In Press: Foundations of Social Work Practice, G. Mallon editor, Harrington Park Press.
Direct clinical practice with gay men in the 1990s is a vastly different area of expertise than it was even ten years ago. This article illustrates that there is no one typical kind of gay man nor one typical presenting problem for gay men seeking social or psychological services. While HIV/AIDS has had a pervasive and devastating impact on the individual and communal psyches and lives of the members of the gay men's community, it is by no means the only significant mental health issue for which gay men seek professional clinical social work services. This chapter summarizes the variety of issues, dynamics and techniques required to work effectively with adult gay men at different points in their development and life cycles.
Social workers preparing to do individual practice with men who identify as gay need to understand that these clients will present at any social service or health care agency or in private practice seeking direct or clinical social work services. These men may be at any stage of the life cycle, and it is crucial that social workers do not make any assumptions about the nature of these clients or their presenting problems prior to doing a complete psychosocial assessment. In addition it is important for social workers to understand that men who simply have sex with other men, repeatedly and over time, may never identify themselves as homosexual or gay (Kinsey, Pomeroy & Martin, 1948). Thus in order to successfully intervene with this population, social workers should familiarize themselves with the various stages of gay identity formation that homosexually active men may be at in the process of forming an identity as a gay man (Cass, 1979; Coleman, 1988; Isay, 1989).
Germain, (1981) and Gitterman and Germain (1976) both discuss social work practice in terms of both understanding and being able to intervene on both the ecological or environmental level as well as with the individual client, and his or her immediate system. Germain (1980) explains that "ecology seeks to understand the transactions that take place between environments and living systems and the consequence of these transactions for each." She then goes on to elaborate on how an ecological perspective is a useful lens for through which to examine the social context of clinical social work. It is essential for worker to incorporate an ecological perspective into their clinical work with clients from any marginalized population like racial, ethnic or sexual minorities. It is only through utilizing this broad systems perspective that a worker will be able to understand and correctly reflect back to the client how the biases and assumptions of the mainstream culture have impacted upon them, and contributed to their unique psychodynamic and psychosocial realities. In the case of gay men, this means that an awareness on the worker's part about how the pervasiveness of both societal and internalized homophobia, as well as heterosexual bias has effected the client's development, self-image and current functioning, both adaptively and maladaptively. The material in this chapter is based on over twenty years of direct clinical practice with gay men, initially in agency work and private practice, and since 1983 exclusively in private practice. Additionally, the author draws on experiences from supervising clinical social workers in practice with gay men.
Gonsiorek and Rudolph (1991) state that developing a gay identity would be highly sensitive to cultural, class, socio-economic, racial and ethnic variation. Economic privilege provides middle class gay men with opportunities to experiment with forming gay identities that is lacking for men who must continue to live with families and rely upon them for concrete support. Therefore one area that will be tremendously useful for any social worker seeking to provide services to gay men is to develop cultural competency in order to have the sensitivity and skills necessary to work with men who come from various racial, cultural, religious and economic backgrounds.
It is a mistake to make assumptions about who is and who is not gay simply on the basis of appearances. A client may in fact be gay who looks and initially presents as indistinguishable from a heterosexual man. Many men who have a current self definition as gay went through periods of their lives when they attempted to hide their homosexual feelings from themselves and others, some married and fathered children (Ross, 1983). Other men choose to remain married even after accepting their homosexual feelings (Wyers, 1987). With increasing frequency, openly gay men are choosing to adopt or actually father and raise children (Martin, 1993; Shernoff, 1996). There are times that these men are reluctant to seek out services from openly gay clinicians out of fears of being pressured into coming out or ending long term marriages to women. Ultimately the only way a worker knows with certainty that a client is gay is when and if he chooses to disclose his sexual orientation. It is never the goal of treatment to make the client feel that he must reveal his sexual orientation, but rather that the worker can tolerate his or her own discomfort with the client's unwillingness to label where he may be on the spectrum of sexual orientation.
Social workers need to be prepared to work with some heterosexually married male clients who are sexually active and even romantically involved with other men. Counseling these men is complex, and the clients will be alert to any indications of being judged by the worker. Bozett (1981) points out that these men often experience difficulty in achieving a positive gay identity in part because of the perceived incongruity between the two identities of father and gay man. When a heterosexually married, but homosexually active man is HIV sero-positive or has AIDS there are potentially complicated legal and ethical questions for the clinician if the client has not disclosed his health status to his wife.
