NRNP 6645 Psychotherapy Midterm & Final Exam –
Advanced Practice Study Guide
1. In the context of psychodynamic therapy, a patient consistently arrives late to sessions and
avoids discussing a recent conflict with a supervisor. The therapist notes that the patient's behavior
mirrors the passive-aggressive dynamic described in the patient's relationship with a critical
parent. This phenomenon is best described as:
A. Transference neurosis
B. Enactment
C. Projective identification
D. Resistance
Answer: B
Rationale: Enactment refers to the patient unconsciously reenacting relational patterns from the past
within the therapeutic relationship, often without awareness. Transference neurosis involves a broader
regression, projective identification is a defense where the patient induces feelings in the therapist, and
resistance is a broader term for behaviors that impede progress.
2. A patient with borderline personality disorder frequently splits staff, idealizing one clinician
while devaluing another. The treatment team decides to use a structured approach where all
communications are coordinated through a single primary therapist. This intervention is grounded
in which therapeutic principle?
A. Containment and holding environment (Winnicott)
B. Dialectical abstinence (Linehan)
C. Limit-setting and structure (Kernberg)
D. Mentalization-based treatment (Bateman & Fonagy)
Answer: C
Rationale: Kernberg's object relations approach emphasizes structure and limit-setting to manage
splitting and maintain a consistent therapeutic frame. Dialectical abstinence is a DBT concept,
containment is from Winnicott, and mentalization-based treatment focuses on reflective function.
3. A patient undergoing CBT for panic disorder reports that after a panic attack, they think 'I'm
going to die' and then engage in safety behaviors like checking their pulse repeatedly. According to
the cognitive model, the thought 'I'm going to die' is best classified as a:
A. Automatic thought
B. Intermediate belief
C. Core belief
D. Cognitive distortion
Answer: A
Page 1
,Rationale: Automatic thoughts are rapid, evaluative cognitions that occur spontaneously in response to a trigger.
Intermediate beliefs are rules/attitudes, core beliefs are global and rigid, and cognitive distortion is a thinking error; the
thought itself is an automatic thought.
4. In Interpersonal Therapy (IPT), a patient who has recently moved to a new city and feels
isolated is assigned to the problem area of:
A. Role transition
B. Interpersonal deficit
C. Role dispute
D. Grief
Answer: A
Rationale: Role transition involves adapting to a life change such as relocation, which alters social roles
and relationships. Interpersonal deficit refers to chronic loneliness and skill deficits, role dispute
involves conflict with a significant other, and grief is loss of a loved one.
5. A therapist using Motivational Interviewing (MI) with a patient who is ambivalent about
substance use says, 'It sounds like you enjoy the social aspect of drinking but are concerned about
the impact on your health. On one hand, you want to fit in with friends; on the other, you worry
about your liver.' This technique is known as:
A. Double-sided reflection
B. Amplified reflection
C. Agreement with a twist
D. Complex reflection
Answer: A
Rationale: Double-sided reflection reflects both sides of the patient's ambivalence, helping them
articulate the discrepancy between behavior and values. Amplified reflection exaggerates the statement,
agreement with a twist adds a new perspective, and complex reflection adds meaning but not necessarily
both sides.
6. In family therapy, a therapist observes that whenever the adolescent child expresses anger, the
mother becomes tearful and the father withdraws, after which the child apologizes and the family
returns to a calm state. This repetitive pattern is best described by Minuchin's concept of:
A. Enmeshment
B. Triangulation
C. Circular causality
D. Homeostasis
Answer: A
Rationale: Enmeshment refers to diffuse boundaries where family members are overly involved in each
other's emotional states, leading to reactive patterns like the one described. Triangulation involves a
third party in a dyadic conflict, circular causality is a systemic concept, and homeostasis is the tendency
to maintain equilibrium.
Page 2
,7. A patient with PTSD has a strong startle response and experiences intrusive memories. The
therapist decides to use Eye Movement Desensitization and Reprocessing (EMDR) but the patient
is unable to tolerate the standard bilateral stimulation. According to EMDR protocol, an
appropriate modification is to:
A. Switch to a different modality (e.g., tactile taps instead of eye movements)
B. Increase the speed of stimulation to promote habituation
C. Use cognitive interweave to address the distress
D. Terminate reprocessing and focus on resourcing
Answer: A
Rationale: EMDR allows for alternative forms of bilateral stimulation (auditory or tactile) if eye
movements are not tolerated. Increasing speed may worsen distress, cognitive interweave is used for
processing blocks, and terminating reprocessing is not the first step; resourcing is part of preparation
phase.
