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

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.

An intensive outpatient program's intake protocol says trauma screening should wait until a client has 90 days of abstinence. Dana, 28, has just started the program for opioid use disorder, and during intake she mentions 'bad things from when I was a kid' and nightmares. What does SAMHSA's trauma-informed guidance recommend?

• a.Screen for trauma now rather than waiting✓
• b.Wait 90 days to avoid triggering relapse
• c.Ask for a detailed account at intake
• d.Screen only if Dana requests it

TIP 57 advises counselors to ask all clients about trauma, to screen early, and specifically not to delay screening until a period of abstinence or stabilization. It also says clients should not be required to describe overwhelming traumatic events in detail; screening focuses on how symptoms affect current functioning. Waiting 90 days or only screening if she asks misses symptoms that may be driving her use. Asking for a detailed account at intake risks overwhelming her.

At intake for alcohol use disorder, Jamal, 45, an Army veteran, scores above the cutoff on a brief trauma screening questionnaire. The intake counselor, who is not trained to conduct trauma assessments, wants to record 'PTSD' as a co-occurring diagnosis today. What is the MOST appropriate next step?

• a.Arrange a full assessment by a clinician qualified to assess trauma✓
• b.Disregard the screen, because veterans often report combat stress
• c.Repeat the same screening questionnaire each week until the score drops
• d.Record PTSD as a diagnosis, since the screening score was positive

TIP 57 explains that screening answers yes/no questions about whether further assessment is warranted. A positive screen does not mean a disorder exists, and assessment for trauma-related disorders requires a qualified mental health professional. Diagnosing from the screen alone goes beyond what a screen can tell. Dismissing a positive screen ignores possible co-occurring PTSD, which is common alongside substance use. Repeating the screen is not a substitute for assessment.

Mr. Haddad, 60, arrived from Syria two years ago and is in counseling for anxiety; the intake diagnosis is generalized anxiety disorder. The counselor gives him a standardized anxiety inventory whose norms came only from U.S.-born college students. His score is very high. How should the counselor use this result?

• a.Report it as invalid in his record without further explanation
• b.Interpret it with caution and alongside other information about him✓
• c.Discard it, because no instrument can be used with immigrant clients
• d.Treat the score as conclusive, since the inventory is standardized

ACA E.8 says counselors use caution with techniques normed on populations other than the client's and place results in perspective with other relevant factors, and E.6.a encourages using multiple forms of assessment. NBCC standard 66 asks counselors to learn a test's normative groups and limits before interpreting it. A standardized instrument is not conclusive for a population it was not normed on. A blanket ban on using instruments with immigrants is not what the codes say, and the codes ask counselors to note reservations about validity, not simply label a result invalid.

A counselor gives a new depression checklist to Ivy, 33, whose intake diagnosis is major depressive disorder, on Monday and again on Wednesday. Nothing in her life or symptoms changed, but her score jumps from 12 to 31. The counselor sees the same kind of swing with other stable clients. Which property of the checklist is MOST in question?

• a.Face validity
• b.Norm sampling
• c.Reliability✓
• d.Standardization

CDC's evaluation guide defines a measure as reliable to the extent that it produces the same results repeatedly, and valid when it captures the construct it was designed to capture. Large swings over two days in people whose symptoms have not changed are a reliability problem, since the instrument is not consistent. Face validity concerns whether items look like they measure the construct. Norm sampling and standardization concern who the comparison group was and how the test is given, neither of which explains inconsistent scores within the same person.

Sofia, 27, is being treated for social anxiety disorder, diagnosed at intake. At the first session she completed a standardized social-anxiety scale. At session 8 she says she 'thinks' things are better, but the counselor wants a clearer picture of whether counseling is working. Which approach BEST evaluates her progress?