Wyers (1987) posits that formerly married gay men are likely to fall into two different groups. When the men have not fully acknowledged to themselves or to others that they are homosexual, the services they require are similar to the services needed by other gay men who are in the early process of coming out. After resolving some or many of their personal problems with being homosexual, they may need assistance in working out relationships and custody issues with their former spouses and children. Concerns about custody of or at least access to children is of prime importance to gay fathers. When a gay man has children who live with him at least part time, family therapy is very useful, especially if the client resides with a male lover and step-parenting concerns need to be addressed (Shernoff, 1984).
There are no stereotypes or generalizations which are universally relevant to all gay men.
Differences exist in class, ethnicity, health status, rural or urban environment, and stage of gay
identity formation. The skilled social worker must assess the impact of the above issues in
addition to the individual's psychodynamics, ego strengths and social supports. For instance, a
middle class gay white man who lives in one of the large cities and who does not conceal his
sexual orientation from family, friends, colleagues or employer may view being gay as his primary
cultural identification of at least equal importance to his religious or ethnic background. In
contrast, a poor inner city gay man of color often views his experience of being black or Latino as
the primary way he relates to the world and to a social service agency or practitioner even if the
presenting problem is somehow associated with his homosexuality.
Commonly, African-American gay men feel torn between loyalties to homophobic black community institutions or families and racist gay white culture (Loiacano, 1989). The author's experience has been that successful professional gay African-American men in his practice have reported a significant degree of pain about the lack of acceptance for them as total human beings within either of their two communities. The most self-actualized clients in this category find deep nurturance within the traditional institutions of the African-American community and at the same time developed a peer support group of other gay men of color, who functioned as additional family.
Understanding and responding to cultural differences becomes crucial when attempting to intervene with nonwhite gay men around such life threatening situations as AIDS prevention efforts. De La Vega (1995) notes that "it is difficult to speak of sexuality issues among Latinos in the U.S. as if they were just one homogeneous group of individuals." The worker must be alert to distinctive differences of clients of various Hispanic nationalities. For instance, a gay man from Argentina will not have many cultural identifications with a Mexican American or a Puerto Rican.
Carballo-Dieguez (1988) points out that when counseling gay Latino men, religion and folk beliefs must be considered. The impact of conservative Catholicism and its emphasis on traditional values (which strongly reject gay love or sexual expression) is a powerful influence for most Latino men. Although gay Latino men will generally refrain from discussing Santeria and Espiritismo (Spiritualism) with non-Latino professionals out of fear that they will not be taken seriously, these widespread folk beliefs should be explored in counseling and therapy with gay Latino men (Carballo-Dieguez, 1988).
Similar issues arise when working with Native-American gay men. Tafoya & Rowell (1988) write that "one must remember there is no such thing as "the" American Indian; rather, there are literally hundreds of different tribes with different languages, customs and world views. Native American gay and lesbian clients often combine elements of common gay experiences with the uniqueness of their own ethnicity. To treat them only as gay and to ignore important cultural issues may bring therapy sessions to a quick end with little accomplished."
Chan (1989) explains that for Asian-American gay men identifying as gay may be perceived as a rejection of traditional family roles and Asian cultural values. However, to identify as Asian-American may require negating one's gay identity, at least within the family. Therefore Asian-American gay men often develop a dual identity that encompasses both facets of their cultural identification.
Little is known about the lives of rural gay men and the barriers they encounter when in need of social services (Gunter, 1988). Moses and Bucker (1980) have identified specific problem areas, such as the clients' isolation, fear of discovery of their homosexuality, and the effects of generalized anxiety on self-image. They go on to address issues that a professional should consider when providing services to rural gay men. These included clients' misconceptions and attitudes about being gay, lack of local resources and information systems, limited options and alternatives and the need for the worker to assess the situation realistically.
Breeze (1985) discusses the need for legal assistance and networking services in order to
intervene effectively with this population. He asserts that the professional must be prepared to
become involved in some or all of the following activities in order to work productively with rural
gay men: advocacy work, educating professionals and other service providers about problem
areas and actively enlisting support from other sympathetic professionals.
Gunter (1988) cautions against the assumption that the majority of gay men and lesbians are natives of the metropolitan and suburban environments in which they end up living. "Individuals who have successfully adapted to a gay lifestyle within a metropolitan area may have difficulties during visits home or when family and friends visit the city" (Gunter, 1988, p.50).
