Claire was a 30-year-old Caucasian woman who presented for treatment with depression, suicidal thinking, and selfinjurious behavior. Raised in the Midwest, Claire had moved to Boston to complete her residency in obstetrics and gynecology. Claire was an only child who felt only conditionally cherished by her parents. She had experienced her mother as highly intrusive and controlling, yet easily injured when Claire displayed “negative” or “critical” emotions. Claire’s father was generally passive, never intervening to mitigate her mother’s reactivity.

Claire thus learned to avoid attracting notice and “be a good girl” by excelling in school, joining athletic teams, participating in extracurricular activities, and always appearing happy to prevent upsetting her mother. When Claire left home for college, the facade began to crack. Phone conversations with her mother and perceived rejection by classmates triggered extreme emotional instability. Claire oscillated unpredictably between intense anger toward others and self-hatred, once declaring,“I am bad, disgusting, ugly, and worthless. No one wants to be with me, and that is never going to change.”