MFT CVE Strategies Manual 2010-04

CALIFORNIA MFT WRITTEN CLINICAL VIGNETTESTRATEGIES MANUAL

Table of Contents

Table of Contents

Quick Start Guide™ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

I. Written Clinical Vignette Examination Format . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

II. Written Clinical Vignette Content Areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

III. Taking the Written Clinical Vignette Exam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

A. Applying to take the Written CVE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

B. In the Examination Room . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

C. Dealing With Anxiety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

IV. Strategies For Approaching the MFT Written Clinical Vignette Examination . . . . . 12

A. Section 1: Thinking Skills for the Written CVE. . . . . . . . . . . . . . . . . . . . . . . . . . . 12

B. Section 2: Strategies for Approaching the Written CVE as a Whole . . . . . . . . . . . 13

C. Section 3: Stages of Treatment in the Written CVE. . . . . . . . . . . . . . . . . . . . . . . . 17

D. Section 4: Strategies for Reading Written CVE Exhibits . . . . . . . . . . . . . . . . . . . . 18

E. Section 5: Strategies for Analyzing and Choosing Written CVE Responses . . . . . . 19

F. Section 6: Written CVE Content Areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

G. Section 7: Studying with CaseMASTER’s Rationales . . . . . . . . . . . . . . . . . . . . . . 44

H. Section 8: BBS Sample Exhibit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

I. Section 9: Practice Exercises . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

J. Section 10: Additional Study: Theory Concepts . . . . . . . . . . . . . . . . . . . . . . . . . . 77

� 2010, Association for Advanced Training Page i

Strategies ManualCalifornia MFT Clinical Vignette Exam Table of Contents

CALIFORNIA MFT WRITTEN CLINICAL VIGNETTESTRATEGIES MANUAL

Quick Start Guide™

Quick Start Guide

Welcome to the AATBS preparation program for the MFT Written Clinical Vignette Exam!While candidates should modify the study plan according to their own circumstances, we dorecommend a basic study plan similar to this:

1. Skim through the Candidates’ Handbook and the MFT Study Guide in the Appendix ofthis Strategies manual, unless you are already very familiar with these documents.The Handbook and the Study Guide are published by the BBS, and offer you “official”guidance as to the overall structure of the exam and the procedures involved in takingit.

2. Try the sample questions in the MFT Study Guide, and check your answers. Be awarethat these practice items offered by the BBS were actually used on previous exams,but they are examples of the very easiest level of questions that appear on the exam.

3. Next, read through this entire STRATEGIES MANUAL. Pay particular attention to thesections on strategies for rating responses, so that you will have some tools to usewhen you begin your practice with CaseMaster. (The Additional Study: TheoryConcepts section is optional, and if you decide to review this section, you shouldspread the exercises across several days or weeks.)

4. Once you have reviewed the Strategies Manual, register for CaseMASTER, whichcontains the practice exhibits and questions. Go to the AATBS Website(www.aatbs.com), and click on the “CaseMASTER” option under the Program Loginmenu. Enter your invoice number and create a password as instructed. Remember:CaseMASTER is active for a designated period of time, which begins when you registeronline, so don’t login too early. You want to plan your access so that you are able topractice right up until the time you take your exam.

5. CaseMASTER consists of two sections: Sets of Practice Questions (which listindividual exhibits with five or six related questions) and Mock Exams (which providefull-length exams with vignettes and questions not previously encountered.) As youwork through these practice vignettes and questions, you will be exposed to a varietyof clinical situations, questions, and answer choices that are very similar to the realClinical Vignette Exam. Because you studied this material for the first exam, youshould not need to go back to review concepts, diagnoses, legal/ethical issues, or othercontent, Your job is to develop a process for analyzing the vignette and sorting throughanswer options quickly. CaseMASTER is your primary study tool, and there are atleast two equally effective ways to use it. Consider your own preferred learning styleand decide which procedure suits you.

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Strategies ManualCalifornia MFT Clinical Vignette Exam Quick Start Guide

A. STUDY mode first, then EXAM mode:

First complete all of the Practice Questions in Study Mode, while applying the strategies thatyou learned from the Strategies Manual. Start with all of the Easy Practice Exhibits, thenprogress to the Mediums, and finally complete the Hard Practice Exhibits. Read all of therationale pages, regardless of whether you got the question correct or incorrect. Notice whichsuggested strategies are most effective for you.

Once you have completed all of the Practice Questions, begin a second review of the PracticeQuestions using Exam Mode this time. String together two or three sets of exhibits initially tobuild your stamina and increase the number of exhibits until you are answeringapproximately 40 questions at a time, since the actual exam is comprised of 40 questions thatmust be completed within 2 hours. However, at this stage, you should give yourself extra timeto complete the questions, but work towards finishing within this time-limit.

Next, you should complete the Mock Exams in Exam Mode, under exam-like conditions, e.g.,no more than 2 hours, no water or food at the desk, no phone calls, the timer does not stopduring bathroom breaks, etc. Again, read all rationale pages for all of the questions aftercompleting the exam. Notice any areas where you consistently make mistakes. Review contentif necessary. Reflect on which strategies are most effective for you.

B. EXAM mode first, then STUDY mode:

Approach each set of questions first in EXAM mode, allowing three minutes per question, notchecking to see how you are doing, not stopping to read rationales or comments on strategies.This will give you the opportunity to simulate real exam conditions as often as possible.Remember that there are a limited number of questions to practice with, and once you haveworked with them in STUDY mode, you will no longer be able to have the experience ofencountering brand new material under stressful conditions. Doing EXAM mode first willexpose you and desensitize you to this stress. After to use EXAM mode, you can use STUDYmode as often as you want, as described in Procedure A, reviewing content and consideringstrategies for each set of questions. We recommend going through each set of practicequestions and the two mock exams at least twice after the initial practice in EXAM mode.

Whichever procedure you use, begin with all of the Easy Practice Exhibits, then progress tothe Mediums, and finally complete the Hard

Do NOT wait to do the Mock Exams until just before the real test. Do NOT be overly focusedon your scores. Your scores on mock exams are not a predictor of your performance on theactual exam. While there is a mix of difficulty levels in the mocks, they are deliberatelyconstructed to be quite difficult. We want to to “over train “ you for the real experience.

Be sure to check the What’s New box in CaseMASTER frequently for any updates to theprogram or news that pertains to the examination process.

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Strategies ManualQuick Start Guide California MFT Clinical Vignette Exam

I. Written Clinical Vignette Examination Format

Clinical Vignette Examination Format

To become a Licensed Marriage and Family Therapist (LMFT) in California, the Board ofBehavioral Sciences (BBS) requires that the licensee pass two licensing exams: The StandardWritten Exam, and the Written Clinical Vignette Exam (CVE). The BBS contracts with aprivate provider who actually administers the exams at testing centers located throughoutCalifornia. This California MFT Written Clinical Vignette Strategies Manual will introduce youto the Written CVE, show you strategies for analyzing and approaching vignettes and theirassociated questions and give you homework assignments to sharpen your critical thinkingskills as they relate to the Written CVE.

The exam usually consists of 8 clinical vignettes with 4-7 multiple-choice questions associatedwith each vignette. The total number of multiple-choice items is 40, but 10 of these items arequestions which are being pre-tested, and do not count toward your total score. Allmultiple-choice items (other than the pre-test items) are equally weighted. Candidates aregiven 2 hours to complete the exam.

The passing score is re-set at the beginning of every six month cycle, depending on thedifficulty of the questions and how a group of subject matter experts performs on it. Therange has been wide, between 18 and 22 correct. Remember, that means 18-22 out of the 30items that comprise the real exam. That is anywhere from 60-73% correct. The Board doesnot announce the passing score, but you can find the current score on the “What’s New” pageof CaseMASTER. Most frequently the required score has been 19 or 20. As with the firstexam, candidates aren’t told their score unless they don’t pass.

The Board of Behavioral Science examiners two helpful publications: the “BBS Marriage andFamily Therapist Written Clinical Vignette Examination Candidate Handbook” and the “MFTStudy Guide.” Both are available at their web site, www.bbs.ca.gov, but we have also includedcopies in this strategies volume. The same six content areas measured on the StandardWritten exam are used—Crisis Management, Clinical Evaluation, Treatment Plan, Treatment,Ethics and Law. However, the associated knowledges and tasks identified in the Candidate’sHandbook are a little different from the first exam, and we invite you to review our overviewon the next few pages. The exact number of items devoted to each content area will varyslightly from one examination version to another in accordance with the clinical features andkey factors associated with each vignette. Also, exam items will often require you to applyknowledge from more than one content area. Thus it is not useful to study areas separately,or to identify some areas as more important to study than others.

The Candidate’s Handbook contains two sample questions, and the MFT Study Guide hastwelve more examples to review. You will notice that each answer choice typically has fourelements contained within it, and that these elements are often repeated in subsequentresponse choices.

The following is an example of a typical Exhibit and question/answer set, just to illustrate theformat. We will give you the answer to the question and illustrate a process for arriving at theanswer later on in this manual.


Strategies ManualCalifornia MFT Clinical Vignette Exam Clinical Vignette Examination Format

EXHIBIT 1

George, a 66-year-old man is referred by his minister. He lost his wife, only daughter, and

son-in-law in an auto accident three months ago. He suffered a concussion. He has the two

grandchildren living with him now, ages 8 and 10. He wonders if he should get another

job to help support the grandchildren. His son-in-law's parents offered to take the children

and raise them. He is tearful and says he isn’t sleeping at all. He states that he and his

wife had made so many plans together for when they grew old and now everything has

changed.

Question 1 of 2: What diagnoses would you consider in this case?

1. Primary Insomnia

Major Depressive Disorder

Adjustment Disorder with Anxious Mood

Phase of Life Problem

2. Bereavement

Acute Stress Disorder

Histrionic Personality Disorder

Adjustment Disorder with Depressed Mood

3. Major Depressive Disorder

Malingering


Dysthymic Disorder

4. Adjustment Disorder with Anxious Mood

Bereavement

PTSD


Key Procedures:

Make sure you carefully read the instructions you are given at the testing center so you knowhow to negotiate all the available options during your exam. Making use of the tutorial beforebeginning the exam is highly advised. You may believe that taking the first exam with thetesting company was sufficient to familiarize yourself with how the software is set up, but youmay encounter new procedures, and there is no downside to using the practice module.

The timer on the computer will start counting down the moment you press “Start,” so be sureto be aware of your time. If you take a bathroom break, the timer will continue to count downwhile you are away from the computer.

Never leave a question unanswered. You are allowed to flag a question that you would like toreturn to, and can ask the computer to bring you back to the flagged questions. Always pickan answer choice, even if you are unsure, because you might run out of time to come back toyour flagged responses. If you simply pick any answer, you have a 25% chance of getting itright. It is more common to find yourself struggling between only two of the answer choices.Statistically this means you have a 50% chance of getting it right. However, if you leave ananswer choice blank and can’t get back to it, you have a 0% chance of getting it right.


Strategies ManualClinical Vignette Examination Format California MFT Clinical Vignette Exam

After you are done, the computer asks if you would like to take a survey about yourexperience – you may choose to answer the survey questions or not. Candidates receive theirresults immediately via the computer once they press the END button.


Strategies ManualCalifornia MFT Clinical Vignette Exam Clinical Vignette Examination Format

II. Written Clinical Vignette Content Areas

Clinical Vignette Content Areas

The six content areas for the Written CVE are delineated in the BBS Written CVE Handbook.The Written CVE Handbook defines what knowledge is expected in each area, and what tasksthe therapist is expected to perform as they relate to the content areas. Questions can beanchored in a single content area, or may cover more than one content area simultaneously.

Crisis Management — what is being rated:

• Identify crisis situations and psychosocial stressors

• Recognize the severity of crises and psychosocial stressors

• Evaluate plans to clinically manage crises and psychosocial stressors

Typical Written CVE Questions:

• What crisis issues and psychosocial stressors are presented in this case?

• Describe the assessment and clinical management of (a major crisis).

• Describe the clinical management of (a psychosocial stressor).

Clinical Evaluation — what is being rated:

• Identify human diversity issues

• Evaluate clinical issues and assessment information from theoretical frameworks

• Evaluate diagnostic impressions including those consistent with DSM-IV-TR


• How will you gather additional information to develop a clinical assessment for

this case?

• What human diversity issues are specific to this case and how would you assess

for their impact on this situation?

• What are your diagnostic considerations in this case?

Treatment Planning — what is being rated:

• Apply theoretical frameworks to a vignette

• Evaluate treatment plans with beginning, middle and end stages

• Evaluate and prioritize treatment goals

• Evaluate the incorporation of human diversity into the treatment plan


• What are the early stage treatment goals for this couple?


Strategies ManualClinical Vignette Content Areas California MFT Clinical Vignette Exam

• Working from a family systems perspective what would be appropriate goals for

this family?

• What human diversity issues do you need to incorporate into your treatment

plan?

Treatment — what is being rated:

• Select theoretically consistent and client-specific clinical interventions

• Evaluate the progress of treatment

• Consider alternative interventions


• What interventions would you use in the middle stage of therapy if you were

treating this case from a cognitive behavioral perspective?

• How would a structural therapist proceed if giving paradoxical instructions failed

to produce results?

Ethics — what is being rated:

• Recognize professional ethical responsibilities specific to the case

• Apply ethical standards and principles throughout the treatment process

• Identify the clinical impact of ethical responsibilities on treatment


• What are your ethical responsibilities in this case and how would you manage

them?

• Describe your clinical management of your ethical responsibilities in this

situation.

Law — what is being rated:

• Recognize legal obligations specific to the case

• Apply legal obligations throughout the treatment process

• Identify the clinical impact of legal obligations on treatment


• Describe your legal obligations in this case.

• Identify the clinical management of _______________ legal obligation.

• What legal and ethical issues are most likely to impact your treatment plan?


Strategies ManualCalifornia MFT Clinical Vignette Exam Clinical Vignette Content Areas

III. Taking the Written Clinical Vignette Exam

Taking the Written Clinical Vignette Exam

A. Applying to take the Written CVE

Candidates who have passed the Standard Written examination are qualified to take theWritten Clinical Vignette examination and may apply immediately by submitting a Request forExamination form (available on the BBS website and at testing centers) and a $100 fee to theBoard. First-time candidates should allow three weeks for processing and notification ofeligibility. Your deadline to take the Written Clinical Vignette examination is:

• One year from the date you passed the Standard Written examination

OR

• One year from the date you last failed the Written Clinical Vignette examination.

The Board of Behavioral Sciences contracts with Psychological Services, LLC (PSI) toschedule and administer the Board’s licensing examinations. Once the Board determinesthat you are eligible to sit for an examination, your information is referred to PSI, and PSI willsend you a Candidate Handbook within two weeks. The handbook will contain the necessaryinformation that you will need to schedule your appointment as well as the procedures forscheduling. The Board strongly recommends that candidates study each section carefully inadvance of the examination to contribute to a successful examination experience.

If you are a FIRST TIME APPLICANT your examination eligibility expires one year from thedate of original eligibility. If you are a RE-EXAMINATION APPLICANT your eligibility expiresone year from the date of your last exam. You must wait approximately 160 days to retake afailed examination. Your eligibility information can be verified by contacting the Board. Thehandbook will have a date indicating the specific date that your eligibility expires. The Boardis unable to grant an extension of eligibility expiration date for any reason. An applicationbecomes abandoned when an applicant fails to sit for an examination within one year afterbeing notified of eligibility or within one year from the most recent date of failure.

When scheduling you will need to provide PSI with your name, social security number, andfile number. If you are currently eligible and have not received a candidate handbook withintwo weeks of your initial eligibility date, are unsure of your file number, or if you haveproblems or difficulties when scheduling or taking an exam, you should contact the Board at(916) 574-7830. To schedule with PSI call (877) 392-6422 or access their on-line

registration system at www.psiexams.com.

Candidates who have a physical or learning disability may apply for accommodations such asextended time, pen and paper exam, etc. by submitting a Request for Accommodationpackage a minimum of 90 days prior to their desired test date. If you had accommodationsfor the Standard Written examination, and your accommodation request is still on file, youwill be granted those same accommodations for the Written Clinical Vignette examination,unless you file a new request.


Strategies ManualTaking the Written Clinical Vignette Exam California MFT Clinical Vignette Exam

Usually, result notices are provided to candidates immediately on site. If you pass the exam,you become eligible to apply for your license. You will receive a Request for Initial LicenseIssuance form, which must be submitted with the required fee prior to issuance of a license.The BBS states that “this fee will not exceed $130 and is established and prorated accordingto the issuance and expiration date of your license.”

B. In the Examination Room

Candidates are usually given a single sheet of scratch paper, so we recommend that youpractice using only one piece of paper when working on questions in our online programs(see Section 5: Strategies for Analyzing and Choosing Written CVE Responses (1) Fold Notes).The PSI computer system allows the candidate to see the vignette, question and answerchoices on one screen, and you may choose answers and navigate through the exam by eitherusing the keyboard (as pictured in the BBS Candidate Handbook) or you may use a mouse.

