Hope and Mortality

Psychodynamic Approaches to AIDS and HIV

Mark J. Blechner

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781134893690
• Edition: 1
• Topic: Psicologia
• Subtopic: Psicologia applicata

AIDS has humbled us. Thus observes editor Mark Blechner in introducing readers to this powerful collection of essays on psychodynamic approaches to AIDS. It is the disease, Blechner tells us, that "has forced us to rethink our relation to sickness and health, mortality, sexuality, drug use, and what we consider valuable in life." In the chapters that follow, experienced clinicians shatter myths about the inapplicability of psychoanalysis to work with AIDS patients. In addition to setting forth general principles involved in working with patients with serious illness, Hope and Mortality explores the wide range of therapeutic issues that have arisen in the wake of AIDS. Among the topics of individual chapters: working with children whose parents have AIDS; working with AIDS patients in an inner-city hospital; disability, dementia, and other realities of late-stage AIDS; treating someone who becomes HIV-positive while in therapy; leading a support group for gay men with AIDS; confronting fears of HIV in the "worried well"; and coming out of the closet as a heterosexual while running a bereavement group for gay men. Most poignant of all are chapters in which therapists examine how they have been transformed by treating people with AIDS. Here contributors candidly discuss how their attitudes toward death have shaped, and in turn been shaped by, their clinical work. They tell of recovering near-death memories, of questioning their reliance on traditional medicine, and of feeling the numbing effects of multiple loss with their patients. The AIDS epidemic has become so widespread that every clinician must learn about the disease and the psychological issues it raises. Hope and Mortality provides an illuminating exploration of these issues and raises profound questions about the overall aims of psychotherapy. It will instruct and challenge all mental health professionals, and provide hope and enlightenment to anyone dealing with a life-threatening condition.

Part 1 Principles of Treatment

1 Psychodynamic Approaches to AIDS and HIV

Mark J. Blechner

DOI: 10.4324/9780203779422-2

In this chapter, I address many aspects of AIDS. First, in order to provide a historical perspective, I tell, from my own viewpoint, how the AIDS epidemic evolved and how psychological attitudes, among patients and all of society, have shifted. In particular, I explore ways in which psychoanalysis can help us understand the terrible, irrational reactions that have made the AIDS epidemic not only a medical tragedy, but a psychological tragedy for society and individuals. I then describe what we have learned, from a psychodynamic perspective, about working with people with AIDS and people with concerns about HIV. We have learned many ways in which psychoanalytic principles can be adapted and expanded to allow all psychotherapists, in many difficult situations, to help people with AIDS and those who love them and take care of them.

Psychological Aspects of the AIDS Epidemic: Historical Overview

In the earliest years, AIDS was a mystery. In 1980, the “epidemic,” as a recognized entity, did not exist. At that time, however, I personally knew one man, James Allen, who was in his late 20s and was having unusual medical problems. He was first diagnosed with shingles, then with Hodgkin's disease, but his medical progress did not fit the diagnoses. By 1981, we knew the rumors of some horrible disease that was striking mainly gay men, but no one knew how it was caused, whether it was contagious, or much of anything else; we knew only that young men were becoming very sick and were dying rather quickly. James now knew that he had this disease, whatever it was. The last time I saw him was at the opera; he was walking feebly with a cane. He said, “Next year at this time, I will be the late James Allen.” He was right. I still remember the shock of seeing a friend, so young and with so much promise, become so debilitated and resigned to death. Now I have seen the same thing happen, over and over, with patients, colleagues, and friends, and the cumulative effect is one of numbing, shock, and despair.

At first, the disease was thought to be restricted to gay men, and was dubbed GRID (Gay-Related Immune Disorder). Colloquially, some people referred to Kaposi's sarcoma as the “gay cancer.” In early 1983, I heard a man at a party bragging cheerfully that he had had the gay cancer and was cured of it. He was wrong. This man's bravado was an example of simple reaction formation, a reversal of the terror that was the most common emotion at the time in gay men. No one knew who would next get the illness. No organism had been identified as causative, and no marker had been identified that would predict who was contagious or who would next be stricken. Physicians and psychotherapists alike had no idea whether one could get the illness just by being with the patient.

In this period of mystery and terror, irrational ideas were rampant and caused much havoc. Psychoanalysis is the field that established the irrational and the unconscious as areas worthy of study. So what can we learn from psychoanalysis about the irrational thinking that is aroused by AIDS? Freud and Sullivan have taught us how all aspects of human psychology—memory, perception, thinking, and reasoning—can be altered by intense emotional concerns. To understand HIV and the irrational attitudes connected with it, one ought to invoke two of the great concepts of psychoanalysis—Freud's concept of wish-fulfillment, and Sullivan's notion of the not-me. Both of these concepts were intended to describe the processes of individual psychology, but both of them can be expanded to describe the group psychological processes of distortion and myth-making that we have seen rampant in the AIDS epidemic and that still continue today.

