CASE PRESENTATION
Case Presentation Paper Assignment
Basic Case Summary
Client’s Information
Carter is a 40-year-old white male, born and raised in New York. He is a financially
successful businessman; he works with investing in multiple businesses. Carter has been married
for 17 years to Lauren, a successful magazine editor, and they have two teenagers, Sophia (17)
and Ben (14). Carter and Lauren came in about a month ago, stating that they decided to begin
therapy because their marriage has been a hot mess. Lauren was on the verge of deciding to end
the relationship. She gave Carter an ultimatum to try couples therapy as their last resort to save
their marriage. He contested that no one ‘leaves him’ and that he would agree to go only to prove
to Lauren that she was the actual problem in the relationship.
Presenting Concern
Laurel explained that she’s been dealing with Carter’s difficult personality for 17 years; at
first, she thought she could handle their conflicts and antagonistic personality types. She said she
is good with people; she can read people well and even help them with their difficulties. Her
friends tell her she’s a good listener and gives good advice. She says her friends are great, and
she feels they are her support system for her emotional issues. Lauren has been trying to
communicate with Carter for years, and in the last few years, things have gotten worse, she feels
exhausted and frustrated. She says Carter does not listen to her. He is not interested in knowing
about her thoughts and feelings, is not present, and does not respect her in many aspects.
She stated that Carter thinks he is the king of the world. He thinks very highly of himself
as a successful businessman and everything else. She said, he is popular and charming, and very
pretentious. Although he seems a cool guy to most people and is constantly flattered by
CASE PRESENTATION
employees, especially women, behind that facade, he is a total jerk at home. He disrespects me;
he’s cold and uninterested in my life. I feel like it’s all about him, his ways, his wants, feelings,
etc. He always wants things done his way, feels entitled to the best of everything, and acts like
I’m there to serve him.
Lauren said that her husband does not take criticism well from her or anyone else. She
reported that if anything goes wrong in his work or when someone challenges him, he
demonstrates that he’s frustrated and feels humiliated. However, he reacts with rage. She also
talked about how she doesn’t think Carter’s friends are genuine; she said he likes to associate
with people of high status and people who constantly praise him. “When I observe them together,
it all seems fake to me,” Lauren reported.
Carter stated that he’s happy and doesn’t see anything wrong with his life, work, or
friends. He says that Lauren is responsible for all the marriage troubles they’re experiencing
because Lauren is dramatic and tends to overthink and exaggerate things. He says she creates
stories in her head and believes them. He also stated that she has no right to make these
accusations against him because he’s been taking care of her and their family all these years. He
has never been unfaithful, and he works really hard to provide such great life for their family,
one that most people are envious of. He told me that he had agreed to see me so that I could
come to the conclusion that Lauren needed help. He said he is willing to work collaboratively
with her in therapy and give her the support she needs to heal.
Lauren reported that he loves the attention he gets everywhere for being good-looking.
He’s always preoccupied with physical appearance; he works out regularly and is particular
about his diet. He always dresses sharp for every occasion, and he wants control over how the
whole family presents themselves when it comes to appearance. He wants to showcase a perfect
CASE PRESENTATION
family and perfect life; he has an inflated feeling of pride and superiority over others, and he’s
always seeking the admiration and praise of others.
He overindulges the kids with material things but is not present for conversations about
their wellbeing and inner conflicts. Both kids complain to Carter about this absence in their lives,
but he always argues that they have nothing to complain about because they have everything they
need and more.
While Lauren explained her feelings, Carter seemed uninterested and had a sarcastic
expression. He reacted to Lauren’s disclosure of her thoughts with disdain, defiance, and a lack
of empathy. When Carter talked, he seemed in control of the situation. He was cool, calm, and
charismatic. He was pretty charming and complimented me on something unrelated to the
problem. Carter stated that Lauren is always stressed out about unimportant silly things. She
always complains and nags and lives most of her days with unnecessary anticipation and anxiety.
He said that he’s been putting up with her ungrateful attitude for years.
Client’s History
Family
Carter and Lauren met in college, fell in love, and started dating. Not too long into the
relationship, their different personality started to clash. They broke up and got back together a
few times. Lauren got pregnant with Sophia, so they decided to get married. Their marriage has
never been easy/harmonious. Both stated that they have always fought a lot and talked about
divorce a few times. Carter thinks this is a normal thing; just like all marriages, none is perfect.
