Is that Ethical?
Name That Diagnosis
Private Practice Skills
What would you do?
DEI & Co.
100
A client asks to review their record and requests that you remove a diagnosis they disagree with.

Answer: What is a client's right to request an amendment, while the therapist is generally not required to alter accurate clinical documentation?

Protocol:

  • Review applicable state law and practice policies.

  • Allow the client to submit a written amendment request if appropriate.

  • Document the request and your response.

  • If denying the request, document the rationale and inform the client of their rights.

100
A client repeatedly pulls out hair from the scalp and eyebrows, reporting mounting tension before pulling and relief afterward. They have attempted to stop multiple times, resulting in noticeable hair loss and social embarrassment.

Answer: What is Trichotillomania?

Protocol:

  • Assess frequency, triggers, and functional impairment.
  • Evaluate for skin-picking, OCD, anxiety, and depressive disorders.
  • Rule out dermatologic or medical causes of hair loss.
  • Assess emotional distress and coping strategies.
100
A therapist notices increasing emotional exhaustion, dreads seeing clients, has become less attentive during sessions, and has fallen behind on documentation.


Answer: What is recognizing clinician burnout and impairment that may affect competence?

Protocol:

  • Conduct an honest self-assessment of clinical functioning.
  • Reduce workload or adjust scheduling as appropriate.
  • Seek consultation, supervision, or personal therapy.
  • Address documentation backlog promptly.
  • Develop a plan to restore competent practice.
100

A client says, "Nothing ever works, so why bother trying?"


Answer: What is cognitive restructuring?

Protocol:

  • Identify cognitive distortions.

  • Gather evidence for and against the belief.

  • Develop alternative thoughts.

100

A therapist assumes a client's emotional reserve reflects resistance before learning that emotional restraint is highly valued within their family.

Answer: What is avoiding cultural assumptions and exploring cultural competency?

Protocol:

  • Use cultural curiosity.

  • Assess meaning before assigning pathology.

200
You receive a subpoena for a client's records but do not have client's authorization.

Answer: What is consulting legal and ethical guidelines before releasing records?

Protocol:

  • Do not immediately release records.

  • Verify the type of subpoena/court order.

  • Consult your malpractice carrier, supervisor, attorney, or professional association.

  • Inform the client when appropriate.

  • Document all actions taken.

  • Document all actions taken.
200

A client reports episodes of feeling detached from their body, describing the sensation as if they are observing themselves from outside. They recognize these experiences are not real and deny hallucinations or substance use.

Answer: What is Depersonalization/Derealization Disorder?

Protocol:

  • Rule out neurologic and substance-related causes.
  • Assess reality testing.
  • Screen for trauma history and dissociative symptoms.
200

A client has accumulated three unpaid sessions and continues requesting additional appointments. Your financial policy states that services may be paused after a specified outstanding balance.

Answer: What is consistently enforcing the practice's financial policy regarding unpaid balances and pausing sessions until payment?

Protocol:

  • Review the signed informed consent and financial agreement.
  • Notify the client of the outstanding balance.
  • Offer payment plan options 
  • Document all communications and decisions.
  • assess for client abandonment if services are clinically necessary.
200

A client repeatedly fails to complete homework assignments despite attending sessions. (2 answers)

Answer: What is exploring barriers and readiness for change?

Protocol:

  • Assess motivation.

  • Simplify assignments.

  • Collaboratively revise treatment plan.

200

A client frequently misses sessions because of unreliable transportation and unpredictable work shifts.


Answer: What is failing to consider socioeconomic barriers and social determinants of health?

Protocol:

  • Assess barriers.

  • Consider telehealth options.

  • Modify scheduling when feasible.

  • Connect with community resources.

300
A client reveals they have secretly recorded sessions for several months.

Answer: What is discussing informed consent, privacy concerns, and applicable state laws?

Protocol:

  • Explore impact on the therapeutic relationship.

  • Clarify state recording laws.

  • Review informed consent documents.

  • Consult supervision if continuation of treatment is affected.

300

A client repeatedly seeks reassurance that they have a serious neurological illness despite multiple normal evaluations. Their anxiety briefly decreases after medical appointments but quickly returns, and they report few physical symptoms.

Answer: What is Illness Anxiety Disorder?

Protocol:

  • Rule out genuine medical conditions.
  • Assess reassurance-seeking and health-related behaviors.
  • Screen for OCD and anxiety disorders.
300
A client has met all treatment goals, consistently reports symptom remission, and has maintained progress for several months. They ask if they should continue weekly therapy indefinitely.

Answer: What is initiating planned termination of therapy?

Protocol:

  • Review treatment goals and progress.
  • Develop a relapse prevention and maintenance plan.
  • Provide referrals or booster-session options if appropriate.
  • Document the rationale for termination and discharge summary.
300

A client with severe anxiety spends every session discussing minor day-to-day frustrations.(2 answers)


Answer: What is identifying avoidance and redirecting treatment toward treatment goals?

