I am a person, also a social worker, who has been living with AIDS since
1982. Although I do not have AIDS myself, I was diagnosed as HIV positive in 1988
and the disease and all of the personal and professional issues surrounding it
have profoundly influenced my life for over a decade. In 1984 my oldest brother
died as a result of AIDS followed by my best friend and partner in my practice
in 1989. Six men who lived in my apartment building have died from AIDS in the
past 12 years, as have numerous acquaintances, colleagues, and several close friends.
Four of my closest friends are currently seriously ill with complications from
AIDS. The man I love and share my life with has AIDS. When patients and therapists
are dealing with virtually identical life crises simultaneously, the potential
for therapeutic mistakes is enormous. Therapists must be highly skilled and self-aware
in order to avert such dangers.
As a therapist with a largely gay
male practice, I work with people who are living with AIDS or who are intimately
affected by it every day. Before the onset of AIDS, active alcoholism, drug addiction
and Hepatitis B were the only life-threatening illnesses likely to kill my patients.
My first professional experience with AIDS was in 1981 when a psychotherapy client
began exhibiting symptoms of what we now know is HIV illness. At that time AIDS
was unknown but shortly thereafter, the syndrome was labeled Gay Related
Immune Deficiency (GRID). It soon became clear to me that the men who were
sick with this new disease had lived no differently than I had for many years.
I assumed that if these people were getting sick, there was an excellent chance
that the same thing could or would probably happen to me. In 1983, I began to
volunteer at Gay Mens Health Crisis (GMHC), working with people with AIDS,
and supervising other volunteers. I still volunteer at GMHC. In the past 12 years,
over 100 patients in my private practice have died from AIDS. My purpose in relating
the above experiences is to attempt to describe how I, along with so many others,
am able to survive and thrive emotionally, psychologically, and spiritually in
the midst of this plague and how I continue to do this work without becoming burned-out.
Colleagues and friends often ask me how it is that Ive been able
to work in AIDS for so long, dealing with all the pain and suffering endemic
to this patient population. Others ask whether its overwhelming to have
intimately known and worked with so many people who have died or who are dying.
As an action-oriented person I have had to struggle to learn that I am indeed
doing something by simply sitting with clients, caring about them, and encouraging
them to share any and all of their feelings about what is happening to them. Of
course, I am unable to change the outcome of their illness. Accepting this reality,
more than anything else, has taught me how to tolerate discomfort.
discomfort I experience is about many things. Often it arises from a genuine
empathetic connection with clients who are honestly experiencing feelings
about their loss of health, career, lover, and their own imminent death. Once
I have grown to care about a person comes all the accompanying discomfort about
losing that person. Sometimes there is simply the uneasiness of being close to
a person who is very ill or who is dying, simply because this reminds me of the
fragility of my own good health.
What follows are some case examples
that illustrate the challenges inherent in attempting to provide competent treatment
while living and practicing under the shadows of HIV/AIDS.
for burnout in AIDS service providers is a serious reality. My experience
is that burnout happens largely when people ignore their feelings. Thus I share
in this chapter what it is like for me to do this work, in the hope that other
therapists doing similar work will find it helpful to read about my struggles.
The challenge remains how do we sustain ourselves and each other for this reality:
AIDS will likely be with us for the rest of our professional lives.
would not have been possible for me to live through all of this, without losing
whatever serenity I had, if I had not been in my own active psychotherapy
and supervision with a remarkable woman who has been my professional mentor for
the past 15 years. In addition, for five years, in the early to mid 1980s, I attended
a support group for health care professionals who were working in AIDS. We met
regularly and provided ourselves with a safe space to ascertain what
each needed in order to continue to do this draining, yet exhilarating work.
It has become increasingly clear to me from supervising therapists working
in AIDS, and facilitating support groups for AIDS professionals, that the only
way any of us are able to continue to expend the prodigious amounts of energy
demanded by this work, is when we are able to feed and nurture our many needs
as individuals. When I ask the professionals I work with what they do to feed
themselves, they often look at me as if I were crazy. I have been told on more
than one occasion, I dont have time to do my work, have a life, and
take care of my own needs as well. This is a poignant conflict. Similarly,
a large part of my work with care-partners of people with AIDS is to encourage
them to take time for themselves and to give themselves much-needed breaks from
their routine. I am amazed at how resistant both colleagues and clients are to
the notion of building in time for play and fun in the midst of the horror.
A Classic Case of Countertransference
Ernie had been a patient
of mine for five years when John, his best friend of 25 years and roommate for
the past eight became acutely ill with AIDS and decided to return home to the
mid west. Ernie felt very guilty that he had not tried to talk John into continuing
to live in New York in their small studio apartment. I fully supported his decision
about the impracticality of Johns continuing to live with him but this proved
to be a mistake because I had not explored Ernies feelings thoroughly enough.
Two weeks after John left, Ernie came to session enraged at me. Appropriately,
he yelled at me for not having urged him to explore options about having John
continue to live with him. Ernie was overwhelmed by guilt that he had abandoned
John in his time of greatest need.
As I listened to Ernie and encouraged
him to tell me all his feelings, I knew I had messed up and would need to examine
this. During supervision I learned why I had behaved as I did in not attempting
to explore Ernies ambivalence.
My failure was largely a result
of my experience with my older brother Henry, who was also gay. As adults
we were not close and, in fact, our first conversation after a three-year silence
was his announcement that he had been diagnosed with AIDS and was going to return
to New York to live. My decision to allow Henry to move in with me was impulsive
I did not like him and did not relish the prospect of having him live with
me I also did not want to become his primary care-partner but being an AIDS activist,
I didnt see how I could refuse to offer my destitute and homeless brother
a place to live. Henry lived with me for 14 months until he died in my bed.
At the time I was working with Ernie on this issue, Henry had been dead for
two years. Interestingly, it was while exploring my reactions to Ernie that my
supervisor, reminded me that, years ago, I had only told her about my brother
moving in the day before he was due to arrive. I had neglected to discuss this
situation with her and to explore my own ambivalent feelings and possible options
before offering to let Henry move in. Because this occurred years before Ernie
became my patient, I was unaware it was influencing me. In my unconscious desire
to protect Ernie from the horrors I experienced as I watched my brother deteriorate,
I had not been neutral in my role as Ernies therapist.
I find that
my work in AIDS, and living surrounded by AIDS, for the past 12 years has increased
my appreciation for and my capacity to enjoy the richness of life. While of course
tremendously saddened, instead of finding myself drained, I am increasingly nourished
and inspired by working with people living with HIV and AIDS, as devastating as
it is. The inspiration comes from their courage.
As a gay man living
in the midst of a community ravished by AIDS, the issues Ive discussed have
an obvious immediacy and urgency to me personally as well as professionally. While
the content of this discussion has been living and practicing psychotherapy in
the face of a particular plague, I think that the dynamics are universally relevant
to all therapists. Which of us has not had to face our own fears and losses, or
grapple with our own mortality? This is the core of human pain and triumph. How
we manage these issues defines our personhood. How we help our patients manage
these issues defines us as therapists.
Reflection Exercise #5
The preceding section contained information
about burnout when working with terminal clients. Write three case study examples
regarding how you might use the content of this section in your practice.
Online Continuing Education QUESTION
What factor contributed to HIV worker, Shernoff, failure,
as he terms it, concerning countertransference? Record the letter of the correct
answer the .