MFT CVE Strategies Manual 2010-04

California MFT Clinical Vignette Exam
Strategies Manual Table of Contents
CALIFORNIA MFT WRITTEN CLINICAL VIGNETTE STRATEGIES 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 CaseMASTERs 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
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Strategies Manual Quick Start Guide
CALIFORNIA MFT WRITTEN CLINICAL VIGNETTE STRATEGIES 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 do recommend a basic study plan similar to this: 1. Skim through the Candidates Handbook and the MFT Study Guide in the Appendix of this 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 taking it. 2. Try the sample questions in the MFT Study Guide, and check your answers. Be aware that 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 the sections on strategies for rating responses, so that you will have some tools to use when you begin your practice with CaseMaster. (The Additional Study: Theory Concepts section is optional, and if you decide to review this section, you should spread the exercises across several days or weeks.) 4. Once you have reviewed the Strategies Manual, register for CaseMASTER, which contains the practice exhibits and questions. Go to the AATBS Website (www.aatbs.com), and click on the CaseMASTER option under the Program Login menu. Enter your invoice number and create a password as instructed. Remember: CaseMASTER is active for a designated period of time, which begins when you register online, so dont login too early. You want to plan your access so that you are able to practice right up until the time you take your exam. 5. CaseMASTER consists of two sections: Sets of Practice Questions (which list individual exhibits with five or six related questions) and Mock Exams (which provide full-length exams with vignettes and questions not previously encountered.) As you work through these practice vignettes and questions, you will be exposed to a variety of clinical situations, questions, and answer choices that are very similar to the real Clinical Vignette Exam. Because you studied this material for the first exam, you should not need to go back to review concepts, diagnoses, legal/ethical issues, or other content, Your job is to develop a process for analyzing the vignette and sorting through answer options quickly. CaseMASTER is your primary study tool, and there are at least two equally effective ways to use it. Consider your own preferred learning style and decide which procedure suits you.
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Strategies Manual Quick Start Guide
A. STUDY mode first, then EXAM mode:

First complete all of the Practice Questions in Study Mode, while applying the strategies that you learned from the Strategies Manual. Start with all of the Easy Practice Exhibits, then progress to the Mediums, and finally complete the Hard Practice Exhibits. Read all of the rationale pages, regardless of whether you got the question correct or incorrect. Notice which suggested strategies are most effective for you. Once you have completed all of the Practice Questions, begin a second review of the Practice Questions using Exam Mode this time. String together two or three sets of exhibits initially to build your stamina and increase the number of exhibits until you are answering approximately 40 questions at a time, since the actual exam is comprised of 40 questions that must be completed within 2 hours. However, at this stage, you should give yourself extra time to 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 stop during bathroom breaks, etc. Again, read all rationale pages for all of the questions after completing the exam. Notice any areas where you consistently make mistakes. Review content if 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, not checking 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 have worked with them in STUDY mode, you will no longer be able to have the experience of encountering brand new material under stressful conditions. Doing EXAM mode first will expose you and desensitize you to this stress. After to use EXAM mode, you can use STUDY mode as often as you want, as described in Procedure A, reviewing content and considering strategies for each set of questions. We recommend going through each set of practice questions 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 to the Mediums, and finally complete the Hard Do NOT wait to do the Mock Exams until just before the real test. Do NOT be overly focused on your scores. Your scores on mock exams are not a predictor of your performance on the actual exam. While there is a mix of difficulty levels in the mocks, they are deliberately constructed to be quite difficult. We want to to over train you for the real experience.
Be sure to check the Whats New box in CaseMASTER frequently for any updates to the program or news that pertains to the examination process.
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Strategies Manual Clinical Vignette Examination Format
I. Written Clinical Vignette Examination Format

Clinical Vignette Examination Format
To become a Licensed Marriage and Family Therapist (LMFT) in California, the Board of Behavioral Sciences (BBS) requires that the licensee pass two licensing exams: The Standard Written Exam, and the Written Clinical Vignette Exam (CVE). The BBS contracts with a private provider who actually administers the exams at testing centers located throughout California. This California MFT Written Clinical Vignette Strategies Manual will introduce you to the Written CVE, show you strategies for analyzing and approaching vignettes and their associated questions and give you homework assignments to sharpen your critical thinking skills as they relate to the Written CVE. The exam usually consists of 8 clinical vignettes with 4-7 multiple-choice questions associated with each vignette. The total number of multiple-choice items is 40, but 10 of these items are questions which are being pre-tested, and do not count toward your total score. All multiple-choice items (other than the pre-test items) are equally weighted. Candidates are given 2 hours to complete the exam. The passing score is re-set at the beginning of every six month cycle, depending on the difficulty of the questions and how a group of subject matter experts performs on it. The range has been wide, between 18 and 22 correct. Remember, that means 18-22 out of the 30 items that comprise the real exam. That is anywhere from 60-73% correct. The Board does not announce the passing score, but you can find the current score on the Whats New page of CaseMASTER. Most frequently the required score has been 19 or 20. As with the first exam, candidates arent told their score unless they dont pass. The Board of Behavioral Science examiners two helpful publications: the BBS Marriage and Family Therapist Written Clinical Vignette Examination Candidate Handbook and the MFT Study Guide. Both are available at their web site, www.bbs.ca.gov, but we have also included copies in this strategies volume. The same six content areas measured on the Standard Written exam are usedCrisis Management, Clinical Evaluation, Treatment Plan, Treatment, Ethics and Law. However, the associated knowledges and tasks identified in the Candidates Handbook are a little different from the first exam, and we invite you to review our overview on the next few pages. The exact number of items devoted to each content area will vary slightly from one examination version to another in accordance with the clinical features and key factors associated with each vignette. Also, exam items will often require you to apply knowledge 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 Candidates Handbook contains two sample questions, and the MFT Study Guide has twelve more examples to review. You will notice that each answer choice typically has four elements contained within it, and that these elements are often repeated in subsequent response choices. The following is an example of a typical Exhibit and question/answer set, just to illustrate the format. We will give you the answer to the question and illustrate a process for arriving at the answer later on in this manual.
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Strategies Manual 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 isnt 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 Acute Stress Disorder Dysthymic Disorder
4. Adjustment Disorder with Anxious Mood

Bereavement PTSD Major Depressive Disorder Key Procedures: Make sure you carefully read the instructions you are given at the testing center so you know how to negotiate all the available options during your exam. Making use of the tutorial before beginning the exam is highly advised. You may believe that taking the first exam with the testing company was sufficient to familiarize yourself with how the software is set up, but you may 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 sure to be aware of your time. If you take a bathroom break, the timer will continue to count down while you are away from the computer. Never leave a question unanswered. You are allowed to flag a question that you would like to return to, and can ask the computer to bring you back to the flagged questions. Always pick an answer choice, even if you are unsure, because you might run out of time to come back to your flagged responses. If you simply pick any answer, you have a 25% chance of getting it right. 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 an answer choice blank and cant get back to it, you have a 0% chance of getting it right.
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Strategies Manual Clinical Vignette Examination Format
After you are done, the computer asks if you would like to take a survey about your experience you may choose to answer the survey questions or not. Candidates receive their results immediately via the computer once they press the END button.
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Strategies Manual Clinical Vignette Content Areas
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 tasks the therapist is expected to perform as they relate to the content areas. Questions can be anchored 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?
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Strategies Manual Clinical Vignette Content Areas
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?
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Strategies Manual Taking the Written Clinical Vignette Exam
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 the Written Clinical Vignette examination and may apply immediately by submitting a Request for Examination form (available on the BBS website and at testing centers) and a $100 fee to the Board. First-time candidates should allow three weeks for processing and notification of eligibility. 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) to schedule and administer the Boards licensing examinations. Once the Board determines that you are eligible to sit for an examination, your information is referred to PSI, and PSI will send you a Candidate Handbook within two weeks. The handbook will contain the necessary information that you will need to schedule your appointment as well as the procedures for scheduling. The Board strongly recommends that candidates study each section carefully in advance of the examination to contribute to a successful examination experience. If you are a FIRST TIME APPLICANT your examination eligibility expires one year from the date of original eligibility. If you are a RE-EXAMINATION APPLICANT your eligibility expires one year from the date of your last exam. You must wait approximately 160 days to retake a failed examination. Your eligibility information can be verified by contacting the Board. The handbook will have a date indicating the specific date that your eligibility expires. The Board is unable to grant an extension of eligibility expiration date for any reason. An application becomes abandoned when an applicant fails to sit for an examination within one year after being 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, and file number. If you are currently eligible and have not received a candidate handbook within two weeks of your initial eligibility date, are unsure of your file number, or if you have problems 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 as extended time, pen and paper exam, etc. by submitting a Request for Accommodation package a minimum of 90 days prior to their desired test date. If you had accommodations for the Standard Written examination, and your accommodation request is still on file, you will be granted those same accommodations for the Written Clinical Vignette examination, unless you file a new request.
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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 License Issuance 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 according to 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 you practice 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 answer choices on one screen, and you may choose answers and navigate through the exam by either using 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 be offered 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 on the exam. Layered clothing is generally advisable, as the examination center may be cold or warm. However, if you remove a layer of clothing such as a sweater, you will likely be asked to leave the examination room and place it in your locker or leave it with the proctor. The timer does not stop when you leave the examination room to place items in your locker, go to the bathroom, etc. If you find that anything is not as expected, for example, the time you are scheduled for your test is different than what you expected, if you have trouble operating the computer, or any other 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 an unusual situation, fill out a complaint form, ask for a supervisor, or notify the BBS and CAMFT as appropriate.
C. Dealing With Anxiety