In the same article, Gunter explains that confidentiality is a difficult issue in rural communities since many agencies utilize para-professionals and volunteers to provide services. There is a legitimate fear on the part of the gay individual seeking services that his or her sexual orientation will be disclosed to other members of a small community, resulting in ostracism or worse. This fear of exposure limits the gay individual's activities and prevents successful identification with other gay people. The rest of this article will focus on individual clinical practice issues relevant to gay men.
Gay men who seek social work services manifest all the symptoms and present the same variety of problems as do every other kind of client. In addition, they often have some unique issues arising from their sexual orientation, including: adaptation to their current stage of gay identity formation (Cass, 1979, Coleman, 1988); the impact of homophobia, which is defined as the "negative attitudes toward homosexual persons and homosexuality" (Herek, 1990, p.552); social stigma; a sense of isolation and alienation; coming out; rejection by families of origin; being victims of anti-gay violence and the impact of AIDS on their own lives and the lives of their friends and lovers. When gay men are economically disadvantaged, their needs for social services like public assistance, food stamps, Medicare or housing if they are homeless, take precedence over issues related to sexual orientation.
"The lesbian and gay communities have been living with the traumatic impact of HIV/AIDS for over a decade. Assessments of the coping and adaptation patterns of gay men seeking psychotherapy have to include the effects of trauma." (Mancoske and Lindhorst, 1995, p.31). The same authors correctly postulate that the paradigm shift from pathology to empowerment of the oppressed is challenged to expand yet again to models of empowerment of the oppressed who are living with ongoing trauma.
In 1973, the American Psychiatric Association ceased to specify homosexual adjustment as psychopathological (Bayer, 1981). The American Psychiatric Association's official position is that "...homosexuality itself is not considered a mental disorder," (American Psychiatric Association, 1987). Letters to the Editor, in NASW News, the organization's newspaper, during 1993 concerning so called "Reparative Therapy For Gay Men" to help them change their sexual orientation, demonstrate that some social workers in North America remain convinced otherwise (Theriot 1993a, Theriot, 1993b). There are still some clinicians who try to change a client's sexual orientation, though there is no evidence that this is possible and there are strong indications that it has a deleterious effect on the client (Davison, 1982; Martin, 1984). Numerous men have arrived in the author's private practice profoundly depressed and/or highly anxious as a direct result of failed psychotherapeutic attempts to change their sexual orientation. These clients need nurturance in the form of helping them understand that there is nothing intrinsically wrong with their sexual orientation, and that society's homophobia and intolerance is the cause of their distress. One way of accomplishing this is through the use of bibliotherapy, where gay affirmative readings are assigned and discussed during sessions. Sometimes just the assignment of going to a lesbian or gay book store and having the client browse will be a powerful initial healing intervention when he sees so many titles that reflect the diversity of the gay community. Theoretically, this kind of intervention represents the kind of synthesis of both ego-psychology and the ecological social work perspective discussed by Germain (1978).
Smith (1988) makes the point that "an understanding of the intrapsychic and psychosocial factors contributing to psychopathology in homosexually oriented persons requires a clear appreciation of the role of homophobia" (p.62). Since gay men do manifest psychiatric illness, social workers must be skilled in diagnosing any psychiatric symptoms in order to be most helpful to clients.
Clinical social workers need to be aware that gay men seeking treatment can present with indications of severe anxiety or depression, thought disorder, persistent characterological problems, chemical dependency, neuropsychological impairment, psychosis, etc. These symptoms may be in addition to or instead of issues related to societal oppression and coming out (Gonsiorek, 1982). "The coming out process by itself can produce in some individuals psychiatric symptomology that is reminiscent of serious underlying psychopathology" (Gonsiorek, 1982, p.11). In addition many high functioning gay men seek out therapy for help in improving the interpersonal areas of their lives. This takes the form of men who are professionally successful and who have friends, and by all appearances live a self-actualized life, but are not happy about the lack of a satisfying primary romantic relationship.
Chronic low grade depression is often the reason gay men seek therapeutic assistance. These symptoms can sometimes arise out of uncompleted developmental stages of gay identity formation in individuals experiencing a conflict between behaviors and values when they are still undisclosed to important people in their lives about being gay (Smith, 1988). In other gay men, long term symptoms of depression are masked by substance abuse and only emerge after the individual begins recovery from chemical dependency. Clinical social workers working with gay men must become skilled in diagnosing depression and urging clients to have consultations with a gay sensitive psychopharmacologist regarding beginning a treatment regime of anti-depressant medication.
For some depressed gay men, therapy needs to facilitate disclosure (when appropriate), and peer socialization. The sense of belonging to a community and the formation of a network of support among friends and family will protect against decompensation during times of stress. A decrease in social isolation, if present, must be a goal in psychotherapy (Smith, 1988).
