It is with great pleasure that I launch a new feature for the Journal of Gay and Lesbian Social Services: Practice Notes. This is the first in what will be a series of contributions by social service professionals in the field: psychotherapists, group workers, community organizers, planners, researchers, and others. With the dawn of a new century, and all its attendant hype and retrospection, it seems timely for me to share some reflections on the evolution of my clinical practice with gay men over almost a quarter century. I need to begin with a few caveats since I am acutely aware that I am writing from an idiosyncratic perspective--- that of a sole practitioner in private practice in the heart of Manhattan's gay ghetto, Chelsea. My clients are all men and at least upper middle class in order to be able to afford my fee. They are overwhelmingly, but not exclusively, white, and all successful professionals. Thus, I write from a skewed and privileged place that does not address women, poor, or rural individuals. One example of the limits of my experience and vision is that at no time in my training (or career) have I ever provided service to a transgendered individual. In a similar vein, I have only once worked with one gay youth, and that was during the time I supervised a nongay drug treatment facility in rural New Jersey.
I don't feel any need to apologize for the composition of my client population. As I once had to remind one of my students, even privileged gay white men have issues and problems that they need professional help to address. Yet in order to insure that this column speaks to the enormous diversity that exists within the gay and lesbian communities, I invite social service professionals who work with other populations of gay or lesbian people, to contact me about submitting their own "Practice Notes" for publication (see below). My goal is by no means to set myself up as THE expert on practice issues with queer people, but to stimulate discussion and a hopefully lively exchange that can benefit all students and practitioners in the field. (Just the fact that today I have grown comfortable, and embrace using the term "queer" to refer to members of our tribe, as the late Paul Monette was so fond of calling our people, is one small example of my own personal and professional evolution over these past years.
When I applied to social work school in 1974 there was a question on the application that asked: "Are you a member of any minority denied representation in the health sciences field?" I answered: "Yes, openly gay men." In my admissions essay I described my history of gay community service, including but not limited to my experience providing gay peer counseling, and being a co-founder of the Gay Teacher's Association. My admissions interview at the Hunter School of Social Work was conducted by an orthodox Jewish woman professor wearing a wig, that almost fell off as I described my involvement with the gay community. She was not quite successful in concealing her contempt for, and dismissive attitude about the worthiness of any of these activities.
A few weeks later I received a telephone call from the admissions office inquiring whether I was still interested in applying because I had not shown up for my interview. There was an embarrassed silence at the other end of the phone as I explained that I had already been interviewed by Professor X. Apparently she was so upset about the interview, that she completely blocked any memory of me, or "accidentally" misplaced the record of my interview. Therefore, I was not surprised to receive my rejection. It is sweetly ironic that today I am on the faculty at Hunter, developed and for the past ten years have taught a course there on social work with today's lesbians and gay men.
In contrast to my experience at Hunter, the interviewer at the State University of New York (SUNY) StonyBrook School of Social Welfare was interested in my volunteer work. I was admitted with a teaching assistant's position for financial aid. As far as I can determine, this made me one of the first two people in the United States to be admitted as an openly gay person to a graduate program in social work. (The other person, my friend Paul Ramsier, a composer of classical music preparing to begin a second career, was also admitted as an openly gay man to StonyBrook at the same time). There were others who preceded us as openly gay students, but they came out only after being admitted to an MSW program, rather than during the application process. Thus I began my career as part of the first generation of mental health professionals who were openly gay throughout graduate school and training.
For my Master's Project, an openly lesbian fellow student and I developed and taught a five week mini course entitled "Lesbians and Gay Men: Colleagues and Clients." As far as I know, this course taught in 1977, was the first course taught at any school of social work in the United States on lesbian and gay issues. Most of the students who signed up used the class as a forum to help them in their own coming out process and discuss trying to integrate being openly lesbian or gay with their entrance into the field of social work, in addition to a place to get knowledge and skills for working with gay people. The administration was so supportive that the dean agreed to pay my expenses to travel to the annual CSWE (Council on Social Work Education) conference in Phoenix, once a submission to give a presentation on this course was accepted. It was at this conference that I met the late Patrick Moriarity, an openly gay employee of CSWE who informed me that the presentation that my colleague and I gave was the very first time that lesbian and gay course content had ever been included in a CSWE program.
