to decline and talk it through with Jordan, using the moment clinically. Accepting in any form breaks the prohibition. Blocking him without any discussion risks a sense of rejection and passes up a chance to talk about the relationship.

Two years ago a counselor ended a 9-month course of treatment with Aaron, 31, whose adjustment disorder had followed a breakup. Aaron runs into the counselor at a bookstore, says he has thought about the counselor often, and asks the counselor out to dinner. The counselor is single and finds the invitation flattering. Which response is consistent with both the ACA and NBCC codes?

• a.Decline for now and suggest meeting after 3 years
• b.Accept if the counselor documents it is not exploitive
• c.Decline, since the codes bar this for 5 years after termination✓
• d.Accept, since more than 1 year has passed

ACA A.5.c prohibits sexual or romantic relationships with former clients for 5 years after the last professional contact, and NBCC standard 24 sets the same minimum of at least 5 years after termination. Two years falls inside that window, so neither the 1-year nor the 3-year idea matches either code. Documenting that the relationship is not exploitive is something ACA requires before any such relationship after the 5 years; it does not shorten the waiting period.

Priya, 45, comes to an outpatient practice asking for help with gambling that has emptied her retirement account; the intake diagnosis is gambling disorder. The counselor assigned to her is skilled in treating depression but has had no training or supervised experience with gambling or other process addictions, and no colleague in the practice has it either. What is the MOST appropriate course of action?

• a.Treat the gambling with general depression techniques, since the skills overlap
• b.Accept the case and learn about gambling treatment from online articles as sessions go
• c.Tell Priya that gambling is a financial problem better handled by a debt counselor
• d.Refer Priya to a qualified provider and support her in the meantime✓

ACA C.2.a limits practice to the boundaries of competence, and C.2.b allows work in a new specialty area only after appropriate education, training, and supervised experience. ACA A.11.a says that when counselors lack competence, they avoid entering the relationship and suggest appropriate referral resources. Using unrelated techniques or learning on the job from online articles falls short of both standards. Calling gambling disorder only a money problem misrepresents a recognized clinical concern and abandons the client.

Ruth, 39, has major depressive disorder, diagnosed at intake, and says her marriage has been emotionally abusive for years. At session 4 she says she has decided to explore divorce. The counselor's own faith teaches strongly against divorce, and the counselor feels uncomfortable helping with this goal. What should the counselor do?

• a.Refer Ruth to another counselor, because the counselor's values conflict with her goal
• b.Encourage Ruth to try marriage counseling first, since divorce is a major decision
• c.Continue with Ruth's goal and seek consultation on the value conflict✓
• d.Tell Ruth about the counselor's beliefs so she can decide whether to continue

ACA A.11.b says counselors do not refer clients based solely on the counselor's personal values and instead pursue training in areas where their values could be imposed on clients. A.4.b says counselors are aware of their values and avoid imposing them, especially when those values do not match the client's goals. Steering her toward marriage counseling puts the counselor's values in place of her own goal. Sharing the counselor's beliefs puts pressure on a depressed client in a relationship she describes as abusive.

Victor, 41, is in counseling for intermittent anger outbursts after his wife left him. At session 6 he is agitated and says, 'I bought a gun last week. When she shows up at the custody exchange Saturday, I'm going to make her pay.' He names her and describes the location. He refuses to talk about any alternatives. Which statement BEST describes the counselor's confidentiality obligation?

• a.Confidentiality yields when needed to protect an identified person from serious harm✓
• b.Confidentiality must be kept because Victor has not yet acted on what he said
• c.Confidentiality applies until the counselor has confirmed that Victor actually bought the gun
• d.The counselor may disclose only if Victor signs a release allowing the counselor to warn his wife

ACA B.2.a says the duty of confidentiality gives way when a disclosure is needed to keep a client or an identified person safe from serious, foreseeable harm, and NBCC standard 19 has the same exception. Victor names a specific person, time, place, and weapon, which is serious and foreseeable risk. The exception does not wait for an act or for independent proof, and it does not depend on the client consenting. The counselor should also consult and follow the state's specific law, as B.2.a advises.