The kids grew up with nannies, but they have a very comfortable life. Carter thinks his kids are
lucky for having everything they want. He said he and Lauren love them, and they don’t lack
anything. There isn’t much sitting together for dinners or talking around the table because
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everyone is busy. The kids have school and several extra activities like dance lessons, sports, etc.
Both Carter and Lauren work every day. Carl stated that their life is better than all his friends’
lives.
Physical Health
Carter was a healthy child, he never experienced any major illness, but he said he has
always felt a little depressed and lonely. He mentioned that he felt like he had no one to talk to
during his teenage years about his internal conflicts. He felt like his parents didn’t care about his
emotional life; they were more concerned with material things. He said he struggled when
transitioning from a teenager to a young adult. He resorted to friends, parties, some alcohol, and
girls, but he always felt empty and lonely in the end. His parents weren’t present and didn’t have
access to his inner life.
Occupational History
After graduating from High School, Carter went to a good university in New York, where
he grew up. He majored in Business Administration, followed by a master’s program in business.
He started his professional career in his father’s business. He said he always tried to be the best
at everything he did and was very competent at his job; he and his dad got along well in business.
Substance Use History
Carter went through phases of drinking more than just socially. While in school, he would
get drunk with friends at parties and on regular weekends. Throughout college, he drank but
never to the point of becoming dependent. He said he currently drinks socially only. He also has
never experimented with any drugs.
Spiritual Information
CASE PRESENTATION
Carter has never been religious; he affirmed he is actually skeptical about God’s existence
and never really had a spiritual experience. His extended family is predominantly Catholic, but
his parents did not have the habit of going to any church. He is not in touch with his spirituality,
and he says he is not looking for a religion.
Cultural/ Social Justice Factors
Carter is a privileged white male, American, born in a wealthy family. He has everything
going for him, regarding social issues.
Barriers to Treatment/Success
Carter’s personality could be a barrier to the treatment. He is arrogant and full of pride.
He has a big attitude and acts like he’s better than other people. He acts superior and looks down
on others. He’s disdainful, prideful, and obnoxious. It is hard to help someone with such a
personality because they seem incapable of looking inside themselves to reflect and see their
limitations.
Family of Origin
Carter was the only child of very successful parents who gave him the best life a child
could have. He had the best toys, the best games, the best vacations, etc. He went to a private
school, was a good student, and had a few friends with the same social status. Carter reported
that his parents always encouraged him to be the best at everything. They paid for him private
classes in music, swimming, and other sports. He was an active/busy kid growing up. His parents
supported him in his competitions; they always went to his school to watch his games and
rewarded him for all his achievements with super cool presents. Carter reported feeling well
taken care of by his parents. However, he also felt alone most of the time. Both his parents
worked a lot and didn’t have much time to spend with him, especially on ordinary days when he
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was not winning a competition. He confessed that he felt most valued by his parents when he
achieved something. He stated that he was always an overachiever and wanted to be the best in
everything because if he weren’t, his parents would criticize him. He would be a little depressed
and withdraw from social activities when this happened.
Sexual Adjustment
Carter reported that his sex drive is typical of a 40-year-old man. He said he is still
attracted to Lauren, but their intimate life is not as he wished. Because they have constant fights,
they are usually mad at each other, leaving no space for romance. They both stated that when
they make peace, they get intimate, and they’re both satisfied.
Mental Status Exam
Carter’s appearance is impeccable. His style is classy and sophisticated. He wears
expensive clothes and accessories such as rings and a watch. He wears cologne to every session.
He is a tall good looking white man with an erect posture. He has a superior/arrogant demeanor
and seems calm and in control all the time. He appears to be open and friendly to the therapy
sessions, but he makes it seem like he is teamed up with me (the therapist) to cooperate with the
treatment for his wife’s problems. He gets defensive and argumentative when confrontation starts
steering his way. He does not raise his voice and seems dismissive of his wife’s talking. He
responds to her inputs quickly, sharply, and in a way that invalidates her thinking and feeling. He
is persuasive and defends his points very convincingly.
He never looks into Lauren’s eyes; he usually looks up at nothing or gazes at an object
while talking. He seems alert and focused on his thought process and speech. He has a vast
vocabulary and speaks eloquently. His judgment is completely impaired concerning a general
view of the issue, he is his own advocate, and he will argue his defense strong and persuasively.
CASE PRESENTATION
His mood is pretty consistent, but he will complain about inconveniences, the weather, etc. He
seems to expect to be greeted with enthusiasm, special treatment, or admiration like he is
someone famous or important.