My first year placement was at Manhattan's Institute For Human Identity (IHI), a gay psychotherapy center founded by pioneering lesbian social worker Bernice Goodman, and openly gay psychologist and activist Charles Silverstein. Bernice was my first year field supervisor, and an inspirational role model about how to integrate gay activism into professional social work and sound clinical practice. I was part of the first class of a two year training program offered by The Institute. My advisor at Stony Brook allowed me to use the training program at IHI as independent study.
I did not encounter any overt homophobia until I began interviewing for my second year placement. Not about to go back into the closet, during interviews for prospective placements I routinely raised the fact that I was gay and asked if this would pose a problem. Some interviewers stated directly that they would not accept an "acknowledged homosexual" in placement, and seemed indignant that I was turning the tables and asking about their position regarding openly gay trainees. Although this was a couple of years after The American Psychiatric Association declassified homosexuality as a mental illness (prompting several newspapers to proclaim: "The Single Biggest Cure of Homosexuals in History" ) NASW had not yet added nondiscrimination regarding sexual orientation into the professional code of ethics. Thus, there was no recourse against these agencies for their blatant homophobia.
There are significant differences between psychotherapy practice with gay men today, and practice when I first began this work over 20 years ago. During the late 1970s and early 1980s it was not unusual to work with many clients who were wrestling with coming out issues, as well as depression, anxiety, substance abuse, etc. I have not been consulted by anyone in over ten years who stated they wanted assistance in coming out as their primary presenting problem. In contrast, in recent years I have worked with several heterosexually married gay men who wished to remain married, and who wanted to explore a variety of ways to do this. Then there have been other heterosexually married gay men who consulted me as their marriages and lives as heterosexually identified men were ending, and they began to live as gay men. Among these men, those who were parents felt emphatically that they were ready to fight for joint custody of their children. Not one of these men was willing to relinquish his right to be an active parent, simply because he was gay. Perhaps not surprisingly, as an openly gay psychotherapist, I have literally never once had a client seek my help because he wanted to change his sexual orientation.
In the early days of my career many clients were often hungry for a gay role model, someone who could show them how to be gay in a way that felt authentic and meaningful. Just two decades ago, gay men saw their options for expressing a gay identity in a limited way-- passing, being queens, being hyper-masculine, ( the term back then was "Clones"), hyper-buff , or disco boys (yes, we even had disco boys back when I was a young man). Like my straight colleagues who were starting their practices, I had to know how to do therapy. But unlike them, I also had to learn how to be an effective and appropriate gay role model. Luckily, I had wonderful teachers in my first clinical supervisors, Dr. Harold Kooden and Bernice Goodman. Both were pioneers as openly gay and lesbian therapists. One of the biggest challenges inherent in being visibly present as a mental health professional serving our community was and remains that we live, work and play within the confines of a small community, even when that community is Manhattan's Chelsea, West Hollywood, South Beach, San Francisco or Dupont Circle. This close proximity is exponentially increased for those of us who do not work in large urban centers.
In the early days of my practice, alcoholism, drug addiction, and Hepatitis B infection were the only life threatening illnesses that were likely to kill the gay men who made up most of my clientele. But by the mid-1980s, I suddenly found myself with a clientele made up largely of gay men who were either symptomatic with AIDS or anticipating the onset of symptoms. Many of these men were under the age of 40. By the time that today's triple combination AIDS therapies arrived, over 150 of my current and former clients had died. In contrast, I have not had one patient die in the past five years. There is not even one seriously ill client currently in my practice.