Alicia, 36, has seen a counselor for 5 months for panic disorder while going through a contested divorce. The counselor receives a court order to produce Alicia's treatment records for a custody hearing. Alicia does not yet know about the order. Which action is MOST consistent with the counselor's ethical obligations?

• a.Notify Alicia first, then release only what the order requires✓
• b.Refuse, since counseling records are always privileged
• c.Release the records, then tell Alicia afterward
• d.Send the complete file immediately

NBCC standard 31 says counselors make efforts to inform clients of a court-ordered release before it happens, and release only the information the court requires. ACA B.2.d likewise says counselors seek the client's informed consent or work to keep the disclosure as narrow as possible. Sending the whole file ignores the minimal-disclosure duty. A flat refusal ignores a lawful order; the counselor may ask the court to withdraw it, but may not simply defy it. Telling Alicia only afterward defeats the purpose of informing her first.

Kai, 15, is in counseling for social anxiety disorder after months of bullying at school. At the start of treatment the counselor, Kai, and his mother agreed that session content stays private unless Kai's safety is at risk. At week 6 his mother calls and demands to know 'everything he's been saying about us.' No safety concerns have come up. What is the counselor's BEST response?

• a.Review the agreed limits with her and offer ways to collaborate within them✓
• b.Refuse to speak with the mother at all, since Kai is the only client
• c.Tell the mother that Kai will decide whether she can remain involved in his treatment
• d.Give the mother a full summary, because parents of minors are entitled to all information

ACA B.5.b asks counselors to inform parents about the counselor's role and the confidential nature of counseling, to respect parents' rights, and to build collaborative relationships with them. NBCC standards 38-39 say the same about protecting a minor's confidential information while honoring parental rights. Handing over everything breaks the agreed limits. Refusing all contact ignores the parent's legitimate role. Giving a 15-year-old authority over whether his parent can stay involved misstates both the law and the agreement.

Hannah, 22, has been seen weekly for 12 sessions for binge-eating disorder, diagnosed at intake. Her binges have increased despite the planned interventions, and she now reports vomiting after some binges. The counselor believes Hannah needs a specialized eating-disorder program that the counselor cannot provide. What should the counselor do?

• a.End services today and suggest she search online
• b.Add a second weekly session with the same plan
• c.Continue weekly sessions with no changes
• d.Prepare her for ending and refer her to specialized care✓

ACA A.11.c says counselors end a counseling relationship when the client is not likely to benefit, and provide pretermination counseling and recommend other providers. A.12 bars abandonment, which means an abrupt ending without arrangements for continued care. Continuing a plan that is not working, or doubling it, ignores both the lack of benefit and the new purging. Ending services and leaving her to search online is abandonment. NBCC standard 11 also requires discussing termination and giving appropriate referrals.

A counselor whose spouse died 3 weeks ago has returned to a full caseload. Several clients are working on grief after deaths in their families. In two recent sessions the counselor started crying and lost track of what the client was saying, and has been sleeping poorly. What is the counselor's ethical obligation?

• a.Seek help and reduce or pause grief work until able to practice safely✓
• b.Tell grieving clients about the loss so they understand the counselor's tears
• c.Keep seeing all clients, since sharing grief can strengthen the relationship
• d.Keep the full caseload and take extra time off only if a client complains

ACA C.2.g asks counselors to watch for signs of impairment from their own emotional problems, to seek help, and if necessary to limit, suspend, or end professional duties until they can safely resume. NBCC standard 4 likewise requires seeking assistance or withdrawing from practice when one's condition prevents appropriate services. Losing track of sessions is a sign of impairment, not a relationship tool. Turning the session toward the counselor's loss puts the counselor's needs ahead of the client's. Waiting for complaints puts the burden on clients.