One of the most difficult things for most candidates to master in the Written Clinical Vignette Exam is anxiety. Anxiety in any test taking situation is normal, but it tends to become amplified in the Written CVE because 1) it is the final step toward getting licensed, 2) the structure 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 run away, or stand and fight. Unfortunately, this is not the most cognitively present state you can be in for an exam. All of the energy is channeled into preparing to run or fight, and very little into thinking and analyzing. Therefore, managing anxiety is key to success in the Written CVE. The quickest and most effective way of eliminating feelings of stress and panic is to close your eyes and take several long, slow deep breaths. Breathing this way calms your whole nervous
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system. Simultaneously you could give yourself some mental pep-talk by mentally repeating "I am 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 your performance on the next several questions, so it is important to stay calm and use calming self-talk, breathing, etc. when having difficulty with a particular question. Focus on slow, deep breathing for about one minute. If you still have trouble with the question, choose any of the answers, Mark it, move on to another question and return to this question later. People also tend to panic more toward the beginning of the exam because the experience is new, which may 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 be familiar 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 give you a single sheet of scratch paper, which can be used front and back. There will likely be 5 to 8 vignettes with a total of 40 questions, so you can divide your scratch paper into 40 squares (one for each question) before you begin your exam. You should do this before you press the START button on your exam. One method is to make 40 boxes and label each one in advance (1 through 40). Label each box as you begin the question with the name of the vignette client and the number and series number of the question (for example: Jane 1 of 6). If you dont need a box for a particular question, you can still make a check mark in the box, which will help you track which question you are on. If you like, you can also note what time you expect it to be after a certain amount of questions for example, if you begin your exam at 1:00, you will want to have finished 10 questions by 1:30, and so on. Breathe When you read a vignette, take a moment to close your eyes, take a couple of slow, deep breaths, and imagine yourself sitting in your office with the client(s). Imagine how they make you feel, what kinds of associations or concerns jump into your mind, and what you think the problem might be. Breathe deeply while you do this it only takes a few seconds. Also, take a long, slow breath from your solar plexus at each question while you rephrase the question in your own words. While you breathe, straighten your back - as if someone 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 to panic' etc). halt the spiraling thoughts by mentally shouting 'STOP!'. Or picture a road STOP sign, or traffic lights on red. Once you have literally stopped the thoughts, you can take a deep breath or practice a relaxation technique briefly before returning to the question. In exam anxiety or panic we often give ourselves negative messages, 'I can't do this' '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's going to be OK', I'm getting there, nearly over, or This item is probably hard because its a pre-test item and doesnt even count!
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California MFT Clinical Vignette Exam Creating mild pain
Pain effectively overrides all other thoughts and impulses. Even very mild pain - such as lightly pressing your fingernails into your palm - can block feelings of anxiety. Some people find it helpful to place an elastic band around one wrist, and lightly twang it when they 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 over again, 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 a moment 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 a positive or a negative experience during the study and exam process. Taking care of your physical and emotional needs during the preparation period is critical to putting yourself in the best position to succeed. Leave plenty of time to study and practice CVE questions so that you don't get into a situation of having to do last minute cramming. This will help to boost your confidence and reduce any pre-exam stress. You will know you have prepared well. Develop a timetable so that you can track and monitor your progress. Make sure you allow time for fun and relaxation so that you avoid burning out. Take breaks. As soon as you notice your mind is losing concentration, take a short break. 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 caffeine will 'hype' you and make your thinking less clear. Eat healthy and regularly; your brain will benefit from the nutrients. Regular moderate exercise will boost your energy, clear your mind and reduce any feelings of stress. Try out some yoga, tai chi or relaxation techniques. They will help to keep you feeling calm and balanced, improve your concentration levels and help you to sleep better. Believe in yourself. You wouldn't have completed your hours or passed the Standard Written Exam if you didn't have any ability. Therefore, if you prepare for the Written CVE properly 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 Vignette Exam more than your ability to be an effective therapist can help you keep the exam in perspective. Don't try to be perfect. It's great to succeed and reach for the stars. But keep things in balance. If you think that "anything less than A+ means I've failed" then you are creating mountains of unnecessary stress for yourself. Aim to do your best but recognize that none of us can be perfect all of the time. It is very likely that no one gets 100% on the Written CVE.
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Be proactive. If you find you don't understand some of the material or consistently get lower scores than you would like, getting stressed out won't help. Instead, take action to address the problem directly by asking for consultation or talking with other candidates about your process. Reframe the process. Instead of thinking of the exams as do or die events or some kind of torture, reframe the exams for yourself as an opportunity to review material that you havent thought about in a long time (probably since graduate school), a chance to be exposed to interesting new ideas, and best of all, an opportunity to consolidate and sharpen 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.
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Strategies Manual Strategies for Approaching the Exam
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 to recognize the ways in which the exam questions are designed to tap into the abilities you use as a clinical MFT. The exam questions will test both whether you know relevant information and if you can apply that information and your skills to hypothetical cases. Youve taken many exams that require you to demonstrate your knowledge base. You probably have less experience with test questions that require you to apply your knowledge and skills to hypothetical cases. The Standard Written Exam included application questions, but the response choices contained only one element, as most multiple choice exams do. Even candidates who lack much exposure to application exams have useful experience to draw on for the Written CVE because the thinking skills needed to answer Written CVE questions are similar to ones that MFTs use with their clients. To work effectively with clients, you bring to mind relevant knowledge, you apply that knowledge to a concrete situation (the clients case), and you use your reasoning ability to evaluate and integrate information so that you can draw valid inferences and conclusions and make sound decisions. Our strategies and your practice with CaseMASTER will help you adapt these real-life thinking skills into test-taking abilities that will help you successfully answer questions on the Written CVE. For now, lets take a closer look at each thinking skill.
1. Recall
Recall involves remembering, or bringing to mind, information you know, such as the diagnostic criteria for a mental disorder. Many Written CVE questions will require to you recall information in order to recognize the correct answer and why elements of other responses are wrong.
2. Application
The Written CVE also assesses abilities that go beyond recall. The questions will also test your ability to apply your knowledge and skills to specific cases. Applying information entails using your knowledge and skills to make appropriate decisions about cases involving hypothetical clients. On the Written CVE, this means using your knowledge and skills to correctly answer questions about different aspects of the cases presented in vignettes, or Exhibits.
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3. Reasoning
Reasoning is related to application but goes a step further. It requires you to combine your knowledge and skills with your judgment. For example, some questions will offer incorrect responses that describe acceptable clinical practice, but do not reflect the best answer for the specific case described in the Exhibit. Many of the test-taking strategies we offer are designed to 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 our CaseMASTER program.
4. Test Taking Skills

The Written CVE is a very different style of test construction, and requires specialized skills in order to pass. The Written CVE tests the same knowledge base as the Standard Written Exam, but it also tests application of knowledge, ability to read between the lines and discern disguised meaning, and the ability to discern subtle differences between similar elements. Because each set of answers involves 10 or more different responses in different combinations, learning how to eliminate bad elements quickly is essential. One must know how 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 of the questions are designed to tease out the difference between good elements that are relevant to 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 Standard Written Exam. For AATBS customers, this would be our Standard Written Exam Workbooks. Since the Clinical Vignette Exam asks about theory-specific Treatment Planning and Treatment interventions we recommend that you review each of the major theories and the goals associated with them in those workbooks. An optional set of three compact discs for our MFT Written Clinical Vignette Examination program is available that will give you the comprehensive knowledge you need for the theoretical perspectives of Extended Family Systems, Narrative, Solution-focused, Cognitive, Humanistic-existential, Structural and Object Relations 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 the assumptions, concepts, and methodology associated with cognitive-behavioral, humanistic-existential, postmodern, psychodynamic, and systems. The most common theories appearing on the Written CVE are: Extended Family Systems (Bowen), Experiential Communications (Satir), Structural, Strategic, Cognitive Behavioral, Object Relations and Solution Focused theory.
1. Pace Yourself During the Exam

The Written CVE includes 30 questions that count toward your score and 10 additional nonscored items for the purpose of pre-testing, for a total of 40 questions. These pretest items will not be identifiable to you, and you will have to answer all 40 questions in the two hours allotted to complete the exam.
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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 have time left over to re-examine some of the questions if you need to. Questions have been labeled, 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 longer to answer than the later questions, because you will need to read the Exhibit carefully and become familiar with its content. Additionally, your anxiety is likely to be highest at the beginning of the exam, and may interfere with your cognitive ability and speed. As you relax a bit, your speed and rhythm should improve.
2. Take Breaks
We recommend that you take a few short breaks during the test period, without leaving the exam room. You can do this in your seat by stopping for a moment, shutting your eyes, and taking a few deep breaths. This can give you the rest you need in order to continue with a calm and clear mind. Taking a break is particularly useful when you encounter a difficult question: If a question makes you feel anxious, stop for a moment and take a few deep, even breaths. 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 time you do the rephrase step of the question answering strategy, this will help you stay more relaxed during the entire exam.
3. Dont Skip Around

We recommend that you never skip questions as you go through the exam. Answer each question in order. If you are stumped by a question, record your best guess, Mark the item as one you want to review later, and move on. If you have time, you can go back to your Marked questions after completing the rest of the exam. Because there is no penalty for guessing, its better to record an answer for every question the first time you work with it. Otherwise, you risk running out of time and being forced to leave some questions unanswered. Consider that since usually candidates are stumped between two responses, by simply picking an answer and moving on, you have about a 50% chance of getting it right. If you run out of time at the end of the exam and cant answer the last three questions (because you spent so much time trying to figure out the earlier, difficult question) you have a 0% chance of getting those unanswered questions right! Or, if you skip a question thinking you will come back to it, you may 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 for changing your mind. For example, you could change an answer because you remember specific information that leads you to a different answer or because, on reviewing the question or Exhibit, you realize that you read it incorrectly the first time around. You should not change an answer simply because you dont feel good about your original response. This is probably 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 elements in the responses. These decision-making variables, and others, are applied throughout our rationale in CaseMASTER. There, you will see many examples of the kinds of considerations that can help you identify correct (High) rated), possible (Medium rated), and incorrect (Low rated) elements in our rationale, but we want to highlight a few of them here. 2010, Association for Advanced Training
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5. Be Careful About Making Unsupported Assumptions

As weve noted, for some questions you may find two, or even more, responses that appear equally right. Sometimes this happens because youve jumped to conclusions or made assumptions or inferences that arent well supported by information in the Exhibit. When re-examining elements consider whether the Exhibit truly provides sufficient information to support your beliefs - it may be that youve rated an element too high or too low because youve made an unsupported assumption.
6. Use All the Available Information

For some questions, youll find that you have two or more responses with equal ratings because youve overlooked key information or hints in the Exhibit. When using the Pair and Compare step in the Strategy, be sure to re-read the Exhibit carefully; it may be that information 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 have overlooked 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 reading the responses because of information presented in the Exhibit. For example, you might determine as you read an Exhibit that the client is clearly in the midst of a major depressive episode. Take advantage of strong impressions like this one when evaluating the answer options. You might discover, for instance, that answer 3 for a diagnosis question about this clients Exhibit doesnt include any depressive disorders as diagnostic considerations, whereas the other three responses do. If something like this happens, you can set aside an answer option 3 in this example and focus your efforts on evaluating the responses that contain the element you know is correct. This strategy can help with questions related to other content areas, as well. For example, you might determine as you read an Exhibit that the correct answer to a question about initial goals 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 this issue in some way. (If none of the responses address it, however, put it out of your mind and concentrate 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 own responses before reading the ones given on the exam. Instead, were recommending that you take full advantage of all the knowledge and skills at your disposal - if your knowledge and skills lead you to form certain impressions or draw certain conclusions as you read an Exhibit, and these are properly supported by information in the Exhibit dont 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 an incorrect 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