Once again using Germain's (1980) description of an environmental or ecological approach to clinical social work is a useful theoretical framework for making appropriate interventions with gay men that are actually within the realm of "milieu therapy." For example, introducing the concept of "homosocializing" (Isay, 1989) to a client. Often it is appropriate to explore the client's knowledge of gay social organizations and clubs where he might go to meet other men who have similar interests. In order to help facilitate the development of relationships with peers, social workers need to be aware of local resources for gay clients, and how to direct the client in their direction. Most large cities now have gay political, athletic, social and religious groups that can provide clients with the opportunity to strengthen affiliations with other gay men.
Many gay men do not accomplish the normal developmental tasks of adolescence, such as forming a peer group, exploring sexuality, experimenting with intimacy and initial forays into love when they are in their teens or their twenties. Therefore when experiencing some of the turbulence and emotionality of teenagers as adults in their twenties, thirties or even older, there is a dissonance between chronological age and the developmental tasks they are struggling with. This discrepancy between age and developmental tasks is often the source of high anxiety and/or depression that is resolved as the man gains mastery over these new situations. Thus there are frequently aspects of psychotherapy with gay men that are in fact counseling rather than intrapsychic explorations of unresolved feelings. Very often the content of therapy sessions will focus on how to learn the various social skills necessary to meet and date other men, and similar issues relating to practical concerns like safe sex.
During the course of therapy, most gay men will easily recall and discuss early childhood memories of feeling different and bad which they connect to their homosexuality. These recollections are important to explore, yet the skilled clinician must also lead his or her client in an exploration of experiencing difference that has its etiology before feelings for members of the same sex began to emerge (Shernoff & Finnegan, 1991). Once explored, this early sense of being different can relate to family secrets like a parent's drinking, childhood sexual abuse, or simply to being the only one in a blue collar family not interested in sports.
Social workers should also understand that growing up gay in a heterosexual family is, by its very nature, a dysfunctional process - unless the family is not homophobic (Shernoff & Finnegan, 1991). This is not to say that being gay is dysfunctional; rather, when people grow up in a family system where they cannot be or acknowledge who they truly are, they are placed in a system of dysfunction. A gay youth then must create a false self that he presents to his family in order to survive. Very often the gay adult is still maintaining a false self in some components of his life, whether it be work, family or with non-gay friends. The intrapsychic toll that this takes, and how it is manifested in either symptoms of depression or anxiety are often the material of psychotherapeutic treatment with gay men. The toll of hiding one's true self, must be identified and validated in order for the gay man to be able to move on and develop a positive gay image not based on shame and the need to hide (Shernoff & Finnegan, 1991).
Mentally retarded gay men, like all others who are mentally handicapped, have sexual needs. If the retardation is not severe, and the individual is able to live independently then he is likely able to find partners as part of his adjustment to adulthood. Social workers in agencies that serve this population must take the lead in developing interventions which teach safer sexual practices regarding preventing AIDS.
Smith (1988) explains that for those with a severe handicap, the attitudes of care-givers are important. Expressing a need for sexual release may be viewed as "acting out," rather than the expression of a legitimate need, especially if the sexual desires are for a person of the same sex. On the other hand professionals who condone or facilitate sexual expression between gay clients may find themselves vulnerable to accusations of "condoning" homosexuality, which in fact they are.
Gay men with severe psychopathology who have had multiple psychiatric hospitalizations are often clients in day treatment programs. Social workers in these settings need to be alert to gay clients, and how issues pertaining to their sexual orientation may exacerbate psychiatric symptoms. Ball (1994) discusses how these clients' psychosocial potential can be maximized in a group that addresses issues relating to their sexual orientation, including their double stigmatization as both mental patients and homosexuals. Ball also notes that psychiatrically disabled gay and lesbian clients must often leave their rehabilitation program to find support for their social and sexual needs. Yet in more mainstream settings within the gay community, these clients report feeling awkward because of their mental health history. Houston-Hamilton et al (1989 discuss that like all people, clients who are severely emotionally disturbed need education about AIDS that is customized for them.
Stall and Wiley (1988) reported that gay men not only used drugs more often but used a greater variety of drugs than did heterosexual men, and Shernoff (1983) reported incidence of injected drug use among middle class gay white men. Despite different geographic areas and sampling methods used in studies, there is strong evidence that gay men have more problems related to substance abuse than do heterosexuals (McKirnan & Peterson 1989). Explanations for this phenomenon include internalization of society's homophobia, nonacceptance of self, fear of coming out, leading a double life and low self-esteem (Finnegan & McNally, 1987; Kus, 1988; McKirnan & Peterson, 1988).