Mr. Alvarez, 78, is being seen for depression after his wife's death, diagnosed at intake. He is cognitively intact and signed no release of information. His adult daughter calls the clinic, says she is worried, and asks the counselor, 'Is my father actually coming to his appointments?' What should the counselor do?

• a.Tell the daughter she must obtain a court order to get any information
• b.Neither confirm nor deny that he is a client without his written consent✓
• c.Share a brief progress update because family involvement helps older adults
• d.Confirm his attendance only, since that reveals nothing clinical

Even confirming that someone is a client is a disclosure. ACA B.1.c permits disclosure only with appropriate consent or sound legal or ethical justification, and NBCC standard 19 requires specific written consent from a competent client, apart from harm or legal exceptions. Attendance and progress are protected information. The counselor can listen to the daughter's concern and suggest that her father sign a release; saying a court order is the only route is inaccurate, since his consent would do.

A counselor is starting an 8-week bereavement group for adults whose spouses died in the past year; each member was screened individually beforehand. Several members are nervous about sharing personal details with strangers. At the first session, which statement about confidentiality is MOST accurate for the counselor to give?

• a.A signed pledge guarantees confidentiality
• b.Members agree to privacy, but the counselor cannot guarantee it✓
• c.Group talk has the same legal privilege as individual sessions
• d.Members may discuss others' stories if names are omitted

ACA B.4.a asks the group counselor to explain clearly the importance and the limits of confidentiality in the specific group. The counselor is bound, but other members are not bound the way a professional is, so confidentiality can be agreed to but not guaranteed. A signed pledge helps but does not guarantee anything, and the legal protection of group talk is not the same as in individual sessions. TIP 41 says members may discuss themes and their own disclosures, but not other members' stories.

Earl, 52, lives in a rural county with one counseling practice. He has adjustment disorder after losing his job and his health insurance. He asks whether he could repair the counselor's car in exchange for sessions, and says that trading services is common in his town. The counselor is considering it. Under the ACA Code of Ethics, which condition must be met before bartering?

• a.The goods or services are worth more than the counseling fee
• b.The agreement is documented in a clear written contract✓
• c.The counselor's supervisor approves the trade in writing
• d.The arrangement is limited to the first three sessions

ACA A.10.e allows bartering only if the client requests it, it does not result in exploitation or harm, it is an accepted practice among professionals in the community, and the arrangement is documented in a clear written contract after discussing cultural implications. The code does not require the trade to exceed the fee, a session limit, or a supervisor's written approval. Under A.10.c the counselor could also adjust fees or help find affordable services. Note that NBCC standard 20 is stricter, allowing bartering only when no referral is possible.

A counseling intern is seeing Denise, 29, for panic disorder with frequent attacks while driving. The intern's university supervisor wants recordings of sessions for supervision. At the next session the intern would like to start recording. What must the intern do before recording?

• a.Record only audio, because audio recordings do not require client permission
• b.Tell Denise recording is mandatory because the intern is still in training
• c.Record the session first, then ask whether she objects to it being kept
• d.Obtain Denise's permission and tell her who will review the recording✓

ACA B.6.c requires permission from clients before recording sessions by any means, and B.6.d requires permission before anyone observes or reviews recordings, including supervisors. F.5.c also requires students and supervisees to disclose their status and how supervision affects confidentiality. Asking after the fact is not prior permission, audio is still a recording, and making recording mandatory overrides her right to decide.

A community clinic offers an 8-week stress-management group. To see whether it works, staff compare the stress scores of clients who chose to join the group with those of clients who chose not to join. The clients were not randomly assigned. When reading the results, which limitation should a counselor recognize?

• a.Preexisting group differences could explain the results✓
• b.The design lacks standardized stress scores
• c.It is qualitative, so its results are invalid
• d.Random assignment would make groups less comparable

Per CDC's evaluation guide, experimental designs use random assignment, which makes groups comparable and allows change to be attributed to the program. Comparing groups that are not equivalent without random assignment is a quasi-experimental design, and critics can argue that other differences between the groups caused the results. The scenario says stress scores were compared, so data were gathered and the design is quantitative. Random assignment makes groups more comparable, not less.