Freud (1900,1901) postulated that when we are under great emotional stress, our reasoning can become illogical by the same mechanisms that usually make our dreams so strange. Our waking thoughts can be distorted by primary processes and ego defenses, like displacement, repression, denial, and reaction formation. I think that the great fear and panic invoked by the AIDS epidemic have led to those kinds of distorted thinking. The distortions, however, have not been only on the level of individual psychology, but also on the level of large groups, and ultimately all of society. Over and over during the AIDS epidemic we have seen the distortions of individuals coalescing into distorted group beliefs, which we also call “myths.” Because these myths fulfill such a strong psychological need, they are very hard to dispel.

And what are the AIDS myths that have been produced? There have been many; but a common theme of the myths is that the AIDS epidemic affects someone who is “not-me,” to use Sullivan's term. In the beginning of the epidemic, when so few facts were available, everyone wanted to project the danger of the epidemic onto someone else, and the most convenient targets were groups that are hated or looked down upon. For instance, in the beginning of the epidemic, there was a rumor among white gay men that the only people getting AIDS were those who were sleeping with black men. Meanwhile, as Washington (1995) has documented, black men thought the opposite, that AIDS was a disease of white gay men and that black men could be safe as long as they only slept with each other. Of course, both groups were wrong. The same phenomenon is repeating today in many parts of the world; in Cambodia, for example, a poll showed that most hospital nurses believe that AIDS is a disease of foreigners, and that it cannot be passed between Cambodians (Shenon, 1996).

In 1983, things changed dramatically. A virus was finally isolated that was presumed to cause AIDS, which was eventually called “HIV” (human immunodeficiency virus). Soon thereafter, there was a blood test for antibodies to the virus. Now there was a name for what was happening and a biological marker for the presumed cause of the illness. It was recognized that the illness was contagious through sexual contact or exchange of blood products, and that those who had already acquired the virus but were asymptomatic could be identified.

The psychological effect of this medical discovery was of tremendous importance. What had previously been blind terror now became more concrete. Those who were ill had some idea of what was going on, although much was still unknown. Those who were HIV-negative could find out, and could react to that news (with relief, guilt, or other reactions). A class of psychopathology, the “worried well,” became more precise, now that it could be determined who was well in a biological sense. And in those days, with more concreteness to the horror, there was concomitantly more hope as well. Science had developed vaccines against other viral diseases. Surely, people thought, science would find a way to cure or prevent AIDS. People spoke of a cure around the corner, and, on April 23,1984, Margaret Heckler, secretary of health and human services, even made an official government announcement to that effect. Such events often crossed the border into denial; there was a pervasive belief among white American heterosexuals that the illness was restricted primarily to “risk groups”—gay men, IV drug users, hemophiliacs, and Haitians. This was maintained despite the fact that in Africa it was clear the epidemic, for the most part, was affecting heterosexuals, but this was explained away vaguely as a result of open chancre sores caused by other sexually transmitted diseases, or perhaps by female circumcision or some other exotic practices—anything to prove that the African is “not-me.” Denial is a strong defense, and it finds ways to produce all sorts of flimsy data that seem to acquire merit through the wish that they be true. There was a continual attempt to ascribe AIDS to the “other,” the “not-me.” Gay men in their 20s originally thought that they were safe as long as they avoided sex with people over 30. The subsequent upsurge in HIV infection in young people proved how wrong and tragic such misconceptions are.

“Risk groups,” the term used by epidemiologists, was itself very misleading. It implied that those who were not part of the risk groups were not at risk of contracting HIV. Perhaps “highest risk” groups would have been more accurate and allowed for less denial. But the damage has been done, and the epidemic has spread among heterosexuals who were once not included in the risk groups (see Blechner, 1986). In the 1990s, women became the fastest growing group affected by AIDS in the United States; their numbers were increasing by 45 percent each year.¹

¹ HIV Center for Clinical and Behavioral Studies Report, New York, New York State Psychiatric Institute, Vol. 1, May 1991.

Over time, our understanding of the nature and epidemiology of the disease has changed, and with it our assessment of fears of it. Yesterday's irrationality has more than once become today's reality, and vice versa. In the mid 1980s, when it was thought that only 30 percent of sero-positive individuals would progress to AIDS, the belief that one was facing certain death from HIV infection was considered irrational. Since then, the estimate has been gradually moved upward, so that some clinicians felt that with time, nearly all HIV-infected individuals would contract the disease. This most dire outlook was somewhat tempered when a certain group of individuals, the “nonprogressors,” seemed not to become symptomatic despite HIV infection. One reason for nonprogression was clarified in 1996, when it was found that a genetic anomaly produced a natural resistance to the HIV virus in about one person in 100 among Caucasians.

