California Law and Ethics Examination (Dental)

Correct: Preparation (Phase 2) is the stage where the clinician explains the process and ensures the client has sufficient coping skills (resourcing) to handle the distress of reprocessing. In addiction counseling, this phase is critical to prevent the client from using substances to cope with the emotional intensity of the trauma work.

Incorrect: Assessment (Phase 3) involves identifying the specific components of the target memory, such as the negative cognition and the level of distress. Desensitization (Phase 4) is the actual reprocessing using bilateral stimulation. Installation (Phase 5) focuses on strengthening the positive cognition. None of these phases involve the initial stabilization and resource development found in the Preparation phase.

Correct: Behavioral Activation (BA) is a core component of Cognitive Behavioral Therapy that operates on an ‘outside-in’ principle. It posits that behavior change can lead to mood change. In the context of addiction and co-occurring depression, BA involves identifying and scheduling activities that provide a sense of mastery or pleasure. This increases the client’s exposure to positive reinforcement in their environment, which helps break the cycle of withdrawal and inactivity that often leads to relapse.

Incorrect: Focusing on cognitive restructuring first is a traditional CBT approach but is not the primary mechanism of Behavioral Activation, which emphasizes behavior change as the catalyst for cognitive and emotional shifts. Encouraging a client to wait for motivation to return naturally is counter-therapeutic in BA, as the goal is to use activity to generate motivation. Aversive conditioning is a behavioral technique used to reduce unwanted behaviors through punishment, which is the opposite of the positive reinforcement-seeking goal of Behavioral Activation.

Takeaway: Behavioral Activation treats co-occurring depression in recovery by systematically increasing engagement in rewarding activities to break the cycle of avoidance and improve mood through positive reinforcement.

Correct: TIPP (Temperature, Intense exercise, Paced breathing, Paired muscle relaxation) is the specific Dialectical Behavior Therapy (DBT) module designed for crisis survival when the client is at a high level of physiological arousal (the ‘red zone’). These skills work by physically changing the body’s chemistry to lower the heart rate and activate the parasympathetic nervous system, making them the most appropriate choice for immediate, acute physical agitation.

Incorrect: Radical Acceptance is a distress tolerance skill used for accepting reality as it is when a situation cannot be changed, but it does not address immediate physiological ‘fight or flight’ responses. The ACCEPTS technique focuses on distraction (Activities, Contributing, Comparisons, Emotions, Pushing away, Thoughts, Sensations), which is useful but often less effective than TIPP when a client is experiencing a peak physiological surge. The IMPROVE technique (Imagery, Meaning, Prayer, Relaxation, One thing at a time, Vacation, Encouragement) is designed to make the current moment more tolerable over a longer duration rather than providing an immediate biological reset.

Takeaway: TIPP skills are the primary DBT distress tolerance intervention for rapidly reducing high physiological arousal and autonomic nervous system activation during an acute crisis.

Correct: Under 42 CFR Part 2, which governs the confidentiality of substance use disorder (SUD) patient records, information that would identify a patient as having a SUD cannot be disclosed without specific written consent. This regulation is more stringent than HIPAA and does not include an exception for financial risk or corporate safety protocols. Even if the counselor is contracted by the bank, the client’s individual right to confidentiality regarding SUD treatment remains protected unless a specific exception (such as a court order or medical emergency) is met.

Incorrect: Option b is incorrect because there is no ‘public interest’ exception in 42 CFR Part 2 that covers financial or economic risk. Option c is incorrect because a QSOA is used for agencies providing services to the treatment program itself (like legal or accounting services), not for disclosing patient data to an employer. Option d is incorrect because the ‘duty to warn’ (Tarasoff) typically applies only to threats of serious physical violence against a specific, identifiable victim, not to potential financial loss or general professional impairment.

Takeaway: Federal confidentiality regulations under 42 CFR Part 2 strictly prohibit the disclosure of substance use disorder records to employers without explicit written consent, even when significant financial risks are involved.

Correct: According to the DSM-5-TR and best practices in addiction counseling, the most reliable way to differentiate between a substance-induced disorder and an independent co-occurring disorder is to observe the client during a period of abstinence. If psychiatric symptoms persist for a significant period (typically 4 weeks or 30 days) after the cessation of acute withdrawal or intoxication, an independent mental health diagnosis is more likely. This longitudinal observation ensures that the treatment plan addresses both the addiction and the mental health condition appropriately.

Incorrect: Waiting for six months of sobriety before considering a dual diagnosis is clinically inappropriate as it delays necessary psychiatric intervention and increases the risk of relapse. Assuming that high-severity substance use precludes a mental health diagnosis is a logical fallacy that ignores the common reality of self-medication. Relying solely on self-reported history during the detoxification phase is unreliable because the client may be experiencing cognitive impairment, denial, or acute distress that skews their perception of their own history.

Takeaway: Distinguishing between substance-induced and independent psychiatric disorders requires monitoring the persistence of symptoms during a period of sustained abstinence, typically lasting at least 30 days.