• a.Give a different anxiety scale now
• b.Ask how satisfied she is with the counselor
• c.Readminister the same scale and compare scores✓
• d.Judge by how talkative she is in session

Using the same measure before and after treatment (a pre-test/post-test design) gives a direct comparison of change on the treatment target, which is how counselors monitor effectiveness (ACA C.2.d) and how outcome evaluations measure change. Satisfaction with the counselor is a different outcome from reduced symptoms. The counselor's impression in session is useful but not systematic. Switching instruments makes the before and after scores hard to compare.

Evan, 22, was diagnosed with schizophrenia 6 months ago; his hallucinations have decreased with medication. His mother reports that he now spends most of the day in bed, rarely speaks, shows little facial expression, and has lost interest in the music he used to love. How are these current symptoms BEST classified?

• a.Negative symptoms✓
• b.Cognitive symptoms
• c.Psychotic symptoms
• d.Medication side effects only

NIMH groups schizophrenia symptoms into psychotic symptoms (hallucinations, delusions, thought disorder), negative symptoms (loss of motivation, loss of interest or enjoyment, social withdrawal, reduced emotional expression), and cognitive symptoms (problems with attention, concentration, and memory). Evan's withdrawal, flat expression, and loss of interest are negative symptoms. His hallucinations have improved, and nothing here describes attention or memory problems. Side effects should be discussed with the prescriber, but calling these only side effects would miss a core part of the illness.

Talia, 19, a college runner, is referred by her coach; the referral diagnosis is anorexia nervosa. She eats about 600 calories a day, says she is 'terrified' of gaining weight, and has lost a large amount of weight this semester. She mentions feeling dizzy and nearly fainting at practice twice this week. What should the counselor do FIRST?

• a.Refer her to a nutrition class offered on campus
• b.Arrange an urgent medical evaluation✓
• c.Ask her coach to monitor what she eats at team meals
• d.Start weekly CBT sessions focused on her body image

NIMH describes anorexia as potentially fatal, with complications such as heart damage and organ failure, and lists medical monitoring as part of treatment, with hospitalization sometimes needed for severe cases. Dizziness and near-fainting with severe restriction are signs of possible medical instability, so the level of care has to be decided medically first. Body-image work and nutrition education belong in later treatment, and giving her coach a monitoring role would share her information without consent.

Brenda, 42, reports that two or three times a week she eats very large amounts of food quickly, feels she cannot stop, and afterward feels ashamed. She does not vomit, use laxatives, fast, or exercise to make up for the binges, and she has gained weight over the past year. Which diagnosis BEST fits?

• a.Anorexia nervosa, binge-purge type
• b.Avoidant/restrictive food intake disorder
• c.Bulimia nervosa
• d.Binge-eating disorder✓

NIMH describes binge-eating disorder as regularly losing control of eating and eating unusually large amounts, while bulimia nervosa involves binge eating followed by behaviors to prevent weight gain, such as forced vomiting or laxatives. Brenda has no such compensating behaviors, so she does not fit bulimia. Anorexia requires restriction of food intake, and ARFID involves limiting food out of fear or dislike of food's characteristics.

Kevin, 34, asks to be evaluated for ADHD after reading about it online. He says he loses focus in meetings, misses deadlines, and misplaces his keys, and that these problems began when he started a demanding new job 5 months ago. He says school was 'easy and uneventful,' and his partner says he is organized at home. Which information is MOST needed before an ADHD diagnosis could be supported?

• a.A score on a single online self-test showing a high number of symptoms
• b.Evidence of childhood onset and problems in several settings✓
• c.Confirmation that his symptoms improve when he drinks caffeine
• d.Evidence that his current job is more demanding than his last one

NIMH describes ADHD as a pattern whose symptoms begin in childhood and whose behaviors are frequent and occur across multiple situations, such as school, home, and work. Kevin reports recent, job-specific problems with an uneventful childhood and good functioning at home, so the counselor would need evidence of childhood onset and difficulty in several settings before ADHD could be supported, and should also look at other explanations such as stress or anxiety. An online self-test is not diagnostic. Caffeine response does not diagnose anything, and a harder job is itself another possible explanation.