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incorrect statements
Your knowledge base will help you identify errors, misconceptions, and other inaccurate information. For example, an element that says you would maintain the clients confidentiality when the Exhibit has clearly described a situation in which you have a duty to warn would be inaccurate (Low); an element that suggests that a client has schizophrenia when the client has never 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 is testing 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 the Exhibit and whether an element applies to that case. A particular intervention may be acceptable 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 is incorrect. 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 is correct in this case, but if an answer that is specific to the question or to the vignette is available, the specific answer is probably better (however, the entire answer set must be evaluated as well). For example, if the question asks, What intervention would you use to address this clients anxiety? a broad answer might be something like, teach relaxation skills, versus a specific answer might be, have the client learn breathing techniques and thought stopping. The latter answer is more specific because it actually states what the therapist is going to do. However, one needs to be cautious and look at each question individually whereas in one case specific is the best approach, in another case, a more inclusive answer might be the best choice. For example, for the question, What would be the best approach to help with this clients depression? the more inclusive answer, Include a cognitive 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 down into its components, or chunks and evaluate the merit of the answer choices based on how many, and which chunks are represented in the answer. Take, for example, the question, What crisis issues are evident in this case? There are two components 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. A Medium answer might be a relevant issue that alludes to a danger but doesnt name it outright, or to a true, relevant statement that does not constitute a danger, and a Low would be 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).
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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 the
symptoms mentioned are not especially characteristic of Acute Stress Disorder, and more 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 danger
alluded to = Medium).
She has PTSD (relevant, but time frame may be wrong for PTSD, since the trauma
of fathers death was recent, and PTSD cannot be diagnosed for at least a month following 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 question correctly requires that you bring in your knowledge of DSM IV diagnosis, which is technically part 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 consider the 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. Some theories have specific interventions that they use during specific stages of therapy, but one effective way to differentiate between what to do when, is to consider what the priorities are in each 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. Your priorities in this stage of therapy (roughly the first 3 or 4 sessions) are to: R I M S build a Rapport with the client gather Information and assess attend to the Management issues (setting the fee, the time, getting releases, etc.) 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 of the RIMS issues. Pay careful attention to any statement or hint that could indicate that you might be in the early phase of therapy. The Treatment Plan is created at the end of the early phase of therapy, and is the transitional bridge to the middle phase of therapy. A treatment plan consists of defining: who you are going to treat, what you are going to treat (diagnosis), how you are going to treat it 2010, Association for Advanced Training
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(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 lasting changes. How to go about this is predicated by the clients problems, diagnosis, goals, the theory, the timeframe allowed by funding, etc. The Late Phase of Therapy focuses on consolidating the work, and transitioning the client out of therapy. Referrals are made throughout the course of therapy, and relate to what the priorities of what phase of therapy the client is in. Referrals in the early phase tend to be referrals that help gather information or stabilize any safety issues. Referrals in the middle phase are usually aimed at supporting lasting growth. Referrals in the late phase are usually designed to help the 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 Exhibit very carefully before attempting to answer a question about it, noting all the information you are provided about the client(s). If you find that you cant identify the right answer to a question, 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 the Exhibit or through additional information given to you in the question. Your clinical skills will 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 while answering the questions that follow it. You should, however, read every Exhibit carefully and completely, 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 the following: (1) who the client is (an individual, a couple, a family, a minor, etc.); (2) whether the client has come in voluntarily or not; (3) who referred the client; (4) the presenting problem; (5) specific details about symptoms (including their intensity and duration); (6) current level of functioning; (7) coping skills and deficits; (8) social, material, and other support; (9) reported and apparent level of distress; (10) recent and current psychosocial stressors in the clients life (recent death of family member, unemployed, separated or divorced, etc.); (11) the clients (and familys) history; (12) indicators of clinical risk (e.g., suicide, homicide, abuse, medical problems, serious psychiatric symptoms, grave disability, a lack 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, the nature of the clients 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 different Exhibits will emphasize different kinds of information. Question writers seem to be trying to use words to give you this missing informationthey frequently refer to clients body posture, voice tone, appearance. Take these descriptions seriously. In addition, information about the client will often come in the form of hints from which you must draw inferences by using 2010, Association for Advanced Training
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your knowledge and skills. This is similar to what you do with real clients. Based on the initial, incomplete information you receive about a client, you develop certain hypotheses about what might be going on. You then test these hypotheses by, for example, gathering additional information from the client, collateral sources, and life records. On the exam, you wont be able to gather more information; instead, you will rely on the inferences, or hypotheses you are able to form on the basis of information in the Exhibit. Note, too, that inferences available from an Exhibit often become more apparent when you read the follow-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 you have experience applying your skills and knowledge to cases involving real clients, you may feel more confident if you remember to deal with the exam clients in essentially the same way as you treat your real clients. There is nothing mysterious about the Exhibits on the exam. They differ from real-life cases in the sense that you may have less information about the 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 work effectively with real-life clients. Remember, the examiners write the Exhibits and questions so 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 after you read a vignette, and imagine the client(s) in the room with you. Feel how it would be if they were sitting in front of you. Notice your reactions, your associations, and how it feels to be with them. While you have your eyes closed, take advantage of the moment and draw a couple of deep, calming breaths. Not only will the case seem more alive to you, but you will also be combating the anxiety that many candidates find so cognitively debilitating in the exam process. If you can get into the habit of doing this every time you read a practice vignette, then you are much more likely to use the same exercise in the exam room to help you visualize the client(s) and relax. Your education, training, and experience have provided you with the analytical skills to read a case study in a more sophisticated manner than you did before receiving your degree and becoming an MFT intern. These skills are what the BBS is attempting to measure through your licensing examinations to determine your entry level competence and your safeness to practice 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 and ethical issues. You will also discover details to inform you as to how you, as the MFT, would develop a treatment plan and interventions to resolve the presenting issues. On the other hand, you may find that something is mentioned in the case that would be very important in real life, but doesnt get addressed in any of the questions.
E. Section 5: Strategies for Analyzing and Choosing Written CVE Responses
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In this section, we present a 4-Step process for approaching Written CVE questions. Within these steps are test-taking strategies that will help you 1) understand the questions and the response 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 so that you are comfortable using the approach during your exam. While practicing, experiment with our strategies, and determine which ones work well for you and feel free to adapt them to 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 and more effectively you will be able to apply them. Dont worry if it takes a long time to answer some CaseMASTER questions at first speed is not that important in the beginning of the process focus on understanding the process and working on increasing speed later. As you do so, youll find that youre more comfortable applying the test-taking and thinking processes 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 will require you to keep track of your thought process on scratch paper. At the exam site, you will be provided with just one blank sheet. If you want a new sheet during your exam, you will have to turn in your used sheet, which of course takes time and means you cant look back at notes from the beginning of the exam when you want to review at the end. Thus, it is best to plan 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. Because CVE answer choices are usually lengthy and complex, you will usually need to rate each of three or four answer elements, and use the scratch paper to help you select the answer that has the best collection of responses. You may also want to use the scratch paper to help keep track of time, and to prioritize which items you most want to review and reconsider if you have time remaining at the end. In this section, we model several quick and effective ways of analyzing answer choices as you work on a question. When using CaseMASTER, experiment with these strategies, and discover what is effective for you. Remember there is no single correct way to manage information or to make decisions on this exam, and what we describe are suggestions you should 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. Divide the paper (an 8-1/2 inch by 11 inch sheet) into squares, or boxes, by folding it before your exam begins. You want to divide the paper into 20 roughly equal rectangles, so that there will be 40 boxes representing the 40 test questions. Just in case you need a description: Hold the paper in your hands as though you were reading a regular document printed on the paper. First, fold the bottom of the paper up about an inch and a half, and then fold over and over four times. Unfold the paper and you will see it is divided into five roughly equal sections. Now fold the paper lengthwise, in half and then in half again, so there are four vertical columns. You now have a 4 X 5 grid. If you want to see the 20 cells more clearly, you can draw lines in the creases on both sides.
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Some people prefer not to fold the paper, but simply draw the 4X5 grid on each side of the blank paper. Again, experiment with what works for you. You can number the boxes one through forty, but this may not be necessary after you have practiced for awhile, and become intuitively aware of how far along you are in your grid. You can 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 each vignette sequence, eg, Question 1 of 5, Question 2 of 5, etc, and then beginning over again when the vignette changes. Seeing all forty boxes at once on your scratch paper will make your progression through the exam visually clear. So, for example, as you begin to answer a series of five questions based on a vignette series about Barbara and her daughter Jane, you would write the following: #1Barbara and Jane 1.HHMM 2. HLLM 3. MMLM 4. HHHL 2. 7. 12. 17. 6. 11. 16.
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 your ratings of each element vertically if that is easier for you to follow. Also it is probably not necessary to number 1,2,3,4 within each box. This could take some time, and the boxes are small. It should be obvious just by its placement which answer you are rating.
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When you see a pattern emerging that allows you to select the best answer, you should mark it 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 can indicate 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. We recommend setting benchmarks every thirty minutes to see if you are on schedule. Note how many minutes should be left out of the 120 allowed for the exam, and check with the timer on your 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 exam that started with Barbara and Jane, and moved on to three questions about Jorge and his daughter, Carmen. We have shaded the correct answer, but you will more likely circle it with your pencil. #1Barbara and Jane 1.HHMM 2.HLLM 3.MMLM 4. HHHL Custody? #2 1.LLMM 2.MMMM 3.HHML 4.MHHH 3. MMHH HHHM LLMM MMMH Crazy. Check if time 4. HHMM LLMH MMML M+ H- LL 9. 14. 19. 7. Law? Probation? HHHL MMML LMMM HHMM 8. DX is wrong in all but #3, so thats got to be right 13. 18. 12. 17. 6. Jorge Carmen MMML HMMH LMML MMMM 11. 16.
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5. H-M+M+L M-M L H MM H H LL MH
10.
15.
20.
90 mins left
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, and arrive at the right answer without further analysis.
2. The 4-Step Strategy

Under pressure during an exam, its fairly common to read carelessly or choose responses too quickly. The 4-Step approach is designed to help you attack every exam question in a systematic way, no matter how pressured.
Step 1 Read and Rephrase the Question: Read the question carefully and make sure
you understand it. Rephrase the question in your own words, focusing on the most critical elements of the question. (For example: What are the crisis issues? can be rephrased as, What is potentially dangerous or physically harmful in this case?) This step ensures that you approach a question in the right frame of mind, with a clear understanding of what youre looking for. If you have trouble with anxiety during the exam, you might want to take a moment, close your eyes, and take a deep breath each time you do your rephrasing.
Step 2 Scan the Responses for Extremely Bad Elements: Scan the responses
visually to see if there are any really outstandingly bad elements that jump out at you which could allow you to eliminate an answer or two as a whole (do not read them through word for word at this point, however). Be careful though, because there may be 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 that endanger the client, or have the therapist doing something blatantly unethical, or a diagnosis that isnt even in the DSM or is not possible for the client. Dont eliminate a response just because an element doesnt seem right it has to be really bad to throw the whole answer out. (In fact, there will be some questions where you cannot eliminate any responses at all during this step.)
Step 3 Rate the Elements: Evaluate each element in each response choice that is left
after Step 2 in light of the question, the Exhibit, and your knowledge, and assign a rating to each element of High, Medium or Low. (The rating system will be explained in more detail later.) At this point, you may be able to choose an answer based on the ratio of Highs to Mediums or Lows, and you can skip Step 4. However, be sure to take another look at your answer as a set before choosing it, and make sure that it truly is the best answer, since ratings are subjective and there are sometimes other considerations to take into account.
Step 4 Pair and Compare: If you end up with two or more response choices that are
rated equally, move on to comparing individual elements to each other to see which answer is better. This step allows you to work effectively with questions you find
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difficult, including those that seem to have more than one correct answer. This step will be explained in detail below. For some questions, youll use only Step 1 and 2, because the answer will be obvious to you after youve read the question and eliminated the worst response choices visually. For other questions, youll need to proceed to Step 3 and rate the elements. After Step 3, you may know which answer is correct. For more difficult questions, youll need to also use Step 4 before you 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 carefully and identify its focus, or purpose. Using CaseMASTER will get you accustomed to doing this properly. Determine the Content Area: For some questions, it will be easy to determine what content area is being addressed. However, many questions are now appearing on the exam that cover more than one content area. A treatment question might address an ethical issue, for example, Which interventions would be most appropriate considering the clients culture? In the case of multiple content area questions, you must define which content area is most important as a foundation, i.e., something that must be included in your answer choice, and which content areas are less critical. In the above question, your answer must have treatment interventions (things that you do) and must also address the cultural issues present in the case in order to rate a High. However, if an element is an appropriate intervention for that specific case, that doesnt specifically relate to the clients culture, you would not want to throw it out completely by rating it Low, but instead might settle for a Medium. You will want to make a mental note as you read the question about what content areas are being addressed and which content areas are the most important to have in your answers. This tactic will ensure that you approach the question in the right frame of mind. Note Key Qualifier Words: Note words in the question that affect its meaning in a particular way. For example, a question might ask you to choose your initial goals for the case in the Exhibit. The words initial and goals are equally critical, as they both have an 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-TR terms. The Key words in this question are: diagnoses (versus diagnosis, i.e., the question is asking for more than one), consider (meaning you dont have to pick a diagnosis that is final or certain, just answer with what is possible), and this case (obviously referring to George). Dont 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. For example, if the examiners want you to focus on one member of a family that has presented for treatment, rather than the entire family, the question will say so. The order in which the elements are presented in each answer option is usually unimportant i.e., the correct answer will be the one that has the best collection of elements, in any order. (You may on very rare occasions need to consider the order of the elements for a question only if you
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have compared the responses on all other levels and then discover that the order of the elements is the only real difference between two or more seemingly correct responses.) Despite the best of intentions, however, some people over-read questions when under pressure during an exam and become anxious as a result. You can avoid doing this by taking questions at face value and retaining your natural common sense. For example, if a question asks for your diagnostic considerations, recognize that your job must be to choose the most likely possible diagnoses from among the responses. Although this question 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 you understand the question and for retaining your understanding of the question as you work with it. If the question is relatively long, break it down into its key parts and then rephrase 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? For George, Question 1: What diagnoses would you consider in this case? we can rephrase it as: What possible diagnoses might fit for George? Rephrasing the question in your own words forces you to slow down and really understand what the question is asking. Since it is very difficult to find an answer for a question you dont fully comprehend, this is a critical step in the process. Breaking the question into its component chunks, deciding what the content areas are, and rephrasing it in your own words will come naturally to you if you do it enough times while practicing with 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 process while reading the responses for the first time. However, before getting bogged down in rating every single item, quickly skim through the responses to see if there is any element that is so Low, that no matter how High the rest of the set is, you could not have that element in a correct answer. Examples of this might be: things that endanger or harm a client, completely off base diagnoses, non-sensical elements or elements with made up, non-existent words, etc. However, be cautious! Avoid throwing out responses because of some off-base item that is wrong, but not extremely wrong. You may have to live with responses that dont seem quite right, or that even have a bad or irrelevant element in them, so use this step only on extremely bad elements. By scanning the responses before rating the elements, youll also get an initial sense of which elements are possibilities and which are probably incorrect as you scan. You may notice that some elements are repeated in more than one answer. You will get a sense of what the answer offerings are as a whole, which will provide you a context within which to rate the elements. This is true for three reasons: First, the content of the responses often helps you understand more precisely what the question is asking. Second, the content of the responses may help you draw inferences about the case that didnt occur to you when you read the Exhibit. It helps to have all these inferences in mind before you begin rating the elements. Lastly, if you know the content of the responses, youll be prepared to rate the elements not only in relationship to the Exhibit but also against elements in the other responses. As you will see in this section, this is particularly important when two or more elements are similar.
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Keep an open mind when reading the responses. The old MFT Oral Exam measured your readiness for independent practice by assessing what you would do with clients in a vignette. Because the Written CVE is a multiple-choice test, it measures your abilities in a different 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 its unlikely that you will find many (or perhaps any) responses on the exam that match exactly what you would do with the Exhibit client(s). This doesnt mean that you wont be able to identify the best responses. Instead, it means that you should be prepared to see responses that differ from what you expected to see and should evaluate these responses on their own merits against information in the Exhibit, using the strategies we recommend in this manual. In other words, keep in mind what you would do in real life, but dont overfocus on it because this might prevent you from finding an answer you can live with You also should be prepared to see responses with long, wordy elements on the exam. We illustrate these in CaseMASTER. While you might worry about needing to read and decipher long elements on the exam, many of the strategies in this section and CaseMASTER are designed to help you do this, and using CaseMASTER will allow you to practice applying these strategies. The responses to exam questions may also include several elements that are similar, but not identical. The Pair and Compare strategy will help you deal with these types of response choices. Lets scan the first question for George (the case presented in the previous chapter) for extremely 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 isnt 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
2. Bereavement