A counselor is starting telehealth services with Sam, 33, who has major depressive disorder, diagnosed at intake, and a past suicide attempt. Sam lives 200 miles from the counselor's office and will join from different places depending on his work schedule. Which step is MOST important to include in the telehealth informed-consent process?

• a.A statement that telehealth sessions are fully secure, so there are no confidentiality risks
• b.Written emergency steps with local responders, and a location check each session✓
• c.An agreement that Sam will email the counselor whenever he has suicidal thoughts
• d.A policy that emergencies will be handled by calling the police near the counselor's office

NBCC standard 105 requires written emergency procedures for telehealth clients, listing emergency services close to where the client is, plus the client's own emergency contacts. Standard 106 requires verifying the client's identity and current location at the start of each contact. ACA H.2.a lists emergency procedures among the required telehealth consent items. No telehealth platform removes all confidentiality risk (ACA H.2.c). Emailing is not a crisis plan, and police near the counselor's office cannot respond where Sam is.

Gloria, 50, is referred by her employer's assistance program; the intake diagnosis is major depressive disorder. She describes 2 months of fatigue, slowed thinking, weight gain, and feeling cold all the time, and says she has not seen a physician in over 5 years. She is not taking any medications. Which step should the counselor take during the intake?

• a.Recommend a medical evaluation to rule out a physical cause of her symptoms✓
• b.Change her diagnosis to persistent depressive disorder because of the fatigue
• c.Hold off on any treatment until she has lost the weight she gained
• d.Begin cognitive restructuring now, since her symptoms fit major depression

NIMH notes that certain medical conditions, such as thyroid disorders, and some medications can cause the same symptoms as depression, and its psychotherapy guidance says a medical examination helps rule out a physical cause. Gloria has no recent medical care and physical complaints that could come from a medical condition, so a medical referral belongs in the intake. Starting treatment without it may miss the real cause. Persistent depressive disorder requires symptoms for at least 2 years, and she reports 2 months. Delaying all care until she loses weight makes no clinical sense.

Martin, 44, was laid off 10 days ago. An urgent-care provider wrote 'major depressive disorder' on his referral. He reports low mood, poor sleep, and trouble concentrating that began the day he was laid off. He denies suicidal thoughts. To confirm the major depressive disorder diagnosis, which information is still needed?

• a.Depressed mood lasting at least 6 months
• b.Symptom onset before any identifiable stressor
• c.Symptoms most of the day, nearly every day, for 2+ weeks✓
• d.A past period of elevated or irritable mood

NIMH states that a diagnosis of depression requires symptoms most of the day, nearly every day, for at least 2 weeks. Martin's symptoms began 10 days ago, so the duration requirement has not yet been met, and the counselor should reassess. Six months is the anxiety-disorder duration NIMH gives for GAD, not depression. A period of elevated mood would point toward bipolar disorder, not confirm depression. A stressor does not rule out major depression.

Beatrice, 38, says she 'can't remember the last time I felt good.' For about 3 years she has had low mood on most days, low energy, and poor self-esteem, but she keeps working and caring for her children. She has never had a period of elevated mood, and her symptoms have never been severe enough to stop her from functioning. Her symptoms did not start after any particular event. Which diagnosis BEST fits this presentation?

• a.Cyclothymic disorder
• b.Persistent depressive disorder✓
• c.Generalized anxiety disorder
• d.Adjustment disorder with depressed mood

NIMH describes persistent depressive disorder as depressive symptoms that are less severe than major depression but last at least 2 years, which matches Beatrice's 3 years of chronic low mood with preserved functioning. Cyclothymic disorder involves recurrent hypomanic as well as depressive symptoms, and she has never had elevated mood. Adjustment disorder is tied to an identifiable stressor, and she names none. Her main problem is mood rather than excessive worry, so GAD does not fit.