Faltz (1988) notes that often gay men have sought treatment for relationship difficulties, depression, anxiety, compulsive behavior or phobias and have never been asked about, nor have they mentioned their drug or alcohol use. Thus social workers should be skilled at diagnosing substance abuse problems, and need to take an alcohol and drug use history of each gay client seeking clinical services.
Finnegan & McNally (1987) described the stages of coming out as lesbian or gay and how these experiences affect chemically dependent behavior. Commonly, a client may be in one stage of denial about his chemical dependency and in another about being gay. To be effective the worker must assess both stages of denial in order to formulate an effective treatment plan. Ratner (1993) cautions that the clinician should be wary of clients who enter treatment claiming to be comfortable with their sexual orientation and therefore insist that talking about life-styles is unnecessary.
Shernoff & Finnegan (1991) suggest that a client's chemical dependency is not always the only justifiable focus early in treatment. There are times when people's concerns about their sexual orientation may demand attention if they are to get or stay clean and sober. For instance, counselors need to recognize that sometimes it is very important to validate clients' bitter or pained assertions that homophobia has seriously contributed to their use of chemicals.
A worker in a detox unit or other substance abuse facility may encounter an individual who does not identify as gay or bisexual and who has trouble maintaining his sobriety. This kind of client has repeatedly relapsed into active use of chemicals even when attending AA meetings and ostensibly working his program. In an attempt to help the client make sense of why he is unable to remain sober, it can be helpful to explore with this client the possibility that he might be struggling with feelings or fantasies related to being attracted to other men, even if he has never acted on these feelings.
The AIDS epidemic has contributed to the urgency of addressing gay men's chemical dependency. Stall (1988) has documented that a majority of men who fail to practice safer sex to prevent the transmission of HIV are under the influence of alcohol and/or drugs. Greene and Faltz (1991) discuss treatment strategies for gay men with a history of sobriety who relapse upon learning that they have been exposed to HIV or after an AIDS diagnosis.
Social workers must be alert to instances where a gay client is either a victim or perpetrator of domestic violence. Walber (1988) discusses that no group within the gay community, regardless of race, class, ethnicity, age, ability, education, politics, religion, or lifestyle is exempt from domestic violence. Gay men can be battered or abused by a lover, ex-lover, roommate or family member.
The worker may have difficulty identifying either a batterer/abuser or a survivor. Being abusive is not determined by a gay man's size, strength or economic status. Gay men who batter or abuse can be friendly, physically unintimidating, sociable and charming. Gay men who are battered or abused can be strong, capable and dynamic (Walber, 1988). The issue in domestic violence, however, is control and it is this unequal power relationship that distinguishes battering from fighting. Reports from both batterers and survivors are that abuse and violence most often occur when the abusive individual is under the influence of alcohol and or drugs.
It is important for the clinician to remember that it usually is no easier for a gay man to leave an abusive or violent relationship than for any other abused spouse to do so. Battering relationships are rarely ONLY violent or abusive. Love, caring and remorse are often part of the cyclical pattern of abuse. This cycle can cause a survivor to feel confused and ambivalent about the nature of the relationship (Walber, 1988).
Berrill (1992) reports that thousands of episodes--including defamation, harassment, intimidation, vandalism, assault, murder, and other abuse--have been reported to police departments and to local and national organizations (NGLTF Policy Institute, 1991); while countless more incidents have gone unreported. Wertheimer (1992) notes that although lesbians and gay men are prone to a level of victimization which far exceeds that of the non-gay population, existing crime victim service networks have largely failed to acknowledge gay victims of violent crime. He further contends that regardless of whether this failure has resulted from ignorance, neglect, or conscious hostility, its consequence is that gay people still frequently suffer the often devastating consequences of victimization in isolation and silence. As a result, the initial physical and psychological injuries that follow an assault are compounded. Wertheimer (1990) also asserts that most crime victim service providers remain unfamiliar with and insensitive to the needs of gay crime victims. Consequently, gay men who report crimes committed against them frequently must choose between hiding their sexual orientation from the service providers or disclosing it and risking ridicule and revictimization.
Social workers can offer invaluable assistance to gay victims of anti-gay violence in a number of concrete ways. After an assault, a gay client will desperately be in need of an ally who can assist during the period immediately following an attack. A social worker should be prepared to advocate for the client with both the local police precinct and prosecutor's offices, by accompanying the survivor to police stations and to interviews with prosecutors. This support helps insure that officials treat the survivor with sensitivity and respect.