Candidates are not allowed to take anything into the examination with them, but may beoffered a locker to store items like jackets, food, water, keys, etc. Watches are not allowed.Additionally, a clock runs backward on the computer screen, stating how much time is left onthe exam. Layered clothing is generally advisable, as the examination center may be cold orwarm. However, if you remove a layer of clothing such as a sweater, you will likely be askedto leave the examination room and place it in your locker or leave it with the proctor. Thetimer does not stop when you leave the examination room to place items in your locker, go tothe bathroom, etc.

If you find that anything is not as expected, for example, the time you are scheduled for yourtest is different than what you expected, if you have trouble operating the computer, or anyother technical problem, be sure to be assertive and discuss the issue with the proctors.Mistakes do occur at the testing center, and if you feel that you have had to deal with anunusual situation, fill out a complaint form, ask for a supervisor, or notify the BBS andCAMFT as appropriate.

C. Dealing With Anxiety

One of the most difficult things for most candidates to master in the Written Clinical VignetteExam is anxiety. Anxiety in any test taking situation is normal, but it tends to becomeamplified in the Written CVE because 1) it is the final step toward getting licensed, 2) thestructure of the exam is so unusual, and 3) the time pressure is very intense for most people.

A little bit of anxiety tends to sharpen thinking processes, but too much anxiety puts you into“fight or flight” mode, where adrenaline courses through your body and prepares you to runaway, or stand and fight. Unfortunately, this is not the most cognitively present state you canbe in for an exam. All of the energy is channeled into preparing to run or fight, and very littleinto thinking and analyzing. Therefore, managing anxiety is key to success in the WrittenCVE.

The quickest and most effective way of eliminating feelings of stress and panic is to close youreyes and take several long, slow deep breaths. Breathing this way calms your whole nervous


Strategies ManualCalifornia MFT Clinical Vignette Exam Taking the Written Clinical Vignette Exam

system. Simultaneously you could give yourself some mental pep-talk by mentally repeating "Iam calm and relaxed" or "I know I will do fine".

If your mind goes blank, don't panic! Panicking will just make it harder to recall information.Allowing yourself to give into panic because of one difficult question will affect yourperformance on the next several questions, so it is important to stay calm and use calmingself-talk, breathing, etc. when having difficulty with a particular question. Focus on slow, deepbreathing for about one minute. If you still have trouble with the question, choose any of theanswers, Mark it, move on to another question and return to this question later. People alsotend to panic more toward the beginning of the exam because the experience is new, whichmay lead to more errors in the beginning and taking too much time on earlier questions.

Practice these anxiety reduction techniques when using CaseMASTER so that they will befamiliar to you when you take the real exam.

Set up your Scratch Paper

Use the act of setting up your scratch paper as a calming exercise. The proctor will giveyou a single sheet of scratch paper, which can be used front and back. There will likelybe 5 to 8 vignettes with a total of 40 questions, so you can divide your scratch paper into40 squares (one for each question) before you begin your exam. You should do this beforeyou press the START button on your exam. One method is to make 40 boxes and labeleach one in advance (1 through 40). Label each box as you begin the question with thename of the vignette client and the number and series number of the question (forexample: Jane 1 of 6). If you don’t need a box for a particular question, you can stillmake a check mark in the box, which will help you track which question you are on. Ifyou like, you can also note what time you expect it to be after a certain amount ofquestions – for example, if you begin your exam at 1:00, you will want to have finished 10questions by 1:30, and so on.

Breathe

When you read a vignette, take a moment to close your eyes, take a couple of slow, deepbreaths, and imagine yourself sitting in your office with the client(s). Imagine how theymake you feel, what kinds of associations or concerns jump into your mind, and what youthink the problem might be. Breathe deeply while you do this – it only takes a fewseconds. Also, take a long, slow breath from your solar plexus at each question while yourephrase the question in your own words. While you breathe, straighten your back - as ifsomeone were pulling a lever between your shoulder blades.

Thought Stopping and Self Talk

If you find yourself giving in to negative thoughts, ('I can't answer anything', 'I'm going topanic' etc). halt the spiraling thoughts by mentally shouting 'STOP!'. Or picture a roadSTOP sign, or traffic lights on red. Once you have literally stopped the thoughts, you cantake a deep breath or practice a relaxation technique briefly before returning to thequestion. In exam anxiety or panic we often give ourselves negative messages, 'I can't dothis' 'I'm going to fail' 'I'm useless'. Try to consciously replace these with positive,encouraging thoughts: “This is just anxiety, it can't harm me,” “Relax, concentrate, it'sgoing to be OK',” “I'm getting there, nearly over,” or “This item is probably hard becauseit’s a pre-test item and doesn’t even count!”



Creating mild pain

Pain effectively overrides all other thoughts and impulses. Even very mild pain - such aslightly pressing your fingernails into your palm - can block feelings of anxiety. Somepeople find it helpful to place an elastic band around one wrist, and lightly twang it whenthey are becoming anxious.

Use a mantra

Derived from meditation, a mantra is a word or phrase which you repeat to yourself.Saying something like 'calm' or 'relax' under your breath or in your head, over and overagain, can help defuse anxiety. “I am a good therapist,” or “I passed the Standard Written,I can pass this too,” etc.

Bridging objects

It can help to wear something with positive associations to another person or place.Touching this bridging object can be comforting in its own right, then allow yourself amoment to think about the person or situation which makes you feel good.

Overall Attitude Towards Preparing for the Exam

Overall, your attitude towards yourself and towards the exam affects whether you have apositive or a negative experience during the study and exam process. Taking care of yourphysical and emotional needs during the preparation period is critical to putting yourself inthe best position to succeed.

Leave plenty of time to study and practice CVE questions so that you don't get into asituation of having to do last minute cramming. This will help to boost your confidenceand reduce any pre-exam stress. You will know you have prepared well. Develop atimetable so that you can track and monitor your progress. Make sure you allow time forfun and relaxation so that you avoid burning out.

Take breaks. As soon as you notice your mind is losing concentration, take a shortbreak. You will then come back to your study refreshed.

Take care of your body. Don't drink too much coffee, tea and fizzy drinks; the caffeinewill 'hype' you and make your thinking less clear. Eat healthy and regularly; your brainwill benefit from the nutrients. Regular moderate exercise will boost your energy, clearyour mind and reduce any feelings of stress. Try out some yoga, tai chi or relaxationtechniques. They will help to keep you feeling calm and balanced, improve yourconcentration levels and help you to sleep better.

Believe in yourself. You wouldn't have completed your hours or passed the StandardWritten Exam if you didn't have any ability. Therefore, if you prepare for the Written CVEproperly you should do fine, meaning that there is no need to worry excessively.Recognizing that this exam seems to measure “test taking skills for the Clinical VignetteExam” more than your ability to be an effective therapist can help you keep the exam inperspective.

Don't try to be perfect. It's great to succeed and reach for the stars. But keep things inbalance. If you think that "anything less than A+ means I've failed" then you are creatingmountains of unnecessary stress for yourself. Aim to do your best but recognize that noneof us can be perfect all of the time. It is very likely that no one gets 100% on the WrittenCVE.


Strategies ManualCalifornia MFT Clinical Vignette Exam Taking the Written Clinical Vignette Exam

Be proactive. If you find you don't understand some of the material or consistently getlower scores than you would like, getting stressed out won't help. Instead, take action toaddress the problem directly by asking for consultation or talking with other candidatesabout your process.

Reframe the process. Instead of thinking of the exams as “do or die” events or some kindof torture, reframe the exams for yourself as an opportunity to review material that youhaven’t thought about in a long time (probably since graduate school), a chance to beexposed to interesting new ideas, and best of all, an opportunity to consolidate andsharpen your thinking and refine your ideas about what it takes to do psychotherapy.The process of preparing for the exams will make you a better therapist.

Keep things in perspective. The exams might seem like the most crucial thing right now,but in the grander scheme of your whole life they are only a small part.



IV. Strategies For Approaching the MFT Written Clinical Vignette

Examination

Strategies for Approaching the Exam

A. Section 1: Thinking Skills for the Written CVE

One of the most important things you can do as you prepare for the Written CVE is torecognize the ways in which the exam questions are designed to tap into the abilities you useas a clinical MFT. The exam questions will test both whether you know relevant informationand if you can apply that information and your skills to hypothetical cases.

You’ve taken many exams that require you to demonstrate your knowledge base. Youprobably have less experience with test questions that require you to apply your knowledgeand skills to hypothetical cases. The Standard Written Exam included “application”questions, but the response choices contained only one element, as most multiple choiceexams do.

Even candidates who lack much exposure to “application” exams have useful experience todraw on for the Written CVE because the “thinking skills” needed to answer Written CVEquestions are similar to ones that MFTs use with their clients. To work effectively withclients, you bring to mind relevant knowledge, you apply that knowledge to a concretesituation (the client’s case), and you use your reasoning ability to evaluate and integrateinformation so that you can draw valid inferences and conclusions and make sounddecisions.

Our strategies and your practice with CaseMASTER will help you adapt these real-lifethinking skills into test-taking abilities that will help you successfully answer questions on theWritten CVE. For now, let’s take a closer look at each thinking skill.

1. Recall

“Recall” involves remembering, or bringing to mind, information you know, such as thediagnostic criteria for a mental disorder. Many Written CVE questions will require to yourecall information in order to recognize the correct answer and why elements of otherresponses are wrong.

2. Application

The Written CVE also assesses abilities that go beyond recall. The questions will also testyour ability to apply your knowledge and skills to specific cases. “Applying” informationentails using your knowledge and skills to make appropriate decisions about cases involvinghypothetical clients. On the Written CVE, this means using your knowledge and skills tocorrectly answer questions about different aspects of the cases presented in vignettes, orExhibits.


Strategies ManualCalifornia MFT Clinical Vignette Exam Strategies for Approaching the Exam

3. Reasoning

“Reasoning” is related to application but goes a step further. It requires you to combine yourknowledge and skills with your judgment. For example, some questions will offer incorrectresponses that describe acceptable clinical practice, but do not reflect the best answer for thespecific case described in the Exhibit. Many of the test-taking strategies we offer are designedto help you practice the reasoning skills needed to do well on the Written CVE. In addition,we illustrate and explain many questions that require “reasoning” abilities in ourCaseMASTER program.

4. Test Taking Skills

The Written CVE is a very different style of test construction, and requires specialized skillsin order to pass. The Written CVE tests the same knowledge base as the Standard WrittenExam, but it also tests application of knowledge, ability to read between the lines and discerndisguised meaning, and the ability to discern subtle differences between similar elements.Because each set of answers involves 10 or more different responses in differentcombinations, learning how to eliminate bad elements quickly is essential. One must knowhow to move quickly in certain parts of the analytical process, and when to slow down and“micro-analyze” at other points. Above all, relevance to the vignette is crucial, and many ofthe questions are designed to tease out the difference between good elements that are relevantto the case, versus good elements that are slightly less relevant or less supported by the case.

B. Section 2: Strategies for Approaching the Written CVE as a Whole

You may want to read or reread the materials you used to prepare for your MFT StandardWritten Exam. For AATBS customers, this would be our Standard Written ExamWorkbooks. Since the Clinical Vignette Exam asks about theory-specific Treatment Planningand Treatment interventions we recommend that you review each of the major theories andthe goals associated with them in those workbooks. An optional set of three compact discsfor our MFT Written Clinical Vignette Examination program is available that will give you thecomprehensive knowledge you need for the theoretical perspectives of Extended FamilySystems, Narrative, Solution-focused, Cognitive, Humanistic-existential, Structural and ObjectRelations including goals, and interventions. However, the best preparation for the Written

Clinical Vignette Exam will be found within our online CaseMASTER program.

The BBS indicates the theoretical frameworks you need to be knowledgeable about are theassumptions, concepts, and methodology associated with cognitive-behavioral,humanistic-existential, postmodern, psychodynamic, and systems. The most commontheories appearing on the Written CVE are: Extended Family Systems (Bowen), ExperientialCommunications (Satir), Structural, Strategic, Cognitive Behavioral, Object Relations andSolution Focused theory.

1. Pace Yourself During the Exam

The Written CVE includes 30 questions that count toward your score and 10 additionalnonscored items for the purpose of “pre-testing,” for a total of 40 questions. These pretestitems will not be identifiable to you, and you will have to answer all 40 questions in the twohours allotted to complete the exam.


Strategies ManualStrategies for Approaching the Exam California MFT Clinical Vignette Exam

You will want to monitor your time carefully as you take the test. Watches are not allowed.Try to complete 11 or 12 questions during each 30-minute period if you can, so that you havetime left over to re-examine some of the questions if you need to. Questions have beenlabeled, “1, 2, 3, 4” and so on to the total number of questions.

As you pace yourself, recognize that the first few questions for each Exhibit may take longerto answer than the later questions, because you will need to read the Exhibit carefully andbecome familiar with its content. Additionally, your anxiety is likely to be highest at thebeginning of the exam, and may interfere with your cognitive ability and speed. As you relax abit, your speed and rhythm should improve.

2. Take “Breaks”

We recommend that you take a few short breaks during the test period, without leaving theexam room. You can do this in your seat by stopping for a moment, shutting your eyes, andtaking a few deep breaths. This can give you the rest you need in order to continue with acalm and clear mind. Taking a break is particularly useful when you encounter a difficultquestion: If a question makes you feel anxious, stop for a moment and take a few deep, evenbreaths. You get no points for being the first person to finish the exam, so take short “mental”breaks if you need them. If you train yourself to close your eyes and take a breath every timeyou do the “rephrase” step of the question answering strategy, this will help you stay morerelaxed during the entire exam.

3. Don’t Skip Around

We recommend that you never skip questions as you go through the exam. Answer eachquestion in order. If you are stumped by a question, record your best guess, Mark the item asone you want to review later, and move on. If you have time, you can go back to your Markedquestions after completing the rest of the exam. Because there is no penalty for guessing, it’sbetter to record an answer for every question the first time you work with it. Otherwise, yourisk running out of time and being forced to leave some questions unanswered. Considerthat since usually candidates are stumped between two responses, by simply picking ananswer and moving on, you have about a 50% chance of getting it right. If you run out of timeat the end of the exam and can’t answer the last three questions (because you spent so muchtime trying to figure out the earlier, difficult question) you have a 0% chance of getting thoseunanswered questions right! Or, if you skip a question thinking you will come back to it, youmay run out of time and not be able to come back. Never skip a question!

4. Be Cautious About Changing Your Responses

You may decide that you want to change some of your responses when you review your exam.You should rarely change an answer and should only do so if you have a sound reason forchanging your mind. For example, you could change an answer because you rememberspecific information that leads you to a different answer or because, on reviewing the questionor Exhibit, you realize that you read it incorrectly the first time around. You should notchange an answer simply because you don’t feel good about your original response. This isprobably a reaction to your anxiety level and is not a good basis for changing your answer.

Following are some additional things to think about when examining and comparing elementsin the responses. These decision-making variables, and others, are applied throughout ourrationale in CaseMASTER. There, you will see many examples of the kinds of considerationsthat can help you identify correct (High) rated), possible (Medium rated), and incorrect (Lowrated) elements in our rationale, but we want to highlight a few of them here.



5. Be Careful About Making Unsupported Assumptions

As we’ve noted, for some questions you may find two, or even more, responses that appearequally right. Sometimes this happens because you’ve jumped to conclusions or madeassumptions or inferences that aren’t well supported by information in the Exhibit. Whenre-examining elements consider whether the Exhibit truly provides sufficient information tosupport your beliefs - it may be that you’ve rated an element too high or too low becauseyou’ve made an unsupported assumption.

6. Use All the Available Information

For some questions, you’ll find that you have two or more responses with equal ratingsbecause you’ve overlooked key information or “hints” in the Exhibit. When using the Pair andCompare step in the Strategy, be sure to re-read the Exhibit carefully; it may be thatinformation you overlooked has caused you to rate an element either too high or too low.Other times, you might have difficultly choosing the correct answer because you haveoverlooked key words in the question, such as the word “initial.” Be sure to read (and

rephrase) every question carefully.

7. Take Advantage of Your Initial Impressions

For some questions, you will come up with probable responses on your own before readingthe responses because of information presented in the Exhibit. For example, you mightdetermine as you read an Exhibit that the client is clearly in the midst of a major depressiveepisode. Take advantage of strong impressions like this one when evaluating the answeroptions. You might discover, for instance, that answer “3” for a diagnosis question about thisclient’s Exhibit doesn’t include any depressive disorders as diagnostic considerations,whereas the other three responses do. If something like this happens, you can set aside ananswer option — “3” in this example — and focus your efforts on evaluating the responsesthat contain the element you know is correct.

This strategy can help with questions related to other content areas, as well. For example, youmight determine as you read an Exhibit that the correct answer to a question about initialgoals for the case should describe something about managing an obvious clinical risk factor,such as potential danger to self. Here, the correct answer will almost certainly address thisissue in some way. (If none of the responses address it, however, put it out of your mind andconcentrate on the responses you are given to choose from.)

Note that we are not recommending that you spend any time trying to come up with your ownresponses before reading the ones given on the exam. Instead, we’re recommending that youtake full advantage of all the knowledge and skills at your disposal - if your knowledge andskills lead you to form certain impressions or draw certain conclusions as you read anExhibit, and these are properly supported by information in the Exhibit – don’t dismiss them.Use them as part of your “arsenal” as you evaluate and compare the answer options.