Andre, 26, is referred with a diagnosis of major depressive disorder, and his physician plans to start an antidepressant. During intake Andre mentions that last spring he went 8 days sleeping 2-3 hours a night without feeling tired, spent his savings on equipment for a business idea, and talked so fast that friends could not follow him. Which diagnosis should the counselor assess for?

• a.Generalized anxiety disorder
• b.Bipolar I disorder✓
• c.Persistent depressive disorder
• d.Attention-deficit/hyperactivity disorder

NIMH defines bipolar I disorder by manic episodes lasting at least 7 days, with symptoms such as little need for sleep, racing thoughts, rapid speech, and risky activities. Andre describes 8 days of these. The question matters now: NIMH warns that antidepressants are not used alone in bipolar disorder because they can trigger mania or rapid cycling. The counselor should assess the history and, with Andre's consent, share it with the prescriber. The other options do not explain a distinct episode of elevated energy and decreased need for sleep.

Nadia, 31, has had two clear depressive episodes, each lasting over a month. Between them she has had several 4-day periods of unusually high energy, reduced need for sleep, and nonstop ideas; coworkers noticed the change, but she was never hospitalized, never had psychotic symptoms, and kept working normally. Which diagnosis BEST fits this history?

• a.Bipolar II disorder✓
• b.Bipolar I disorder
• c.Major depressive disorder, recurrent
• d.Cyclothymic disorder

NIMH defines bipolar II disorder as a pattern of depressive and hypomanic episodes, where the hypomanic episodes are less severe than full mania. Nadia's noticeable but non-disabling 4-day elevations with full depressive episodes fit this. Bipolar I is defined by full manic episodes (NIMH: lasting at least 7 days). Cyclothymic disorder applies when symptoms never reach full hypomanic or depressive episodes, but she has had full depressive episodes. A diagnosis of recurrent depression alone would ignore the hypomanic periods.

Luis, 47, a small-business owner, says he has 'worried about everything' for about 7 months: money, his children's safety, his health, and customers' reviews. He cannot stop the worry, feels on edge, has tense shoulders, is tired, and wakes at 3 a.m. He has had no sudden attacks of intense fear and does not avoid social situations. Which diagnosis BEST fits?

• a.Social anxiety disorder
• b.Obsessive-compulsive disorder
• c.Generalized anxiety disorder✓
• d.Panic disorder

NIMH says GAD requires difficulty controlling worry on most days for at least 6 months, with at least three symptoms such as restlessness, fatigue, muscle tension, or sleep problems. Luis has 7 months of widespread, uncontrollable worry with four such symptoms. Panic disorder requires recurrent unexpected panic attacks, which he denies. Social anxiety centers on fear of being judged in social situations. OCD involves intrusive obsessions and repetitive compulsions, not general worry about many life areas.

Keisha, 24, has been cleared of heart problems by her physician. Over 3 months she has had five sudden episodes of pounding heart, shaking, chest tightness, and fear of dying, several of them 'out of nowhere' while watching TV. For the past 6 weeks she has stopped driving on highways in case an attack happens. Which diagnosis BEST fits this presentation?

• a.Generalized anxiety disorder
• b.Panic disorder✓
• c.Illness anxiety disorder
• d.Specific phobia of driving

NIMH describes panic disorder as recurring unexpected panic attacks followed by at least a month of worry about more attacks or changes in behavior to avoid them. Keisha has unexpected attacks and 6 weeks of avoiding highways, after medical causes were ruled out. Her avoidance is driven by fear of having an attack, not by fear of driving itself, which argues against specific phobia. GAD is chronic worry rather than discrete attacks. She is not preoccupied with having an undiagnosed illness.