2010, Association for Advanced Training Page 27
Strategies Manual Strategies for Approaching the Exam Bereavement PTSD Major Depressive Disorder
In scanning these answer choices (Step 2), you should be able to spot Histrionic Personality Disorder and Malingering as two extremely bad elements. They are simply so 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 this point, and are certain about your choice, you can mark your answer and move on to the next item. If you dont know the answer yet, you will move on to Step 3, in which you rate the answer elements. Keep in mind, though, that there will be times where this step does not 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. Question 1 of 2: What diagnoses would you consider in this case?
1. Primary Insomnia
2. Bereavement


Bereavement PTSD Major Depressive Disorder We have set aside 2 because of the Histrionic Personality Disorder (see the Rationale in Section 7.) It is an extremely bad element that disqualifies the entire answer set from consideration. Additionally, in 3 Malingering is a very bad element there simply is no reason to consider that Georges 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 a value to each element in the responses. Rating the elements helps you ground and organize your decision making about the responses by providing a framework for identifying correct, maybe, and wrong elements, keeping track of your decisions about the elements, and comparing the responses. The value you assign to an element will be based primarily on its accuracy (is it consistent with your knowledge about the content area?) and its relevance to the case in
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the Exhibit. For some elements, the value you assign will also depend, in part, on the other elements. That is, sometimes an element in one answer (e.g., 1) will appear correct until you compare it to an element in another answer (e.g., 3) that is more correct. We will illustrate how to Pair and Compare elements in Step 4. The Rating System: This strategy relies on a High/Medium/Low rating system. Each element of an answer option is given a rating of High, Medium or Low. This process is used for each answer option for a question, and the option that receives the highest overall 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/very likely/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 somewhat important/somewhat relevant/somewhat likely/somewhat appropriate, partially true. An answer element that might be correct, true, relevant, and/or appropriate would receive a Medium rating. These elements are less obviously correct than those that receive a High rating, but they are not entirely incorrect either, so you dont want to eliminate them. A rating of Low is equivalent to no/incorrect/untrue or not important/not relevant/not likely/not appropriate. An answer element that is clearly incorrect, untrue, irrelevant, and/or inappropriate would receive a Low rating. Assigning a Low rating means you think that the element can be eliminated from consideration. Well say a bit more about incorrect elements below. If you look closely at the questions, you will see that each question is composed of at least two chunks. A High answer should address all of the elements in the question. For example, for the question: What are the crisis issues presented in this case? the two chunks are crisis issues and this case. For an answer to rate a High, there needs to be an issue that 1) presents the possibility of danger and 2) the issue needs to apply to the case. If the issue applies to the case, but is not a danger, perhaps it can be rated a Medium. However, if the issue doesnt have anything to do with the case, or is a blatantly false 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 wasnt 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 it imperative that you remain within a cognitive behavioral framework? Or is it more important to do something that would be appropriate for the vignette client even if it
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means using another theory? How about stage of therapy how important is that? Or, if it is an appropriate cognitive behavioral goal (rather than an intervention), how would you rate that? The following is an example of two answer types to illustrate some of these elements 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 Middle stage cognitive behavioral intervention Middle stage cognitive behavioral intervention While some answer choices meet several appropriate criteria (middle stage, cognitive behavioral, intervention) some meet only two criteria (cognitive behavioral, intervention, but in the wrong stage, or cognitive behavioral intervention in the early stage). The three or 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 various elements though, you cannot pick 2 because of the harmful intervention. Essentially, of these two responses, you must pick the answer with the psychodynamic intervention rather than insist upon staying within your cognitive behavioral framework and doing something 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 because of the quality of the Low element in 2 it is never okay to take an action that harms a client. Another example would be a question that covers legal, crisis and ethics: Define how you would manage the crisis issues in this case and the legal impact of your interventions. In fact, 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 more than 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 legal impact 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 response addresses an ethical issue that is present in the case rather than a legal one that is still potentially dangerous (the client is using drugs for example), the response cannot be rated a High, and a Medium would be a better rating. If the element is simply a legal issue and not a crisis issue (releases and confidentiality for example) it might be a Medium, or even a Low, because the question is asking about crisis. The difference between rating the element 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 it is broad and applies to all cases (and is not a crisis) it might be better to rate it a Low. If the answer doesnt even apply to the case (even if it is a crisis), you would have to rate the 2010, Association for Advanced Training
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response as a Low. Crisis and case specificity are your most important foundation content areas in this particular question. Legal or ethical implications would be a lesser content area, and the management portion (what you do about the issue) is also important. 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 call
the police; Janes 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). Lets rate the elements in response 1.
1. If Jane is serious about harming her boss, you will have to warn him and call the
police; (Content areas: 1) crisis (yes), 2) applies to this case (yes), 3) legal (yes), 4) management/interventions (yes) = High)
Janes 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.
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Fortunately you will usually find that some elements appear in more than one answer option. This will save you time when it happens: Once you have assigned a rating to a particular element, you can apply that rating to the element each time it appears in the answer options for the same question. (Remember, if you change an element in one, be sure to change the rating any place the element is repeated in other responses.) Read carefully before doing this, to make sure that the elements are truly identical. Also, on rare occasions an exam question might ask you to choose a series of priorities or a sequence of interventions. However, the rule is to not assume that the answer is asking for a sequence unless told so by the question. Below, we review what an incorrect element is on the Written CVE. Understanding this information will help you know when you can eliminate an element and the answer that contains 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, as you first practice rating elements in CaseMASTER, but it might also happen on the exam. Dont 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 the same rating, use Step 4, in which you Pair and Compare elements to see which answer is best. You may feel more comfortable using some other code to rate elements, however, such as yes, maybe, and no, or a 0 1 2 rating (in which case you can add them up to get 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 to a 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 is clearly incorrect. Lets 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 common error or misconception or is simply an inaccurate statement. This is true for most multiple-choice tests. For example, an element that says you would maintain the clients confidentiality when the Exhibit has clearly described a situation in which you have a duty to warn would be clearly incorrect. Or an element that suggests that a client has schizophrenia when the client has never experienced any psychotic symptoms would be clearly incorrect. The issue of relevance is very important when deciding whether an element is right or wrong: If an element is not at all relevant to the case presented in the Exhibit (or to the question), or is not supported in any meaningful way by information in the Exhibit, it is incorrect. If the element is clearly and completely irrelevant, you can give it a Low rating. For instance, for our sample question about Georges diagnosis, an element would be clearly incorrect if it was an irrelevant diagnostic consideration for George because the Exhibit 1) doesnt provide any information to support it or 2) provides information that contradicts it. To recognize the incorrect elements for our sample question, you must read 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.
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However, be careful not to set aside an answer element that is a bit off, but not completely wrong. Your instinct might tell you that the element is wrong, but youre not sure. Or maybe it is partially correct, but some part of it doesnt quite fit. If youre not sure that an element is wrong, dont give it a Low rating - give it a Medium rating instead. An example of this might be Georges Adjustment Disorder with Anxious Mood in 1 and in 4. This is an example of an element that doesnt quite fit, or is partially correct, or for which there is no evidence but is not outside the realm of possibility. Rather than completely throw out the answer because of this kind of element, you are better off giving it a Medium. Remember, you are attempting to find the best collection of elements, not necessarily the answer with all correct elements. You dont want to set aside an element and the answer that contains it unless you are absolutely certain that the element is completely unacceptable. If two responses contain questionable elements that prevent you from identifying which answer is the best after youve rated the elements in Step 3, you will proceed to Step 4. Our Step 4 strategies are designed to help you tackle the more difficult questions. Begin with option 1 and consider each diagnosis in light of information in the Exhibit. If the diagnosis seems likely, give it a High rating. If it seems possible, but receives somewhat less support from the Exhibit, or youre not sure enough to give it a High or a Low, give it a Medium rating. If it is clearly incorrect, give it a Low rating. Scan the responses to see if any of the elements youve rated also appears in other responses. If so, apply your rating to the element there, as well. Continue this process until you have assigned a rating to each element in the responses that you have not previously set aside in Step 2 (in this case 1 and 4). Consider your ratings carefully, using all the knowledge and skills at your disposal and the information in the Exhibit. For most questions, you will select the correct answer based on the ratings you assign to the elements. For some questions, you will be able to rate elements and keep track of your ratings without writing anything down. This will be especially true after youve practiced Step 3 using CaseMASTER. It will also be true for questions that offer more obviously correct and/or incorrect elements and responses. For other questions, you will want to use your scratch paper to keep track of your ratings. Having these notes will also help in Step 4, if you need to examine the responses more closely. Additional Tips For Using the Rating System: Keep the following tips in mind, as they will help 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 set that you think is the answer, then slow down and read every word carefully to make sure you didnt miss some important detail before selecting it as your answer. Or, if youve quickly rated the elements and found that you need to move on to Step 4 Pair and Compare - slow down during the Pair and Compare process and focus on the tiny details 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 by
rating each discrete element only one time: For example, once we determined that a High rating was appropriate for Major Depressive Disorder in 1, we also applied that rating to Major Depressive Disorder in 4.
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Look for the Best Collection of Elements: You may have a response set that has three
High rated elements and one Medium rated element, or it may even contain a Low element, and it will still be the best response to choose. The response you pick doesnt have 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 primary

criteria when rating elements are their accuracy and their relevance to the Exhibit. A High rated element should be both accurate and relevant to the case you are working on. Sometimes, however, an elements rating may also be affected by one or more of the other elements. This is particularly true when two or more elements are similar to each other and, therefore, appear equally good. At first glance these elements may even appear identical, but on careful reading youll see that they differ in some important way.
Work with Each Question Individually: Your goal when using the rating system is to
develop a basis for comparing the four response choices for a particular question. Dont waste time worrying about whether an element you rated High (or Medium) for an earlier question is equivalent to an element you want to rate High (or Medium) for the current question you are working on. Address each question independently, with the goal of identifying the response choice that receives the highest overall rating.
Use Mid-Point Rating if This Helps You: Sometimes, you may believe that an
elements score should fall somewhere between a High and a Medium rating or a Medium and Low. It is fine to assign a + or a - to a rating to indicate that you find something particularly good for that rating or borderline bad. However, as a general rule, you might want to save using + or - for when you need to use Pair and Compare. Again, your goal is to assign ratings in a way that helps you compare the four answer options so that you can identify which one receives the highest score and, therefore, should be selected. Experiment with assigning mid-point ratings when using CaseMASTER, so that youll be comfortable with your system during the exam. Well be saying more about mid-point ratings in Step 4, where we illustrate using them when answering a sample question. Lets continue with Georges diagnosis question: Question 1 of 2: What diagnoses would you consider in this case?
1. Primary Insomnia
2. Bereavement