8. Pay Attention to Case Relevance

One of the most important things to remember during your exam is what constitutes anincorrect element (and, therefore, an incorrect answer, if you have properly rated the element)on the Written CVE. To review, the BBS states that incorrect elements are:

• common errors and misconceptions

• true but not relevant statements, or



• incorrect statements

Your knowledge base will help you identify errors, misconceptions, and other inaccurateinformation. For example, an element that says you would maintain the client’s confidentialitywhen the Exhibit has clearly described a situation in which you have a duty to warn would beinaccurate (Low); an element that suggests that a client has schizophrenia when the client hasnever had psychotic symptoms would also be inaccurate (Low).

We particularly want to reinforce the issue of relevance here, because on the Written CVE“relevance” can be the one factor that distinguishes a correct element from an

incorrect one, and yet it can be easy to overlook under the pressure of an exam. The exam istesting whether you can apply your skills and knowledge to specific clinical situations.Therefore, in choosing your answer, you must always consider the case presented in theExhibit and whether an element applies to that case. A particular intervention may beacceptable in a general way, for example, but to be “correct” on the Written CVE, it must

apply well to the Exhibit case you are working with. A “true but not relevant” statement isincorrect. We illustrate this many times in our CaseMASTER rationales.

Also, an answer might be correct in a broad sense, i.e., it applies to all cases and therefore iscorrect in this case, but if an answer that is specific to the question or to the vignette isavailable, the specific answer is probably better (however, the entire answer set must beevaluated as well). For example, if the question asks, “What intervention would you use toaddress this client’s anxiety?” a broad answer might be something like, “teach relaxationskills,” versus a specific answer might be, “have the client learn breathing techniques andthought stopping.” The latter answer is more specific because it actually states what thetherapist is going to do. However, one needs to be cautious and look at each questionindividually – whereas in one case specific is the best approach, in another case, a moreinclusive answer might be the best choice. For example, for the question, “What would be thebest approach to help with this client’s depression?” the more inclusive answer, “Include acognitive behavioral approach in the treatment plan,” would be better than the too specific,and too limited answer, “Teach thought stopping.”

Another way to think about the issue of relevance to the case is to break the question downinto its components, or “chunks” and evaluate the merit of the answer choices based on howmany, and which “chunks” are represented in the answer.

Take, for example, the question, “What crisis issues are evident in this case?” There are twocomponents to this question: 1) crisis or danger issues and 2) relevance to this case. The best(High) answer would consist of a relevant issue that presents a danger or obvious crisis. AMedium answer might be a relevant issue that alludes to a danger but doesn’t name itoutright, or to a true, relevant statement that does not constitute a danger, and a Low wouldbe any answer that is not relevant to the case or is false. Some examples follow:

EXHIBIT 2

Sally comes to you because her father just died in a car accident that she survived. She is

tearful and complains of having trouble sleeping.

Question 1 of 1: What crisis issues are evident in this case?

• She is depressed and could have suicidal ideation (relevant and danger is present =

• High).



• She likely has Acute Stress Disorder which increases her risk of suicide (relevant,

• danger is present = High, but not as high as the previous element, because thesymptoms mentioned are not especially characteristic of Acute Stress Disorder, andmore common in depression).

• She is depressed (relevant, but the crisis issue, suicide, is not clearly stated =

• Medium/High).

• She probably feels guilty about surviving the accident (relevant, but no dangeralluded to = Medium).

• She has PTSD (relevant, but time frame may be wrong for PTSD, since the traumaof father’s death was recent, and PTSD cannot be diagnosed for at least a monthfollowing the trauma. There is no danger identified = Medium).

• Her life has changed dramatically with the loss of her father (relevant but no danger

• present = Medium/Low).

• She is gravely disabled (not relevant/untrue = Low).

• She wishes she were dead too (not relevant/no evidence = Low).

By the way, you will notice in this example that answering a crisis management questioncorrectly requires that you bring in your knowledge of DSM IV diagnosis, which is technicallypart of the Clinical Evaluation content area. Expect to do this throughout the exam.

C. Section 3: Stages of Treatment in the Written CVE

Some questions in the areas of Treatment Plan and Treatment may require you to considerthe stages of therapy. Questions may ask for goals or interventions in early, middle or late(termination) stages of therapy. Sometimes a specific theory may be mentioned. Sometheories have specific interventions that they use during specific stages of therapy, but oneeffective way to differentiate between what to do when, is to consider what the priorities are ineach phase or stage of therapy, regardless of the theoretical approach.

In the Early Stage of Therapy, your priorities can be captured in the acronym RIMS. Yourpriorities in this stage of therapy (roughly the first 3 or 4 sessions) are to:

R build a Rapport with the client

I gather Information and assess

M attend to the Management issues (setting the fee, the time, getting releases, etc.)

S attend to any Safety issues (crisis, medical, etc.)

Most questions that pertain to the early phase of therapy are going to be about one or more ofthe RIMS issues. Pay careful attention to any statement or hint that could indicate that youmight be in the early phase of therapy.

The Treatment Plan is created at the end of the early phase of therapy, and is the transitionalbridge to the middle phase of therapy. A treatment plan consists of defining: who you aregoing to treat, what you are going to treat (diagnosis), how you are going to treat it



(therapeutic modality), what you and the client hope to accomplish (goals) and potentially,time frames and measurable objectives.

The Middle Phase of Therapy is the stage that focuses on helping the client make lastingchanges. How to go about this is predicated by the client’s problems, diagnosis, goals, thetheory, the timeframe allowed by funding, etc.

The Late Phase of Therapy focuses on consolidating the work, and transitioning the client outof therapy.

Referrals are made throughout the course of therapy, and relate to what the priorities of whatphase of therapy the client is in. Referrals in the early phase tend to be referrals that helpgather information or stabilize any safety issues. Referrals in the middle phase are usuallyaimed at supporting lasting growth. Referrals in the late phase are usually designed to helpthe client transition out of therapy.

D. Section 4: Strategies for Reading Written CVE Exhibits

Reading carefully is a critical skill for the Written CVE. For starters, you must read an Exhibitvery carefully before attempting to answer a question about it, noting all the information youare provided about the client(s). If you find that you can’t identify the right answer to aquestion, it might be because you have overlooked a key piece of information.

All the information you need to know to answer the questions are contained within theExhibit or through additional information given to you in the question. Your clinical skillswill help you discern whether this information supports your conclusions when choosing the“best” answer choice among those given.

During the exam, you will be able to refer back to an Exhibit as often as you need to whileanswering the questions that follow it. You should, however, read every Exhibit carefully andcompletely, either the first time you see it or when working with the questions that follow it.

1. Look for Key Information and “Hints”

Be sure to notice all the details provided in an Exhibit, such as information about thefollowing: (1) who the client is (an individual, a couple, a family, a minor, etc.); (2) whetherthe client has come in voluntarily or not; (3) who referred the client; (4) the presentingproblem; (5) specific details about symptoms (including their intensity and duration); (6)current level of functioning; (7) coping skills and deficits; (8) social, material, and othersupport; (9) reported and apparent level of distress; (10) recent and current psychosocialstressors in the client’s life (recent death of family member, unemployed, separated ordivorced, etc.); (11) the client’s (and family’s) history; (12) indicators of clinical risk (e.g.,suicide, homicide, abuse, medical problems, serious psychiatric symptoms, grave disability, alack of access to critical resources, such as adequate food, shelter, or medical care); (13)human diversity issues (e.g., age, race, culture, sexuality, disability, socioeconomic status, thenature of the client’s disorder or life experiences); and (14) potential legal and ethical issues.

An Exhibit on the exam will not offer information about all of these areas, and differentExhibits will emphasize different kinds of information. Question writers seem to be trying touse words to give you this missing information—they frequently refer to clients’ body posture,voice tone, appearance. Take these descriptions seriously. In addition, information about theclient will often come in the form of “hints” from which you must draw inferences by using



your knowledge and skills. This is similar to what you do with real clients. Based on theinitial, incomplete information you receive about a client, you develop certain hypothesesabout what might be going on. You then test these hypotheses by, for example, gatheringadditional information from the client, collateral sources, and life records. On the exam, youwon’t be able to gather more information; instead, you will rely on the inferences, orhypotheses you are able to form on the basis of information in the Exhibit. Note, too, thatinferences available from an Exhibit often become more apparent when you read thefollow-up questions and answer options.

In our rationale for questions in CaseMASTER, we highlight the kinds of details and “hints”in an Exhibit that can be critical for identifying correct responses to exam questions.

2. Make Exhibit Clients “Real”

We recommend that you try to make the people described in an Exhibit “real.” Because youhave experience applying your skills and knowledge to cases involving real clients, you mayfeel more confident if you remember to deal with the “exam clients” in essentially the sameway as you treat your real clients. There is nothing mysterious about the Exhibits on theexam. They differ from real-life cases in the sense that you may have less information aboutthe clients and have no way of obtaining more information, but you can still approach an“exam case” using the same reasoning and other thinking skills that have enabled you to workeffectively with “real-life” clients. Remember, the examiners write the Exhibits and questionsso that you have the information you need in order to identify correct responses to questions.

You may find it helpful to get into the habit of closing your eyes for just a few moments afteryou read a vignette, and imagine the client(s) in the room with you. Feel how it would be ifthey were sitting in front of you. Notice your reactions, your associations, and how it feels tobe with them. While you have your eyes closed, take advantage of the moment and draw acouple of deep, calming breaths. Not only will the case seem more alive to you, but you willalso be combating the anxiety that many candidates find so cognitively debilitating in theexam process. If you can get into the habit of doing this every time you read a practicevignette, then you are much more likely to use the same exercise in the exam room to helpyou visualize the client(s) and relax.

Your education, training, and experience have provided you with the analytical skills to read acase study in a more sophisticated manner than you did before receiving your degree andbecoming an MFT intern. These skills are what the BBS is attempting to measure throughyour licensing examinations to determine your entry level competence and your safeness topractice independently. When you read a case study now, it is not just a little story. Instead,you may find it filled with information about crisis, diagnostic information, and legal andethical issues. You will also discover details to inform you as to how you, as the MFT, woulddevelop a treatment plan and interventions to resolve the presenting issues. On the otherhand, you may find that something is mentioned in the case that would be very important inreal life, but doesn’t get addressed in any of the questions.

E. Section 5: Strategies for Analyzing and Choosing Written CVEResponses



In this section, we present a 4-Step process for approaching Written CVE questions. Withinthese steps are test-taking strategies that will help you 1) understand the questions and theresponse choices, 2) evaluate and compare the responses, and 3) identify the best response.

We encourage you to use the 4-Step approach as you work with questions in CaseMASTER sothat you are comfortable using the approach during your exam. While practicing, experimentwith our strategies, and determine which ones work well for you and feel free to adapt themto your own style. The extent to which a specific strategy is useful for you will depend, in part,on your thinking style and, in part, on the specific question you are working with.

Practice is critical. The more you use the 4-Step approach and its strategies, the quicker andmore effectively you will be able to apply them. Don’t worry if it takes a long time to answersome CaseMASTER questions at first – speed is not that important in the beginning of theprocess – focus on understanding the process and working on increasing speed later. As youdo so, you’ll find that you’re more comfortable applying the test-taking and thinkingprocesses needed to answer Written CVE questions correctly.

1. Using Scratch Paper

As you will learn in this section, working with most of the questions on the Written CVE willrequire you to keep track of your thought process on scratch paper. At the exam site, you willbe provided with just one blank sheet. If you want a new sheet during your exam, you willhave to turn in your used sheet, which of course takes time and means you can’t look back atnotes from the beginning of the exam when you want to review at the end. Thus, it is best toplan on only one piece of paper for the entire exam.

It is important to decide well before exam day how you will use this piece of paper. BecauseCVE answer choices are usually lengthy and complex, you will usually need to rate each ofthree or four answer elements, and use the scratch paper to help you select the answer thathas the best collection of responses. You may also want to use the scratch paper to help keeptrack of time, and to prioritize which items you most want to review and reconsider if youhave time remaining at the end.

In this section, we model several quick and effective ways of analyzing answer choices as youwork on a question. When using CaseMASTER, experiment with these strategies, anddiscover what is effective for you. Remember there is no single correct way to manageinformation or to make decisions on this exam, and what we describe are suggestions youshould modify or customize to suit your cognitive style.

Fold Notes:

When you are given a single piece of paper, we recommend using the Fold Note system. Dividethe paper (an 8-1/2 inch by 11 inch sheet) into squares, or boxes, by folding it before yourexam begins. You want to divide the paper into 20 roughly equal rectangles, so that there willbe 40 boxes representing the 40 test questions.

Just in case you need a description: Hold the paper in your hands as though you werereading a regular document printed on the paper. First, fold the bottom of the paper up aboutan inch and a half, and then fold over and over four times. Unfold the paper and you will seeit is divided into five roughly equal sections. Now fold the paper lengthwise, in half and thenin half again, so there are four vertical columns. You now have a 4 X 5 grid. If you want to seethe 20 cells more clearly, you can draw lines in the creases on both sides.



Some people prefer not to fold the paper, but simply draw the 4X5 grid on each side of theblank paper. Again, experiment with what works for you.

You can number the boxes one through forty, but this may not be necessary after you havepracticed for awhile, and become intuitively aware of how far along you are in your grid. Youcan label each box as you use it, with a word or two to remind you which vignette is involved.Remember that the exam does not number questions consecutively, but only within eachvignette sequence, eg, “Question 1 of 5, Question 2 of 5,” etc, and then beginning over againwhen the vignette changes. Seeing all forty boxes at once on your scratch paper will makeyour progression through the exam visually clear.

So, for example, as you begin to answer a series of five questions based on a vignette seriesabout Barbara and her daughter Jane, you would write the following:

#1Barbara and Jane

1.HHMM

2. HLLM

3. MMLM

4. HHHL

6. 11. 16.

2. 7. 12. 17.

3. 8. 13. 18.

4. 9. 14. 19.

5. 10. 15. 20.

You could of course number horizontally instead of vertically, and you could record yourratings of each element vertically if that is easier for you to follow. Also it is probably notnecessary to number 1,2,3,4 within each box. This could take some time, and the boxes aresmall. It should be obvious just by its placement which answer you are rating.



When you see a pattern emerging that allows you to select the best answer, you should markit on your scratch paper as well as choosing it with the mouse or the cursor on the actual test.If you feel stuck with a particular question, and you decide to flag it for review later, you canindicate why in the box where you have your notes for that item.

Some people like to make a note about the time at several points on their scratch paper. Werecommend setting benchmarks every thirty minutes to see if you are on schedule. Note howmany minutes should be left out of the 120 allowed for the exam, and check with the timer onyour monitor when you arrive at that point.

Here is a sample of how scratch paper notes might look for the first ten questions of an examthat started with Barbara and Jane, and moved on to three questions about Jorge and hisdaughter, Carmen. We have shaded the correct answer, but you will more likely circle it withyour pencil.

#1Barbara and Jane

1.HHMM

2.HLLM

3.MMLM

4. HHHL

Custody?

6. Jorge Carmen

MMML

HMMH

LMML

MMMM

11. 16.

#2

1.LLMM

2.MMMM

3.HHML

4.MHHH

7. Law? Probation?

HHHL

MMML

LMMM

HHMM

12. 17.

3.

MMHH

HHHM

LLMM

MMMH

Crazy. Check if time

8. DX is wrong in allbut #3, so that’s gotto be right

13. 18.

4.

HHMM

LLMH

MMML

M+ H- LL

9. 14. 19.



5.

H-M+M+L

M-M L H

MM H H

LL MH

10.

90 mins left

15. 20.

60 mins left

Notice that it may not always be necessary to rate every element High, Medium or Low.Occasionally a quick scan of answer elements may allow you to eliminate entire clusters, andarrive at the right answer without further analysis.

2. The 4-Step Strategy

Under pressure during an exam, it’s fairly common to read carelessly or choose responsestoo quickly. The 4-Step approach is designed to help you attack every exam question in asystematic way, no matter how pressured.

• Step 1 – Read and Rephrase the Question: Read the question carefully and make sureyou understand it. Rephrase the question in your own words, focusing on the mostcritical elements of the question. (For example: “What are the crisis issues?” can berephrased as, “What is potentially dangerous or physically harmful in this case?”) Thisstep ensures that you approach a question in the right frame of mind, with a clearunderstanding of what you’re looking for. If you have trouble with anxiety during theexam, you might want to take a moment, close your eyes, and take a deep breath eachtime you do your rephrasing.

• Step 2 – Scan the Responses for Extremely Bad Elements: Scan the responsesvisually to see if there are any really outstandingly bad elements that jump out at youwhich could allow you to eliminate an answer or two as a whole (do not read themthrough word for word at this point, however). Be careful though, because there maybe some less than savory elements that you may have to consider in your analysis.Eliminate only the “worst of the worst” kinds of elements – such as elements thatendanger the client, or have the therapist doing something blatantly unethical, or adiagnosis that isn’t even in the DSM or is not possible for the client. Don’t eliminate aresponse just because an element doesn’t seem right – it has to be really bad to throwthe whole answer out. (In fact, there will be some questions where you cannot eliminateany responses at all during this step.)

• Step 3 – Rate the Elements: Evaluate each element in each response choice that is leftafter Step 2 in light of the question, the Exhibit, and your knowledge, and assign arating to each element of High, Medium or Low. (The rating system will be explained inmore detail later.) At this point, you may be able to choose an answer based on theratio of Highs to Mediums or Lows, and you can skip Step 4. However, be sure to takeanother look at your answer as a set before choosing it, and make sure that it truly isthe best answer, since ratings are subjective and there are sometimes otherconsiderations to take into account.