Owen, 29, an engineer, was offered a promotion that requires presenting to clients. For about 8 months he has dreaded meetings, fearing others will see him blush and think he is incompetent. He skips team lunches and has twice called in sick on presentation days. He is comfortable with close friends and has no panic attacks outside these situations. Which diagnosis BEST fits?

• a.Social anxiety disorder✓
• b.Adjustment disorder with anxiety
• c.Agoraphobia
• d.Panic disorder

NIMH describes social anxiety disorder as anxiety or fear in situations where a person may be scrutinized, evaluated, or judged, lasting at least 6 months and interfering with daily life. Owen's 8 months of fear of negative evaluation at work, with avoidance, fit this. Agoraphobia involves fear of places where escape may be difficult, not fear of judgment. Panic disorder requires unexpected panic attacks, which he does not have. His fear is not a time-limited reaction to one stressor, so adjustment disorder fits less well.

Farah, 35, a nurse, has been late to work repeatedly. She describes intrusive thoughts that she may have spread germs to her family, and she washes her hands in a set sequence until her skin cracks, often for more than 2 hours a day. She knows the washing is excessive but feels unbearable anxiety if she stops. Which diagnosis should the counselor consider FIRST?

• a.Obsessive-compulsive disorder✓
• b.Illness anxiety disorder
• c.Posttraumatic stress disorder
• d.Generalized anxiety disorder

NIMH defines obsessions as repeated, intrusive, unwanted thoughts that cause anxiety, and compulsions as repetitive behaviors done in response to them, and notes that people with OCD spend more than an hour a day on them. Farah's contamination fears and ritualized washing for over 2 hours a day fit. GAD worry is not relieved by rituals. Nothing in the case describes a traumatic event. Her fear is of spreading germs to others and is answered by rituals, rather than a worry that she herself has an illness.

Carmen, 32, was assaulted in a parking garage 2 weeks ago. She reports nightmares, startling at loud noises, and avoiding the garage. An emergency-room note lists 'PTSD.' She is functioning at work with effort and denies suicidal thoughts. Which statement about her diagnosis is MOST accurate?

• a.PTSD is ruled out, because she is still able to work
• b.PTSD is confirmed, because she has symptoms from more than one category
• c.PTSD can be diagnosed only if her symptoms started 6 months after the event
• d.PTSD cannot yet be diagnosed, because symptoms must last at least 1 month✓

NIMH states that an adult must have the required symptoms for at least 1 month to be diagnosed with PTSD, and notes that most people's early reactions lessen over time. At 2 weeks, Carmen's symptoms should be monitored and reassessed rather than labeled PTSD. Symptoms across categories do not replace the duration requirement. Keeping a job with effort does not rule out the disorder. NIMH says symptoms usually begin within 3 months of the event, and there is no requirement that they start 6 months later.

Grant, 49, is referred after a workplace injury while hungover; the referral diagnosis is alcohol use disorder. During the diagnostic interview he endorses that in the past year he drank more than intended, tried and failed to cut down, needs more alcohol for the same effect, gave up his weekend fishing trips to drink, and kept drinking despite arguments with his wife. He denies other criteria. How should the counselor specify the severity?

• a.Severe
• b.In early remission
• c.Moderate✓
• d.Mild

NIAAA explains that AUD severity depends on how many DSM-5 criteria are met: mild is two to three, moderate is four to five, and severe is six or more. Grant endorses five (drinking more than intended, failed efforts to cut down, tolerance, giving up activities, and continuing despite relationship problems), which is moderate. Mild would require only two or three and severe six or more. 'In early remission' describes someone who no longer meets criteria after meeting them, and Grant is still drinking.

Ines, 55, has drunk about a fifth of vodka daily for 6 years; the intake diagnosis is alcohol use disorder, severe. She has had morning shakes and sweating that go away when she drinks. At the end of intake she says, 'I'm quitting cold turkey tonight. I don't need any doctor.' What is the counselor's MOST important response?