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Bereavement PTSD Major Depressive Disorder 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 for Malingering in Step 2 because they were really, really bad elements, and therefore we don'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 youve focused your decision 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, refer back to the Exhibit. If you remain stumped, however, then continue with Pair and Compare. Step 4 - Pair and Compare Some Written CVE questions may require something beyond a High/Medium/Low rating to arrive at the correct answer. Sometimes you are left with two, even three responses that are rated the same after Step 3. Or, when the responses present a lot of information or similar elements, you may mis-rate an element during Step 3 and end up with more than one answer that seems correct. Step 4 provides a systematic method for addressing this 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 to re-evaluate some of your ratings because more than one answer has received the highest score total. This outcome is hard to avoid entirely on an exam like the Written CVE, which requires you to deal with a lot of information at once to find the correct answer. So, dont worry if it happens to you. The Pair and Compare strategy used in Step 4 gives you an effective and quick way of dealing with questions that appear to have more than one correct answer after youve used Step 3. The basic Pair and Compare strategy is used for questions with two seemingly correct responses. Well present this first. Afterwards, well present a modified Pair and Compare strategy that can be used in the rare event that you find a question that seems to 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 the elements in Step 3. When Step 3 doesnt allow you to find the correct answer, you may use the Pair and Compare process to identify the difference between closely rated or equally valued elements and to check whether youve mis-rated anything. 2010, Association for Advanced Training
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Strategies Manual Strategies for Approaching the Exam The stages of Pair and Compare are:
a. Set aside any exact pairs: (elements that are present in both responses that are exactly the same and therefore do not influence the outcome of the answer). In George, the exact pairs are: 1. Major Depressive Disorder (High) Adjustment Dis. w/Anxious Mood (Medium) 4. Major Depressive Disorder (High) 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 further focus our decision making. Weve simplified our work by reducing the number of elements we need to reconsider, but because we decided in Step 3 that theyre all about equal in value it will help if we can find a useful way to further organize our decision making about them. One thing we can do is look for inexact like pairs (ones that 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 these pairs, well compare the elements in each pair head-to-head. You wont always find inexact like pairs - they can simplify your work when they exist, but when they dont you can simply re-evaluate all the unlike elements that remain at this point (well illustrate this in a moment.) The key is that you will have zeroed in on fewer elements to re-evaluate and compare. b. Compare inexact like pairs: An inexact like pair must have the same rating in order to be compared: Low to Low, High to High, etc. Do your best to also compare them according to some similarity (V-Code with V-Code, early stage to early stage, family systems to family systems, etc.): 1. Phase of Life Problem (High) 4. Bereavement (High)
We consider these to be like pairs because they have two things in common: 1) they are both rated High, 2) they are both V-Codes. If we decide we think one of them is just a little bit better, we will add a + sign to our note. We compare the Lows and Mediums before comparing the Highs because theres a greater likelihood that youll find some reason, on re-evaluation, to decide that at least one of them is better or worse than you initially thought it was.
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Sometimes you will find that, even though the pair is inexact, that you really cannot value 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 Life Problem (George has suddenly become the caretaker for two prepubescent children as well as becoming a widower), Bereavement is a better fit because the loss of so many loved ones is the issue with the most impact on his symptoms. Therefore, we will give the High mark that stands for Bereavement a +. (Notice, that at this point, we are no longer trying to work with 16 elements in the responses, we are working at comparing only four items): George 1 of 6
1. H H M H 2. H L 3. H L
L H L M
4. M H+ H H
c. Compare any leftover inexact unlike pairs: In the final stage of Pair and Compare, youll pair up inexact pairs. Inexact pairs are two elements one from each answer still under consideration that differ from each other but are equally valued in terms of how correct they appear to be. They say something different, but they are both either High, or both Medium, or both Low. Our job at this point is to rate this pair, using + or - to help us make our final determination about which is the best collection of elements. 1. Primary Insomnia (High) 4. PTSD (High)
In this case, it is very likely that George is suffering from Post Traumatic Stress Disorder. Because his insomnia is likely a function of PTSD, Depression or Bereavement (i.e., it is a secondary diagnosis, rather than a primary one) we will give it a - making 4 the best answer. George 1 of 6
1. H- H M H 2. H L 3. H L
L H 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
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Strategies Manual Strategies for Approaching the Exam c. Compare inexact unlike pairs
For some questions, using just the first two stages of Pair and Compare will narrow your choices sufficiently that you will be able to see the correct answer. Because you are dealing with less information than before, you might be able to discern something you overlooked before and understand that one of your remaining responses is actually better than the other. If not, youll continue with Pair and Compare. Pair and Compare will not take long to apply once youve practiced it. It primarily reflects a useful way of thinking about the elements in the responses and organizing your decision making about them. We present Pair and Compare as a series of discrete stages here, so that you understand how it works; once youre comfortable with the strategy and understand its basic principles, these stages will flow smoothly and quickly from one to the next. In fact, once youre familiar with this strategy, you wont necessarily need to use each stage in a deliberate way. Youll be able to zero in quickly on the elements that are most useful to re-evaluate in order to determine the correct answer. Note-Taking Tip: You might want to cross out the elements in an inexact yes pair in a different way than you cross out the elements that form exact matches. You might, for example, use an X to cross off elements in your exact matches and a slash to cross off elements in your inexact yes pairs. As you move back and forth between your scratch paper and the computer screen, this is a good way of keeping track of which elements you might need to re-examine. Remember, you never need to re-examine elements that form exact matches because you know that youll choose them and there is no difference to consider, but you may need to re-examine elements that form inexact yes pairs. You might try writing your pairs down (see below) while youre learning this strategy using CaseMASTER, but as you become more adept at working with vignette questions, youll usually be able to simply Pair and Compare elements mentally or by using your scratch paper with High/Medium/Low without writing any part of the actual element down. If you do write down your pairs, you might write something like the following: 1. Phase/life (High) Insomnia (High) vs vs 4. Bereavement (High) PTSD (High)
The idea is to use a short-hand thats meaningful to you, but that also retains all the key parts of an element so that you make sure that what youre re-evaluating and comparing 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 move your eyes from computer screen to notepaper and back again. A solution for this situation is to jot down the essence of the elements to the right of your ratings so that you can compare the set (usually of two) against another set. Lets say we have a
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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 to Pair them up, sometimes it is easier to simply look at the elements as a set and Compare them that way. A way to help get the elements clear, is to jot them down on our scratch paper to the right of our ratings:
1. X H H X 2. X X X X 3. X X H H 4. X X X X
Joes medications and call the police
psychological evaluation and contact school
Now we can see the four elements clearly, and compare the set of elements in 1 with the set of elements in 3 to decide which answer best addresses providing safety in this case. Now, going back to Georges diagnosis question, lets change things a bit and assume that our four remaining 1-rated (maybe) elements are all very different. Well replace Primary Insomnia with Anxiety Disorder, NOS, and Phase of Life Problem in 1. with Dysthymia.
1. Anxiety Disorder, NOS

Major Depressive Disorder Adjustment Disorder with Anxious Mood Dysthymia versus

Bereavement PTSD Major Depressive Disorder As you can see, we cant create any inexact like pairs because all the remaining elements (after setting aside the two exact pairs, Major Depressive Disorder and Adjustment Disorder) are very different. And, while we could combine these four elements into inexact unlike pairs, several combinations are possible and it would be a waste of time to examine each combination. We have, however, reduced our two remaining responses to only two elements each. Its much easier now to sort out which 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 to see that one of these responses contains at least one element that is better (or perhaps worse) than you initially thought. You might want to keep track of your new ratings in your notes. You can use a + or - sign, or even change the rating altogether. (If you
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change the rating altogether (for example, from a High to a Medium) you might want to write 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 same ratings (say three responses have three Highs and a Medium), you can adapt the Pair and Compare strategy to encompass more responses. You can try to make inexact like and unlike triplets if you want to, but this wont always make it easier to compare the remaining responses. Head-to-head comparisons dont work as well when youre dealing with more than two variables. Instead, for questions that appear to have three or four correct responses, the primary benefit of this strategy is that it encourages you to zero in on a smaller, more manageable number of elements to re-examine. In dealing with Triplets, zeroing in on Medium or Low rated elements first is best, because youre already uncertain about them; theres a greater likelihood that youll find some reason, on re-examination, to change your mind and decide that one (or more) of these element(s) is actually better or worse than you thought it was during Step 3. You then re-examine each of these Medium or Low rated elements in light of information in the Exhibit. For example, let's assume we have the following ratings for our hypothetical question about Joe, our client who we were talking about in the Abbreviated Notes section:
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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. Lets say there is only one High that is the same in the remaining answers and all of the other elements are different (a difficult 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 that we can compare. Are any of them a little better or a little worse than the others? Lets say that the Medium in 1 and the Medium in 3 are different, but essentially of the same value, but the Medium in 2 really isnt that good of an element at all. Our best strategy here is to set aside 2 and attempt to Pair and Compare 1 and 3. Because the remaining elements are different (and lets assume they dont pair up easily), we can use an abbreviation strategy to sort them out:
1. X H H X 2. X X X X 3. X X H H 4. X X X X
Joes medications and call the police
psychological evaluation and contact school
Assuming that our hypothetical question is asking about establishing safety (and that each of these elements truly rates High) it would be clear that, taken as a set 1 is probably 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 4 and decide whether to give a plus or minus, or raise or lower your rating for an element, you must refer back to the Exhibit and determine the extent to which the element 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 in on just a few elements, which you then re-evaluate and compare to determine which of your 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 any
further attention to that response set, but move on to another cluster of possibilities. However, be careful not to set aside responses that are only mildly wrong - you may end up having to use them in your answer choice and setting aside the entire response set may hinder your decision making. 2010, Association for Advanced Training
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An answer choice that has the response choices in an appropriate chronological

sequence 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 for sequence (for example, asking you in what order should the therapist proceed? Or what would be your priorities?). In other words, unless the question specifically asks 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 in
doubt.
Sometimes answer choices contain what appear to be contradictory response

choices, 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 would consider, and since you can consider both PTSD and Acute Stress Disorder, then it is fine to have them both in the same response set.
Anchor yourself in what is surely correct, and what is surely incorrect, and trust
that the ambiguous middle ground will sort itself out.
Remember the BBS is measuring entry level knowledge. The entry level knowledge
required is based upon the average amount of education, training, and experience found in the general pool of MFT interns throughout California. A response choice that 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 ruled out.
Be careful not to carry over assumptions and information from one question to the
next. Each question stands on its own. If it doesnt, it should be apparent in the wording of the question. Do not be concerned if there are inconsistencies with responses in previous questions, unless instructed otherwise.
Never, ever leave a question blank. Even if you are completely stumped, pick an
answer. You can always flag it and come back to it, and if you cant come back to it, you at the very least have a 25% chance of getting it right. If you leave it blank and you cant 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) Clinical Evaluation 3) Treatment Planning 4) Treatment 5) Ethics and 6) Law. Each question on the Written CVE will cover one or more content areas. The trend has been toward questions that address more than one content area, for example: How would the legal issues in this case affect your treatment plan? This question addresses three issues: 1) legal, 2) this case, and 3) treatment planning. Your task is to consider which content area is most important (the one that you cannot live without in your answer) which in this case would be this case. In
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other words, something that is legal or has to do with treatment planning, but has nothing to do 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.
Dont expect that the Exhibit will include the words, The crisis(es) John is experiencing is/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 some
assumptions, based on clinical common-sense, but not going too far afield. For example, if the client is tearful, you can assume that depression (and thus suicidality) is a possibility, but you cant necessarily assume that the client is depressed and/or suicidal.
Your knowledge of developmental issues and the family life cycle may be helpful in
terms of identifying individual and family crisis(es).
Think generically about how you would assess a crisis. You would ask sources who
have information and who have observed the persons current functioning. Its always a good idea to go to the referring source, because they must have had some concern in order to send the client(s).
Remember, the cause of the crisis and the level of risk will determine the intervention.
2. Clinical Evaluation
Dont assume that an individual diagnosis requires individual treatment, but do

