its havoc. Even the most comprehensively bureaucratized medical knowledge can be made to speak, if only we are willing to listen closely to the blank spaces, the paraphrases, and even the acronyms.
The Crack-Up (1969–1970)
August 16, 1969
Trigg Clifton, MD/MB*
Harvard University Health Services, Psychiatric Clinic
Patient is seen as a courtesy visit because he is no longer actually eligible for consultation here, as he graduated here from the college [Harvard] in June of this year. He has plans to attend Columbia Graduate School.
He comes with very intense questions regarding Catholicism. In the last several months he has begun to question increasingly whether he can support a body of thought which stresses orthodoxy and lack of investigation. He approaches the problem with me and with himself quite intellectually, but he is indeed, in spite of intellect, feeling in much emotional turmoil over this. Support was given to him to move towards a middle ground, which, in his style, is very hard for him. He has felt frightened of the loss of the Church, and, therefore, it was clarified that he need not give up the Church, or the organization to which he belongs in the Church, to pursue his questioning, and that he would not be able to be content in any position he took until he opened up the questions with himself and others. He was also concerned that some of his actions have been inappropriate, and I did not feel that they were inappropriate save that they were indicative of a young man in considerable turmoil over some very important questions in life, and this was stated to the patient.
He will be talking with several priests and may indeed, when he gets to Columbia, seek psychiatric help for his semi-crippling obsessive-compulsive personality, i.e., he is often paralyzed by self-doubts and unable to be decisive.
At the end of the interview he questioned whether his difficulties would make him draft-deferrable. I stated that I did not think so.
Diagnoses: Adjustment Reaction of Adolescence in an obsessive-compulsive personality.
September 9, 1969
Trigg Clifton, MD/MB
Patient asked to be seen again because he now has to decide whether to go to Harvard Law School or to Columbia Graduate School. He spent the first fifty minutes of the session obsessing intellectually on both sides of the question, and I asked him very directly what his emotions told him, i.e. what he felt. He says that he now felt very uneasy about even the Church and Opus Dei. He felt that to pay attention to his emotions was a sign of weakness and lack of intellectual integrity. I clarified that man is both emotions and intellect, and it is lack of integrity not to be aware of the fact in making decisions. One must pay attention to one’s intellect, although one does not necessarily obey what it says.
We worked further on the thought that Harvard Law School would be a somewhat more predictable school to be in, and that the more stable day-to-day life it would provide might allow him a base from which to (1) obtain psychotherapy with a lessening of day-to-day anxiety and (2) to allow him to think over his religious questions. Patient will consider these ideas, and if he does go to Harvard Law School will contact me regarding psychotherapy.
September 30, 1970
Trigg Clifton, MD/MB
The patient has been in New York City in graduate school at Columbia but had a severe obsessive breakdown in functioning, necessitating his dropping out of school. He was in treatment for about eight months in New York City but left two months ago, for reasons that are not clear. He is now back here, hoping to pull himself together, and plans to take courses through the Extension School.
He came to see me to reestablish contact, and to question if he could get into treatment. I am aware that his treatment has been difficult for him but see him as a very troubled man, and probably sicker than an adjustment reaction of adolescence—more likely borderline personality with obsessive-compulsive features. Obviously, he could not be treated at this clinic, and he is uncertain whether he wants to get into treatment at all. I told him that if he did, he should feel free to get in touch with me and I would find him a clinic in the area.
He is not suicidal, and there are no signs of acute decompensation.
A Season in Hell (1981)
August 17, 1981
Jennifer R. Hornstein, MD/MB
Harvard University Health Services, Psychiatric Clinic
This was the first Mental Health Service visit for this 33-year-old man, currently working as a receptionist for the Center for International Studies. He is a neatly groomed, articulate young man who has been suffering extreme anxiety for the past four months. Since April, he has had difficulty falling asleep, with midnight awakening and early morning awakening. Over the past few weeks he has only been able to sleep around five hours per night. He describes compulsive eating and heavy intake of “junk foods.” He reports a loss of energy, anhedonia, and a decrease in sexual interest as well as a difficulty in obtaining erections. He denies suicidal or homicidal ideation. No history of hallucinations or delusions. No drug or alcohol use.
He says his current agitation reminds him of a period when he was 21, when he decided to leave a Catholic religious order which he had committed himself to, an order for laymen who dedicated themselves to chastity and poverty. Since then he has not been able to commit himself to any pursuits. Over the past several months, he has gone from one therapist to another, even including primal therapy. A therapist at the Harvard Community Health Plan prescribed some Valium, which helps him sleep but has not relieved his anxiety. Another therapist prescribed Sinequan, but it did not help.
Patient reports severe anxiety and obsessionality. He is unable to decide about anything, even whether to continue therapy. He is worried that there might be something medically wrong with him and has made an appointment to see his PCP [primary care physician]. He is not sure what he would like from me at this time, other than some instant relief or reassurance that his symptoms will not get much worse. He is afraid he will become so tired that he will not be able to walk across the campus to see me for our next appointment. I will see him Friday and then refer him for the two weeks that I am on vacation. He says he has friends who visit him occasionally, so he is not entirely isolated.
My initial impression is of a young man with agitated depression or anxiety attacks. No hyperventilation or palpitations but does describe some phobic symptoms (afraid he will stay in his house and not be able to leave). I do not think hospitalization is necessary. We discussed antidepressants, but I advised him that we would need further work-up before beginning medication.
August 21, 1981
Jennifer R. Hornstein, MD/MB
Mr. Scialabba returned for his second appointment. He appears slightly calmer than last time. His speech was slower and his affect more depressed. He describes a continuation of the symptoms noted on 8/17: difficulty falling asleep, early morning awakening, an urge to eat “junk food,” difficulty making decisions, loss of energy, decrease in libido. He has frequent thoughts of dying and going to hell, which he connects with his experience in the Catholic Church.
He also appeared rather guarded when talking about a referral several years ago to the Homophile Community Health Service. He was referred to an individual who was a “good therapist.” He denied that he had any thoughts about homosexuality or experience with homosexual liaisons.
He continued to demonstrate obsessive thought processes, though there were some loose associations, for instance when he began to quote from the gospel. Although the quotation was relevant to our discussion, his thinking did appear slightly tangential.
We continued to discuss his therapeutic history. He has had many experiences with therapists in the past, mostly short-term. After college he began therapy with Dr. Wendell O’Grady, a New York psychoanalyst, for six months. Shortly thereafter, he began treatment with the counselor at the Homophile Community Health Service. In the ’70s he saw a therapist for one year, who was a member of SOMA [an alternative therapy collective]. In ’71 he was in treatment for eight months as part of a group therapy