Walt, 39, meets criteria for alcohol use disorder, moderate. He has had no withdrawal symptoms, has no medical or psychiatric complications, lives with a supportive spouse, wants to keep his job, and is ready to change. His employer's assistance program suggests 'a 30-day residential program because he has a diagnosis.' According to the ASAM Criteria principles, how should his level of care be determined?

• a.From the length of stay the employer's program usually approves
• b.From the diagnosis alone, because moderate AUD requires residential treatment
• c.By a multidimensional assessment, using the least intensive safe setting✓
• d.From his preference alone, regardless of his risk in any dimension

The ASAM Criteria materials stress that a diagnosis is necessary but not sufficient to decide level of care. Placement comes from a multidimensional assessment of severity and functioning, delivered in the least intensive but safe setting, and fixed-length programs are criticized as program-driven rather than client-driven. Walt shows little risk across dimensions, which points to an outpatient level. Diagnosis alone, a usual length of stay, or client preference that ignores risk do not follow the model.

Corey, 29, entered outpatient treatment for cocaine use disorder 5 days ago and has not used since. He reports intense sadness, poor sleep, and says, 'What's the point of any of this?' A staff member says the mood 'will pass once the cocaine is out of his system, so there's no need to screen for suicide.' How should the counselor respond?

• a.Screen for suicide now, since even short-lived depression raises risk✓
• b.Agree, and reassess his mood only after 30 days of abstinence
• c.Diagnose major depressive disorder today based on the current symptoms
• d.Treat his comment as a normal reaction and move on to relapse prevention

TIP 50 notes that intense, short-lived depression is common among people seeking treatment for cocaine, methamphetamine, and alcohol use, and that even temporary depression is a potent risk factor for suicidal behavior in people with substance use disorders. 'What's the point' also suggests hopelessness, a warning sign that calls for follow-up questions. Waiting 30 days ignores current risk. Diagnosing MDD at day 5 is premature because the mood may be substance-related. Treating the comment as normal skips the needed follow-up.

At a family intake for Mia, 14, who is skipping school, the counselor observes that every time Mia is asked a question, her mother answers for her, finishes her sentences, and reports how Mia 'feels.' The mother says, 'We're best friends; we share everything, even my problems with her dad.' Which pattern is the counselor MOST likely observing?

• a.Disengaged boundaries between mother and daughter
• b.A clear, flexible generational boundary
• c.Homeostasis in response to Mia's recovery
• d.Enmeshed boundaries between mother and daughter✓

TIP 39 describes boundaries ranging from enmeshment, where family members are 'smotheringly close' and struggle to function as separate people, to disengagement, where members are distant and unreachable. A mother speaking for her teen and confiding marital problems to her fits enmeshment and a weak generational boundary. Disengagement is the opposite pattern, and a clear boundary would let Mia speak for herself. Homeostasis refers to a family resisting change, such as when a member stops using substances, which is not what this case describes.

Jasmine, 26, is being evaluated for an outpatient program's alcohol-use group; the intake diagnosis is alcohol use disorder, moderate. This week she was evicted, her partner left, and she punched a wall in the waiting room when her name was mispronounced. She is not suicidal. She asks to start group tonight. Which modality is MOST appropriate to begin with?

• a.A process-oriented group focused on intense emotional expression
• b.Individual sessions until her crisis and impulse control stabilize✓
• c.A family-therapy session with the partner who just left
• d.The general group tonight, since peer support helps people in crisis

TIP 41 lists people in the throes of a life crisis and people who cannot control impulses among those who may not be suited to group therapy, and says placement begins with a thorough assessment of stability and interpersonal functioning. Jasmine is in acute crisis with recent impulsive aggression, so individual sessions to stabilize her come first, with group reconsidered later. Starting group tonight, or joining an intense process group, risks harm to her and to members. A joint session with a partner who just left does not match her stated needs.