consider scope of practice if the diagnosis requires primarily medical intervention.
Dont hesitate to choose a diagnosis for which there isnt enough information, if there
isnt any other plausible alternative offered in the question.
Your general clinical experience with children tells you that certain information is more
likely to emerge when the parent and child are interviewed separately, and that young children (under 10) need indirect exploration, rather than direct verbal questions.
Since this exam is not about testing your personal values, but rather the general
expected competency of the candidates, each person could have a different answer when addressing questions of diversity. It would be expected that you have been educated about 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, you
should know the difference between PTSD and Acute Stress Disorder criteria; Bipolar I and II; Major Depressive Disorder and Dysthymia; Conduct Disorder, Oppositional Defiant Disorder, and Child or Adolescent Antisocial Behavior, to name a few.
With a straightforward question about diagnosis for one individual, your best bet is to
speculate first on the possibilities, and then look at the response choices offered.
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To discriminate and eliminate response choices, consider key differentials like duration
and the nature of any triggering events (for example, Oppositional Defiant Disorder, PTSD, Separation Anxiety Disorder, Adjustment Disorder, etc. ). However, just because a duration or triggering event is not specifically mentioned, if the diagnosis is fairly common 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, and
prognosis of mental disorders, according to the DSM-IV.
Provisional diagnosis means you are not 100% sure of your diagnosis because you need
more information. It is guesstimating your most likely diagnosis for the time being based upon what you have.
Differential diagnosis means there is more than one diagnostic possibility and you must
differentiate between these to determine what the best diagnosis is.
Diagnosis is fairly straightforward. You may need to make a lot of assumptions. The
question is how far to stray from what is actually described in the Exhibit. To stretch from Alcohol Abuse to Alcohol Dependence is possible, even if the Exhibit only describes abuse. But to guess that a person has an Antisocial Personality Disorder just because 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 the
clients perspective on the problem, the diagnosis, human diversity, and information obtained from collateral consultation. The BBS emphasizes that the treatment plan should be based on the assumptions, concepts, and methodology associated with a theoretical framework. The treatment plan also includes the unit of treatment, modalities of treatment (what kind of techniques are planned, i.e., theory interventions), and possibly, but not always a plan for frequency of sessions, a time frame for the length of therapy, baseline behaviors and measurable objectives.
Remember that the writers of the examination are more likely to use common sense
language when describing goals of treatment, and not necessarily terms found in textbooks.
The phrase cognitive-behavioral can mean different things, but generally refers to
approaches that modify both dysfunctional behaviors and distorted, limited beliefs or cognitions.
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 clients needs be the primary consideration in treatment planning and treatment questions, with the theory being secondary.
Remember that what the client wants is not always a valid way to decide who should be
seen for treatment.
Remember that systemic therapy does not always mean treating everybody together, but
does involve goals that change the way relationships operate. Page 44 2010, Association for Advanced Training
Many candidates report that the most confusion they experience during their exam was
in the areas of Treatment Planning and Treatment. When a question includes a particular theoretical model a translation is often needed because the language used in the response choices tends to be vague and confusing. The response choices may use language that is associated with different theoretical models (but that essentially means the same thing) rather than the textbook language that you may be used to. For example, Structural Therapy refers to mimesis, (using the clients style of language, body posture, tone, etc.) however, even though Solution Focused therapists dont use the actual word mimesis, mimesis is very important in a Solution Focused approach. Consequently, a textbook understanding of the theoretical models cited in the Candidate Handbook is necessary but not sufficient for the type of treatment planning and treatment questions posed in the exam. You need to be very flexible because concepts may be described in uncommon language. 4. Treatment
Choosing a correct answer choice in this area may require you to choose interventions
that 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 still working 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 would actually do with this client if they were real. However, make sure that if you go outside your theory framework that your interventions are at least consistent with the theory that the question asks for. For example, a Solution Focused therapist doing a Cognitive Behavioral problem list would be anti-theory.
Pay close attention to what stage of treatment the question is referring to you have
different priorities at different stages of therapy.
If a question is asking about interventions to achieve specific goals, you need to

consider 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 may expect 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 prevent
harm to self or others, is an instance that breaching confidentiality is a permitted (non-mandated) breach of confidentiality, under Evidence Code 1024. The legal aspect is that it is a law that permits you to breach confidentiality, however the use of this law is purely an ethical/clinical decision. But hospitalization AND 1024 are both in LAW, not ETHICS in their handbook.
You should assume that childrens needs take priority over adults when it comes to
setting therapy goals. This is a common-sense or ethical rather than a theoretical position.
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
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standards, and use general principles and common sense. Be sure to read over the CAMFT ethical standards in their entirety, so that you can recall the precise wording and apply them to the issues in the Exhibit. 6. Law
Breaching confidentiality mandated (reporting child, elder, or dependent adult abuse

and Tarasoff warnings) or permitted (taking necessary steps to prevent a clients suicide or when making the may report abuse reports) are legal issues. Tarasoff situations require you to breach confidentiality when your client is a likely threat to the physical safety of a reasonably identifiable victim or victims, and mandates that you inform the police and the intended victim. Consult Workbook #2 for other instances permitted or mandated by law for breaching confidentiality.
Candidates must have knowledge of legal criteria for determining involuntary

hospitalization, and laws regarding privileged communication.
The examination may require you to know about some laws not directly related to MFT
practice, such as family law issues, including divorce and child custody. You can review this material in the Associations 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 privilege
and confidentiality, especially when minors are involved. Many professionals do not make the distinctions clearly, and those who write the questions may be similarly imprecise. Therefore, dont throw out an answer just because confidentiality is called privilege, and vice versa.
G. Section 7: Studying with CaseMASTERs Rationales