8. A therapist is treating a patient with major depressive disorder using Behavioral Activation
(BA). The patient reports feeling too fatigued to engage in any activities. The therapist should first:
A. Explore the function of the fatigue using a functional analysis
B. Prescribe a graded activity schedule starting with very small tasks
C. Challenge the belief that fatigue prevents activity with Socratic questioning
D. Reinforce any effort by providing positive reinforcement for attempted activities
Answer: A
Rationale: In BA, functional analysis helps identify antecedents and consequences of behavior; fatigue
may be a consequence of avoidance rather than a primary symptom. Graded activity is used but after
understanding the function; cognitive challenging is more CBT; reinforcement is part of the plan but not
the first step.
9. A patient in dialectical behavior therapy (DBT) frequently calls the therapist between sessions to
report suicidal ideation. According to DBT protocol, the therapist's first response should be to:
A. Conduct a brief suicide risk assessment and then use chain analysis
B. Remind the patient of the 24-hour rule and limit calls to skills coaching
C. Refer the patient to the emergency department for evaluation
D. Validate the patient's distress and then problem-solve alternative coping strategies
Answer: D
Rationale: DBT emphasizes validation followed by problem-solving to build skills. While risk assessment
is important, the first response is to validate and then coach skills. The 24-hour rule applies to therapist
availability, not to the response itself. Emergency referral is reserved for imminent risk.
10. A 45-year-old patient with chronic depression and a history of childhood emotional neglect is
starting psychodynamic psychotherapy. The therapist notices the patient frequently says 'I don't
know' when asked about feelings. The therapist responds, 'Perhaps it feels safer not to know.' This
intervention is an example of:
A. Confrontation
Page 3
, B. Interpretation
C. Clarification
D. Supportive therapy
Answer: A
Rationale: Confrontation gently points out a discrepancy or avoidance in the here-and-now, here
highlighting the defensive function of 'I don't know.' Interpretation links to unconscious meaning,
clarification seeks more information, and supportive therapy would be more reassuring.
11. In the context of psychodynamic psychotherapy, the concept of 'enactment' refers to a specific
interaction between therapist and patient. Which of the following best describes its contemporary
understanding and clinical utility?
A. A deliberate therapeutic technique where the therapist role-plays a significant figure from the patient's past to
provoke emotional responses.
B. An unconscious re-creation of the patient's early relational patterns within the therapeutic relationship, which
can be explored to deepen insight.
C. A behavioral intervention aimed at rehearsing new interpersonal skills in a safe environment.
D. A cognitive restructuring exercise that challenges maladaptive schemas through guided discovery.
Answer: B
Rationale: Enactment in contemporary psychodynamic therapy is understood as an unconscious
interpersonal process where the patient's internal conflicts are reenacted with the therapist. It is not a
deliberate technique (A) or a behavioral/cognitive intervention (C, D). Exploring enactments provides
rich material for understanding relational patterns.
12. A patient with borderline personality disorder frequently expresses intense anger toward the
therapist, accusing them of being uncaring. The therapist feels irritated and notices a desire to
withdraw emotionally. Which concept best captures this interpersonal dynamic?
A. Projective identification
B. Transference neurosis
C. Countertransference resistance
D. Therapeutic alliance rupture
Answer: A
Rationale: Projective identification involves the patient projecting disowned feelings onto the therapist,
who then unconsciously identifies with and experiences those feelings. Here, the patient's anger is
projected, and the therapist feels irritated, reflecting the dynamic. Transference neurosis (B) is a
broader phenomenon. The therapist's reaction is not primarily resistance (C), and while a rupture may
occur (D), the specific mechanism is projective identification.
13. A therapist is treating a patient with generalized anxiety disorder using cognitive-behavioral
therapy. The patient holds the belief, 'If I feel anxious, it means something terrible will happen.'
Which cognitive distortion is most evident?