Gay victims of hate crimes need skilled professional assistance in working through their responses to the attack, turning the initial trauma into a potential growth experience(Garnets, Herek & Levy, 1992). Helping the client transform his experience from that of a victim to one of a survivor is key. Garnets et al (1992) suggest that the cognition that "Bad things happen because I'm gay" can be reformulated to "Bad things happen." They also discuss the need for mental health workers to help survivors of anti-gay sexual assault to separate the victimization from their experience of sexuality and intimacy.
Berger, (1984) states that older gays and lesbians are most vulnerable to social, economic and psychological forces, and therefore, are likely to come to the attention of social workers. Berger's research found that the social recluse did exist, but most older gay men studied function in networks of friends, lovers and family as well as social civic and religious organizations within the gay community. The same study found that the majority of respondents were still sexually active, but not as frequently as in their youth. Social workers serving the elderly must learn about these networks and use them as available resources for older gay clients to meet other people.
Older gay people need the same services as all older people (Berger, 1984). Berger (1980) found that older gay men reported less depression and fewer psychosomatic symptoms than younger gay men. Older men in the midst of a transition to a newly acquired gay identity may seek out counseling for help with this passage (Berger, 1984). Social workers may also be of assistance in responding to an older gay client's request for a gay visitor from the friendly visiting service. Social workers in nursing homes can be helpful to elderly gay clients by trying to facilitate that roommates be other gay residents if so desired, or providing counseling to the male couple when one member is placed in a nursing home. Clinicians may also be called upon to provide bereavement counseling for the surviving partner of a gay couple.
In order to work effectively with today's gay men, social workers simply can not underestimate the pervasive impact that more than a decade of HIV/AIDS has had on gay male communities as well on individual and collective psyches. "Understanding that trauma creates an unexpected and dramatic shift in feelings of safety and connection to others is vital to comprehending the intrapsychic and interpersonal issues of many people affected by HIV/AIDS in the gay community" (Mancoske & Lindhorst, 1995, p. 30). Rofes (1996) notes that "many gay men throughout America are suffering a wide range of psychological responses that extend beyond bereavement and grief. Some may be at the stage of simple grief or multiple loss, but many others are experiencing severe depression, mood disorders, trauma, chronic trauma and post-traumatic stress disorder(p. 26)." Rofes goes on to explain that he is not attempting to pathologize gay men, but rather seeks to document the critical psychological reactions to AIDS of contemporary gay men. Almost all gay men have been directly effected by HIV/AIDS. Every time a gay man has sex, he is reminded of the potential lethalness of an unprotected act. Most gay men living in large urban centers have had at least one friend or lover become ill and die. It is not uncommon for some men to have experienced many friends and in some cases entire friendship networks predecease them.
For both the uninfected and men living with HIV/AIDS the result is a chronic state of grieving and what has been termed "bereavement overload" that manifests itself in symptoms that are identical to post traumatic stress disorder. Only since the traumas are chronic, there is little opportunity for resolution of the situation, or reduction of the precipitating stressors. As Mancoske and Lindhorst (1995) state: "People in the gay community are struggling to create new models and definitions of "family (p. 33)." The advent of HIV/AIDS further complicates this struggle. The care giving provided within families of choice is fatiguing. Exhaustion becomes a major factor for individuals with multiple friends/partners/family members who have become ill. Few supports have been developed to provide relief. These supports are particularly underdeveloped in rural areas, and overwhelmed in urban areas most heavily impacted by the epidemic (p. 33)."
The psychodynamics of the impact of AIDS on the uninfected has just recently begun to explored in work by Odets (1995) and Ball (1996). The uninfected are a population in dire need of psychosocial supports that both provide a place for them to express their feelings about the impact that having survived the epidemic so far has on them. In addition the life saving work of helping insure that these men remain uninfected is often best accomplished in psychotherapy or groups composed only of HIV negative gay men. These men often present with symptoms that are similar to Post Traumatic Stress Syndrome, and often include survivor guilt. With increasing frequency there are reports that some HIV negative gay men behave in ways that place themselves at risk for becoming infected. Often these men report having difficulties adjusting to their roles as survivors. Their emotional distress must not be minimized or neglected in counseling. Odets (1994), explains that in many cases HIV-negative gay and bisexual men have a psychological experience--a personal and social identity--that is more that of a sick or dying man than that of many HIV-positive men.