In addition, there is more hope than ever that a medical solution will be found, and that AIDS will shift from being a terminal illness to a chronic, manageable one, like diabetes, or even a totally curable or preventable one. Also, we now know that the human immunodeficiency virus is transmitted only through the transfer of blood products or body fluids directly into the bloodstream or through mucous membranes, and so fears of casual contact are unfounded. There is no danger that a psychotherapist who chooses to work with AIDS patients will get AIDS from them.

But AIDS is psychologically threatening. It is not acceptable to the unconscious. AIDS, somewhat like schizophrenia and the Holocaust, is a horrifying, death-in-life situation that we would like not to exist, so much so that denials are repeatedly propagated in the public consciousness that these things, in fact, do not exist. The Holocaust didn't happen, claim some historians. Schizophrenia is not an illness, claim some psychiatrists. And the so-called general population does not have to worry about AIDS, say some public health officials. Since there can be a latency period of many years between infection with the HIV virus and the onset of symptomatic AIDS, it may be possible to maintain such a myth until it is too late, but already the rising incidence of HIV infection among teenagers is an alarming sign.

Many other myths continue to develop about AIDS, driven by the wish for immunity from the disease. As mentioned above, young gay men in their 20s often think that they are safe from the virus as long as they have sex only with others younger than 30. Also, physicians have studied AIDS primarily in men. Until 1991, the Centers for Disease Control's definition of AIDS did not even mention several opportunistic infections that occur only in women, such as various forms of cancer and pelvic inflammatory disease, so that many women are not properly diagnosed. One physician put it this way: “In the United States, women don't get AIDS; they just die of it.” It is important for a psychotherapist to challenge such myths, but he cannot do so unless he has educated himself and overcome his own unconscious tendencies toward such irrational beliefs.

The level of irrationality about AIDS produces the most bizarre belief systems. Think about the following question: What do you believe is the chance that two gay men who are HIV-negative can transmit the HIV virus to one another during anal intercourse? Herek and Capitanio (1993) studied this question. They found that about half of their subjects believed there was a strong chance of HIV transmission between two uninfected homosexual men. Of course, the correct answer is zero. But their study shows how many people irrationally connect HIV transmission with specific behaviors. If anal intercourse is one of the most efficient ways of spreading the HIV virus, then any act of anal intercourse is thought to cause AIDS. This is not so different from the principle of von Domarus (1944) that has been applied to schizophrenic reasoning, in which things that are merely associated with one another are seen to have a causal or inclusive relationship. For example, a schizophrenic may think, “If my mother's name is Mary, and Mary is the mother of God, then I am God.” You may think that only schizophrenics think like this, but as Freud and Jung have shown us, when we are under great emotional pressure we are all capable of reasoning like madmen.

One would like to think that after a decade and a half of AIDS, we would see the most severe forms of irrationality, fear, and ignorance disappearing. But we are not. In 1995, a group of gay political leaders were to meet with President Clinton at the White House. Secret Service agents who frisked them wore rubber gloves as a precaution against contracting AIDS. What was their reasoning? The same von Domarus principle seems to have been at work. Many gay people have AIDS. Therefore, all gay people have AIDS. Doctors use rubber gloves when examining AIDS patients where there are bodily fluids. So rubber gloves will prevent me from getting AIDS when frisking gay men. Of course, the fact is that you cannot get AIDS by frisking anyone, with or without gloves. But if such ignorance exists in the American federal government, what can we expect of those with less education and less public responsibility?

Irrational beliefs and prejudice also limit research into issues of drug use and sexuality that are crucial to AIDS transmission. June Osborn (1992), as chair of the National Commission on AIDS, said that “even our most basic efforts to better understand and respond to this new plague have been hampered. Efforts have been made to constrain or forbid behavioral research.” Even though we know that clean needles dramatically reduce the spread of HIV among IV drug users (Karel, 1993; Hausman, 1993), most states do not allow ready access to such clean needles, because of a fear that this will encourage drug use. Even though anal intercourse is known to be the most efficient means of transmitting HIV sexually, the government has refused funding for literature that would explicitly mention anal intercourse, for fear that it will encourage such behavior. The unconscious ideas here are that if you talk about a behavior, you encourage it. Not talking or thinking about it causes the behavior to be less present. Both of these ideas are false and dangerous. Needle-exchange programs do not cause more people to be drug addicts, and safe-sex education does not increase the rate of anal intercourse. But while such programs are discouraged in Congress, AIDS has been spreading relentlessly.

The press has shown many of the same psychological defenses and prejudices in its coverage of AIDS news, a combination of denial and dissociation of the not-me. When Legionnaire's disease took 29 live...

Table of contents

• Cover Page
• Half-Title Page
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• Contributors
• Acknowledgments
• Introduction
• Part 1. PRINCIPLES OF TREATMENT
• Part 2. CASE STUDIES
• Index