A. Emotional reasoning
B. Catastrophizing
C. Overgeneralization
Page 4
Advanced Practice Study Guide
1. In the context of psychodynamic therapy, a patient consistently arrives late to sessions and
avoids discussing a recent conflict with a supervisor. The therapist notes that the patient's behavior
mirrors the passive-aggressive dynamic described in the patient's relationship with a critical
parent. This phenomenon is best described as:
A. Transference neurosis
B. Enactment
C. Projective identification
D. Resistance
Answer: B
Rationale: Enactment refers to the patient unconsciously reenacting relational patterns from the past
within the therapeutic relationship, often without awareness. Transference neurosis involves a broader
regression, projective identification is a defense where the patient induces feelings in the therapist, and
resistance is a broader term for behaviors that impede progress.
2. A patient with borderline personality disorder frequently splits staff, idealizing one clinician
while devaluing another. The treatment team decides to use a structured approach where all
communications are coordinated through a single primary therapist. This intervention is grounded
in which therapeutic principle?
A. Containment and holding environment (Winnicott)
B. Dialectical abstinence (Linehan)
C. Limit-setting and structure (Kernberg)
D. Mentalization-based treatment (Bateman & Fonagy)
Answer: C
Rationale: Kernberg's object relations approach emphasizes structure and limit-setting to manage
splitting and maintain a consistent therapeutic frame. Dialectical abstinence is a DBT concept,
containment is from Winnicott, and mentalization-based treatment focuses on reflective function.
3. A patient undergoing CBT for panic disorder reports that after a panic attack, they think 'I'm
going to die' and then engage in safety behaviors like checking their pulse repeatedly. According to
the cognitive model, the thought 'I'm going to die' is best classified as a:
A. Automatic thought
B. Intermediate belief
C. Core belief
D. Cognitive distortion
Answer: A
Page 1
,Rationale: Automatic thoughts are rapid, evaluative cognitions that occur spontaneously in response to a trigger.
Intermediate beliefs are rules/attitudes, core beliefs are global and rigid, and cognitive distortion is a thinking error; the
thought itself is an automatic thought.
4. In Interpersonal Therapy (IPT), a patient who has recently moved to a new city and feels
isolated is assigned to the problem area of:
A. Role transition
B. Interpersonal deficit
C. Role dispute
D. Grief
Answer: A
Rationale: Role transition involves adapting to a life change such as relocation, which alters social roles
and relationships. Interpersonal deficit refers to chronic loneliness and skill deficits, role dispute
involves conflict with a significant other, and grief is loss of a loved one.
5. A therapist using Motivational Interviewing (MI) with a patient who is ambivalent about
substance use says, 'It sounds like you enjoy the social aspect of drinking but are concerned about
the impact on your health. On one hand, you want to fit in with friends; on the other, you worry
about your liver.' This technique is known as:
A. Double-sided reflection
B. Amplified reflection
C. Agreement with a twist
D. Complex reflection
Answer: A
Rationale: Double-sided reflection reflects both sides of the patient's ambivalence, helping them
articulate the discrepancy between behavior and values. Amplified reflection exaggerates the statement,
agreement with a twist adds a new perspective, and complex reflection adds meaning but not necessarily
both sides.
6. In family therapy, a therapist observes that whenever the adolescent child expresses anger, the
mother becomes tearful and the father withdraws, after which the child apologizes and the family
returns to a calm state. This repetitive pattern is best described by Minuchin's concept of:
A. Enmeshment
B. Triangulation
C. Circular causality
D. Homeostasis
Answer: A
Rationale: Enmeshment refers to diffuse boundaries where family members are overly involved in each
other's emotional states, leading to reactive patterns like the one described. Triangulation involves a
third party in a dyadic conflict, circular causality is a systemic concept, and homeostasis is the tendency
to maintain equilibrium.
Page 2
,7. A patient with PTSD has a strong startle response and experiences intrusive memories. The
therapist decides to use Eye Movement Desensitization and Reprocessing (EMDR) but the patient
is unable to tolerate the standard bilateral stimulation. According to EMDR protocol, an
appropriate modification is to:
A. Switch to a different modality (e.g., tactile taps instead of eye movements)
B. Increase the speed of stimulation to promote habituation
C. Use cognitive interweave to address the distress
D. Terminate reprocessing and focus on resourcing
Answer: A
Rationale: EMDR allows for alternative forms of bilateral stimulation (auditory or tactile) if eye
movements are not tolerated. Increasing speed may worsen distress, cognitive interweave is used for
processing blocks, and terminating reprocessing is not the first step; resourcing is part of preparation
phase.