• Step 4 – Pair and Compare: If you end up with two or more response choices that arerated equally, move on to comparing individual elements to each other to see whichanswer is better. This step allows you to work effectively with questions you find



difficult, including those that seem to have more than one correct answer. This stepwill be explained in detail below.

For some questions, you’ll use only Step 1 and 2, because the answer will be obvious to youafter you’ve read the question and eliminated the worst response choices visually. For otherquestions, you’ll need to proceed to Step 3 and rate the elements. After Step 3, you may knowwhich answer is correct. For more difficult questions, you’ll need to also use Step 4 beforeyou can identify the correct answer.

Step 1 – Read and Rephrase the Question

This strategy focuses on the stem of the question. By “stem,” we mean the question itself,apart from its answer options. You must read a question following an Exhibit carefullyand identify its focus, or purpose. Using CaseMASTER will get you accustomed to doingthis properly.

Determine the Content Area: For some questions, it will be easy to determine whatcontent area is being addressed. However, many questions are now appearing on theexam that cover more than one content area. A treatment question might address anethical issue, for example, “Which interventions would be most appropriate consideringthe client’s culture?” In the case of multiple content area questions, you must definewhich content area is most important as a “foundation,” i.e., something that must beincluded in your answer choice, and which content areas are less critical. In the abovequestion, your answer must have treatment interventions (things that you do) and mustalso address the cultural issues present in the case in order to rate a High. However, if anelement is an appropriate intervention for that specific case, that doesn’t specifically relateto the client’s culture, you would not want to throw it out completely by rating it Low, butinstead might settle for a Medium.

You will want to make a mental note as you read the question about what content areasare being addressed and which content areas are the most important to have in youranswers. This tactic will ensure that you approach the question in the right frame ofmind.

Note Key Qualifier Words: Note words in the question that affect its meaning in aparticular way. For example, a question might ask you to choose your initial goals for thecase in the Exhibit. The words “initial” and “goals” are equally critical, as they both havean important bearing on which answer is correct, or best. For Question 1 for George:“What diagnoses would you consider in this case?” the content area is Clinical Evaluation,and since the question is asking for “diagnoses”, is specifically referring to DSM-IV-TRterms. The Key words in this question are: “diagnoses” (versus diagnosis, i.e., thequestion is asking for more than one), “consider” (meaning you don’t have to pick adiagnosis that is final or certain, just answer with what is possible), and “this case”(obviously referring to George).

Don’t Read Too Little or Too Much into Questions: Take exam questions at face value.Almost all of the questions (stems) will be straightforward. They will provide the“instructions” you need in order to properly focus your search for the correct answer. Forexample, if the examiners want you to focus on one member of a family that has presentedfor treatment, rather than the entire family, the question will say so. The order in whichthe elements are presented in each answer option is usually unimportant – i.e., the correctanswer will be the one that has the best collection of elements, in any order. (You may onvery rare occasions need to consider the order of the elements for a question only if you



have compared the responses on all other levels and then discover that the order of theelements is the only real difference between two or more seemingly correct responses.)

Despite the best of intentions, however, some people “over-read” questions when underpressure during an exam and become anxious as a result. You can avoid doing this bytaking questions at face value and retaining your natural “common sense.” For example, ifa question asks for your “diagnostic considerations,” recognize that your job must be tochoose the most likely possible diagnoses from among the responses. Although thisquestion is broad, the responses will direct your focus to a limited set of diagnoses.

Rephrase the Question in Your Own Words: This is useful for verifying that youunderstand the question and for retaining your understanding of the question as youwork with it. If the question is relatively long, break it down into its key parts and thenrephrase it in words that are meaningful to you. For example, for a question that asks,“What are the initial interventions in this case?” the key parts are “initial,” “interventions,”and “this case,” and you might say to yourself, “What would I do first in this case?” ForGeorge, Question 1: “What diagnoses would you consider in this case?” we can rephraseit as: “What possible diagnoses might fit for George?”

Rephrasing the question in your own words forces you to slow down and reallyunderstand what the question is asking. Since it is very difficult to find an answer for aquestion you don’t fully comprehend, this is a critical step in the process. Breaking thequestion into its component chunks, deciding what the content areas are, and rephrasingit in your own words will come naturally to you if you do it enough times while practicingwith CaseMASTER.

Step 2 - Scan the Responses for Extremely Bad Elements

Many of you will begin thinking about Step 3 (rating the elements) of the 4-Step processwhile reading the responses for the first time. However, before getting bogged down inrating every single item, quickly skim through the responses to see if there is any elementthat is so Low, that no matter how High the rest of the set is, you could not have thatelement in a correct answer. Examples of this might be: things that endanger or harm aclient, completely off base diagnoses, non-sensical elements or elements with made up,non-existent words, etc. However, be cautious! Avoid throwing out responses because ofsome off-base item that is wrong, but not extremely wrong. You may have to live withresponses that don’t seem quite right, or that even have a bad or irrelevant element inthem, so use this step only on extremely bad elements.

By scanning the responses before rating the elements, you’ll also get an initial sense ofwhich elements are possibilities and which are probably incorrect as you scan. You maynotice that some elements are repeated in more than one answer. You will get a sense ofwhat the answer offerings are as a whole, which will provide you a context within which torate the elements. This is true for three reasons: First, the content of the responses oftenhelps you understand more precisely what the question is asking. Second, the content ofthe responses may help you draw inferences about the case that didn’t occur to you whenyou read the Exhibit. It helps to have all these inferences in mind before you begin ratingthe elements. Lastly, if you know the content of the responses, you’ll be prepared to ratethe elements not only in relationship to the Exhibit but also against elements in the otherresponses. As you will see in this section, this is particularly important when two or moreelements are similar.



Keep an open mind when reading the responses. The old MFT Oral Exam measured yourreadiness for independent practice by assessing what “you would do” with clients in avignette. Because the Written CVE is a multiple-choice test, it measures your abilities in adifferent way: The answer options contain choices that the “Exhibit MFT” is considering –you, in effect, are voiceless and are either agreeing or disagreeing with the various choices.One result of this is that it’s unlikely that you will find many (or perhaps any) responseson the exam that match exactly what you would do with the Exhibit client(s). This doesn’tmean that you won’t be able to identify the best responses. Instead, it means that youshould be prepared to see responses that differ from what you expected to see and shouldevaluate these responses on their own merits against information in the Exhibit, using thestrategies we recommend in this manual. In other words, keep in mind what you woulddo in real life, but don’t overfocus on it because this might prevent you from finding ananswer you can live with

You also should be prepared to see responses with long, wordy elements on the exam. Weillustrate these in CaseMASTER. While you might worry about needing to read anddecipher long elements on the exam, many of the strategies in this section andCaseMASTER are designed to help you do this, and using CaseMASTER will allow you topractice applying these strategies. The responses to exam questions may also includeseveral elements that are similar, but not identical. The Pair and Compare strategy willhelp you deal with these types of response choices.

Let’s scan the first question for “George” (the case presented in the previous chapter) forextremely bad elements.

EXHIBIT 1

George, a 66-year-old man is referred by his minister. He lost his wife, only daughter,

and son-in-law in an auto accident three months ago. He suffered a concussion. He has

his two grandchildren living with him now, ages 8 and 10. He wonders if he should get

another job to help support his grandchildren. His son-in-law's parents offered to take

the children and raise them. He is tearful and says he isn’t sleeping at all. He states

that he and his wife had made so many plans together for when they grew old and now

everything has changed.


1. Primary Insomnia




2. Bereavement





Malingering


Dysthymic Disorder




Bereavement

PTSD


In scanning these answer choices (Step 2), you should be able to spot “HistrionicPersonality Disorder” and “Malingering” as two extremely bad elements. They are simplyso bad, that your answer cannot contain them, so you can immediately set aside “2” and“3” and move on to the next step. If you know the answer to an exam question at thispoint, and are certain about your choice, you can mark your answer and move on to thenext item. If you don’t know the answer yet, you will move on to Step 3, in which you ratethe answer elements. Keep in mind, though, that there will be times where this step doesnot help you – either there are no extremely bad elements, or there are too many of them.When this occurs, move on and rate the elements.


1. Primary Insomnia




2. Bereavement





Malingering


Dysthymic Disorder


Bereavement

PTSD


We have set aside “2” because of the Histrionic Personality Disorder (see the Rationale inSection 7.) It is an “extremely” bad element that disqualifies the entire answer set fromconsideration. Additionally, in “3” Malingering is a very bad element – there simply is noreason to consider that George’s distress might not be real. This leaves us with “1” and“4” to more closely examine.

Step 3 - Rate the Elements

Our next step is to rate the elements. In Step 3, you will use a rating system to assign avalue to each element in the responses. Rating the elements helps you ground andorganize your decision making about the responses by providing a framework foridentifying correct, “maybe,” and wrong elements, keeping track of your decisions aboutthe elements, and comparing the responses.

The “value” you assign to an element will be based primarily on its accuracy (is itconsistent with your knowledge about the content area?) and its relevance to the case in



the Exhibit. For some elements, the value you assign will also depend, in part, on theother elements. That is, sometimes an element in one answer (e.g., “1”) will appear correctuntil you compare it to an element in another answer (e.g., “3”) that is more correct. Wewill illustrate how to Pair and Compare elements in Step 4.

The Rating System: This strategy relies on a “High/Medium/Low” rating system. Eachelement of an answer option is given a rating of High, Medium or Low. This process isused for each answer option for a question, and the option that receives the highestoverall rating is the correct answer.

These values are applied as follows:

A rating of High is equivalent to “yes/correct/true” or “very important or relevant/verylikely/very appropriate.” An answer element that is clearly correct, true, relevant,and/or appropriate would receive a High rating.

A rating of Medium is equivalent to “maybe,” “OK,” “possible,” or “somewhatimportant/somewhat relevant/somewhat likely/somewhat appropriate, partially true.”An answer element that might be correct, true, relevant, and/or appropriate wouldreceive a Medium rating. These elements are less obviously correct than those thatreceive a High rating, but they are not entirely incorrect either, so you don’t want toeliminate them.

A rating of Low is equivalent to “no/incorrect/untrue” or “not important/notrelevant/not likely/not appropriate.” An answer element that is clearly incorrect,untrue, irrelevant, and/or inappropriate would receive a Low rating. Assigning a Lowrating means you think that the element can be eliminated from consideration. We’llsay a bit more about “incorrect” elements below.

If you look closely at the questions, you will see that each question is composed of at leasttwo “chunks.” A High answer should address all of the elements in the question. Forexample, for the question: “What are the crisis issues presented in this case?” the twochunks are “crisis issues” and “this case.” For an answer to rate a High, there needs to bean issue that 1) presents the possibility of danger and 2) the issue needs to apply to thecase. If the issue applies to the case, but is not a danger, perhaps it can be rated aMedium. However, if the issue doesn’t have anything to do with the case, or is a blatantlyfalse statement, you would rate it Low, even if it was referring to a crisis element.

Question: If you were a cognitive behavioral therapist and cognitive rehearsal wasn’t

working, what would you try next?

The elements of this question are:

• Cognitive behavioral (stated explicitly)

• Interventions (“try next” refers to something you “do”, which is an intervention)

• Middle stage (which is implied by the intervention)

• This case (it has to make sense in the context of the case)

• Different from cognitive rehearsal but aimed at achieving the same goal

In this situation, you need to decide which of these elements are highest in priority. Is itimperative that you remain within a cognitive behavioral framework? Or is it moreimportant to do something that would be appropriate for the vignette client even if it



means using another theory? How about stage of therapy – how important is that? Or, ifit is an appropriate cognitive behavioral goal (rather than an intervention), how would yourate that? The following is an example of two answer types to illustrate some of theseelements and how they relate:

1. Early stage cognitive behavioral intervention

Middle stage cognitive behavioral intervention

Middle stage cognitive behavioral goal

Middle stage psychodynamic intervention

2. Middle stage cognitive behavioral intervention

Harmful cognitive behavioral intervention



While some answer choices meet several appropriate criteria (middle stage, cognitivebehavioral, intervention) some meet only two criteria (cognitive behavioral, intervention,but in the wrong stage, or cognitive behavioral intervention in the early stage). The threeor more criteria responses (depending on the criteria met, however) might be Highs,whereas the two criteria responses might be Mediums. However else you rate the variouselements though, you cannot pick “2” because of the “harmful intervention.” Essentially,of these two responses, you must pick the answer with the psychodynamic interventionrather than insist upon staying within your cognitive behavioral framework and doingsomething that would be harmful to the client.

We would rate these “1” and “2” using the High/Low/Medium system:

1. M H H M

2. H L H H

Although “2” has three Highs (versus only two in “1”), “1” is still a better answer becauseof the quality of the Low element in “2” – it is never okay to take an action that harms aclient.

Another example would be a question that covers legal, crisis and ethics: “Define how youwould manage the crisis issues in this case and the legal impact of your interventions.” Infact, this question breaks down into four different components: 1) crisis, 2) legal, 3)management (interventions) and 4) as applied to this case. When there seems to be morethan one content area addressed, think about which content area is most important as a“foundation,” i.e., something that must be included in your answer choice. For example,in the question: “Define how you would manage the crisis issues in this case and the legalimpact of your interventions,” the “crisis” issues and “this case” would be the foundations,or the criterion that must be present for an answer to be rated High. If the responseaddresses an ethical issue that is present in the case rather than a legal one that is stillpotentially dangerous (the client is using drugs for example), the response cannot be rateda High, and a Medium would be a better rating. If the element is simply a legal issue andnot a crisis issue (releases and confidentiality for example) it might be a Medium, or evena Low, because the question is asking about “crisis.” The difference between rating theelement Medium or Low might be in how important the issue is to the specifics of the case– if the issue is highly relevant (although not a crisis) we might give it a Medium. But if itis broad and applies to all cases (and is not a crisis) it might be better to rate it a Low. Ifthe answer doesn’t even apply to the case (even if it is a crisis), you would have to rate the



response as a Low. Crisis and case specificity are your most important foundationcontent areas in this particular question. Legal or ethical implications would be a lessercontent area, and the management portion (what you do about the issue) is alsoimportant. Here's an example:

EXHIBIT 3

You have been seeing Jane for 6 months to work on issues related to the loss of her

stillborn baby. She has had symptoms ranging from being quite lethargic and tearful

to being extremely angry. She comes into session and tells you that she just lost her

job and wants to kill her boss.

Question 1 of 1: Define how you would manage the crisis issues in this case and the

legal impact of your interventions.

1. If Jane is serious about harming her boss, you will have to warn him and callthe police;

Jane’s homicidal intentions indicate that she is also suicidal;

Legally, you must take notes about what is occurring in the session;

This represents a Tarasoff situation.

The content areas to consider in rating this question are: 1) crisis, 2) applies to this case,3) legal, and 4) management (interventions). Let’s rate the elements in response “1.”

1.

• If Jane is serious about harming her boss, you will have to warn him and call thepolice;

(Content areas: 1) crisis (yes), 2) applies to this case (yes), 3) legal (yes), 4)

management/interventions (yes) = High)

• Jane’s homicidal intentions indicate that she is also suicidal;

(Content areas: 1) crisis (yes), 2) specific to the case (no), 3) legal (no), 4)

management/interventions (no), = Low)

• Legally, you must take notes about what is occurring in the session;

(Content areas: 1) crisis (no), 2) specific to the case (yes, but very broad, applies

to all cases, 3) legal (yes), 4) management/intervention (sort of),) = Low)

• This represents a Tarasoff situation.

(Content areas: 1) crisis (yes), specific to the case (yes), 3) legal (yes), 4)

management/interventions (no) = Medium)

On our scratch paper, our rating for “1” would look like:

Jane 1 of 1

1. H L L M

2.

3.

4.



Fortunately you will usually find that some elements appear in more than one answeroption. This will save you time when it happens: Once you have assigned a rating to aparticular element, you can apply that rating to the element each time it appears in theanswer options for the same question. (Remember, if you change an element in one, besure to change the rating any place the element is repeated in other responses.) Readcarefully before doing this, to make sure that the elements are truly identical. Also, onrare occasions an exam question might ask you to choose a series of priorities or asequence of interventions. However, the rule is to not assume that the answer is asking fora sequence unless told so by the question.

Below, we review what an “incorrect” element is on the Written CVE. Understanding thisinformation will help you know when you can eliminate an element and the answer thatcontains it. Sometimes, however, you might give so many elements a Low or “no/incorrect”rating that every answer appears incorrect. This is especially likely to occur initially, asyou first practice rating elements in CaseMASTER, but it might also happen on the exam.Don’t let this throw you: Simply work to find the best of four “imperfect” responses.Either choose the answer that has the most Highs, or if two or more responses have thesame rating, use Step 4, in which you Pair and Compare elements to see which answer isbest.

You may feel more comfortable using some other “code” to rate elements, however, suchas “yes,” “maybe,” and “no,” or a 0 – 1 – 2 rating (in which case you can add them up toget a numerical value). In this case, a “yes” or “2” rating is equivalent to a High rating, a“maybe” or “1” rating is equivalent to a Medium rating, a “no” or “0” rating is equivalent toa Low rating. Use whatever code works best for you.