• a.Suggest she taper on her own without a physician
• b.Praise her decision and see her next week
• c.Send her to a mutual-support meeting tonight instead
• d.Arrange a medical evaluation before she stops drinking✓

NIAAA warns that people with severe AUD may need medical help to avoid alcohol withdrawal, which is potentially life-threatening after heavy, prolonged drinking. Ines already has signs of withdrawal (morning shakes and sweating relieved by drinking), so the level of care must include medical assessment before she stops. Praising and waiting a week, or telling her to taper on her own, ignores that risk. Mutual-support groups are valuable, but they do not manage withdrawal.

During a mental status exam, Tyrone, 40, whose intake diagnosis is major depressive disorder, says his mood is 'fine, really, no complaints.' Throughout the interview his eyes are tearful, his voice is quiet, and he looks down. How should the counselor document this finding?

• a.Reported mood and observed affect are incongruent✓
• b.Thought content is paranoid
• c.Mood is tearful and affect is 'fine'
• d.Insight is intact because he answered every question

In an MSE, mood is how the person says they feel, and affect is the visible evidence of mood; the Minnesota DHS guide flags a mismatch between reported mood and visible affect as clinically meaningful, giving the example of saying mood is good while tears run down the cheeks. Tyrone reports 'fine' while looking tearful, which is incongruent. Swapping mood and affect confuses the two terms. Nothing he says suggests paranoia. Answering questions says nothing about insight.

Leon, 58, is brought by his sister, who says he has been 'acting strange.' His speech is organized and follows a logical order, but he insists that neighbors have planted listening devices in his walls and are plotting to take his house. He shows no signs of intoxication. In the mental status exam, where should this belief be recorded?

• a.Attention span
• b.Thought process
• c.Thought content✓
• d.Orientation

The Minnesota DHS guide separates thought process, which is how a person thinks (logical order versus jumping between topics), from thought content, which is what the person is thinking about, including beliefs such as paranoia that others are plotting against them. Leon's speech is logical, so his thought process is intact, and the persecutory belief belongs under thought content. Nothing in the case describes disorientation or trouble with concentration.

Mrs. Park, 81, is referred by her primary care office for low mood after her husband's death. Her daughter adds that her mother 'forgets conversations from earlier in the day.' During the MSE the counselor names three objects, has Mrs. Park repeat them right away, and asks her to recall them about 5 minutes later. She recalls one. Which function does this task mainly assess?

• a.Judgment
• b.Long-term memory
• c.Short-term memory✓
• d.Abstract thinking

The Minnesota DHS MSE guide describes testing short-term memory by listing three objects, having the person repeat them to confirm they were heard, and asking for them again after 5 to 10 minutes. Abstract thinking is assessed with proverbs or metaphors, judgment by asking what the person would do in a common situation, and long-term memory by the person's account of past life events. Poor recall with depression in an older adult calls for further evaluation, not a conclusion.

At intake, Ellen, 43, whose referral diagnosis is major depressive disorder, says she feels 'like a burden to everyone' since her divorce. The counselor, who is new, worries that asking about suicide might plant the idea in Ellen's mind. What should the counselor do?

• a.Avoid the topic unless Ellen raises suicide on her own
• b.Ask in a roundabout way whether she 'has ever felt low' so as not to upset her
• c.Ask Ellen directly whether she has thought about killing herself✓
• d.Give Ellen a crisis hotline card instead of asking about suicide

TIP 50 is explicit: available data do not support the idea that asking about suicide puts the idea in a person's mind, and counselors are encouraged to ask directly because they may never learn about suicidal thoughts otherwise. Feeling like a burden is also a warning sign (NIMH lists 'being a burden to others'), which raises the need to ask. Waiting for her to raise it, asking vaguely, or handing her a card instead of asking all leave her level of risk unknown.

Marcus, 37, with alcohol use disorder, says yes when asked whether he has had thoughts of killing himself in the past month. The counselor responds, 'Can you tell me about those thoughts?' Marcus describes them but does not mention anything else. Which information is MOST important for the counselor to gather next?