An important dynamic that clinicians must remain alert to when working with in this population is "survivor guilt" (Moon, 1992). Odets (1995) describes how the clinical presentation of these clients is unusual. He states that the impact of AIDS on the man's community and sense of self creates an exceptionally potent stressor. Treatment consists of addressing the consequent depressive and manic defenses, fear for one's health, hypochondriacal anxiety and sexual dysfunction (Odets, 1995).
For men who are themselves infected or are symptomatic with full blown AIDS there are understandable worries about who will take care of me now that most of my friends have died? Living with AIDS in the second decade of the epidemic is a vastly different experience than it was in the early years of this plague. Today 5% of gay men who have a documented exposure to HIV for at least ten years are still remaining asymptomatic (Cao et al, 1995). The National Institute of Health has labeled people who have a documented exposure to HIV for ten or more years and who remain asymptomatic "nonprogressors." Nonprogressors live with constant dread of their health status changing, and all of the corresponding anxieties that this brings. They have also seen numerous friends and loved ones become ill and die. They are ever vigilant for any indication that their lives have begun to move onto the path that they have watched so many others travel. This often results in these men suffering from symptoms of an anxiety disorder. A systemic mental health approach that helps these men identify remaining sources of social support and utilizing these supports is critical in order to maximize their psychosocial functioning.
In addition to the nonprogressors there are now long term survivors of AIDS. In 1990 the CDC defined long term survivors as individuals who have been diagnosed with a major opportunistic infection for at least three years and are alive with a reasonably good quality of life (Moore et al, 1991). Some of these individuals may still be employed full time. "When viewing HIV as a chronic, life-threatening illness, a strengths perspective helps orient clients to the long haul of being HIV positive or of being a long term survivor" (Mancoske & Lindhorst, 1995, p.36). Interventions include supportive counseling to help individuals sustain their intimate relationships, while letting them express all of the discomfort that accompanies living with such a stressful and uncertain condition.
Remien and Wagner (1995) find that mental health professionals can help clients manage the following issues: uncertainty about the future, grief reactions to multiple loss; accessing support networks; romantic relationships; managing a satisfactory relationship with his primary care physician; deciding about treatment options; the progression of symptoms and career decisions. With many of these individuals numerous therapeutic hours are spent evaluating the costs versus the benefits of going on full time disability before they become too debilitated to enjoy retirement. Remien and Wagner (1995) specify that therapeutic tasks include: validating emotional reactions; focusing on short term goals; facilitating feelings of empowerment; obtaining concrete services; assessing psychiatric risk and suicidal ideation; promoting adaptive coping strategies; fostering family communication and cooperation; and talking about the meaning of death and dying.
HIV antibody testing centers, community based AIDS service organizations (Lopez & Getzel, 1984), hospitals, home health care services, private practice are all settings where gay men receive social work services. With the onset of AIDS, gay men seek therapy for a variety of new reasons: fears about getting AIDS(Forstein, 1984); the trauma of learning one is HIV positive; telling one's parents about a diagnosis of HIV sero-positivity or of AIDS; learning to live with AIDS; exploring new priorities; approaching the end of one's life; and bereavement overload as a result of decimated friendship groups.
In addition to helping clients with AIDS obtain needed services and benefits, social workers have an important role to play in providing psycho-social support to those living with AIDS and their loved ones (Gambe & Getzel, 1989; Shernoff, 1990; Getzel, 1991). A key component of psychotherapy with this population is to help clients manage the anxiety disorders which are probably the most frequent psychiatric complications of HIV disease in both those who are uninfected, yet at high risk, as well as those symptomatic of HIV disease (Dilley & Boccellari, 1989). Depression in people with AIDS and symptomatic HIV disease is common (Dilley & Boccellari, 1989); clinicians must be alert to the possibility that the depression can be organic in origin and usually responds well to psychotropic medication. Helping clients balance hope with the realities of living with a life threatening illness is another essential component of counseling.