What does “incorrect” mean? An answer element should be given a Low rating only if it isclearly incorrect. Let’s take a look at what “incorrect” means on the Written CVE.According to the BBS, incorrect elements are: 1) common errors and misconceptions, 2)

true but not relevant statements, or 3) incorrect statements.

So, an answer element on the Written CVE may be incorrect because it reflects a commonerror or misconception or is simply an inaccurate statement. This is true for mostmultiple-choice tests. For example, an element that says you would maintain the client’sconfidentiality when the Exhibit has clearly described a situation in which you have a dutyto warn would be clearly incorrect. Or an element that suggests that a client hasschizophrenia when the client has never experienced any psychotic symptoms would beclearly incorrect. The issue of “relevance” is very important when deciding whether anelement is right or wrong: If an element is not at all relevant to the case presented in theExhibit (or to the question), or is not supported in any meaningful way by information inthe Exhibit, it is incorrect. If the element is clearly and completely irrelevant, you can giveit a Low rating.

For instance, for our sample question about George’s diagnosis, an element would beclearly incorrect if it was an irrelevant diagnostic consideration for George because theExhibit 1) doesn’t provide any information to support it or 2) provides information thatcontradicts it. To recognize the incorrect elements for our sample question, you mustread the Exhibit carefully and be familiar with diagnostic criteria contained in the DSM.Examples of these “extremely bad” elements are “Histrionic Personality Disorder” and“Acute Stress Disorder” (because it has been more than four weeks since the accident) in“2” and “Malingering” and “Acute Stress Disorder” in “3.”



However, be careful not to set aside an answer element that is a bit “off,” but notcompletely wrong. Your instinct might tell you that the element is wrong, but you’re notsure. Or maybe it is partially correct, but some part of it doesn’t quite fit. If you’re notsure that an element is wrong, don’t give it a Low rating - give it a Medium rating instead.An example of this might be George’s “Adjustment Disorder with Anxious Mood” in “1”and in “4.” This is an example of an element that doesn’t quite fit, or is partially correct,or for which there is no evidence but is not outside the realm of possibility. Rather thancompletely throw out the answer because of this kind of element, you are better off givingit a Medium. Remember, you are attempting to find the best collection of elements, notnecessarily the answer with all correct elements. You don’t want to set aside an elementand the answer that contains it unless you are absolutely certain that the element iscompletely unacceptable. If two responses contain questionable elements that prevent youfrom identifying which answer is the best after you’ve rated the elements in Step 3, youwill proceed to Step 4. Our Step 4 strategies are designed to help you tackle the moredifficult questions.

Begin with option “1” and consider each diagnosis in light of information in the Exhibit. Ifthe diagnosis seems likely, give it a High rating. If it seems possible, but receivessomewhat less support from the Exhibit, or you’re not sure enough to give it a High or aLow, give it a Medium rating. If it is clearly incorrect, give it a Low rating. Scan theresponses to see if any of the elements you’ve rated also appears in other responses. If so,apply your rating to the element there, as well. Continue this process until you haveassigned a rating to each element in the responses that you have not previously set asidein Step 2 (in this case “1” and “4”).

Consider your ratings carefully, using all the knowledge and skills at your disposal andthe information in the Exhibit. For most questions, you will select the correct answerbased on the ratings you assign to the elements.

For some questions, you will be able to rate elements and keep track of your ratingswithout writing anything down. This will be especially true after you’ve practiced Step 3using CaseMASTER. It will also be true for questions that offer more obviously correctand/or incorrect elements and responses. For other questions, you will want to use yourscratch paper to keep track of your ratings. Having these notes will also help in Step 4, ifyou need to examine the responses more closely.

Additional Tips For Using the Rating System: Keep the following “tips” in mind, as they willhelp you use the rating system effectively.

• Move through rating the elements fairly quickly: Try to rate the elements quickly,and avoid getting bogged down in reading every detail. Once you identify a response setthat you think is the answer, then slow down and read every word carefully to makesure you didn’t miss some important detail before selecting it as your answer. Or, ifyou’ve quickly rated the elements and found that you need to move on to Step 4 – Pairand Compare - slow down during the Pair and Compare process and focus on the tinydetails of the elements. Try to do your initial elimination (Step 2) and ratings (Step 3)quickly.

• Rate Once to Save Time: In working with our sample question, we saved time byrating each discrete element only one time: For example, once we determined that aHigh rating was appropriate for “Major Depressive Disorder” in “1,” we also applied thatrating to “Major Depressive Disorder” in “4.”



• Look for the Best Collection of Elements: You may have a response set that has threeHigh rated elements and one Medium rated element, or it may even contain a Lowelement, and it will still be the best response to choose. The response you pick doesn’thave to be a perfect set in order to qualify - just the best collection of elements.

• Compare Similar Elements to Each Other: As we mentioned earlier, your primarycriteria when rating elements are their accuracy and their relevance to the Exhibit. AHigh rated element should be both accurate and relevant to the case you are workingon. Sometimes, however, an element’s rating may also be affected by one or more of theother elements. This is particularly true when two or more elements are similar to eachother and, therefore, appear equally good. At first glance these elements may evenappear identical, but on careful reading you’ll see that they differ in some importantway.

• Work with Each Question Individually: Your goal when using the rating system is todevelop a basis for comparing the four response choices for a particular question. Don’twaste time worrying about whether an element you rated High (or Medium) for anearlier question is equivalent to an element you want to rate High (or Medium) for thecurrent question you are working on. Address each question independently, with thegoal of identifying the response choice that receives the highest overall rating.

• Use Mid-Point Rating if This Helps You: Sometimes, you may believe that anelement’s score should fall somewhere between a High and a Medium rating or aMedium and Low. It is fine to assign a “+” or a “-” to a rating to indicate that you findsomething particularly good for that rating or borderline bad. However, as a generalrule, you might want to save using “+” or “-” for when you need to use Pair andCompare. Again, your goal is to assign ratings in a way that helps you compare the fouranswer options so that you can identify which one receives the highest score and,therefore, should be selected. Experiment with assigning mid-point ratings when usingCaseMASTER, so that you’ll be comfortable with your system during the exam. We’ll besaying more about mid-point ratings in Step 4, where we illustrate using them whenanswering a sample question.

Let’s continue with George’s diagnosis question:


1. Primary Insomnia




2. Bereavement





Malingering


Dysthymic Disorder




Bereavement

PTSD


Using the High/Medium/Low rating system, we would represent it on our scratch paper as(remember, we set aside “2” for the Histrionic Personality Disorder and “3” forMalingering in Step 2 because they were really, really bad elements, and therefore wedon't need to rate the rest of the elements in the sets):

George 1 of 2

1. H H M H

2.

3.

4. M H H H

For some questions, your notes may show that two or more responses are equally rated,such as in this case. This is when you will need to use Step 4. In this case, “1” and “4”are equally rated, which means we will have to proceed and use Pair and Compare.However, the correct answer may stand out at this point because you’ve focused yourdecision making onto just a few elements. If you know the correct answer at this point,you can choose it now. If you think you know the correct answer, but are uncertain, referback to the Exhibit. If you remain stumped, however, then continue with “Pair andCompare.”

Step 4 - Pair and Compare

Some Written CVE questions may require something beyond a High/Medium/Low rating toarrive at the correct answer. Sometimes you are left with two, even three responses thatare rated the same after Step 3. Or, when the responses present a lot of information orsimilar elements, you may “mis-rate” an element during Step 3 and end up with morethan one answer that seems correct. Step 4 provides a systematic method for addressingthis problem. That is, after making your initial decisions about the value(accuracy/relevance) of each element during Step 3, you may find that you need tore-evaluate some of your ratings because more than one answer has received the highestscore total. This outcome is hard to avoid entirely on an exam like the Written CVE, whichrequires you to deal with a lot of information at once to find the correct answer. So, don’tworry if it happens to you. The “Pair and Compare” strategy used in Step 4 gives you aneffective and quick way of dealing with questions that appear to have more than onecorrect answer after you’ve used Step 3.

The basic “Pair and Compare” strategy is used for questions with two seemingly correctresponses. We’ll present this first. Afterwards, we’ll present a modified “Pair andCompare” strategy that can be used in the rare event that you find a question that seemsto have three or four seemingly correct responses.

Remember, Step 4 Pair and Compare is needed only when you find that two (or more)responses for a question have received the highest score total after you have rated theelements in Step 3. When Step 3 doesn’t allow you to find the correct answer, you may usethe “Pair and Compare” process to identify the difference between closely rated or equallyvalued elements and to check whether you’ve mis-rated anything.



The stages of Pair and Compare are:

a. Set aside any “exact pairs”: (elements that are present in both responses that areexactly the same and therefore do not influence the outcome of the answer). InGeorge, the exact pairs are:

1. 4.

Major Depressive Disorder (High) Major Depressive Disorder (High)

Adjustment Dis. w/Anxious Mood (Medium) Adjustment Dis. w/Anxious Mood (Medium)

We “set aside” these exact pairs by drawing a line through them on our note paper.

George 1 of 2

1. H H M H

2.

3.

4. M H H H

The next phase of “Pair and Compare” involves creating additional pairs to furtherfocus our decision making. We’ve simplified our work by reducing the number ofelements we need to reconsider, but because we decided in Step 3 that they’re allabout equal in value it will help if we can find a useful way to further organize ourdecision making about them. One thing we can do is look for inexact “like” pairs (onesthat have something in common but are rated the same) and inexact “unlike” pairs(ones that are completely different although rated the same). Once we create thesepairs, we’ll compare the elements in each pair head-to-head. You won’t always findinexact “like” pairs - they can simplify your work when they exist, but when they don’tyou can simply re-evaluate all the “unlike” elements that remain at this point (we’llillustrate this in a moment.) The key is that you will have zeroed in on fewer elementsto re-evaluate and compare.

b. Compare “inexact like pairs”: An inexact like pair must have the same rating inorder to be compared: Low to Low, High to High, etc. Do your best to also comparethem according to some similarity (V-Code with V-Code, early stage to early stage,family systems to family systems, etc.):

1. 4.

Phase of Life Problem (High) Bereavement (High)

We consider these to be “like pairs” because they have two things in common: 1) theyare both rated High, 2) they are both V-Codes. If we decide we think one of them isjust a little bit better, we will add a “+” sign to our note. We compare the Lows andMediums before comparing the Highs because there’s a greater likelihood that you’llfind some reason, on re-evaluation, to decide that at least one of them is better orworse than you initially thought it was.



Sometimes you will find that, even though the pair is inexact, that you really cannotvalue one higher than the other. If this is the case, set it aside as if it is an exact pair,and look for other differences between elements that are more telling.

In this case, our inexact like pair are both Highs, and while there is a Phase of LifeProblem (George has suddenly become the caretaker for two prepubescent children aswell as becoming a widower), Bereavement is a better fit because the loss of so manyloved ones is the issue with the most impact on his symptoms. Therefore, we will givethe High mark that stands for Bereavement a “+.” (Notice, that at this point, we areno longer trying to work with 16 elements in the responses, we are working atcomparing only four items):

George 1 of 6

1. H H M H

2. H L L H

3. H L L M

4. M H+ H H

c. Compare any leftover “inexact unlike pairs”: In the final stage of “Pair andCompare,” you’ll pair up “inexact pairs.” Inexact pairs are two elements – one fromeach answer still under consideration – that differ from each other but are equallyvalued in terms of how correct they appear to be. They say something different, butthey are both either High, or both Medium, or both Low. Our job at this point is torate this pair, using “+” or “-” to help us make our final determination about which isthe best collection of elements.

1. 4.

Primary Insomnia (High) PTSD (High)

In this case, it is very likely that George is suffering from Post Traumatic StressDisorder. Because his insomnia is likely a function of PTSD, Depression orBereavement (i.e., it is a secondary diagnosis, rather than a primary one) we will giveit a “-” making “4” the best answer.

George 1 of 6

1. H- H M H

2. H L L H

3. H L L M

4. M H+ H H

To review, the stages of “Pair and Compare” are as follows:

Pair and Compare

a. Set aside exact pairs

b. Compare inexact like pairs



c. Compare inexact unlike pairs

For some questions, using just the first two stages of “Pair and Compare” will narrowyour choices sufficiently that you will be able to see the correct answer. Because youare dealing with less information than before, you might be able to discern somethingyou overlooked before and understand that one of your remaining responses isactually better than the other. If not, you’ll continue with “Pair and Compare.”

Pair and Compare will not take long to apply once you’ve practiced it. It primarilyreflects a useful way of thinking about the elements in the responses and organizingyour decision making about them. We present “Pair and Compare” as a series ofdiscrete stages here, so that you understand how it works; once you’re comfortablewith the strategy and understand its basic principles, these stages will flow smoothlyand quickly from one to the next. In fact, once you’re familiar with this strategy, youwon’t necessarily need to use each stage in a deliberate way. You’ll be able to zero inquickly on the elements that are most useful to re-evaluate in order to determine thecorrect answer.

Note-Taking Tip: You might want to cross out the elements in an inexact “yes” pair in adifferent way than you cross out the elements that form exact matches. You might, forexample, use an X to cross off elements in your exact matches and a slash to cross offelements in your inexact “yes” pairs. As you move back and forth between yourscratch paper and the computer screen, this is a good way of keeping track of whichelements you might need to re-examine. Remember, you never need to re-examineelements that form exact matches because you know that you’ll choose them and thereis no difference to consider, but you may need to re-examine elements that forminexact “yes” pairs.

You might try writing your pairs down (see below) while you’re learning this strategyusing CaseMASTER, but as you become more adept at working with vignettequestions, you’ll usually be able to simply Pair and Compare elements “mentally” or byusing your scratch paper with High/Medium/Low without writing any part of the actualelement down. If you do write down your pairs, you might write something like thefollowing:

1. 4.

Phase/life (High) vs Bereavement (High)

Insomnia (High) vs PTSD (High)

The idea is to use a short-hand that’s meaningful to you, but that also retains all thekey parts of an element so that you make sure that what you’re re-evaluating andcomparing is what actually appears on the exam.

D. Abbreviated Notation

Sometimes it is hard to keep elements in mind when they are dissimilar as you moveyour eyes from computer screen to notepaper and back again. A solution for thissituation is to jot down the essence of the elements to the right of your ratings so thatyou can compare the set (usually of two) against another set. Let’s say we have a



hypothetical case of Joe, and a question that is asking about how to establish safety.We will assume that we are trying to Pair and Compare between two High elements in“1” and “3” and that all four elements are dissimilar to each other. Rather than try toPair them up, sometimes it is easier to simply look at the elements as a set andCompare them that way. A way to help get the elements clear, is to jot them down onour scratch paper to the right of our ratings:

1. X H H X Joe’s medications and call the police

2. X X X X

3. X X H H psychological evaluation and contact school

4. X X X X

Now we can see the four elements clearly, and compare the set of elements in “1” withthe set of elements in “3” to decide which answer best addresses providing safety in

this case.

Now, going back to George’s diagnosis question, let’s change things a bit and assumethat our four remaining 1-rated (“maybe”) elements are all very different. We’ll replace“Primary Insomnia” with “Anxiety Disorder, NOS,” and “Phase of Life Problem” in “1.”with “Dysthymia.”

1. Anxiety Disorder, NOS



Dysthymia

versus


Bereavement

PTSD


As you can see, we can’t create any inexact “like” pairs because all the remainingelements (after setting aside the two exact pairs, Major Depressive Disorder andAdjustment Disorder) are very different. And, while we could combine these fourelements into inexact “unlike” pairs, several combinations are possible and it would bea waste of time to examine each combination. We have, however, reduced our tworemaining responses to only two elements each. It’s much easier now to sort outwhich answer is best. Now we can re-evaluate each of the four remaining elements

against the Exhibit.

1. Anxiety Disorder, NOS and Dysthymia

versus

4. Bereavement and PTSD

At this point, because you are working with much less information, it will be easier tosee that one of these responses contains at least one element that is better (or perhapsworse) than you initially thought. You might want to keep track of your new ratings inyour notes. You can use a “+” or “-” sign, or even change the rating altogether. (If you



change the rating altogether (for example, from a High to a Medium) you might want towrite your new rating over the old one – but remember, if you change an element in

one answer, you must change the same element in every answer).

M

1. H H M M

E. Triplets

In the event that you find a question with three or four responses that have the sameratings (say three responses have three Highs and a Medium), you can adapt the “Pairand Compare” strategy to encompass more responses.

You can try to make inexact “like” and “unlike” “triplets” if you want to, but this won’talways make it easier to compare the remaining responses. Head-to-head comparisonsdon’t work as well when you’re dealing with more than two variables. Instead, forquestions that appear to have three or four “correct” responses, the primary benefit ofthis strategy is that it encourages you to zero in on a smaller, more manageablenumber of elements to re-examine.

