upon his mother, whom he also saw as a kind bureaucrat, and as vindictive and unavailable. In contrast he said he felt close to his father, a civil engineer.
He continued, affirming his anger at having to depend upon incompetent people, and at the same time acknowledged his very strong wish to be taken care of. He felt this particularly strongly in our sessions and wished I could see him more often. He could not articulate what he had hoped to gain by meeting more often, other than a sense that he was being looked after.
His affect was alternately sad and angry. He started to cry at one point, talking about his own compassion for suffering people and his wish that his own suffering would be treated with similar compassion.
September 28, 1981
Jennifer R. Hornstein, MD/MB
Mr. Scialabba appeared slightly more energetic and less fatigued than previously. He continues angry and frustrated with the psychological evaluation, and with bureaucracy in general.
He went on to speak about a longstanding sense of frustration, dating back at least to the age of 21. Again he spoke now of a strong wish to be taken care of, as well as frustration that he was not getting immediate relief from the medication. Despite that frustration, he appeared notably more animated today.
October 5, 1981
Jennifer R. Hornstein, MD/MB
He appears much improved today: more alert and articulate, less angry and agitated. His sleep has improved and he feels less anxious. He attributed this in part to the medication and in part to his article being accepted for publication by the Village Voice. During today’s session the change in his presentation was noticeable. He was less argumentative and more thoughtful. He was more obsessional than usual but less tearful and distracted. He spoke of the significance of his becoming 33. He felt that this age marked the end of early adulthood and meant he could no longer fall back on the fact that he was young, but had to begin to consider why he had not achieved more to date.
He wonders whether he should return to primal scream therapy and whether his current episode may have been related to early childhood experiences. In particular, he described a sense of frustration of not being taken care of as he would have liked by his mother. He fears that such concerns would not be taken seriously in other forms of therapy.
Mr. Scialabba appears to be coping with his anxiety with more obsessional defenses at this point. He appears more available for therapy at this time.
October 19, 1981
Jennifer R. Hornstein, MD/MB
Mr. Scialabba appeared calm and in good spirits today. He has felt quite confident since his article appeared. He also attributes some of the improvement to the medication. We discussed some of the results of the psychological testing.
In answer to his question about primal therapy, I suggested that he embark on a weekly course of psychotherapy, probably long term. I told him that his difficulty was not in experiencing affect, but rather in integrating his feelings with his intellectual perceptions. When he begins to experience feelings, he feels overwhelmed, panicked, and becomes frightened. When writing, on the other hand, uses his intellectual capacity exclusively. It appears that the task will be to help integrate both the intellectual and the affective experiences. I referred him to Dr. James Garcia, for possible therapy.
November 17, 1981
Jennifer R. Hornstein, MD/MB
Mr. Scialabba has decided not to continue with Dr. James Garcia. There is apparently some financial difficulty. He has decided instead to meet in once-a-week therapy with Dr. Buenavista through the Boston Center for Modern Psychoanalysis. I have suggested that he ask whether he could receive the medication through the Boston Center for Modern Psychoanalysis or through a physician associated with the Center. I have advised him quite strongly that I see difficulties in splitting up the therapy from the medication in his case. He will get back to me next week about this.
He seems in good spirits today. He is calm, less anxious, and reports that he is sleeping six to seven hours a day. His appetite is good. He has more energy and is attending work without difficulty. No crying episodes. He has occasional headaches—every two or three weeks. Other than this, no medication-related side effects. I renewed his prescription for desipramine and advised him to increase his fluid intake since his last BUN was 20.
Reality Components (1986–1987)
December 29, 1986
Grace Franklin, MD/MTL
McLean Hospital
Of his background I learned that he is the younger of two children born to second-generation Italian parents. Although he speaks kindly and sensitively about his parents, he describes his home life as deprived in some ways, based on his parents’ educational and socio-economic status. Very difficult relationship with his mother, who was highly critical and demanding and who could not be pleased. He has a good relationship with his only sibling, a brother who lives in the area, is married with children, and works in the same city department for which his father worked for twenty or thirty years. He feels somewhat estranged from his family because he broke away intellectually and educationally, but nonetheless sees them on a regular basis every three or four weeks and the relationship is cordial.
As we talked about what he is seeking in therapy, it came out that he has a good deal of intellectual insight. Indeed his major defenses are intellectual and rather powerful. He defends against affect and he defends against intimacy; I suspect this is the reason his therapy has not gotten very far in the past. Indeed, his relationships with therapists haven’t gone much further than his relationship with anyone else in his life. When we began to talk about his wishes regarding a therapist, the resistances immediately surfaced. Money is a problem for him: his insurance coverage is not good, and while he does have some small savings, he is not sure at this point how much he wants to commit his savings to treatment. This clearly is not going to be an easy treatment situation, although I think he would be a very interesting person to work with. I think he should be in the hands of a very experienced therapist, someone well trained in developmental issues. There’s an additional factor: this man has had two major periods of upheaval in his life, and although the history is not clear-cut, I found myself thinking in terms of a possible recurrent depression. At one point in 1980, when he was seen at UHS [University Health Service], he was put on an antidepressant. He cannot tell me whether his depression responded to the antidepressant or just went away spontaneously. His mother seems to have a great deal of emotional difficulty, and there was a cousin on the mother’s side who committed suicide, so there is a possible biochemical or genetic vulnerability. For this reason, I feel that he also ought to be in the hands of a physician who will be sensitive to medical issues. In short, in this one session, the diagnosis is not clear. This is a man with a narcissistic character; a manic-depressive diagnosis must be ruled out. Because he could not make up his mind today about treatment and could not advise me how to refer him it was left that he will consider his assets, get more information about his insurance, and when he is ready to be referred he will be in touch with me so that I can be more helpful to him.
February 1987
Grace Franklin, MD/MTL
Mr. Scialabba remains ambivalent about therapy. He couches it in terms of his inability to afford any ongoing treatment, and I do think that is partly realistic. He asked whether Valium on a regular basis might be useful. As we discussed this, he mentioned an article by a prominent writer about using Valium for symptoms not unlike his. Unfortunately, she became a Valium addict, so Mr. Scialabba in effect answered his own question. I reaffirmed my views that many of the things he was coping with were characterological, and that was not an indication for Valium use. We did talk a bit about anti-depressants, whether they had a role in his treatment. Since I saw him last, he’s had two periods of depression, which were very short-lived, generally just a couple of days, and most of the time he’s been feeling fairly well. I don’t have enough of the indications myself to put him on anti-depressant, but I told him that I was fairly conservative about the use of drugs and encouraged him, if he wished, to have a consultation with a psycho-pharmacologist to see whether someone with this