Never having worked with clients who were critically ill, when my clients and friends began to learn about their HIV infection and become symptomatic, I had to learn a new set of clinical skills. During the early days of the epidemic I worked to help men with AIDS adjust to living with a life threatening illness and all too often prepare to die. All I really knew about counseling clients and their families at the end of life was Elisabeth Kubler-Ross's work on the stages of grief and loss. Back then, I remember being surprised and annoyed when my clients refused to follow the predictable, linear pattern she had laid out. Without realizing it, I romanticized death and unconsciously glorified each of my dying clients. I wanted to see them as noble and worthy of my care because of their nearing death, but I was constantly brought up short: People die in character. I didn't yet want to see that a self-involved man who became sick with AIDS might very well handle his illness narcissistically and die the way he had lived: thinking only of himself. I had to learn that I wasn't going to like every client simply because he was dying, and that death doesn't necessarily transform people for the better.
Today, near the end of the second decade of the AIDS epidemic in the United States and other developed countries, increasing numbers of people with HIV are living normally healthy lives, only with the disease. Although many are still dying from HIV-related illness, overall rates of illness and death in the developed world have decreased dramatically, largely due to the introduction of combination antiviral therapies, for those individuals lucky enough to have access to these treatments and the ability or health insurance to afford to pay for them. So many seriously ill people with HIV disease have seen significant improvements that combination therapies are described as producing a "Lazarus Syndrome," named for the biblical story about a man Jesus was said to have raised from the dead. Yet ironically, as news of the success of combination therapy has hit the mainstream media, client after client has arrived in therapists' offices with feelings that have ranged from anxiety to outright panic. After preparing for death, they now have begun to contemplate continued life. Some have even asked, "What if I don't die?"
From the beginning of this epidemic, mental health professionals have played a critical role in helping their clients make sense of the ever-changing terrain of life in the face of AIDS. Combination therapies indeed have changed the landscape of AIDS, but not in ways that have always been predictable or expected. In order to address these issues, all social service and mental health professionals need to understand the issues that have accompanied the arrival of combination antiviral therapies.
The changes brought about by combination therapy have created unique challenges for all social service professionals in two areas. The first relates to the rapidly changing knowledge base with which mental health professionals must feel comfortable in order to help their clients handle medical issues. Topics include the use of laboratory tests to assess the client's stage of illness, the importance of adherence to complex treatment regimens, and the side effects of the new therapies. Social service professionals also may have to help their clients make decisions about treatment; assure that their clients are knowledgeable about medications they are considering; assess the limitations of the medications' effects; and help clients explore the implications for choosing or not choosing to use them. Part of the decision-making process is helping clients understand the range of their options and their readiness to undertake treatment, and helping them feel empowered to make decisions. Providers must also appreciate the difficulties in making such decisions, including managing the differences of opinion that exist among medical experts about the best course of action. This area has become ever more complex and confusing to clients especially since physicians and scientists are not in uniform agreement about when the best time is to initiate HAART (Highly Active Anti-Retroviral Therapy).
Clients who regain their health may feel overwhelmed by other problems in their lives, such as addictions or unsatisfying relationships that previously may have been submerged by HIV disease. Some who regain a sex drive may face a broadening horizon of intimate relationships. This is an exhilarating prospect that may also bring complications, including the possibility of engaging in sexual behaviors that can spread the virus or expose clients to other sexually transmitted diseases or drug resistant strains of HIV. Many people who had become disabled from HIV related illnesses are feeling well enough to contemplate returning to work. Accompanying this development are crucial concerns about loss of benefits, and the ability to regain them if ever necessary, and having been out of the work environment for several years with the resulting loss of once current professional or vocational skills. All of these concerns produce understandable anxieties and concrete issues that must be addressed, for an individual to be able to assess his or her readiness to return to work. Finally, clients who do not do well on combination treatment or cannot tolerate these regimens may compare themselves unfavorably to others who are gaining a "new lease on life," and feel understandably as one client expressed: "It's hard to feel overjoyed by these new treatments when the so called Protease Miracle is passing me by." Many of these people report feeling like "failures." It is necessary for clinicians to remind people who are unable to follow the rigid medication schedules, or who can not tolerate the side effects, or whose strain of the virus is resistant to the drugs, that it is not they who are the failures, but rather that it is the drugs that have failed them. Conversely, some who are doing well on triple combination therapy report feeling guilty about friends who are not. Mental health professionals can be particularly useful in helping clients manage these feelings and complex issues.
