Case Study
Patient Demographic: Initial Intake: Age: 53 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Caucasian Relationship Status: Married Counseling Setting: Community Agency Type of Counseling: Individual
Mental Status Exam: The client appears his stated age and is dressed appropriately for the circumstances. He rates his mood as “anxious.” His affect is congruent though he appears to relax as the session continues.  He demonstrates some limited insight and frequently responds with “I don’t know” but when encouraged, is able to access thoughts and emotions that are disturbing to him. He demonstrates appropriate judgment, memory, and orientation. He reports never having considered suicide or harming himself or anyone else. He states that he is very engaged individually and with his family in their religious practices and views these as a source of strength. He currently takes 50 mg of Pristiq and Concerta 18 mg.
Presenting Problem: You are a counselor in a community agency setting.  Your client is a 53 year-old male who presents with complaints of feeling insignificant, unworthy, and a failure. He admits to having these feelings for the past 30 years and while he has never had suicidal ideations or plans, he has often wondered if his life had purpose and what that purpose was. Your client additionally tells you that he doesn’t feel happy on most days though he does have happy feelings at times; they just don’t last. He is good at his job and finds it challenging, yet tells you “it’s a job” and that there is nothing special or “exciting” about it to him. He tells you that he has been married for twenty years and has five children; three of whom he adopted when he married his wife. He states he adores his wife and children, though he knows that he often does not meet their needs emotionally, “tunes out,” and frequently puts his own “wants and desires” before their requests, needs, or previously made plans. He admits he gets “jealous, I guess” when someone else in the family gets something that he didn’t. He also says that he often says “the wrong thing” when his wife or children are upset about something and he struggles to understand how they are feeling. He tells you that these actions cause conflict in his marriage and with his children and he is ashamed that he does this, but feels hopeless that things will change because he cannot figure out how to change or why he does these things. He reports that he does not believe himself to be better than others but that others often perceive that he sees himself that way because of how he interacts with them. He also tells you that his family often wishes he would “think before I speak or make decisions.” He reports that in spite of these “failures,” he and his wife have a very strong marriage and express their love for each other daily. They enjoy activities together although he needs very active recreation such as roller coasters, bike riding, and swimming while his wife leans towards less physical activities. Finally, your client tells you that over the years he has had some trouble focusing at work and at home. He views himself as “forgetful” and says “I don’t have a good memory.” He says this causes troubles at home and work when he frequently forgets to do something that he said he would do or when he is not as careful or gets distracted in his work and is slow to finish projects or makes small mistakes that have greater impacts on reports.
Other Contexts: Family History:
The client reports his parents were married to each other until his father’s death at age 60. Your client states he was very close to his father although his father’s activities were often curtailed due to illness. He states that his father accompanied him to boy scouts and was involved with the client and his older siblings. The client states that he has always been close to his mother although he acknowledges often feeling angry at her but being unable to tell her that, so instead he “tuned her out.” He describes her as extremely “critical and consistent.” He tells you that the first time he decorated a Christmas tree was with his wife as his mother always decorated their family trees “so they were done right.” He also says his father and siblings could always count on her to be the one who made the family late for everything and left them waiting during outings. In one example, he shares that when going out together, his mother would often set a meeting place and time for him. He reports that he would either wait at the meeting spot for hours because she was late or that he would sometimes go looking for her and then get in trouble for leaving the meeting spot. He reports that his oldest sibling died in his 40s from excessive drug and alcohol use, and that his other sibling has a very conflictual relationship with their mother and sees their mother “when needed” but is often angry with their mother. He describes his relationship with his mother over the past twenty-five years as one in which his mother makes promises without keeping them and was often dismissive of the client’s wife and children during the time that he was dating and for several years after their marriage. He relates one account where his mother was helping his wife organize something in their home, but refused to organize it in the manner that his wife needed it, and instead became very angry, defensive, and accusatory when his wife reorganized what his mother had done.

Question: Given the information provided, what should the counselor focus on during the initial part of the session?
(A): The client's need to have his wife help him see another perspective
(B): The client's inability to express regret or remorse for his actions
(C): The client's feelings about his job and whether he is truly happy in it
(D): The client's feelings about himself and how others view him

Correct Answer: The client's feelings about himself and how others view him
Explanation: The client's reaction to his supervisor highlights his feelings about himself and how others view him and is the most important area to focus on for this part of the session. The client's reaction to his supervisor is indicative of people with NPD or narcissistic traits. These individuals tend to have a very fragile self-esteem which makes them extremely sensitive to criticism, making them feel ashamed, humiliated, and that they have no value at all. The client's inability to understand another perspective without help and his difficulty expressing regret or remorse are also indicative of people with NPD or narcissistic traits. Because this client possesses insight, it is most helpful to work with him on understanding how his feelings about himself and others' perceptions of him impact his self-esteem. Helping the client to understand his self-esteem as the problematic factor in his relationship with himself and others, will later allow him to work on improving his ability to empathize and acknowledge potential or actual mistakes without injury to his self-esteem. The client's current job is not a factor in this event; it is the relationship between the client and the criticism that the client has internalized into a self-esteem injury. Therefore, the correct answer is (D)
Competency: intake, assessment, and diagnosis