8. A therapist is treating a patient with major depressive disorder using Behavioral Activation
(BA). The patient reports feeling too fatigued to engage in any activities. The therapist should first:
A. Explore the function of the fatigue using a functional analysis
B. Prescribe a graded activity schedule starting with very small tasks
C. Challenge the belief that fatigue prevents activity with Socratic questioning
D. Reinforce any effort by providing positive reinforcement for attempted activities
Answer: A
Rationale: In BA, functional analysis helps identify antecedents and consequences of behavior; fatigue
may be a consequence of avoidance rather than a primary symptom. Graded activity is used but after
understanding the function; cognitive challenging is more CBT; reinforcement is part of the plan but not
the first step.
9. A patient in dialectical behavior therapy (DBT) frequently calls the therapist between sessions to
report suicidal ideation. According to DBT protocol, the therapist's first response should be to:
A. Conduct a brief suicide risk assessment and then use chain analysis
B. Remind the patient of the 24-hour rule and limit calls to skills coaching
C. Refer the patient to the emergency department for evaluation
D. Validate the patient's distress and then problem-solve alternative coping strategies
Answer: D
Rationale: DBT emphasizes validation followed by problem-solving to build skills. While risk assessment
is important, the first response is to validate and then coach skills. The 24-hour rule applies to therapist
availability, not to the response itself. Emergency referral is reserved for imminent risk.
10. A 45-year-old patient with chronic depression and a history of childhood emotional neglect is
starting psychodynamic psychotherapy. The therapist notices the patient frequently says 'I don't
know' when asked about feelings. The therapist responds, 'Perhaps it feels safer not to know.' This
intervention is an example of:
A. Confrontation
Page 3
, B. Interpretation
C. Clarification
D. Supportive therapy
Answer: A
Rationale: Confrontation gently points out a discrepancy or avoidance in the here-and-now, here
highlighting the defensive function of 'I don't know.' Interpretation links to unconscious meaning,
clarification seeks more information, and supportive therapy would be more reassuring.
11. In the context of psychodynamic psychotherapy, the concept of 'enactment' refers to a specific
interaction between therapist and patient. Which of the following best describes its contemporary
understanding and clinical utility?
A. A deliberate therapeutic technique where the therapist role-plays a significant figure from the patient's past to
provoke emotional responses.
B. An unconscious re-creation of the patient's early relational patterns within the therapeutic relationship, which
can be explored to deepen insight.
C. A behavioral intervention aimed at rehearsing new interpersonal skills in a safe environment.
D. A cognitive restructuring exercise that challenges maladaptive schemas through guided discovery.
Answer: B
Rationale: Enactment in contemporary psychodynamic therapy is understood as an unconscious
interpersonal process where the patient's internal conflicts are reenacted with the therapist. It is not a
deliberate technique (A) or a behavioral/cognitive intervention (C, D). Exploring enactments provides
rich material for understanding relational patterns.
12. A patient with borderline personality disorder frequently expresses intense anger toward the
therapist, accusing them of being uncaring. The therapist feels irritated and notices a desire to
withdraw emotionally. Which concept best captures this interpersonal dynamic?
A. Projective identification
B. Transference neurosis
C. Countertransference resistance
D. Therapeutic alliance rupture
Answer: A
Rationale: Projective identification involves the patient projecting disowned feelings onto the therapist,
who then unconsciously identifies with and experiences those feelings. Here, the patient's anger is
projected, and the therapist feels irritated, reflecting the dynamic. Transference neurosis (B) is a
broader phenomenon. The therapist's reaction is not primarily resistance (C), and while a rupture may
occur (D), the specific mechanism is projective identification.
13. A therapist is treating a patient with generalized anxiety disorder using cognitive-behavioral
therapy. The patient holds the belief, 'If I feel anxious, it means something terrible will happen.'
Which cognitive distortion is most evident?
A. Emotional reasoning
B. Catastrophizing
C. Overgeneralization
Page 4