In CaseMASTER, we include several different rationale pages: Overview, Rationale and Strategies. In the Overview section we show a visual representation in a chart format of the different ratings of each element. It may be helpful to practice creating these charts at some point in your study process, but would probably take too much time to use during the actual exam. The following is an example of the Overview screen in CaseMASTER:
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Overview
Question 1 of 2: What diagnoses would you consider in this case?
Answer Choice 1.
Response Choices
High
Medium
Low
Answer Rating HIGH
Primary Insomnia Major Depressive Disorder Adjustment Disorder with Anxious Mood Phase of Life Problem
X X X
X X X X X LOW
2.
Bereavement Acute Stress Disorder Histrionic Personality Disorder Adjustment Disorder with Depressed Mood
3.
Major Depressive Disorder Malingering Acute Stress Disorder Dysthymic Disorder
X X X X X
LOW
4.
Adjustment Disorder with Anxious Mood Bereavement PTSD Major Depressive Disorder X X X
HIGH
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Strategies Manual Strategies for Approaching the Exam Answer 4 contains the best set of response choices.
Even though 2 also has three Highs, the Low (Histrionic Personality Disorder) is so low, you could have thrown the whole answer out immediately without even ranking the rest of the elements. 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
Question 1 of 2: What diagnoses would you consider in this case? Response Choice Rationale Response Rating HIGH
Bereavement
George qualifies for a V-Code of Bereavement. Many people are confused, however, thinking that the DSM only allows Bereavement to be used for the first two months following the death of a loved one. However, the DSM-IV-TR states only that, The diagnosis of Major Depressive Disorder is generally not given unless the symptoms are still present 2 months after the loss (Italics added). It stresses that The duration and expression of normal bereavement vary considerably among different cultural groups. In other words, the DSM does not specifically prohibit the use of the term Bereavement beyond 2 months, but allows you to consider a diagnosis of Major Depression after 2 months. PTSD is a good diagnosis to consider since he was in the accident and experienced the loss of so many loved ones. We dont see a lot of symptoms present besides the sleeplessness, but again, remember that the question is only asking what you would consider, so the evidence needed to answer this question does not need to be as solid as it would need to be if the question was asking for a definitive diagnosis.
PTSD
HIGH
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Major Depressive Disorder
George may be experiencing a Major Depressive Episode since he is beyond the 2 month period that the DSM suggests holding off on that diagnosis in a bereaved person (however, a bereaved person can be diagnosed with Major Depression even in the first two months if they fit the criteria). The DSM-IV-TR includes a list of possible differential symptoms for depression (from bereavement) including guilt, thoughts of death, morbid preoccupation with worthlessness, marked psychomotor retardation, prolonged and marked functional impairment or hallucinatory experiences regarding the dead person. Insomnia is fine to consider here, although not as strong as some of the other Highs, because one of the criteria for insomnia is that it does not occur exclusively during the course of another mental disorder, which it is likely that George is suffering from. An Adjustment Disorder might fit, although Georges symptoms are a bit extreme for that and are better explained by other disorders. However, he is adjusting to being a single parent of his grandchildren, as well as adjusting to an entirely new reality. We could give this a High minus, or a Medium plus. Phase of Life Problem is another High minus/Medium plus element. There is a major transition occurring here, however, the transition issues pale a bit in comparison to the other issues.
HIGH
Primary Insomnia
HIGH
Adjustment Disorder with Depressed Mood
HIGH
Phase of Life Problem
HIGH
Adjustment Disorder with Anxious Mood
An Adjustment Disorder might fit (see the MEDIUM Adjustment Disorder item above) however, George seems more depressed than anxious. This is a good example of a partially right/partially wrong element that is best rated a Medium. There is no evidence that George has been MEDIUM chronically depressed, however Dysthymic Disorder is a very safe diagnosis to keep in the realm of possibility, since it is so common, so we chose to give it a Medium.
Dysthymic Disorder
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Malingering
There is absolutely no evidence that George is coming into therapy as someone out for gain. There is no evidence of a long term personality disorder here. George is well beyond the four weeks that the DSM-IV-TR specifies as being the time period (after the stressor) in which Acute Stress Disorder can be diagnosed.
LOW
Histrionic Personality Disorder Acute Stress Disorder
LOW
LOW
Click on the Strategies button to read a discussion of strategies and thinking related to that question. Lets 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 the degree of Georges depression and level of functioning; Ask George about the accident.
2. Refer George for a psychiatric and medication evaluation and have George sign a
release 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 a release 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 a release 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
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3. H H M M 4. M H H M
Overview
Question 2 of 2: How will you gather additional information to develop a clinical assessment for this case?
Answer Choice 1.
Response Choices
High
Medium
Low
Answer Rating MEDIUM
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 the degree of Georges depression and level of functioning Ask George about the accident X X X X
2.
Refer George for a psychiatric and medication evaluation and have George sign a release 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
MEDIUM
X X MEDIUM/ HIGH
3.
Get a release and talk with George's physician Refer George for a psychiatric and medication evaluation and have George sign a release to talk with the psychiatrist Ask him to fill out an intake form
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Ask open ended and closed ended questions about various aspects of the situation 4. Do your standard intake
MEDIUM/ HIGH
Get a release and talk with George's physician Refer George for a psychiatric and medication evaluation and have George sign a release to talk with the psychiatrist Ask open ended questions about all aspects of the situation Answer 3 contains the best set of response choices.
Rationale
Question 2 of 2: How will you gather additional information to develop a clinical assessment for this case?
Response Choice
Rationale
Response Rating HIGH
Ask George about the accident
This would be important historical information and could relate to diagnosis (major depression vs. adjustment disorder vs. PTSD). This is a good idea; the accident was only 6 weeks ago and it might help in the diagnosis, but more importantly he may benefit from medication. The signed release is a legal/ethical issue, but this answer would still be correct if it wasnt included. This is a good idea since getting current and past information would give some insight as to the physical changes his M.D. has noticed.
Refer George for a psychiatric and medication evaluation and have George sign a release to talk with the psychiatrist Get a release and talk with George's physician
HIGH
HIGH
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Ask open ended and closed ended questions about various aspects of the situation
This is always a good way to begin an interview with MEDIUM a 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 most important issues to them, without being influenced by the therapist. Closed ended questions (Were you in the accident?) are important as well, as they focus the client on particular issues that the therapist has noted are important to the client. We give this a Medium because it is something you would do with all cases, not just with this one. This is a good thing to do in order to gather more information, however it is not quite as complete as the element above. MEDIUM
Ask open ended questions
Ask him to fill out an intake This is pretty standard in most practices, and a very MEDIUM form generic answer, therefore we gave it a Medium. An intake form can be as simple as a form asking for the clients address and health insurance information, or may be quite detailed with checklists of symptoms, room for a narrative description of the clients concerns, etc. Do your standard intake Again, you do this with all your clients, so it doesnt really rate as a High, which we reserved for elements that are really specific to this case. However, it doesnt rate a Low either, because it is a good way to gather more information. This really doesnt seem that necessary and could be overwhelming for this client. However, if he had been in the accident, a neuro-psychological assessment would be indicated, so we can give this a Medium. MEDIUM
Arrange for a psychologist to do a battery of psychological tests to determine the degree of Georges depression and level of functioning Bring in the grandchildren for an evaluation
MEDIUM
There is no reason this would be needed to develop George's clinical assessment, but it could help develop a systemic evaluation. The minister would probably not provide helpful information for developing a clinical assessment.
MEDIUM
Get a release and talk with George's minister
LOW
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Get a release and talk with the son-in-law's parents
There is no good reason to speak with these people. When needing to develop a clinical picture the best resources are adjunctive professionals or immediate family members.
LOW
Strategies
Question 2 of 2: How will you gather additional information to develop a clinical assessment for this case? Clearly we can set aside 1 and 2 because of the Low elements (and dearth of High elements). 3 and 4 have the same ratings, so we must move on to Pair and Compare in order to find the better answer. First, we set aside the exact pairs (if any): 3 Get a release and talk with George's physician (High) Refer George for a psychiatric and medication evaluation and have George sign a release to talk with the psychiatrist (High) vs 4 Get a release and talk with George's physician (High) Refer George for a psychiatric and medication evaluation and have George sign a release to talk with the psychiatrist (High)
vs
After setting aside the exact pairs, we Pair and Compare similar sets of elements (a similar set must have the same rating in order to be compared, and usually have something else in common): 3 Ask him to fill out an intake form (Medium) Ask open ended and closed ended questions about various aspects of the situation (Medium) vs 4 Do your standard intake (Medium)
vs
Ask open ended questions about all aspects of the situation (Medium)
By comparing the two intake elements head to head, we can see that the element in 3 is more specific it names a concrete tool that helps you get better information. However, a case could be made that the broader, more inclusive element in 4 is better, because an intake form is included in a standard intake. Therefore, we have decided not to give either element a + or a -. Since we are rating them the same, despite their differences (because we 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 we ask to gather more information. While both elements rate a Medium, the element in 3 is more complete than the element in 4, therefore, we can give it a + sign to differentiate this slight advantage, making 3 a slightly better answer.
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California MFT Clinical Vignette Exam 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 questions presented by the BBS on their website in the Written Clinical Vignette Candidates 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, Its tough enough to raise a daughter alone. I cant 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 Julies pregnancy as described in the EXHIBIT?
1. Maintain Julies 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 Julies 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.
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Overview
Question 1 of 2: How should the therapist clinically manage the crisis of Julies pregnancy as described in the EXHIBIT? Answer Choice 1. Response Choices High Medium Low Answer Rating HIGH
Maintain Julies confidentiality Refer Julie to a physician Obtain a release from Julie to speak with her physician
X X X
2.
Include mother in treatment Refer Julie to a physician Obtain a release from Julie to speak with her physician X X
LOW
3.
Maintain Julies confidentiality Refer Julie to a physician for prenatal care Work toward disclosure of pregnancy to mother
X X
MEDIUM
4.
Obtain consent to treat minor Include boyfriend in treatment Refer Julie to a physician for prenatal care
X X X
LOW
"1" is the correct answer.
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Rationale
Question 1 of 2: How should the therapist clinically manage the crisis of Julies pregnancy as described in the EXHIBIT?
Response Choice
Rationale
Response Rating HIGH
Maintain Julies confidentiality
In this case, when considering crisis management, the adolescents ethical entitlement to a confidential relationship supersedes the parents legal entitlement to information.
Obtain a release from Julie Crisis Management includes crisis management to speak with her physician coordination with other health care or mental health care professionals. Obtain consent to treat minor Many legal issues crossover into the content area of Crisis Management. In this case the issue of consent relates to Crisis Management because Julie is seeking services alone for help around the crisis of her pregnancy. Julie may be legally qualified to provide her own consent if she is being abused or there was danger involved (to self or others) and there was a good reason not to get consent from her mother. However, the vignette indicates that Julies mother, Anne, brought Julie to the session and therefore has consented to her daughters treatment. You might end up getting consent from Julie herself to see her alone though, if she doesnt want her mother to know she is being seen, and the other legal criteria are met. Even though you have to assume the purpose of the referral, this is a very good response. This answer is a neutral response and relates more to treatment planning or treatment. It could relate to crisis as well, considering that Anne is a minister and might have some strong reactions to Julies pregnancy.
HIGH
HIGH
Refer Julie to a physician
HIGH
Work toward disclosure of pregnancy to mother
MEDIUM
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Refer Julie to a physician for prenatal care
Prenatal care implies she is going to have the baby, and moves a very High response down quite a bit, since you dont know what she is going to do about the baby and the therapist ethically should not be taking a position on this decision. If the answer choice was include the mother in treatment until crisis issues are resolved, then this could have been a better answer choice. This is a treatment planning or treatment issue. It could be part of Crisis Management, but there is not enough information contained in the Exhibit to conclude that this could be helpful.
MEDIUM
Include mother in treatment
LOW
Include boyfriend in treatment
LOW
Strategies
Question 1 of 2: How should the therapist clinically manage the crisis of Julies pregnancy as described in the EXHIBIT? As you categorize the response choices, remember that the answer should address the content area of Crisis Management. It is easy to get lost and rate the responses based on their relevancy to the case as a whole, and forget that this particular question is asking specifically for crisis oriented responses. Also, many questions apply to more than one content area. Also, with a crisis situation you could be dealing with both legal and ethical issues 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.
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3. Obtain releases for medical provider from Julie if seen alone for pregnancy;
Obtain releases from Anne if seeing mother and daughter together; Maintain Julies 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 Julies confidentiality regarding the phone call; File report with a child protective services agency; Determine need for consent to treat a minor.
Overview
Question 2 of 2: What legal obligations does the therapist have in the case described in the EXHIBIT? Answer Choice 1. Response Choices High Medium Low Answer Rating LOW
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 X
MEDIUM
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3.
Obtain releases for medical provider from Julie if seen alone for pregnancy Obtain releases from Anne if seeing mother and daughter together Maintain Julies confidentiality regarding the phone call Determine need for consent to treat a minor
HIGH
4.
Obtain releases for medical provider from Julie if seen alone for pregnancy Maintain Julies confidentiality regarding the phone call File report with a child protective services agency Determine need for consent to treat a minor
MEDIUM
"3" is the correct answer.
Rationale
Question 2 of 2: What legal obligations does the therapist have in the case described in the EXHIBIT? Response Choice Rationale Response Rating
Determine need for consent You need to consider the criteria for seeing a minor HIGH to treat a minor without consent. If she is being abused or if there is any danger (she is using hard drugs, is suicidal, etc.) and there is a good reason to see her without her mothers consent, the law would allow you to treat her without her mothers consent.
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In the situation described, the MFT would likely be Maintain Julies confidentiality regarding the discussing confidentiality with Julie and Anne together during the initial intake. The discussion phone call could include what would be disclosed (suicidal threat, other potential harm to self [drugs, behavior], etc.). Negotiate a fee with Julie if seen individually for the pregnancy
HIGH
You need to consider the criteria for seeing a minor HIGH without consent. You cannot charge a parent for services they did not consent to, if you end up seeing Julie on her own consent. HIGH
Obtain releases for medical This would permit you to breach confidentiality. provider from Julie if seen Julie would sign the release for medical information. alone for pregnancy Obtain consent from Anne to treat minor if seeing mother and daughter together
Obtaining consent to treat Julie from Anne would be HIGH appropriate as long as she has or shares legal custody of Julie with Julies father. Since she is recently divorced, you would want to check if there are any limitations in the custody agreement about who has the authority to authorize mental health treatment for this minor. Children over 12 sign their own releases, according MEDIUM to the attorneys at CAMFT, however Anne would also likely sign all releases if both mother and daughter are being seen together. Additionally, Anne would most certainly be signing her own releases. We give this a Medium rather than a High, because Julie signing her own releases, which is what the law specifies, is not mentioned. Signed releases permit you to breach confidentiality to obtain or release information.
Obtain releases from Anne if seeing mother and daughter together
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Obtain a consent from Anne You need to consider the criteria for seeing a minor MEDIUM without consent. It is unclear whether there is to see Julie individually abuse or any dangerousness (Julie feeling suicidal, regarding pregnancy etc.) that would qualify her to be seen without parental consent. Without those exceptions, you would need to have Annes consent. However, you have already gotten consent to see Julie in therapy when her mother brought her in, and you do not have to get an additional written consent to see her individually. However, in the course of things, you would be discussing seeing Julie individually with her mother, even while holding confidentiality about the pregnancy. Assert privilege for Julie if mother asks for records Asserting privilege is something an MFT would do in MEDIUM a courtroom or when the MFTs records are being subpoenaed. In the situation described the MFT would be discussing confidentiality as it applies to the development of trust between the MFT and Julie. However, because privilege has to do with confidentiality, and we should maintain Julies confidentiality in this situation, we will still give it a Medium rating. There is nothing in the Exhibit to suggest that the sexual relationship is anything but consensual, and since Julie is 14, you wouldnt have to make a report unless the boyfriend was 21 or older. LOW
File report with a child protective services agency
Strategies
Question 2 of 2: What legal obligations does the therapist have in the case described in the 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, lets say we rated the child abuse reporting higher, so that we could illustrate the use of Pair and Compare. Everyone is going to rate elements differently, due to the subjectivity of the exam, and you shouldnt worry about coming up with different ratings than we do, unless the differences are radical and very frequent.
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California MFT Clinical Vignette Exam 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 and Compare, since the ratings are the same. Using Pair and Compare we can see that all of the elements are the same, except for the two Mediums: 3. Obtain releases from Anne if seeing mother and daughter together (Medium) Julie 2 of 2 4. File report with a child protective services agency (Medium)
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 think about what is essentially different between them. 3 has a partially correct statement about releases (Julie, because of her age, signs her own releases, but you would probably have Anne sign them as well, even though Julies is the only one we need). 4 however, has the therapist assuming that there is a reason to violate Julies 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 the Written Clinical Vignette Exam.
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Exercise 1: Breaking Down Complex Questions/Responses Introduction

Sometimes questions will have several elements that they are asking for, or responses may be long and complex and consist of several components. Breaking the questions down into components is an important part of the rephrasing process, and assures that you are clear about 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 interventions werent working in the middle stage of therapy? There are five components in this question: Object Relations Interventions not working Interventions (actions) to take instead Middle stage Applicable to this case
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Response: The therapist would ask the client what they are feeling in the moment and explore the transference. There are two components in this response: Ask the client what they are feeling right now Explore the transference
Response: Get a consent to treat John from his father and set up an individual session immediately. 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 issues presented in this case into the treatment?
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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 to formulate your treatment plan and how would you obtain it?
Question: Define the legal issues and how the therapist should manage them.
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Question: What interventions would be appropriate to use in the middle stage of therapy if you 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 his anxiety, what other intervention strategies should the therapist consider?
Response: Make a school visit to observe his social skills and ability to resolve conflict.
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Response: Language barriers and the potential for misinterpretation and misunderstandings
Response: Seeing the child alone would conform best to the cultural expectations of both his parents.
Response: Develop a strong therapeutic alliance with her and use it to set appropriate boundaries with her parents.
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Response: His understanding and insight into his ethnic background and the relationship to the 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.
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Response: Reduce the total fee amount that you bill the insurance company if you lower their co-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 understand what the question is asking. A common error for candidates is to make a quick assumption about what the question is asking, which may result in being slightly off focus when choosing their answer. The best way to avoid this error, is to rephrase or restate the question in your own 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
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dangerous in this situation? The focus of your search is now on danger or harm, rather than the broader term crisis. Many people think of losing their wallet, getting divorced, or getting a flat tire as a crisis, but in the exam world, we are thinking of a crisis as a situation where there is potential physical harm, such as suicidality, homicidality, certain substance abuse situations, child or elder abuse, domestic violence, or situations that might lead to any of these 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 Clinical Vignette exam, and ask you to restate or rephrase each of them in your own words. We have done the first few for you. Remember, think simple, easy to understand language that gets to the 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 middle stage 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 presented in 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?
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Rephrase: What DSM-IV diagnoses would you consider for Susan?
Rephrase: The therapist works from a primarily psychodynamic model, and decides to see Susan alone, referring Roberto to other professionals. What would be likely goals of treatment with Susan?
Rephrase: Working on their communication from a broadly Humanistic-existential perspective, what interventions would be most helpful?
Rephrase: If you were a Cognitive therapist and you gave Miguel exercises to work on at home and he didnt 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?
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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 order to 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 most concern?
Rephrase: What would be your goals for the initial stage of treatment?
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Rephrase: What interventions would be appropriate to use in the middle stage of therapy if you 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 for this 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 his anxiety, what other intervention strategies should the therapist consider?
Rephrase: Exhibit?
How should the therapist clinically manage the legal issues presented by this
Exercise 3: Legal and Ethical Differentiation Introduction