Protocol:

  • Review goals.

  • Explore avoidance patterns.

  • Re-establish session focus collaboratively.

300

A therapist begins an intake by asking a client if they have a "husband or wife." The client appears hesitant before clarifying they have a partner.


Answer: What is using inclusive, gender-neutral language until a client self-identifies their relationships and identity?

Protocol:

  • Use neutral terms such as "partner" or "significant other."
  • Allow clients to self-identify sexual orientation and gender identity.
  • Document the client's preferred language and pronouns.
  • Model inclusive communication throughout treatment.
400

A 10-year-old client reports that their mother's boyfriend regularly leaves them unsupervised overnight and recently pushed them into a wall, leaving bruises. The child begs you not to tell anyone.

Answer: What is mandated reporting due to reasonable suspicion of abuse or neglect?

Protocol (Massachusetts 51A):

  1. Assess immediate safety concerns.

  2. Explain the limits of confidentiality to the child in developmentally appropriate language.

  3. File an oral report immediately with the appropriate office of the Massachusetts Department of Children and Families.

  4. Submit a written 51A report within the required timeframe.

  5. Document:


    • Child's statements

    • Observed injuries or concerns

    • Actions taken

    • Consultation obtained

  7. Continue to support the child therapeutically while avoiding investigative questioning.

400
A client consistently seeks to be the center of attention, becomes uncomfortable when others receive recognition, and frequently uses dramatic emotional expression and physical appearance to gain approval. Relationships are often perceived as closer than they actually are.

Answer: What is Histrionic Personality Disorder?

Protocol:

  • Assess long-standing interpersonal patterns across settings.
  • Differentiate from borderline and narcissistic personality disorders.
  • Evaluate for co-occurring mood, anxiety, or substance use disorders.
  • Assess functional impairment and relationship difficulties.
400

A prospective client books an intake online but leaves the insurance information blank and has not completed any required paperwork by the day before the appointment.


Answer: What is holding the appointment until all required onboarding requirements are completed, according to practice policy?

Protocol:

  • Verify insurance or self-pay status.
  • Confirm receipt of intake documents and consent forms.
  • Contact the client regarding missing information.
  • Reschedule if practice policy requirements are not met.
400

A client with panic disorder never leaves home without a specific "safety object."

Answer: What is addressing safety behaviors?

Protocol:

  • Develop a graduated exposure hierarchy.

  • Reduce dependence on safety behaviors over time.

400
A client reports hearing the voice of God during prayer.

Answer: What is assessing the cultural and religious context before pathologizing the experience?

Protocol:

  • Explore religious beliefs.

  • Assess distress, impairment, reality testing, and cultural norms.

  • Consult cultural resources when needed.

500

A client reports a specific intent to seriously harm another person, but the intended victim is not clearly identifiable

Answer: What is conducting a thorough violence risk assessment and evaluating duty-to-protect obligations

Protocol:

  • Assess intent, plan, means, timeframe, and history.

  • Review state-specific duty-to-warn/protect laws.

  • Consult supervisor or legal resources immediately.

  • Develop safety interventions.

  • Thoroughly document assessment and rationale.

500
A client develops delusions, auditory hallucinations, disorganized speech, and markedly impaired functioning that have been present for approximately four months. Mood episodes have been brief and do not account for the majority of the d/o.


Answer: What is Schizophreniform Disorder?

Protocol:

  • Rule out substance-induced psychosis and medical causes.
  • Assess risk of harm to self or others and ability to care for basic needs.
  • Evaluate duration of psychotic symptoms to distinguish from brief psychotic disorder and schizophrenia.
  • Arrange prompt psychiatric evaluation and ongoing monitoring for progression of illness.
500

A client frequently emails between sessions asking for therapeutic advice on multiple issues, expecting detailed responses within a few hours.


Answer: What is setting expectations for between-session communication?

Protocol:

  • Review the communication policy outlined in informed consent.
  • Clarify appropriate uses of email and messaging.
  • Redirect clinical discussions to scheduled sessions when appropriate.
  • Document recurring boundary concerns.
500

A suicidal client denies intent but reports hopelessness, firearm access, social isolation, and a recent major loss.



Answer: What is conducting a comprehensive suicide risk assessment despite denial of intent?

Protocol:

  • Assess ideation, plan, intent, means, and history.

  • Evaluate protective factors.

  • Complete safety planning.

  • Consult supervisor when indicated.

  • Determine level of care needed.

500
A client shares political views that differ from the therapist’s and discusses feeling invalidated in society related to their identity. The therapist notices strong personal reactions and a desire to challenge the client’s perspective.





Answer: What is practicing cultural humility by managing countertransference and maintaining a client-centered, nonjudgmental stance?

Protocol:

  • Notice and manage personal bias and emotional reactions.
  • Use supervision/consultation as needed outside session.
  • Focus on the client’s lived experience and meaning-making.
  • Avoid debating or imposing personal values.
  • Assess relevance of sociopolitical stress to clinical concerns.
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