These days, my gay clients rarely look to me to provide a role model. They are either younger gay men or gay peers dealing with life transitions, and a combination of the mental health problems inherent in any practice, but within the unique frame of being gay. Counseling male couples has always been a component of my clinical work. Recently there have been some interesting new dimensions to working with gay men creating families. In the past year I have begun working with two groups of men in three-way relationships to help them become stable affectional family units. The phenomenon of 'out' gay men choosing to parent and have children is also a thrilling and life affirming part of my clinical practice, as is the accompanying family therapy work with these queer families.
Not infrequently my clients' situations and issues parallel those of my own life. This is one reason I remain in ongoing clinical supervision with a senior therapist. Therapy is a very isolated profession-a great deal goes on behind the closed door, and it's up to the clinician to know the limitations of his or her knowledge. Using supervision has helped me to see my blind spots and monitor my work to insure that my interventions remain appropriate. It's a humbling experience. With our clients, we bring a certain power and authority-even the least authoritarian of us-but in supervision we have to face our self-doubts, admit our mistakes, notice our ruts, tendencies, and deal with the ever-present countertransference.
Mental health and social service delivery to sexual minorities has undergone a transformation in the past quarter century that has evolved from one of almost universal pathologization to one of acceptance of the diversity of affectional and sexual orientations that has been nothing less than revolutionary. Perhaps the biggest indication of the development of our profession in this regard is that all three professional associations have officially condemned efforts to get an individual to change his or her sexual orientation. These changes and the complex ways that queer people are, (and always have) built rich and meaningful lives as well as complex communities has only increased the need that members of our tribe have for compassionate, sophisticated and nonhomophobic delivery of health care, mental health and social services. We are each in a position to help provide these services as well as to train another generation of professional providers in these issues. Additionally we have a responsibility to constantly monitor the quality and caliber of services provided by ourselves as well as our colleagues, both gay and nongay and the institutions in which we work to be ever vigilant to and confront injustices or poor quality treatment to any person. It is crucial that each of us rise to these obligations and challenges, both for people today as well as for the generations to come.
In my next column I will write about ways that the internet has changed and can effectively be integrated into clinical practice.
Michael Shernoff, MSW is in private practice, and is on the faculty of Hunter College Graduate School of Social Work. He is senior consulting editor for this journal, contributing editor for In The Family Magazine, and is the online mental health expert for The Body.com, the world's largest HIV/AIDS web site. His newest book, The Psychosocial Challenges of HIV Medical Treatment: A Guide for Mental Health Professionals is in press and will be published by University of California San Francisco AIDS Health Project. He is also editor of: AIDS and Mental Health Practice: Clinical and Policy Issues; Gay Widowers: Life After The Death of a Partner; Human Services for Gay People: Clinical and Community Practice;CounselingChemically Dependent People With HIV Illness; and co editor of The Sourcebook on gay and Lesbian Health Care; Volumes 1 and 2 and The Second Decade of AIDS: A Mental Health Practice Handbook. He authored four entries in the Encyclopedia of AIDS, an entry in The Encyclopedia of Social Work on Individual Practice With Gay Men and over fifty articles on psychosocial issues of HIV/AIDS and mental health for gay men. He can be reached via his web site at http://www.gaypsychotherapy.com
If you are a social service professional--- psychotherapist, group worker, community organizer, planner, or researcher, and wish to send me your comments about this premier Practice Note, or your own Practice Note (not to exceed 25 pages), please follow the Instructions for Authors that appear in this issue, and send your manuscript to me either via e mail at Mshernoff@aol.com,