In dealing with Triplets, zeroing in on Medium or Low rated elements first is best,because you’re already uncertain about them; there’s a greater likelihood that you’llfind some reason, on re-examination, to change your mind and decide that one (ormore) of these element(s) is actually better or worse than you thought it was duringStep 3. You then re-examine each of these Medium or Low rated elements in light ofinformation in the Exhibit. For example, let's assume we have the following ratings forour hypothetical question about Joe, our client who we were talking about in theAbbreviated Notes section:



1. H H H M

2. M H H H

3. H M H H

4. L M H H

We eliminate “4” because of the lower overall ratings. Let’s say there is only one Highthat is the same in the remaining answers and all of the other elements are different (adifficult situation):

1. X H H M

2. M X H H

3. X M H H

4. X X X X

After setting aside the exact Triplet, we have an “automatic Triplet” of Mediums thatwe can compare. Are any of them a little better or a little worse than the others? Let’ssay that the Medium in “1” and the Medium in “3” are different, but essentially of thesame value, but the Medium in “2” really isn’t that good of an element at all. Our beststrategy here is to set aside “2” and attempt to Pair and Compare “1” and “3.” Becausethe remaining elements are different (and let’s assume they don’t pair up easily), wecan use an abbreviation strategy to sort them out:

1. X H H X Joe’s medications and call the police

2. X X X X

3. X X H H psychological evaluation and contact school

4. X X X X

Assuming that our hypothetical question is asking about establishing safety (and thateach of these elements truly rates High) it would be clear that, taken as a “set” “1” isprobably going to be more pertinent to establishing safety.

One more thing: Remember that during all stages of your work with a question,including during “Pair and Compare,” the most important comparison of all is

against the information in the Exhibit. As you work with the various pairs in Step 4and decide whether to give a plus or minus, or raise or lower your rating for anelement, you must refer back to the Exhibit and determine the extent to which theelement is supported by information presented, or clearly implied, in the Exhibit.Make sure that your responses are as case specific as possible, given the choices.

As you will see, the main advantage of “Pair and Compare” is that it helps you zero inon just a few elements, which you then re-evaluate and compare to determine which ofyour two (or three and rarely four) seemingly correct responses is actually best.

F. Miscellaneous Test-taking Strategies

• When you see absolutely wrong or outrageous response choices, do not give anyfurther attention to that response set, but move on to another cluster ofpossibilities. However, be careful not to set aside responses that are only “mildlywrong” - you may end up having to use them in your answer choice and setting asidethe entire response set may hinder your decision making.



• An answer choice that has the response choices in an appropriate chronologicalsequence would be preferred to one where they were chronologically out of order,but do not assume that there is a sequence, unless the order is the only difference

you can find in the answer set OR unless the question stem specifically asks forsequence (for example, asking you “in what order should the therapist proceed?” Or“what would be your priorities?”). In other words, unless the question specificallyasks for order, consider ordering to be your absolute last resort as a strategy.

• Go for the response set that has all response choices with the most High ratings.

• Go with the clearly true statements even if they are very general, especially if indoubt.

• Sometimes answer choices contain what appear to be contradictory responsechoices, and that may or may not be part of your elimination process. For example,if the question is asking for “a diagnosis,” you cannot have contradictory elements(like PTSD and Acute Stress Disorder). However, if the question is asking for“diagnostic considerations,” the question is asking for what diagnoses you wouldconsider, and since you can consider both PTSD and Acute Stress Disorder, then itis fine to have them both in the same response set.

• Anchor yourself in what is surely correct, and what is surely incorrect, and trustthat the ambiguous middle ground will sort itself out.

• Remember the BBS is measuring entry level knowledge. The entry level knowledgerequired is based upon the average amount of education, training, and experiencefound in the general pool of MFT interns throughout California. A response choicethat requires a special skill that would not necessarily be a part of the education,training or experience found in the general population of interns can likely be ruledout.

• Be careful not to carry over assumptions and information from one question to thenext. Each question stands on its own. If it doesn’t, it should be apparent in thewording of the question. Do not be concerned if there are inconsistencies withresponses in previous questions, unless instructed otherwise.

• Never, ever leave a question blank. Even if you are completely stumped, pick ananswer. You can always flag it and come back to it, and if you can’t come back to it,you at the very least have a 25% chance of getting it right. If you leave it blank andyou can’t come back, you have absolutely 0% chance of getting it right.

F. Section 6: Written CVE Content Areas

There are six content areas covered by the Written CVE: 1) Crisis Management 2) ClinicalEvaluation 3) Treatment Planning 4) Treatment 5) Ethics and 6) Law. Each question on theWritten CVE will cover one or more content areas. The trend has been toward questions thataddress more than one content area, for example: “How would the legal issues in this caseaffect your treatment plan?” This question addresses three issues: 1) legal, 2) this case, and3) treatment planning. Your task is to consider which content area is most important (the onethat you cannot live without in your answer) – which in this case would be “this case.” In



other words, something that is legal or has to do with treatment planning, but has nothing todo with “this case” is not going to be a good element.

The Six Content Areas:

1. Crisis Management

• To evaluate a crisis, you must make some assumptions about what may be occurring.Don’t expect that the Exhibit will include the words, “The crisis(es) John is experiencingis/are: loss, suicidal thoughts, homicidal thoughts, etc.”

• Crisis Management issues are closely related to issues of Law and Ethics.

• Because there are never enough details in the Exhibit, you need to make someassumptions, based on clinical common-sense, but not going too far afield. Forexample, if the client is tearful, you can assume that depression (and thus suicidality) isa possibility, but you can’t necessarily assume that the client is depressed and/orsuicidal.

• Your knowledge of developmental issues and the family life cycle may be helpful interms of identifying individual and family crisis(es).

• Think generically about how you would assess a crisis. You would ask sources whohave information and who have observed the person’s current functioning. It’s alwaysa good idea to go to the referring source, because they must have had some concern inorder to send the client(s).

• Remember, the cause of the crisis and the level of risk will determine the intervention.

2. Clinical Evaluation

• Don’t assume that an individual diagnosis requires individual treatment, but doconsider scope of practice if the diagnosis requires primarily medical intervention.

• Don’t hesitate to choose a diagnosis for which there isn’t enough information, if thereisn’t any other plausible alternative offered in the question.

• Your general clinical experience with children tells you that certain information is morelikely to emerge when the parent and child are interviewed separately, and that youngchildren (under 10) need indirect exploration, rather than direct verbal questions.

• Since this exam is not about testing your personal values, but rather the generalexpected competency of the candidates, each person could have a different answer whenaddressing questions of diversity. It would be expected that you have been educatedabout and have experience with treating clients who are of a different gender, culture,socioeconomic class, sexual orientation, spiritual focus, and different-abled.

• Differential diagnostic skills are important for this content area. For instance, youshould know the difference between PTSD and Acute Stress Disorder criteria; Bipolar Iand II; Major Depressive Disorder and Dysthymia; Conduct Disorder, OppositionalDefiant Disorder, and Child or Adolescent Antisocial Behavior, to name a few.

• With a straightforward question about diagnosis for one individual, your best bet is tospeculate first on the possibilities, and then look at the response choices offered.



• To discriminate and eliminate response choices, consider key differentials like durationand the nature of any triggering events (for example, Oppositional Defiant Disorder,PTSD, Separation Anxiety Disorder, Adjustment Disorder, etc. ). However, just becausea duration or triggering event is not specifically mentioned, if the diagnosis is fairlycommon or it seems possible in the context of the Exhibit, you may still consider it as a“maybe.”

• Psychosocial and environmental problems may affect the diagnosis, treatment, andprognosis of mental disorders, according to the DSM-IV.

• Provisional diagnosis means you are not 100% sure of your diagnosis because you needmore information. It is “guesstimating” your most likely diagnosis for the time beingbased upon what you have.

• Differential diagnosis means there is more than one diagnostic possibility and you mustdifferentiate between these to determine what the best diagnosis is.

• Diagnosis is fairly straightforward. You may need to make a lot of assumptions. Thequestion is how far to stray from what is actually described in the Exhibit. To stretchfrom Alcohol Abuse to Alcohol Dependence is possible, even if the Exhibit onlydescribes abuse. But to guess that a person has an Antisocial Personality Disorder justbecause they committed a crime for example, is going too far afield.

• You should remember that in children, “depressed mood” can mean irritability,conduct problems and/or withdrawal as well as subjective sadness.

3. Treatment Planning

• Treatment planning includes the goals for each stage of treatment integrating theclient’s perspective on the problem, the diagnosis, human diversity, and informationobtained from collateral consultation. The BBS emphasizes that the treatment planshould be based on “the assumptions, concepts, and methodology associated with atheoretical framework.” The treatment plan also includes the unit of treatment,modalities of treatment (what kind of techniques are planned, i.e., theoryinterventions), and possibly, but not always a plan for frequency of sessions, a timeframe for the length of therapy, baseline behaviors and measurable objectives.

• Remember that the writers of the examination are more likely to use common senselanguage when describing goals of treatment, and not necessarily terms found intextbooks.

• The phrase “cognitive-behavioral” can mean different things, but generally refers toapproaches that modify both dysfunctional behaviors and distorted, limited beliefs orcognitions.

• Real life therapists tend to be eclectic, and are willing to go “outside of their theory box”in choosing interventions to benefit their clients. Let the client’s needs be the primaryconsideration in treatment planning and treatment questions, with the theory beingsecondary.

• Remember that what the client wants is not always a valid way to decide who should beseen for treatment.

• Remember that systemic therapy does not always mean treating everybody together, butdoes involve goals that change the way relationships operate.



• Many candidates report that the most confusion they experience during their exam wasin the areas of Treatment Planning and Treatment. When a question includes aparticular theoretical model a translation is often needed because the language used inthe response choices tends to be vague and confusing. The response choices may uselanguage that is associated with different theoretical models (but that essentially meansthe same thing) rather than the textbook language that you may be used to. Forexample, Structural Therapy refers to “mimesis,” (using the client’s style of language,body posture, tone, etc.) – however, even though Solution Focused therapists don’t usethe actual word mimesis, mimesis is very important in a Solution Focused approach.Consequently, a textbook understanding of the theoretical models cited in theCandidate Handbook is necessary but not sufficient for the type of treatment planningand treatment questions posed in the exam. You need to be very flexible becauseconcepts may be described in uncommon language.

4. Treatment

• Choosing a correct answer choice in this area may require you to choose interventionsthat are both within a particular theoretical framework but will likely take into account,common, everyday approaches to problems that are not related to theory.

• Real therapists usually are not rigid about using interventions from only one theory –they may “borrow” different techniques and ideas from other theories, while stillworking within their theoretical framework, especially if there is benefit to the client.Be willing to step out of the textbook theory approach, and consider what you wouldactually do with this client if they were real. However, make sure that if you go outsideyour theory framework that your interventions are at least consistent with the theorythat the question asks for. For example, a Solution Focused therapist doing a CognitiveBehavioral problem list would be “anti-theory.”

• Pay close attention to what stage of treatment the question is referring to – you havedifferent priorities at different stages of therapy.

• If a question is asking about interventions to achieve specific goals, you need toconsider whether the intervention actually would help to accomplish the goal.

5. Ethics

• Confidentiality, according to the Candidates Handbook belongs in Ethics, not Law.However, in truth, confidentiality is both a legal and an ethical issue, and you mayexpect to see considerable overlap of issues between these two areas on the exam.

• Initiating a 5150 for a client who has a mental disorder, and is necessary to preventharm to self or others, is an instance that breaching confidentiality is a permitted(non-mandated) breach of confidentiality, under Evidence Code 1024. The legal aspectis that it is a law that permits you to breach confidentiality, however the use of this lawis purely an ethical/clinical decision. But hospitalization AND 1024 are both in LAW,

not ETHICS in their handbook.

• You should assume that children’s needs take priority over adults when it comes tosetting therapy goals. This is a common-sense or ethical rather than a theoreticalposition.

• Ethics, unlike laws, are written as very broad standards of professional conduct.Therefore in the Ethics area, it is appropriate to broaden principles underlying specific



standards, and use general principles and common sense. Be sure to read over theCAMFT ethical standards in their entirety, so that you can recall the precise wordingand apply them to the issues in the Exhibit.

6. Law

• Breaching confidentiality — mandated (reporting child, elder, or dependent adult abuseand Tarasoff warnings) or permitted (taking necessary steps to prevent a client’s suicideor when making the “may report” abuse reports) are legal issues. Tarasoff situationsrequire you to breach confidentiality when your client is a likely threat to the physicalsafety of a reasonably identifiable victim or victims, and mandates that you inform thepolice and the intended victim. Consult Workbook #2 for other instances permitted ormandated by law for breaching confidentiality.

• Candidates must have knowledge of “legal criteria for determining involuntaryhospitalization,” and “laws regarding privileged communication.”

• The examination may require you to know about some laws not directly related to MFTpractice, such as family law issues, including divorce and child custody. You can reviewthis material in the Association’s material for the Standard Written Examination.However, it is outside your scope of practice to advise or quote the laws to clients.

• You should also be prepared to have questions that confuse the concepts of privilegeand confidentiality, especially when minors are involved. Many professionals do notmake the distinctions clearly, and those who write the questions may be similarlyimprecise. Therefore, don’t throw out an answer just because confidentiality is calledprivilege, and vice versa.

G. Section 7: Studying with CaseMASTER’s Rationales

In CaseMASTER, we include several different rationale pages: Overview, Rationale andStrategies. In the Overview section we show a visual representation in a chart format of thedifferent ratings of each element. It may be helpful to practice creating these charts at somepoint in your study process, but would probably take too much time to use during the actualexam. The following is an example of the Overview screen in CaseMASTER:



Overview


Answer

Choice

Response Choices High Medium Low Answer

Rating

1. Primary Insomnia X HIGH

Major Depressive Disorder X

Adjustment Disorder with AnxiousMood

X

Phase of Life Problem X

2. Bereavement X LOW

Acute Stress Disorder X

Histrionic Personality Disorder X

Adjustment Disorder withDepressed Mood

X

3. Major Depressive Disorder X LOW

Malingering X

Acute Stress Disorder X

Dysthymic Disorder X

4. Adjustment Disorder with AnxiousMood

X HIGH

Bereavement X

PTSD X

Major Depressive Disorder X



Answer “4” contains the best set of response choices.

Even though “2” also has three Highs, the Low (Histrionic Personality Disorder) is so low, youcould have thrown the whole answer out immediately without even ranking the rest of theelements.

The Overview can be reduced on your scratch paper to:

George 1 of 2

1. H H M H

2. H H L H

3. H L L M

4. M H H H

The Rationale page explains the thinking behind the ratings:

Rationale


Response Choice Rationale Response

Rating

Bereavement George qualifies for a V-Code of Bereavement. Manypeople are confused, however, thinking that theDSM only allows Bereavement to be used for thefirst two months following the death of a loved one.However, the DSM-IV-TR states only that, “Thediagnosis of Major Depressive Disorder is generally

not given unless the symptoms are still present 2months after the loss” (Italics added). It stressesthat “The duration and expression of ‘normal’bereavement vary considerably among differentcultural groups.” In other words, the DSM does notspecifically prohibit the use of the termBereavement beyond 2 months, but allows you toconsider a diagnosis of Major Depression after 2months.

HIGH

PTSD PTSD is a good diagnosis to consider since he wasin the accident and experienced the loss of so manyloved ones. We don’t see a lot of symptoms presentbesides the sleeplessness, but again, remember thatthe question is only asking what you wouldconsider, so the evidence needed to answer thisquestion does not need to be as solid as it wouldneed to be if the question was asking for a definitivediagnosis.

HIGH



Major Depressive Disorder George may be experiencing a Major DepressiveEpisode since he is beyond the 2 month period thatthe DSM suggests holding off on that diagnosis in abereaved person (however, a bereaved person canbe diagnosed with Major Depression even in thefirst two months if they fit the criteria). TheDSM-IV-TR includes a list of possible differentialsymptoms for depression (from bereavement)including guilt, thoughts of death, morbidpreoccupation with worthlessness, markedpsychomotor retardation, prolonged and markedfunctional impairment or hallucinatory experiencesregarding the dead person.

HIGH

Primary Insomnia Insomnia is fine to consider here, although not asstrong as some of the other Highs, because one ofthe criteria for insomnia is that it does not occur“exclusively during the course of another mentaldisorder,” which it is likely that George is sufferingfrom.

HIGH

Adjustment Disorder withDepressed Mood

An Adjustment Disorder might fit, althoughGeorge’s symptoms are a bit extreme for that andare better explained by other disorders. However,he is adjusting to being a single parent of hisgrandchildren, as well as adjusting to an entirelynew reality. We could give this a High minus, or aMedium plus.

HIGH

Phase of Life Problem Phase of Life Problem is another Highminus/Medium plus element. There is a majortransition occurring here, however, the transitionissues pale a bit in comparison to the other issues.

HIGH

Adjustment Disorder withAnxious Mood

An Adjustment Disorder might fit (see theAdjustment Disorder item above) however, Georgeseems more depressed than anxious. This is a goodexample of a “partially right/partially wrong”element that is best rated a Medium.

MEDIUM

Dysthymic Disorder There is no evidence that George has beenchronically depressed, however Dysthymic Disorderis a very safe diagnosis to keep in the realm ofpossibility, since it is so common, so we chose togive it a Medium.

MEDIUM



Malingering There is absolutely no evidence that George iscoming into therapy as someone out for gain.

LOW

Histrionic PersonalityDisorder

There is no evidence of a long term personalitydisorder here.

LOW

Acute Stress Disorder George is well beyond the four weeks that theDSM-IV-TR specifies as being the time period (afterthe stressor) in which Acute Stress Disorder can bediagnosed.