Correct: In addiction counseling, particularly for those with a history of substance use disorders, there is a significant risk of cross-addiction or symptom substitution. Because behavioral addictions (like gambling) and substance addictions share similar neurobiological reward pathways, a client may stop one behavior only to initiate another that provides a similar dopamine surge. Mitigation requires a holistic biopsychosocial approach that looks beyond the primary complaint to monitor the client’s overall impulse control and coping mechanisms.

Incorrect: Referring to a medical detox is incorrect because behavioral addictions do not typically require the same medical stabilization as substances like alcohol or opioids. Focusing exclusively on neurobiology ignores the psychological and environmental factors essential to the NCAC II scope of practice. Assuming control over a client’s bank accounts is an ethical violation and outside the scope of practice for an addiction counselor, as it undermines client autonomy and creates a dual relationship.

Takeaway: Counselors must remain vigilant for symptom substitution in clients with behavioral addictions, as the underlying addictive process can easily migrate to new high-risk activities.

Correct: Obstructive Sleep Apnea (OSA) is distinguished by the physical, mechanical collapse of the airway and resulting oxygen desaturation (hypoxemia). In the context of addiction, it is critical to understand that Central Nervous System (CNS) depressants like alcohol and opioids significantly worsen OSA by reducing the muscle tone of the upper airway and suppressing the brain’s respiratory drive. Unlike withdrawal-related insomnia, OSA is a distinct physiological disorder that requires medical diagnosis (polysomnography) and does not simply resolve with the passage of time in recovery.

Incorrect: The focus on REM rebound and vivid dreams describes a common phenomenon during withdrawal from substances that suppress REM sleep, but it does not address the respiratory interruptions characteristic of sleep apnea. The idea that symptoms must only manifest during intoxication is incorrect, as OSA is often a chronic condition that exists independently of, or is permanently worsened by, long-term substance use. Sleep-onset latency and psychomotor agitation are more indicative of insomnia or anxiety disorders rather than the sleep maintenance and respiratory issues found in sleep apnea.

Takeaway: Addiction counselors must recognize that sleep apnea involves mechanical respiratory failure and hypoxemia, which is distinct from substance-induced insomnia and is dangerously exacerbated by the use of CNS depressants.

Correct: According to the DSM-5-TR, the diagnostic criteria for Gambling Disorder include a requirement that the gambling behavior is not better explained by a manic episode. This differential diagnosis is essential because the impulsivity, grandiosity, and excessive involvement in pleasurable activities with high potential for painful consequences seen during a manic episode can manifest as gambling, but in such cases, it is considered a symptom of Bipolar Disorder rather than a primary Gambling Disorder.

Incorrect: The presence of other impulse-control disorders or a history of stimulant use are common comorbidities but do not exclude a diagnosis of Gambling Disorder. Legal consequences were a diagnostic criterion in the DSM-IV, but this was removed in the DSM-5-TR to focus on the psychological and behavioral patterns of the addiction rather than social or legal outcomes.

Takeaway: A diagnosis of Gambling Disorder requires the clinician to rule out manic episodes as the primary cause of the gambling behavior to ensure accurate treatment planning.

Correct: In addiction counseling, bereavement following an overdose is often categorized as disenfranchised grief because it is frequently stigmatized and not openly supported by society. Applying existential and trauma-informed principles involves validating this unique pain and helping the survivor find meaning to prevent the shame-based triggers that lead to relapse. This approach addresses the core psychological needs of the residents while maintaining the therapeutic focus on recovery.

Incorrect: Adhering to a linear five-stage model is often ineffective for the complex, non-linear trauma of overdose loss. While cognitive-behavioral approaches are useful, focusing solely on irrational thoughts ignores the existential and emotional depth of the loss in a community setting. Transitioning strictly to behavioral skills ignores the trauma-informed requirement to process the event, potentially leading to suppressed emotions that increase relapse risk.

Takeaway: Effective bereavement support in addiction treatment must address the disenfranchised nature of overdose loss through existential meaning-making and trauma-informed validation to mitigate relapse risk.

Correct: Cognitive Behavioral Therapy for Insomnia (CBT-I) is the evidence-based gold standard for treating chronic insomnia, particularly in individuals with a history of substance use disorders, as it avoids the risks of cross-addiction associated with sedative-hypnotics. Psychoeducation is vital because clients need to understand that the brain’s sleep-wake regulation, including REM and slow-wave sleep, can remain dysregulated for several months during protracted withdrawal from substances like alcohol.

Incorrect: Benzodiazepines are generally contraindicated for individuals with a history of Alcohol Use Disorder due to the high risk of cross-tolerance and potential for a new addiction. Attributing sleep issues solely to psychological factors ignores the well-documented neurobiological changes in the GABAergic and glutamatergic systems following chronic substance use. Over-the-counter antihistamines like diphenhydramine are not recommended for long-term use due to the rapid development of tolerance and potential side effects that can impair cognitive function and alertness.

Takeaway: Non-pharmacological interventions like CBT-I are the preferred evidence-based treatment for insomnia in recovering populations to avoid relapse and address neurobiological sleep dysregulation.