Given the case information, give a diagnosis, the rationale for the diagnosis, and additional information you would have wanted to know in order to make a more accurate diagnosis.

Formulate a risk and resilience assessment, both for the onset of the disorder and the course of the disorder, including the strengths that you see for this individual. What techniques could you use to elicit additional strengths in the client? Formulate goals and a possible treatment plan for this individual. Formulate a critique of the diagnosis as it relates to this case example.

Marcy is a 36-year-old white woman who came to the women's counseling center several weeks ago reporting feelings of anger and "wanting an outlet to vent" about several of her relationships. She has never seen a psychiatrist or counselor before coming to the counseling center.

Marcy's childhood years were riddled with stresses. Her mother, Gloria, was "beautiful," "high-spirited," "highly dramatic," and an alcohol abuser. Her father, Michael, was (and remains, accordingly to Marcy) emotionally immature and ineffectual in his career, parenting, and many of his relationships. He was emotionally bereft over the marriage's dissolution, which came about because of Gloria's drinking. The couple divorced when Marcy was 2 years old.

Marcy was an only child, and when her parents divorced she remained in her mother's custody. Gloria's addiction caused a rapid deterioration in her physical and emotional state, to the extent that when Michael's mother (Marcy's paternal grandmother) came to visit several years later, she found Marcy emaciated with sores over much of her body. Marcy's paternal grandparents took temporary custody of her but made it clear to Gloria that they wanted her "to get herself together" so that Marcy could eventually return to her mother. Her grandparents described Marcy as a "difficult child," in that she cried easily and was hard to soothe. Gloria's former in-laws ended up paying for Gloria's two lengthy stays in a drug and alcohol rehabilitation center; however, she was unable to stop drinking.

Within several years of Marcy's arrival in their lives, her grandparents sought permanent legal custody through the judicial system to facilitate certain decisions for Marcy, such as schooling and medical care. They still hoped Gloria would "dry out" and "get herself together" so that she and Marcy could be together again. These hopes were dashed when Gloria died in a Las Vegas hotel room, "unintentionally drinking herself to death," when Marcy was 10 years old.

It is clear that from the time Marcy's grandparents took custody of her, they were her primary caregivers. She refers to them as Mom and Dad and refers to her biological father (Michael) as "the big kid." Michael, who also lived with his parents through much of the rest of Marcy's childhood, was always in the background of her life. He took no visible parenting role, for which Marcy continues to hold him in contempt.

Three years ago Marcy married a man named Zach, 6 years her junior. Marcy has no female friends and professes to dislike most women strongly. She rarely drinks alcohol and no longer uses illicit substances, as she fears she may have inherited a propensity toward addiction from her mother. She admitted to drinking "a great deal," and doing her "fair share of drugs" in college, but she now avoids drugs and (mostly) alcohol. She admits to impulsivity in "binge shopping," but the behavior does not appear to cause marital strife, presumably because her grandmother continues to allow Marcy to use her credit cards at several fine department stores.

Marcy admits to a lengthy history of instability in her interpersonal relationships, dating back to when she was in high school, until she married. Whenever she became convinced that a boyfriend was going to leave her, she would "beg and humiliate herself." If that did not work, she said, she would "dump him before he could do it to me." Her romantic relationships prior to her marriage lasted for 6 months at the most. At some point in college, she reported "getting really skinny. It was great! I would run a few miles a day, eat next to nothing, and drink my dinner at bars every night." She was not diagnosed or treated for an eating disorder, and the behavior seemed to resolve itself after graduation.

Marcy acknowledges that she goes through periods of feeling profoundly depressed, empty, and abandoned, no matter how much her husband Zach tries to console her. She fears that "something," by which she means death, will "happen to my husband." In the session she emphasized loudly, "I would kill myself if anything happened to my Zach. He's my world. He fills me up. Every day, I live for the moment he gets home from work. I get so lonely and depressed whenever I am apart from him." She then quickly asserted, "He knows better than to have an affair. I would throw him out, scratch his eyes out, and literally cut the crotches of every pair of pants he owns. He knows better than to mess with me. I'd make him wish he'd never been born!"

Marcy claims she and her husband are very happy and do everything together. They have no outside friends but feel that their family (of two dogs and a cat) is their world. When Marcy mentioned that she had thrown a party for her husband recently on his birthday, the social worker asked who was invited. Marcy retorted that it was only she and Zach and their animals. "Why would I want to invite anyone else? Zach is my world."

Early in Marcy's counseling, she confided that until very recently, she was quite close to her husband's sister, Jessica, but that she had flown into a rage when Jessica apparently set personal boundaries related to Marcy's unsolicited and disparaging advice about Jessica's new boyfriend, whom Marcy had never met. Marcy felt disrespected, that Jessica was "treating me like a neighbor, not like a sister. I hate her. I hate all of my husband's family. Zach and I decided it's just us against the world, and I am fine with that. We don't need anyone else." Since then the two women have "made up," and Marcy has changed her perception of Jessica to one of adoration and admiration. "I can't live without my sister." She also has fluctuated between adoration and devaluation of her mother-in-law during her short tenure at the counseling center.

Marcy says that she made clear to her husband's family when she and Zach became engaged that once her grandparents were gone, she was completely alone and she expected them to be her family. She forbade them to refer to her as an "in-law," stated that she was their daughter or sister, and declared that she wanted a family with whom she could be "naked and vulnerable."

Marcy readily acknowledges that her feelings about people are very "all or nothing," that she "is pretty honest," that she "either loves you or hates you," a quality she highly values in herself.

Marcy has been fired from two jobs in the past two years. Marcy's version of events is, "They're all a bunch of assholes anyway, who set me up to fail from the beginning." She is not receptive to seeing any other possible interpretation and denies the possibility that she may have had any culpability in the outcomes.

Three months ago, Marcy secured a software training position that allows her to work from home, which minimizes her interactions with supervisors and coworkers. This arrangement has apparently worked out quite well for her. Some strife and friction occurred recently, however, in her relationships with her employers and coworkers, with whom she deals primarily via e-mail, telephone, and biweekly meetings. Concurrently, Marcy was under significantly increased stress with a heavy travel and training schedule.

Marcy exhibits remarkably little insight into her behavior, and her husband appears to align with Marcy's interpretations in all instances, whether regarding her troubled career path or her relationships with coworkers, former friends, or even his sister. Marcy acknowledges that early in their relationship, she demanded that of him (as she did of her grandmother): "You are either with me or you are against me. If I can't count on him to side with me no matter what, who can I count on?"