LOW

Click on the Strategies button to read a discussion of strategies and thinking related to thatquestion.

Let’s look at another question based on the same vignette:

Question 2 of 2: How will you gather additional information to develop a clinical

assessment for this case?

1. Get a release and talk with George's minister;

Ask open ended questions;

Arrange for a psychologist to do a battery of psychological tests to determine thedegree of George’s depression and level of functioning;

Ask George about the accident.

2. Refer George for a psychiatric and medication evaluation and have George sign arelease to talk with the psychiatrist;

Bring in the grandchildren for an evaluation;

Get a release and talk with the son-in-law's parents;

Ask him to fill out an intake form.

3. Get a release and talk with George's physician;

Refer George for a psychiatric and medication evaluation and have George sign arelease to talk with the psychiatrist;

Ask him to fill out an intake form;

Ask open ended and closed ended questions about various aspects of the situation.

4. Do your standard intake;

Get a release and talk with George's physician;

Refer George for a psychiatric and medication evaluation and have George sign arelease to talk with the psychiatrist;

Ask open ended questions about all aspects of the situation.

On our scratch paper, we might rate this question like:

George 2 of 2

1. L M M H

2. H M L M



3. H H M M

4. M H H M

Overview



Answer

Choice


Rating

1. Get a release and talk withGeorge's minister

X MEDIUM

Ask open ended questions X

Arrange for a psychologist to do abattery of psychological tests todetermine the degree of George’sdepression and level of functioning

X

Ask George about the accident X

2. Refer George for a psychiatric andmedication evaluation and haveGeorge sign a release to talk withthe psychiatrist

X MEDIUM

Bring in the grandchildren for anevaluation

X

Get a release and talk with theson-in-law's parents

X

Ask him to fill out an intake form X

3. Get a release and talk withGeorge's physician

X MEDIUM/

HIGH

Refer George for a psychiatric andmedication evaluation and haveGeorge sign a release to talk withthe psychiatrist

X

Ask him to fill out an intake form X



Ask open ended and closed endedquestions about various aspects ofthe situation

X

4. Do your standard intake X MEDIUM/

HIGH

Get a release and talk withGeorge's physician

X

Refer George for a psychiatric andmedication evaluation and haveGeorge sign a release to talk withthe psychiatrist

X

Ask open ended questions aboutall aspects of the situation

X

Answer 3 contains the best set of response choices.

Rationale




Rating

Ask George about theaccident

This would be important historical information andcould relate to diagnosis (major depression vs.adjustment disorder vs. PTSD).

HIGH

Refer George for apsychiatric and medicationevaluation and have Georgesign a release to talk withthe psychiatrist

This is a good idea; the accident was only 6 weeksago and it might help in the diagnosis, but moreimportantly he may benefit from medication. Thesigned release is a legal/ethical issue, but thisanswer would still be correct if it wasn’t included.

HIGH

Get a release and talk withGeorge's physician

This is a good idea since getting current and pastinformation would give some insight as to thephysical changes his M.D. has noticed.

HIGH



Ask open ended and closedended questions aboutvarious aspects of thesituation

This is always a good way to begin an interview witha new client, as an open ended question such as,“What brings you in?” or “What can I do for you?”allows the client freedom to bring up the mostimportant issues to them, without being influencedby the therapist. Closed ended questions (“Wereyou in the accident?”) are important as well, as theyfocus the client on particular issues that thetherapist has noted are important to the client. Wegive this a Medium because it is something youwould do with all cases, not just with this one.

MEDIUM

Ask open ended questions This is a good thing to do in order to gather moreinformation, however it is not quite as complete asthe element above.

MEDIUM

Ask him to fill out an intakeform

This is pretty standard in most practices, and a verygeneric answer, therefore we gave it a Medium. Anintake form can be as simple as a form asking forthe client’s address and health insuranceinformation, or may be quite detailed withchecklists of symptoms, room for a narrativedescription of the client’s concerns, etc.

MEDIUM

Do your standard intake Again, you do this with all your clients, so it doesn’treally rate as a High, which we reserved forelements that are really specific to this case.However, it doesn’t rate a Low either, because it is agood way to gather more information.

MEDIUM

Arrange for a psychologistto do a battery ofpsychological tests todetermine the degree ofGeorge’s depression andlevel of functioning

This really doesn’t seem that necessary and couldbe overwhelming for this client. However, if he hadbeen in the accident, a neuro-psychologicalassessment would be indicated, so we can give thisa Medium.

MEDIUM

Bring in the grandchildrenfor an evaluation

There is no reason this would be needed to developGeorge's clinical assessment, but it could helpdevelop a systemic evaluation.

MEDIUM

Get a release and talk withGeorge's minister

The minister would probably not provide helpfulinformation for developing a clinical assessment.

LOW



Get a release and talk withthe son-in-law's parents

There is no good reason to speak with these people.When needing to develop a clinical picture the bestresources are adjunctive professionals or immediatefamily members.

LOW

Strategies



Clearly we can set aside “1” and “2” because of the Low elements (and dearth of Highelements). “3” and “4” have the same ratings, so we must move on to Pair and Compare inorder to find the better answer. First, we set aside the exact pairs (if any):

3 4

Get a release and talk with George'sphysician (High)

vs Get a release and talk with George'sphysician (High)

Refer George for a psychiatric andmedication evaluation and have George

sign a release to talk with the psychiatrist(High)

vs Refer George for a psychiatric andmedication evaluation and have George

sign a release to talk with the psychiatrist(High)

After setting aside the exact pairs, we Pair and Compare similar sets of elements (a similar setmust have the same rating in order to be compared, and usually have something else incommon):

3 4

Ask him to fill out an intake form(Medium)

vs Do your standard intake (Medium)

Ask open ended and closed endedquestions about various aspects of the

situation (Medium)

vs Ask open ended questions about allaspects of the situation (Medium)

By comparing the two “intake” elements head to head, we can see that the element in “3” ismore specific – it names a concrete tool that helps you get better information. However, acase could be made that the broader, more inclusive element in “4” is better, because anintake form is included in a standard intake. Therefore, we have decided not to give eitherelement a “+” or a “-.” Since we are rating them the same, despite their differences (becausewe cannot decide which one is better) we can simply set them aside for now.

This leaves us comparing head to head the two elements that refer to the type of questions weask to gather more information. While both elements rate a Medium, the element in “3” ismore complete than the element in “4,” therefore, we can give it a “+” sign to differentiate thisslight advantage, making “3” a slightly better answer.



George 2 of 2

1. L M M H

2. H M L M

3. H H M M+

4. M H H M

H. Section 8: BBS Sample Exhibit

On the following pages you will find the sample vignette and the two associated questionspresented by the BBS on their website in the Written Clinical Vignette Candidate’s

Handbook.

EXHIBIT 4

Anne, a recently divorced 40-year-old minister, and her 14-year-old daughter, Julie, are

self-referred. Anne complains that Julie stays out past curfew and “sneaks” her 17-year-old

boyfriend into the house. Anne states, “It’s tough enough to raise a daughter alone. I can’t

even get her to go to school.” Julie says, “You and your religion make a big deal out of

everything. Just back off!” After the session, Julie calls the therapist and reports that she is

two months pregnant and is considering having an abortion. Julie asks that her mother not

be told about the pregnancy.

Question 1 of 2: How should the therapist clinically manage the crisis of Julie’s pregnancy

as described in the EXHIBIT?

1. Maintain Julie’s confidentiality;

Refer Julie to a physician;

Obtain a release from Julie to speak with her physician.

2. Include mother in treatment;

Refer Julie to a physician;

Obtain a release from Julie to speak with her physician.

3. Maintain Julie’s confidentiality;

Refer Julie to a physician for prenatal care;

Work toward disclosure of pregnancy to mother.

4. Obtain consent to treat minor;

Include boyfriend in treatment;

Refer Julie to a physician for prenatal care.



Overview



Answer

Choice


Rating

1. Maintain Julie’s confidentiality X HIGH

Refer Julie to a physician X

Obtain a release from Julie tospeak with her physician

X

2. Include mother in treatment X LOW

Refer Julie to a physician X

Obtain a release from Julie tospeak with her physician

X

3. Maintain Julie’s confidentiality X MEDIUM

Refer Julie to a physician forprenatal care

X

Work toward disclosure ofpregnancy to mother

X

4. Obtain consent to treat minor X LOW

Include boyfriend in treatment X

Refer Julie to a physician forprenatal care

X

"1" is the correct answer.



Rationale




Rating

Maintain Julie’sconfidentiality

In this case, when considering crisis management,the adolescent’s ethical entitlement to a confidentialrelationship supersedes the parent’s legalentitlement to information.

HIGH

Obtain a release from Julieto speak with her physician

Crisis Management includes crisis managementcoordination with other health care or mental healthcare professionals.

HIGH

Obtain consent to treatminor

Many legal issues crossover into the content area ofCrisis Management. In this case the issue ofconsent relates to Crisis Management because Julieis seeking services alone for help around the crisisof her pregnancy. Julie may be legally qualified toprovide her own consent if she is being abused orthere was danger involved (to self or others) andthere was a good reason not to get consent from hermother. However, the vignette indicates that Julie’smother, Anne, brought Julie to the session andtherefore has consented to her daughter’streatment. You might end up getting consent fromJulie herself to see her alone though, if she doesn’twant her mother to know she is being seen, and theother legal criteria are met.

HIGH

Refer Julie to a physician Even though you have to assume the purpose of thereferral, this is a very good response.

HIGH

Work toward disclosure ofpregnancy to mother

This answer is a neutral response and relates moreto treatment planning or treatment. It could relateto crisis as well, considering that Anne is a ministerand might have some strong reactions to Julie’spregnancy.

MEDIUM



Refer Julie to a physicianfor prenatal care

“Prenatal care” implies she is going to have thebaby, and moves a very High response down quite abit, since you don’t know what she is going to doabout the baby and the therapist ethically shouldnot be taking a position on this decision.

MEDIUM

Include mother intreatment

If the answer choice was “include the mother intreatment until crisis issues are resolved,” then thiscould have been a better answer choice.

LOW

Include boyfriend intreatment

This is a treatment planning or treatment issue. Itcould be part of Crisis Management, but there is notenough information contained in the Exhibit toconclude that this could be helpful.

LOW

Strategies



As you categorize the response choices, remember that the answer should address thecontent area of “Crisis Management.” It is easy to get lost and rate the responses based ontheir relevancy to the case as a whole, and forget that this particular question is askingspecifically for crisis oriented responses. Also, many questions apply to more than onecontent area. Also, with a crisis situation you could be dealing with both legal and ethicalissues within the context of Crisis Management. In this case, “1” has the highest rating.

Julie 1 of 2

1. H H H

2. L H H

3. H M M

4. H L M

Question 2 of 2: What legal obligations does the therapist have in the case described in the

EXHIBIT?

1. Obtain consent from Anne to treat minor if seeing mother and daughter together;

Obtain releases for medical provider from Julie if seen alone for pregnancy;

Assert privilege for Julie if mother asks for records;

File report with a child protective services agency.

2. Obtain a consent from Anne to see Julie individually regarding pregnancy;

Obtain releases from Anne if seeing mother and daughter together;

Negotiate a fee with Julie if seen individually for the pregnancy;

Assert privilege for Julie if mother asks for records.



3. Obtain releases for medical provider from Julie if seen alone for pregnancy;

Obtain releases from Anne if seeing mother and daughter together;

Maintain Julie’s confidentiality regarding the phone call;

Determine need for consent to treat a minor.

4. Obtain releases for medical provider from Julie if seen alone for pregnancy;

Maintain Julie’s confidentiality regarding the phone call;

File report with a child protective services agency;

Determine need for consent to treat a minor.

Overview


EXHIBIT?

Answer

Choice


Rating

1. Obtain consent from Anne to treatminor if seeing mother anddaughter together

X LOW

Obtain releases for medicalprovider from Julie if seen alonefor pregnancy

X

Assert privilege for Julie if motherasks for records

X

File report with a child protectiveservices agency

X

2. Obtain a consent from Anne to seeJulie individually regardingpregnancy

X MEDIUM

Obtain releases from Anne ifseeing mother and daughtertogether

X

Negotiate a fee with Julie if seenindividually for the pregnancy

X

Assert privilege for Julie if motherasks for records

X



3. Obtain releases for medicalprovider from Julie if seen alonefor pregnancy

X HIGH

Obtain releases from Anne ifseeing mother and daughtertogether

X

Maintain Julie’s confidentialityregarding the phone call

X

Determine need for consent totreat a minor

X

4. Obtain releases for medicalprovider from Julie if seen alonefor pregnancy

X MEDIUM

Maintain Julie’s confidentialityregarding the phone call

X

File report with a child protectiveservices agency

X

Determine need for consent totreat a minor

X

"3" is the correct answer.

Rationale


EXHIBIT?


Rating

Determine need for consentto treat a minor

You need to consider the criteria for seeing a minorwithout consent. If she is being abused or if there isany danger (she is using hard drugs, is suicidal,etc.) and there is a good reason to see her withouther mother’s consent, the law would allow you totreat her without her mother’s consent.

HIGH



Maintain Julie’sconfidentiality regarding thephone call

In the situation described, the MFT would likely bediscussing confidentiality with Julie and Annetogether during the initial intake. The discussioncould include what would be disclosed (suicidalthreat, other potential harm to self [drugs,behavior], etc.).

HIGH

Negotiate a fee with Julie ifseen individually for thepregnancy

You need to consider the criteria for seeing a minorwithout consent. You cannot charge a parent forservices they did not consent to, if you end upseeing Julie on her own consent.

HIGH

Obtain releases for medicalprovider from Julie if seenalone for pregnancy

This would permit you to breach confidentiality.Julie would sign the release for medicalinformation.

HIGH

Obtain consent from Anneto treat minor if seeingmother and daughtertogether

Obtaining consent to treat Julie from Anne would beappropriate as long as she has or shares legalcustody of Julie with Julie’s father. Since she is“recently divorced,” you would want to check if thereare any limitations in the custody agreement aboutwho has the authority to authorize mental healthtreatment for this minor.

HIGH

Obtain releases from Anneif seeing mother anddaughter together

Children over 12 sign their own releases, accordingto the attorneys at CAMFT, however Anne wouldalso likely sign all releases if both mother anddaughter are being seen together. Additionally,Anne would most certainly be signing her ownreleases. We give this a Medium rather than a High,because Julie signing her own releases, which iswhat the law specifies, is not mentioned. Signedreleases permit you to breach confidentiality toobtain or release information.

MEDIUM



Obtain a consent from Anneto see Julie individuallyregarding pregnancy

You need to consider the criteria for seeing a minorwithout consent. It is unclear whether there isabuse or any dangerousness (Julie feeling suicidal,etc.) that would qualify her to be seen withoutparental consent. Without those exceptions, youwould need to have Anne’s consent. However, youhave already gotten consent to see Julie in therapywhen her mother brought her in, and you do nothave to get an additional written consent to see herindividually. However, in the course of things, youwould be discussing seeing Julie individually withher mother, even while holding confidentiality aboutthe pregnancy.

MEDIUM

Assert privilege for Julie ifmother asks for records

Asserting privilege is something an MFT would do ina courtroom or when the MFT’s records are beingsubpoenaed. In the situation described the MFTwould be discussing confidentiality as it applies tothe development of trust between the MFT andJulie. However, because privilege has to do withconfidentiality, and we should maintain Julie’sconfidentiality in this situation, we will still give it aMedium rating.

MEDIUM

File report with a childprotective services agency

There is nothing in the Exhibit to suggest that thesexual relationship is anything but consensual, andsince Julie is 14, you wouldn’t have to make areport unless the boyfriend was 21 or older.

LOW

Strategies


EXHIBIT?

Julie 2 of 2

1. H H M L

2. M M H M

3. H M H H

4. H H L H

It should be obvious that “3” is the best answer. However, let’s say we rated the child abusereporting higher, so that we could illustrate the use of Pair and Compare. Everyone is goingto rate elements differently, due to the subjectivity of the exam, and you shouldn’t worryabout coming up with different ratings than we do, unless the differences are radical and veryfrequent.



Julie 2 of 2

1. H H M M

2. M M H M

3. H M H H

4. H H M H

In this scenario, we can set aside “1” and “2” and focus on “3” and “4” using Pair andCompare, since the ratings are the same. Using Pair and Compare we can see that all of theelements are the same, except for the two Mediums:

3. 4.

Obtain releases from Anne if seeing motherand daughter together (Medium)

File report with a child protective servicesagency (Medium)

Julie 2 of 2

1. H H L M

2. M M H L

3. H M H H

4. H H M H

There is something not quite right about either Medium (see Rationale), so we need to thinkabout what is essentially different between them. “3” has a partially correct statement aboutreleases (Julie, because of her age, signs her own releases, but you would probably have Annesign them as well, even though Julie’s is the only one we need). “4” however, has thetherapist assuming that there is a reason to violate Julie’s confidentiality without good cause,which is a much more serious action than not getting the releases exactly right. Therefore,the Medium in “4” gets a “-” and “3” is the better answer.

Julie 2 of 2

1. H H L M

2. M M H L

3. H M H H

4. H H M- H

I. Section 9: Practice Exercises

Each of these exercises is targeted towards a different skill that is directly applicable to theWritten Clinical Vignette Exam.