• a.Whether he would prefer to be referred to a different counselor
• b.Whether he has a plan, access to a method, and intent to act✓
• c.Whether anyone in his family has ever been treated for depression
• d.Whether his thoughts started before or after he began drinking

TIP 50's Gather-information step says to start with an open question and then, if the client does not raise them, always gather the critical details: whether there is a plan, access to a method (such as a gun or pills), and intent to attempt. These drive the judgment of how serious the risk is and what action to take. When the thoughts started and family history are useful background but secondary to current risk. Offering a different counselor does nothing to assess risk.

Rosa, 23, has major depressive disorder. At session 5 she mentions she gave her guitar and her journals to friends 'since I won't need them,' and her roommate found internet searches about medication overdoses on the shared laptop. Rosa says she is 'just tired.' How are these findings BEST classified?

• a.Long-term risk factors that need no action now
• b.Normal behaviors for her stage of depression
• c.Direct warning signs of acute suicide risk✓
• d.Protective factors showing she is settling her affairs

TIP 50 lists direct warning signs, which signal acute risk and get the highest priority: suicidal communication, seeking access to a method, and making preparations such as giving away possessions. Rosa is giving away belongings and researching overdose methods, so she needs immediate follow-up questions and immediate supervision or consultation. Risk factors describe long-term risk, not acute risk. Giving away possessions is not protective. Calling these behaviors normal would dismiss them.

At intake, Paul, 52, lists several things from his history: he lost his job last year, lives alone, drinks four or five beers most nights, his uncle died by suicide, and he took an overdose of pills 6 years ago during his divorce. He currently denies suicidal thoughts. According to SAMHSA's TIP 50, which item in his history is the MOST potent risk factor for eventual suicide?

• a.His uncle's death by suicide
• b.The job loss last year
• c.The overdose 6 years ago✓
• d.Living alone

TIP 50 lists a prior history of suicide attempts as the most potent risk factor, while noting that about half of deaths by suicide are first attempts. Family history of suicide, job loss, social isolation, and heavy substance use are also listed risk factors and matter in his overall picture, but none is described as stronger than a past attempt. His current denial of suicidal thoughts does not erase this long-term risk, and his history should be monitored throughout treatment.

Tanya, 34, a mother of two young children who attends church weekly, tells the counselor she has thought about driving her car into a bridge pillar and has driven past the bridge twice this week. The counselor notes that her children and her faith are strong protective factors. How should these protective factors affect the counselor's response?

• a.They replace the need to consult a supervisor about her risk
• b.They make suicide contracts the most suitable next step
• c.They do not lessen the need to act on her warning signs✓
• d.They mean her risk is low enough to review at the next session

TIP 50 cautions that once acute warning signs appear, protective factors do not alter the conclusion that preventive action is needed, and they may give no protection in an acute crisis. Tanya describes a method and visits to the site, which count as preparation. TIP 50 does not recommend suicide contracts, calling them never sufficient on their own. Direct warning signs call for immediate consultation, not less.

During a biopsychosocial intake for depression, Renee, 30, says quietly that her boyfriend choked her last weekend, keeps a handgun in the nightstand, and said he would 'finish it' if she ever left. He is waiting for her in the parking lot. What should the counselor do FIRST?

• a.Complete the depression intake so the diagnosis is documented
• b.Schedule a follow-up to explore the relationship in more depth
• c.Invite the boyfriend in so both partners can discuss the conflict
• d.Pause the intake and address Renee's immediate safety✓

TIP 39 directs that when a screening reveals a batterer endangering a client, the provider responds to the danger before any other issue, suspending the rest of the interview if necessary, and connects the client with domestic-violence resources and safety planning. Strangulation, a gun, and a threat of death, with the partner waiting outside, call for immediate safety planning. Finishing the depression paperwork first delays that. Joint sessions are not appropriate while violence continues. Waiting for a follow-up leaves her in danger.