In this exercise, the focus is on differentiating the subtleties of legal and ethical issues, as well as understanding how ethical considerations are related to legal issues. As you go through the 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 and considerations that may come up as you deal with that particular legal issue. We began two areas to provide an example of how you might use this exercise (however, you may want to add additional questions about these areas). Continue with other legal issues as you come across them in practice questions and your review of the material.
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Exercise
LEGAL ISSUE WHAT THE LAW SAYS ETHICAL QUESTIONS TO CONSIDER IN APPLYING THE LAW
Child abuse reporting
Therapist must report child What is reasonably suspicious? abuse when reasonable Do I tell the parents? suspicion exists
What do I say to the child? How much clinical information do I

include in the report?
When does domestic violence

qualify/not qualify as emotional cruelty? Consent to treat a minor Therapist must get consent Do I include a non-custodial parent in to treat a minor from a the therapy? party that holds legal How do I make sure everyone custody, unless the understands confidentiality as it applies exceptions (12 or older, to the minor? abuse or dangerousness or potential harm), in which What kinds of circumstances would case the minor may consent contraindicate involving the parents in for his/her own treatment. treatment (and getting their consent)?
What situations meet the criteria for

dangerousness or potential harm? Tarasoff
Elder/Dependent Adult Abuse
Confidentiality
Scope of practice
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LEGAL ISSUE
WHAT THE LAW SAYS
ETHICAL QUESTIONS TO CONSIDER IN APPLYING THE LAW
Releases
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LEGAL ISSUE
WHAT THE LAW SAYS
ETHICAL QUESTIONS TO CONSIDER 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. This allows you to understand the thinking that goes into making a question difficult. In other words, 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 the right 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 Ive ever had. Question 1 of 3: What are your diagnostic considerations?
1. (a) Adjustment Disorder

(b) ___________________________________ (c) ___________________________________
High, very likely diagnosis Low, not even close diagnosis, such as Primary Insomnia High, different very likely diagnosis)
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Strategies Manual Strategies for Approaching the Exam (d) ___________________________________
California MFT Clinical Vignette Exam Medium, half right or not sure but not completely off base diagnosis, for example, Borderline Personality Disorder (because of her abandonment issues with her daughter and her idealization of the therapist) Write in element (d) from 1 New Medium Same High element (c) as in 1 New High element Use element (c) from 1. Use element (a) from 1. New really, really Low element, such as a made up term that doesnt even occur in the DSM-IV-TR New Medium element New Medium element Use (d) element from 1. Use element (h) from 2. Use element (a) from 1.
2. (e)___________________________________
(f) ___________________________________ (g) ___________________________________ (h) ___________________________________
3. (i) ___________________________________
(j) Adjustment Disorder (k) ___________________________________
(l) ___________________________________
4. (m) ___________________________________
(n) ___________________________________ (o) ___________________________________ (p) Adjustment Disorder
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 Low element that isnt even in the DSM. 1 can be eliminated because it has a Low, as compared to 2 and 4, which do not. (However, if one of these responses, say 2 for example, also had a Low, then we could take 4 as our best answer and move on.) However, we are left with two responses that have the same rating, a not unusual situation. We can use Pair and Compare to help us figure out the difference between the two.
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California MFT Clinical Vignette Exam Jane 1 of 3
The first Medium element in 2 should be the same as the 2nd Medium element in 4, so we can set them aside we are interested in whats different about the answer choices, not what is 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
Now that weve narrowed things down to where we are only looking at whats different about the responses, we can compare the Medium in 2 to the Medium in 4 and the High in 2 to the High in 4. If we like one of them a bit better, we can add a + sign, or if we are slightly less sure about one of them, we can give it a - ranking. Jane 1 of 3
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 treatment modalities. 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 be obscure, 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 another theory, and you must have an understanding of the meaning of the concepts in order to find the best response to a question, and not just memorize lists of key words. Therefore, it is critical to have a thorough understanding of the major therapeutic modalities, so that you
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will be able to discern what the essential meaning is that is hidden in the confusing language of the answer choices. By their nature, the content areas of clinical assessment and treatment, and to a lesser extent, treatment planning are all related to the area of theory. The following 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 a number of hours to devote to it. (Note: If your study time is limited, working the Exhibits in CaseMASTER 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 in
the content area of CLINICAL EVALUATION)
What is it you and the client hope to accomplish with therapy (Goal questions, found in
the content area of TREATMENT PLAN)
What is it you actually do? (Intervention questions, found in the content area of
TREATMENT) Assessment questions can be answered in a number of ways: from the DSM-IV-TR: This client has post traumatic stress disorder; from theory: This client has a negative schema or this client is triangulated; or from a reality point: This client is suicidal, etc. In the following exercise, we will focus on answering the question: What is happening with this client? from a theoretical perspective. Goals for therapy (What is it that you want to accomplish?) can be theory based (resolve the transference, restructure the personality, heal emotional cutoffs) or in a practical sense: 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, confront the client, discuss the situation, ask an open ended question, call a psychiatric emergency team, etc. are all interventions that are non-theory based. Theory based interventions might include interpret a dream, ask the Miracle Question, construct a genogram, or prescribe a symptom, depending on what theoretical model you are using. When working from a particular theory model in the exam, it is not necessarily imperative that you work from within that models set of interventions exclusively. Real therapists are often eclectic, drawing from various tool boxes of theory to help their clients. The Clinical Vignette Exam seems to specifically call for how real life therapists would actually treat their clients, not how the book says a particular theorist would respond. A psychodynamic therapist, for instance, might use cognitive behavioral interventions in the early stage of therapy to provide the client with some immediate coping skills and to establish a holding environment. However, even when drawing from different theories, it is important for the therapist to remain 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 be a Solution Focused therapist formulating a problem list with a client such an action would be anti-theory. In other words, whenever straying from the primary theoretical model in choosing 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 important consideration is, does this work for the client, or is it a good fit?
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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 or psychoanalytical theory. However, all theoretical models require you to analyze something: Bowen analyzes the multi-generational patterns, Structural therapists analyze the transactions between subsystems, Narrative therapists analyze the clients story line, etc. Words like reframe or relabel are associated with different theories, but could easily be used to refer to the same intervention. Mimesis is a word that Minuchin coined to refer to the therapist using the style of language and presence of a client in order to join with them; Solution Focused theory advocates using the clients style of language as well even though they dont call it mimesis - in other words, you would not necessarily be incorrect in saying that a Solution Focused therapist uses mimesis. The Written CVE tends to make clear what theory they are asking for (What would a Structural therapist do in the early phase of therapy, etc.) but tends toward vagueness in the answer choices. You may not see the key words or phrases that you are used to, or you may see key words mis-used, or concepts that are poorly worded, or mixed together. Therefore, it is 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 therapeutic models.
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 writing reinforces your understanding of the meanings. The theories that would be most important to 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 Emotive Therapy, 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 that particular theory would use to answer the question, What is going on with this client?), from memory (this is closed book.) Example: Bowen would say that a particular family might show emotional cutoffs, multi-generational patterns, dysfunctional reciprocal relationships, etc.
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Strategies Manual Strategies for Approaching the Exam Step 2:
For the same theory, write out all of the interventions (things that you do within that particular theory) you can remember. For example, a Cognitive Behavioral therapist might: create a problem list, assign a thought record, rehearse a behavior with a client, etc. Again, this is closed book i.e., just write out what you can remember without referring to any materials. Go to your AATBS Workbooks, AATBS CDs, your textbooks, read on-line articles, etc. about the theory, and then, in a different color pen/font, write in all of the assessment and intervention terms that you left off the list when you did it from memory. Write a one or two sentence definition, in plain language, for each item on your assessment and intervention lists. Try to avoid using jargon, and focus on using language that the average American high school student could understand. Write a short essay (2 or 3 paragraphs) summarizing the philosophy that underlies the theory, how the theorist(s) explains the etiology of mental health symptoms or relationship problems, and what you are trying to change in the client when working from this perspective (their thinking, their behavior, their interactions, their personality structure, etc.).
Step 3:
Step 4:
Step 5:
Bonus Step: Teach someone else about this theory (verbal reinforcement).
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California MFT Clinical Vignette Exam

Strategies Manual Table of Contents

CALIFORNIA MFT WRITTEN CLINICAL VIGNETTE STRATEGIES MANUAL

2010, Association for Advanced Training

California MFT Clinical Vignette Exam

Strategies Manual Quick Start Guide

CALIFORNIA MFT WRITTEN CLINICAL VIGNETTE STRATEGIES MANUAL

Quick Start Guide

2010, Association for Advanced Training

Strategies Manual Quick Start Guide

California MFT Clinical Vignette Exam

A. STUDY mode first, then EXAM mode:

B. EXAM mode first, then STUDY mode:

2010, Association for Advanced Training

California MFT Clinical Vignette Exam

Strategies Manual Clinical Vignette Examination Format

I. Written Clinical Vignette Examination Format

2010, Association for Advanced Training

Strategies Manual Clinical Vignette Examination Format EXHIBIT 1

California MFT Clinical Vignette Exam

3. Major Depressive Disorder

4. Adjustment Disorder with Anxious Mood

2010, Association for Advanced Training

California MFT Clinical Vignette Exam

Strategies Manual Clinical Vignette Examination Format

2010, Association for Advanced Training

Strategies Manual Clinical Vignette Content Areas

California MFT Clinical Vignette Exam

II. Written Clinical Vignette Content Areas

What are your diagnostic considerations in this case?

2010, Association for Advanced Training

California MFT Clinical Vignette Exam

Strategies Manual Clinical Vignette Content Areas

How would a structural therapist proceed if giving paradoxical instructions failed

Describe your clinical management of your ethical responsibilities in this

2010, Association for Advanced Training

Strategies Manual Taking the Written Clinical Vignette Exam

California MFT Clinical Vignette Exam

III. Taking the Written Clinical Vignette Exam

A. Applying to take the Written CVE

2010, Association for Advanced Training

California MFT Clinical Vignette Exam

Strategies Manual Taking the Written Clinical Vignette Exam

B. In the Examination Room

C. Dealing With Anxiety

2010, Association for Advanced Training

Strategies Manual Taking the Written Clinical Vignette Exam

California MFT Clinical Vignette Exam

2010, Association for Advanced Training

California MFT Clinical Vignette Exam Creating mild pain

Strategies Manual Taking the Written Clinical Vignette Exam

Overall Attitude Towards Preparing for the Exam

2010, Association for Advanced Training

Strategies Manual Taking the Written Clinical Vignette Exam

California MFT Clinical Vignette Exam

2010, Association for Advanced Training

California MFT Clinical Vignette Exam

Strategies Manual Strategies for Approaching the Exam

A. Section 1: Thinking Skills for the Written CVE

2010, Association for Advanced Training

Strategies Manual Strategies for Approaching the Exam

California MFT Clinical Vignette Exam

4. Test Taking Skills

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