Exercise 1: Breaking Down Complex Questions/Responses

Introduction

Sometimes questions will have several elements that they are asking for, or responses may belong and complex and consist of several components. Breaking the questions down intocomponents is an important part of the rephrasing process, and assures that you are clearabout what the question is asking for.

Exercise

Break down each question or response into its separate components.

Question: What are the legal issues inherent in this situation?

There are two components in this question:

Legal issues

Applicable to this case

Question: What kinds of actions would an Object Relations therapist take if interventionsweren’t working in the middle stage of therapy?

There are five components in this question:

Object Relations

Interventions not working

Interventions (actions) totake instead

Middle stage

Applicable to this case



Response: The therapist would ask the client what they are feeling in the moment andexplore the transference.

There are two components in this response:

Ask the client what they arefeeling right now

Explore the transference

Response: Get a consent to treat John from his father and set up an individual sessionimmediately.

There are four components to this response:

Consent to treat minor

Get consent from Dad

Individual session

Immediately

Response: How would an Object Relations therapist incorporate the diversity issuespresented in this case into the treatment?



Question: Which crises and psychosocial stressors should be managed first, and why?

Question: What diversity issues would you want to gather more information about in order toformulate your treatment plan and how would you obtain it?

Question: Define the legal issues and how the therapist should manage them.



Question: What interventions would be appropriate to use in the middle stage of therapy ifyou are a Systems therapist and you were treating this case in family therapy?

Question: If cognitive rehearsal with Ryan and his family was not successful in reducing hisanxiety, what other intervention strategies should the therapist consider?

Response: Make a school visit to observe his social skills and ability to resolve conflict.



Response: Language barriers and the potential for misinterpretation and misunderstandings

Response: Seeing the child alone would conform best to the cultural expectations of both hisparents.

Response: Develop a strong therapeutic alliance with her and use it to set appropriateboundaries with her parents.



Response: His understanding and insight into his ethnic background and the relationship tothe mainstream culture.

Response: Cultural values including attitudes about the roles of men and women,parenthood, poverty and crime.

Response: Speak to the pediatrician and the school guidance counselor.



Response: Reduce the total fee amount that you bill the insurance company if you lower theirco-pay because of their financial situation.

Response: Be clear that they know what the ongoing fee is by the time treatment commences,and are clear about what the intake fee is.

Exercise 2: Rephrasing the question

Introduction

A critical element to success in the Written CVE is making sure that you truly understandwhat the question is asking. A common error for candidates is to make a quick assumptionabout what the question is asking, which may result in being slightly off focus when choosingtheir answer. The best way to avoid this error, is to rephrase or restate the question in yourown words, boiling the question down to its most important elements. If the question asks,“What are the crisis issues in this case?” a rephrase might be, “What is potentially harmful or



dangerous in this situation?” The focus of your search is now on danger or harm, rather thanthe broader term “crisis.” Many people think of losing their wallet, getting divorced, or gettinga flat tire as a crisis, but in the exam world, we are thinking of a crisis as a situation wherethere is potential physical harm, such as suicidality, homicidality, certain substance abusesituations, child or elder abuse, domestic violence, or situations that might lead to any ofthese problems (such as being diagnosed with a serious illness, teen pregnancy, etc.).

Below we give a sample of some of the typical questions you might find in your ClinicalVignette exam, and ask you to restate or rephrase each of them in your own words. We havedone the first few for you. Remember, think simple, easy to understand language that gets tothe point of what the question is asking.

Exercise

Write out a restatement of each question in your own words.

Rephrase: What are your diagnostic considerations in this case?

Example: What various diagnoses might work for the client(s) in this case?

Rephrase: Define and manage the crisis issues presented by this client.

Example: What is potentially dangerous and what do you do to keep this client safe?

Rephrase: Prioritize the legal issues inherent in this situation.

Example: List the legal issues from most important to least important.

Rephrase: Working from a family systems perspective, what would be goals in the middlestage of treatment?

Example: What do you want to accomplish in the middle stage with this client(s) if you

were a systems therapist?

Rephrase: How would an Object Relations therapist incorporate the diversity issues presentedin this case into the treatment?

Example: What special interventions or thinking would be helpful in taking into account

the diversity issues in this case, keeping in mind that you are an Object Relations

therapist?

Rephrase: Describe the elements that you would want to include in your treatment plan.

Example: What therapeutic method, goals and possibly interventions would you write

into a treatment plan for this case?

Rephrase: Which crises should be managed first?



Rephrase: What DSM-IV diagnoses would you consider for Susan?

Rephrase: The therapist works from a primarily psychodynamic model, and decides to seeSusan alone, referring Roberto to other professionals. What would be likely goals of treatmentwith Susan?

Rephrase: Working on their communication from a broadly Humanistic-existentialperspective, what interventions would be most helpful?

Rephrase: If you were a Cognitive therapist and you gave Miguel exercises to work on athome and he didn’t do them, what would you do next?

Rephrase: What would be your goals for the initial stage of treatment?

Rephrase: How would you apply Object Relations theory to this case?



Rephrase: What legal and ethical issues are most important in this case?

Rephrase: What are the crisis considerations in this case?

Rephrase: What would a Solution Focused therapist do in the middle stage of therapy?

Rephrase: What diversity issues would you want to gather more information about in orderto formulate your treatment plan?

Rephrase: Define the legal issues and how the therapist should manage them.

Rephrase: What are the crisis issues and psychosocial stressors that are of the mostconcern?

Rephrase: What would be your goals for the initial stage of treatment?



Rephrase: What interventions would be appropriate to use in the middle stage of therapy ifyou are a Systems therapist and you were treating this case in family therapy?

Rephrase: What would be important to address in the termination phase of treatment forthis family?

Rephrase: How do diversity issues affect your clinical management of this case?

Rephrase: If cognitive rehearsal with Ryan and his family was not successful in reducing hisanxiety, what other intervention strategies should the therapist consider?

Rephrase: How should the therapist clinically manage the legal issues presented by thisExhibit?

Exercise 3: Legal and Ethical Differentiation

Introduction

In this exercise, the focus is on differentiating the subtleties of legal and ethical issues, as wellas understanding how ethical considerations are related to legal issues. As you go throughthe practice questions, write down in the left hand column each legal issue that comes up.Then, write a description of the legal principle applied, followed by the ethical questions andconsiderations that may come up as you deal with that particular legal issue. We began twoareas to provide an example of how you might use this exercise (however, you may want toadd additional questions about these areas). Continue with other legal issues as you comeacross them in practice questions and your review of the material.



Exercise

LEGAL ISSUE WHAT THE LAW SAYS ETHICAL QUESTIONS TO CONSIDER

IN APPLYING THE LAW

Child abusereporting

Therapist must report childabuse when “reasonablesuspicion” exists

• What is reasonably suspicious?

• Do I tell the parents?

• What do I say to the child?

• How much clinical information do Iinclude in the report?

• When does domestic violencequalify/not qualify as emotional cruelty?

Consent to treat aminor

Therapist must get consentto treat a minor from aparty that holds legalcustody, unless theexceptions (12 or older,abuse or dangerousness orpotential harm), in whichcase the minor may consentfor his/her own treatment.

• Do I include a non-custodial parent inthe therapy?

• How do I make sure everyoneunderstands confidentiality as it appliesto the minor?

• What kinds of circumstances wouldcontraindicate involving the parents intreatment (and getting their consent)?

• What situations meet the criteria fordangerousness or potential harm?

Tarasoff

Elder/DependentAdult Abuse

Confidentiality

Scope of practice




IN APPLYING THE LAW

Releases




IN APPLYING THE LAW

Exercise 4: Build Your Own Question

Introduction

One way to “get inside” the mind of the exam writers, is to build your own questions. Thisallows you to understand the thinking that goes into making a question difficult. In otherwords, if you can put it together, you will know how to take it apart.

Exercise

For this exercise, enter an answer choice that conforms, in your opinion, to the ranking to theright of the space. Note that some elements will repeat in later response choices.

VIGNETTE 5

Jane is a 40 year old woman who comes to you complaining of feeling sad since her

divorce 3 months ago. She wants to know if you can prescribe “something” to help her feel

better. She has two grown children who she rarely speaks to, because, “They both went as

far away as they could for college.” At the end of the first session, she tells you that she is

sure that you will be the “best therapist I’ve ever had.”

Question 1 of 3: What are your diagnostic considerations?

1. (a) Adjustment Disorder High, very likely diagnosis

(b) ___________________________________ Low, not even close diagnosis, such asPrimary Insomnia

(c) ___________________________________ High, different very likely diagnosis)



(d) ___________________________________ Medium, half right or not sure but notcompletely off base diagnosis, for example,Borderline Personality Disorder (becauseof her abandonment issues with herdaughter and her idealization of thetherapist)

2. (e)___________________________________ Write in element (d) from 1

(f) ___________________________________ New Medium

(g) ___________________________________ Same High element – (c) as in 1

(h) ___________________________________ New High element

3. (i) ___________________________________ Use element (c) from 1.

(j) Adjustment Disorder Use element (a) from 1.

(k) ___________________________________ New really, really Low element, such as amade up term that doesn’t even occur inthe DSM-IV-TR

(l) ___________________________________ New Medium element

4. (m) ___________________________________ New Medium element

(n) ___________________________________ Use (d) element from 1.

(o) ___________________________________ Use element (h) from 2.

(p) Adjustment Disorder Use element (a) from 1.

When you rate your responses on scratch paper, the result should look like:

Jane 1 of 3

1. H L H M

2. M M H H

3. H H L M

4. M M H H

“3” could be eliminated immediately during the initial scan, because of the really, really Lowelement that isn’t even in the DSM. “1” can be eliminated because it has a Low, as comparedto “2” and “4,” which do not. (However, if one of these responses, say “2” for example, alsohad a Low, then we could take “4” as our best answer and move on.) However, we are leftwith two responses that have the same rating, a not unusual situation. We can use Pair andCompare to help us figure out the difference between the two.



Jane 1 of 3

1. H L H M

2. M M H H

3. H H L M

4. M M H H

The first Medium element in “2” should be the same as the 2nd Medium element in “4,” so wecan set them aside – we are interested in what’s different about the answer choices, not whatis the same. Also, the 4th High element from “2” is the same as the 3rd High element in “4.”Once we have set aside the exact pairs, our scratch paper might look something like:

Jane 1 of 3

1. H L H M

2. M M H H

3. H H L M

4. M M H H

Now that we’ve narrowed things down to where we are only looking at what’s different aboutthe responses, we can compare the Medium in “2” to the Medium in “4” and the High in “2” tothe High in “4.” If we like one of them a bit better, we can add a “+” sign, or if we are slightlyless sure about one of them, we can give it a “-“ ranking.

Jane 1 of 3

1. H L H M

2. M M H H

3. H H L M

4. M M H H

Since you are the question writer, you will need to decide which one fits the case better – “2”or “4.”

J. Section 10: Additional Study: Theory Concepts

Exercise Option

Introduction

The MFT CVE requires you to have more than just a good knowledge of theory and treatmentmodalities. While the questions often specify that you are working within a certain modality(Structural, Solution Focused, Object Relations, etc.), the answer choices are likely to beobscure, confusing, hard to understand, and very close to each other in content and value.Additionally, a term from one theory could be used correctly to describe something in anothertheory, and you must have an understanding of the meaning of the concepts in order to findthe best response to a question, and not just memorize lists of key words. Therefore, it iscritical to have a thorough understanding of the major therapeutic modalities, so that you



will be able to discern what the essential meaning is that is hidden in the confusing languageof the answer choices. By their nature, the content areas of clinical assessment andtreatment, and to a lesser extent, treatment planning are all related to the area of theory. Thefollowing exercise has been designed to deepen your understanding of theory and treatment.To gain the maximum benefit from this optional study exercise, you will need to set aside anumber of hours to devote to it. (Note: If your study time is limited, working the Exhibits inCaseMASTER should be your top priority.)

There are three major questions that incorporate theory on the Clinical Vignette exam.Questions that ask:

• What is happening with this client or these clients? (Assessment questions, found inthe content area of CLINICAL EVALUATION)

• What is it you and the client hope to accomplish with therapy (Goal questions, found inthe content area of TREATMENT PLAN)

• What is it you actually do? (Intervention questions, found in the content area ofTREATMENT)

Assessment questions can be answered in a number of ways: from the DSM-IV-TR: “Thisclient has post traumatic stress disorder; from theory: “This client has a negative schema orthis client is triangulated”; or from a reality point: “This client is suicidal, etc. In thefollowing exercise, we will focus on answering the question: “What is happening with thisclient?” from a theoretical perspective.

Goals for therapy (“What is it that you want to accomplish?”) can be theory based (“resolvethe transference,” “restructure the personality,” heal emotional cutoffs”) or in a practicalsense: Help client stop drinking, repair the rift in the marriage, etc.

Interventions (things that you do) can be rooted in theory or not: refer to a doctor, confrontthe client, discuss the situation, ask an open ended question, call a psychiatric emergencyteam, etc. are all interventions that are non-theory based. Theory based interventions mightinclude interpret a dream, ask the Miracle Question, construct a genogram, or prescribe asymptom, depending on what theoretical model you are using.

When working from a particular theory model in the exam, it is not necessarily imperativethat you work from within that model’s set of interventions exclusively. Real therapists areoften eclectic, drawing from various “tool boxes” of theory to help their clients. The ClinicalVignette Exam seems to specifically call for how real life therapists would actually treat theirclients, not how the “book” says a particular theorist would respond. A psychodynamictherapist, for instance, might use cognitive behavioral interventions in the early stage oftherapy to provide the client with some immediate coping skills and to establish a holdingenvironment.

However, even when drawing from different theories, it is important for the therapist toremain consistent with the goals and overarching philosophy of the primary theoretical model- the therapist is not likely to do something that is “anti-theory.” An example of this would bea Solution Focused therapist formulating a problem list with a client – such an action wouldbe “anti-theory.” In other words, whenever straying from the primary theoretical model inchoosing an intervention, make sure that the intervention would 1) be helpful to the client,and 2) be consistent with the goals of the primary theory. However, the most importantconsideration is, does this work for the client, or is it a “good fit?”



Additionally, be careful not to fall into the trap of thinking that key words or phrases can only

be used in association with a particular theory. For example, if you see the word “analyze”you most likely have an immediate association with some kind of psychodynamic orpsychoanalytical theory. However, all theoretical models require you to analyze something:Bowen analyzes the multi-generational patterns, Structural therapists analyze thetransactions between subsystems, Narrative therapists analyze the client’s story line, etc.Words like “reframe” or “relabel” are associated with different theories, but could easily beused to refer to the same intervention. “Mimesis” is a word that Minuchin coined to refer tothe therapist using the style of language and presence of a client in order to join with them;Solution Focused theory advocates using the client’s style of language as well even though theydon’t call it “mimesis” - in other words, you would not necessarily be incorrect in saying thata Solution Focused therapist uses mimesis.

The Written CVE tends to make clear what theory they are asking for (“What would aStructural therapist do in the early phase of therapy,” etc.) but tends toward vagueness in theanswer choices. You may not see the key words or phrases that you are used to, or you maysee key words mis-used, or concepts that are poorly worded, or mixed together. Therefore, itis critical that you understand the concepts underlying theory and treatment modalities,rather than rely on memorizing lists of key words.

The following exercise is designed to strengthen your understanding of the major therapeuticmodels.

Exercise

This exercise involves a good deal of writing, and may be done in a word processing program,spreadsheet or by hand. Writing is emphasized in this exercise because the act of writingreinforces your understanding of the meanings. The theories that would be most importantto do the exercise with are:

• Extended Family Systems (Bowen)

• Experiential Communications (Satir)

• Structural

• Strategic

• Cognitive Behavioral

• Solution Focused

• Object Relations

• Gestalt

You may choose to write out other theories, including Gestalt, Narrative, Rational EmotiveTherapy, general psychodynamic theory, etc., or simply do Step 5 of the process (the essay)with them.

Step 1: For one theory, write out all of the assessment terms you can think of (terms thatparticular theory would use to answer the question, “What is going on with thisclient?”), from memory (this is “closed book.) Example: Bowen would say that aparticular family might show emotional cutoffs, multi-generational patterns,dysfunctional reciprocal relationships, etc.



Step 2: For the same theory, write out all of the interventions (things that you do withinthat particular theory) you can remember. For example, a Cognitive Behavioraltherapist might: create a problem list, assign a thought record, rehearse abehavior with a client, etc. Again, this is “closed book” – i.e., just write out whatyou can remember without referring to any materials.

Step 3: Go to your AATBS Workbooks, AATBS CD’s, your textbooks, read on-line articles,etc. about the theory, and then, in a different color pen/font, write in all of theassessment and intervention terms that you left off the list when you did it frommemory.

Step 4: Write a one or two sentence definition, in plain language, for each item on yourassessment and intervention lists. Try to avoid using jargon, and focus on usinglanguage that the average American high school student could understand.

Step 5: Write a short essay (2 or 3 paragraphs) summarizing the philosophy that underliesthe theory, how the theorist(s) explains the etiology of mental health symptoms orrelationship problems, and what you are trying to change in the client whenworking from this perspective (their thinking, their behavior, their interactions,their personality structure, etc.).

Bonus Step: Teach someone else about this theory (verbal reinforcement).



Documents

MFT CVE Strategies Manual 2010-04