Treatment planning on the NCMHCE

A client who works two jobs keeps missing sessions because of shifting schedules and unreliable buses. How would you respond?

1. Discharge her for repeated no-shows under agency policy.
   Discharging her under a no-show policy cuts off care for a client who wants it; barriers are addressed before termination is considered.
2. Tell her to put her sessions ahead of her work shifts.
   Telling her to put sessions ahead of her jobs ignores her financial needs and puts the burden of the barrier on her.
3. Interpret her absences as resistance to the therapy.
   Interpreting her absences as resistance ignores the practical barriers she describes and blames her for her circumstances.
4. Explore barriers and offer flexible times or telehealth.
   Exploring the barriers and offering flexible times or telehealth adapts the plan to her work and transportation realities and keeps her in care.

A client says the proposed goal of attending a weekly support group "isn't for me." What is your best response?

1. Keep the goal as written because it is evidence-based
   Keeping a goal because it is evidence-based, against her objection, ignores client preference, which is itself part of evidence-based practice.
2. Refer her to a counselor whose goals she may prefer
   Referring her elsewhere over one disputed goal is an overreaction that avoids the work of revising it together.
3. Delete the goal and avoid raising the topic again
   Deleting the goal and never raising it again drops a possible support without learning what made it a poor fit.
4. Explore her concerns and revise the goal together
   Exploring her objection and revising the goal together keeps the plan collaborative; a goal the client rejects is unlikely to be met.

A client with depression is a skilled gardener and belongs to a close church community. How would you use these strengths in her plan?

1. Record them but keep the plan focused on problems
   Recording strengths without using them wastes resources that can drive her activity and support goals.
2. Leave problems out so that the plan stays positive
   Leaving problems out of the plan to keep it positive removes the clinical targets the plan exists to address.
3. Build them into her activity and support goals
   Building gardening and her church community into her activity and support goals uses existing strengths to work on the depression.
4. Replace her symptom goals with goals about hobbies
   Replacing symptom goals with hobby goals drops the depression treatment; strengths support the goals, they do not replace them.

A client with social anxiety drinks heavily before social events. What approach best fits his treatment plan?

1. separate plans for each problem with no coordination
   Separate, uncoordinated plans repeat the old sequential model that integrated treatment replaced.
2. an integrated plan that treats both at the same time
   An integrated plan that treats both at once fits co-occurring disorders, especially when the drinking is a way of coping with the anxiety.
3. treating his anxiety first and setting the drinking aside
   Setting the drinking aside leaves heavy use that undermines anxiety treatment and carries its own risks.
4. treating his drinking first and the anxiety after sobriety
   Treating the drinking first and the anxiety later ignores that he drinks to manage social anxiety; untreated anxiety drives relapse.

Helen, 63, lost her husband 16 months ago. She still yearns for him every day, avoids places they went together, says her life has lost its meaning and has withdrawn from friends. She meets criteria for prolonged grief disorder. Which treatment approach fits her plan best?

1. Grief-focused therapy that revisits the loss and supports a continuing bond
   Prolonged grief disorder responds best to therapy that targets the grief itself: prolonged grief disorder therapy (formerly complicated grief treatment) revisits the loss and supports a continuing bond, and it outperformed interpersonal therapy and citalopram alone in trials.
2. Supportive listening until the grief eases with more time
   Waiting for time to heal fits normal grief; PGD by definition persists at least 12 months after the death in adults under DSM-5-TR (ICD-11 uses 6 months) and calls for targeted treatment.
3. An antidepressant alone, since her symptoms overlap with depression
   PGD overlaps with depression but is a separate diagnosis; in a trial an antidepressant alone did not reduce grief symptoms, while grief-focused therapy did.
4. Advice to remove reminders of him and stop visiting his grave
   Removing reminders and avoiding the grave reinforces the avoidance that keeps PGD going; grief-focused therapy gradually revisits the loss and supports a continuing bond with the person who died.

Your treatment plan for a 30-year-old client with panic disorder includes the objective "Reduce panic attacks from 4 per week to 1 per week within 8 weeks." How would you document her progress toward this objective?

1. Record only improvements, to keep her motivated and encouraged
   Recording only improvements distorts the record; setbacks are data the plan needs.
2. Record her weekly panic attack count from her monitoring log
   Recording her weekly attack count from her log measures progress in the same unit the objective uses, from 4 a week toward 1.
3. Note how satisfied she says she is with her panic treatment
   Satisfaction with her panic treatment is a separate measure and says nothing about how often attacks occur.
4. Note your overall impression of whether her attacks seem milder
   An impression that attacks seem milder is subjective and measures intensity, while the objective counts attacks per week.

A 29-year-old client with alcohol use disorder, severe, drinks a fifth of vodka daily, has morning tremors, and had a withdrawal seizure last year. He asks for weekly outpatient counseling. What would primarily determine the level of care you recommend?

1. His preference for weekly sessions near his workplace after hours
   A preference for weekly sessions near work cannot outweigh the risk of seizures or delirium during withdrawal, so it does not set the level of care.
2. The withdrawal program your agency typically uses for everyone
   Defaulting to the agency's usual program ignores his individual risk profile, which is what level-of-care decisions are based on.
3. The outpatient services that his insurance plan is willing to cover
   Insurance coverage shapes logistics but cannot set the level of care when clinical risk calls for medical supervision.
4. His withdrawal risk and his current medical and functional needs
   Daily heavy drinking, morning tremors and a past withdrawal seizure mean withdrawal could be dangerous, so the level of care follows his withdrawal risk and medical and functional needs, as in the ASAM Criteria.

A 42-year-old client with panic disorder skips his interoceptive exposure practice, saying, "Why would I make myself dizzy on purpose? That's what I'm trying to stop." How would you address this in his treatment plan?

1. Remind him that treatment will end if he keeps skipping exposure practice
   Threatening to end treatment coerces rather than engages, and it does not answer his question about why exposure helps.
2. Explain the rationale for exposure and agree together on practice steps
   Explaining that bringing on dizziness on purpose teaches him the sensations are not dangerous, then agreeing on graded steps, answers his objection and keeps him in the exposure work.
3. Instruct him to do the full exercises daily without further discussion
   Ordering the full exercises daily without discussion ignores his concern and is likely to increase avoidance.
4. Replace interoceptive exposure with relaxation training at his request
   Replacing interoceptive exposure with relaxation drops the active ingredient, and relaxation can act as a safety behavior in panic disorder.

A 50-year-old client with major depressive disorder, recurrent, moderate, shows no PHQ-9 change after 12 weeks of supportive counseling with you and an earlier course of CBT elsewhere. What would you do next in treatment planning?

1. Discontinue treatment for her lack of response to therapy
   Stopping treatment for lack of response abandons a client who still needs care; nonresponse is a reason to change the plan, not to end it.
2. Continue the same supportive counseling for 12 more weeks
   Repeating the same approach for another 12 weeks ignores measurement-based care, which uses a lack of progress to trigger a change of plan.
3. Refer her for medication and end counseling services entirely
   Referring for medication and ending counseling entirely drops psychotherapy, although combined treatment often works better for recurrent depression.
4. Reassess with her and add IPT or a medication evaluation referral
   No change after two courses of treatment calls for reassessing with her and changing the plan, such as another evidence-based therapy like IPT or a referral for a medication evaluation.