"The bereavement process experienced by gays and lesbians who experience losses due to HIV/AIDS must be understood as a chronic state of mourning. The implications of overlapping losses where the onset of mourning for one loss overlaps with the end stage of mourning for another loss are significant. Complicating this chronic state are post traumatic stress, loss saturation, unresolved grief, survivor guilt, and fear of infection with HIV" (Dworkin & Kaufer, 1995, p.42). "Not only are gay men losing those with whom they have shared strong emotional ties, but they are also losing acquaintances, role models and co-workers at a very fast rate" (Dean, Hall & Martin, 1988, p.55). Thus individual clinicians have to be prepared to assume a role of support and bearing witness that transcends traditional psychotherapy or counseling. The experience of many urban gay men is similar to a survivor of a catastrophe, and must be addressed with this understanding and within this context. Doka (1989) explains the concept of disenfranchised grief which occurs when (a) the relationship is not recognized, (b) the loss is not recognized, and (c) the griever is not recognized. These are ordinary experiences for many gay men mourning a friend, lover or community. As Dworkin and Kaufer (1995) correctly note, "all of these factors must be taken into account in redefining the process of grieving and identifying the coping mechanisms and interventions appropriate for responding to the needs of today's gay men (p.43)."
Following the death of his lover, the surviving partner may not receive condolences from family or workers who do not view a gay relationship as the equivalent of a marriage. This absence of understanding and support only increases the pain and anger surrounding his loss. Social workers doing individual counseling must be aware of these additional issues which have an impact upon a gay man's grieving process, and find ways to elicit feelings of anger and shame that may surface in the absence of appropriate support while also actively consoling the grieving partner. Referring gay widowers to an AIDS bereavement group is often one helpful intervention in assisting the surviving partner to work through his grief.
Dworkin and Kaufer (1995) suggest that bereavement interventions also need to respond to developmental issues, existential themes, multiple and chronic primary and secondary losses, and the collective nature of grieving. They must be gay affirmative in addressing lowered self-esteem, personal identity and questions about body image, and need to address the reestablishment of meaning in one's life. Many authors cited by Dworkin and Kaufer (1995) emphasize that social support is the key to coping with any loss, especially multiple loss. Yet with many entire friendship networks being wiped out by this plague, the therapist assumes a role and significance that may be a combination of counselor, friend, significant other and just fellow human being. The weekly sessions may be the only remaining ongoing regular contact with any individual with whom the client has a history.
Any social worker in practice with gay men with AIDS has to be adept at knowing how and when to introduce topics about dying into the clinical conversations. As people develop symptoms of advanced AIDS they increasingly lose control over their bodies and lives. One task of counseling is to help people living with HIV and AIDS recognize what they can control. Clients living with HIV require help in planning for hospitalizations and debilitating illnesses. It is best to raise the difficult and painful issues associated with executing wills, advanced medical directive, living wills and medical proxies long before there is any apparent need for them. One major issue for dying people is that they are at a point where their ability to control what happens to them has been greatly diminished. Clients at the end of their lives can be greatly empowered by therapists or counselors engaging them in a discussion about where they want to die. Many clients may not realize that whether to die at home, in the hospital or in a hospice is a decision that they and their loved ones can and should consciously make together in consultation with the physician. It can be enormously helpful if the clinician or hospital social worker raises the issue of, and explains the concept of hospice care.
It can often be difficult for all concerned to acknowledge that "enough is enough." It is an essential and completely appropriate role of the counselor to encourage the client to explore his or her feelings about whether or not to cease treatments or to continue fighting for extra time. It is not the worker's role to give permission for one choice or another. Dying can be a quality time both for the terminally ill person as well as those who love him. One way to help insure this is for the worker to ask the client questions that will offer him or her options and some control over the process.
Do you feel that you are going to die soon? If so, how do you feel about this?
Whom do you wish to be with you?
Is there anything else you need to do or complete?
As Follansbee (1996) states "the dignity of a peaceful death, without pain, fear or futile therapy, can be realized only if time is spent in its preparation" (p.6).
Individual clinical practice with gay men is suffused with issues of illness, dying, surviving and thriving as members of an oppressed population under siege by both a medical crisis as well as attacks by the religious right wing. State of the art interventions with this population in the 1990s needs to challenge traditional models of therapeutic intervention. While traditional psychotherapy is often still appropriate treatment, the skilled practitioner must be knowledgeable about and ready to employ a variety of case work, counseling, crisis intervention and advocacy skills in addition to intrapsychic exploration and a systems approach. By being eclectic in working with gay men, services are customized to meet diversified client needs. Gay men seeking clinical social work services often discuss issues that have the potential to bewilder and overwhelm the most skilled clinician. The work is intellectually demanding, often exhilarating, at times exhausting and very rarely ever dull. The rewards for being flexible and creative in treatment approaches are tangible when clients invite and allow us to participate in their lives' journey. Contemporary practice with this population brings with it demands and challenges that reenforce the basic social work tenets of the need for regular ongoing supervision, training and supportive self-examination to help enable the practitioner to continue to make a skillful and disciplined use of his or her self in a sustainable fashion.
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