Answer Key
DSM-5 Diagnostic Criteria: Narcissistic
Personality Disorder 301.81 (F60.81)
Client’s Signs/Reported Symptoms:
Criterion A: Has a grandiose sense of self-
importance (e.g., exaggerates achievements
and talents, expects to be recognized as
superior without commensurate
achievements).
The client’s wife stated that he thinks he is the
king of the world. He thinks very highly of
himself as a successful businessman and
everything else
Criterion B: Is preoccupied with fantasies of
unlimited success, power, brilliance, beauty,
or ideal love.
Lauren reported that Carter wants to
showcase a perfect family and perfect life
Criterion C: Believes that he or she is
“special” and unique and can only be
understood by, or should associate with, other
special or high-status people (or institutions).
Carter’s wife said he likes to associate with
people of high status and people who
constantly praise him.
Criterion D: Requires excessive admiration. He has an inflated feeling of pride and
superiority over others, and he’s always
seeking the admiration and praise of others.
Criterion E: Has a sense of entitlement (i.e.,
unreasonable expectations of especially
favorable treatment or automatic compliance
Laura stated that Carter always wants things
done his way, feels entitled to the best of
everything, and acts like she’s there to serve
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with his or her expectations). him.
Criterion F: Is interpersonally exploitative
(i.e., takes advantage of others to achieve his
or her own ends).
Criterion G: Lacks empathy: is unwilling to
recognize or identify with the feelings and
needs of others.
Carter reacted to Lauren’s disclosure of her
thoughts with disdain, defiance, and a lack of
empathy.
Criterion H: Is often envious of others or
believes that others are envious of him or her.
Carter stated that most people are envious of
his life.
Criterion I: Shows arrogant, haughty
behaviors or attitudes.
He has a superior/arrogant demeanor and
seems calm and in control all the time
Treatment Recommendations
Treatment for narcissistic personality disorder (NPD) has not yet been intensively
investigated. The current treatment recommendation is largely based on theoretical models and
the experience of clinicians and psychiatrists worldwide (Caligor et al., 2015). The lack of
empirically supported treatments for the disorder has led professionals to work with effective
treatments for neighbor disorders with adaptation for narcissistic personality disorder. For
instance, a treatment recommendation for borderline disorder can adapt to treat NPD; two of the
most suitable are mentalization-based therapy and schema-focused psychotherapy (Caligor et al.,
2015).
Mentalization-based therapy – Utilizing mentalizing interventions with narcissistic
patients entails techniques to validate and elaborate on the patient’s existing subjective
experiences while also adding “newness” (e.g., moving the patient’s focus from self to others and
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disclosing the therapist’s own views on the issues at hand). The treatment process requires them
to maintain lengthier participation in self-reflection and personal change. MBT’s approach may
foster a more hospitable self-searching scenario for narcissistic patients. They may feel more
comfortable, understood, and adequate, which benefits the therapeutic relationship (Drozek &
Unruh, 2020).
Schema-focused therapy – An integrated psychotherapy that builds on classic cognitive–
behavioral therapy procedures while also including components from object relations,
psychodynamic, and gestalt therapeutic models. SFT’s approach challenges early maladaptive
schemas about self and others and encourages a more mature way of thinking and functioning.
The therapist utilizes a technique that ‘re-parents’ the client, teaching them to control their
emotions, reactions, and narcissistic tendencies and improve on relational skills, empathy, and
intimacy with others (Yakeley, 2018).
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References
American Psychiatric Association, American Psychiatric Association, & American Psychiatric
Association. DSM-5 Task Force. (2013). Diagnostic and Statistical Manual of Mental
Disorders. American Psychiatric Association.
Caligor, E., Levy, K. N., & Yeomans, F. E. (2015). Narcissistic Personality Disorder: Diagnostic
and Clinical Challenges. American Journal of Psychiatry, 172(5), 415–422.
https://doi.org/10.1176/appi.ajp.2014.14060723
Drozek, R. P., & Unruh, B. T. (2020). Mentalization-Based Treatment for Pathological
Narcissism. Journal of Personality Disorders, 34(Supplement), 177–203.
https://doi.org/10.1521/pedi.2020.34.supp.177
Yakeley, J. (2018). Current understanding of narcissism and narcissistic personality
disorder. BJPsych Advances, 24(5), 305–315. https://doi.org/10.1192/bja.2018.20
