Dan Rosenblatt
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Our New Book: Erhard Doubrawa In this book the author has collected stories, which he has often told in his therapeutic work – during individual therapy sessions with clients as well as in group trainings. These stories have already often contributed to helping people open themselves again and be deeply touched by others. [Information] |
More than a dozen years have passed since the medical world determined that a new virus was attacking the immune system. It was named HIV, for human immune deficiency, a precursor to the development of AIDS. Since 1981 more than 160,000 Americans have died from the disease, and it is estimated that at least two Million more Americans are infected. To date there is no cure.
I think it is difficult for members of the General Population to take in the magnitude of this destruction. A further issue involves the nature of those stricken. Approximately sixty percent of the infected are either homosexual or bi-sexual men. Among the homosexual men of New York City and San Francisco, current estimates by public health officials suggest that approximately fifty percent are HIV positive or have AIDS. The implication is that unless a cure is found, they will all die. If we extrapolate this percentage to the total heterosexual Population of the United States we could anticipate over one hundred million deaths.
I can think of no comparable public health crisis of this magnitude for a specific social group. I am reminded of the polio epidemics of the 1930's and 40's. However the numbers were much smaller, and the spread of polio was throughout the Population. During the great influenza epidemic of 1918-19, a greater number of people died, once again among the General Population. Moreover, the epidemic, as severe as it was, lasted only two years, although of course its aftereffects continued as individuals were orphaned or families were destroyed. However the carnage, the dying, lasted for only a two year period.
What is different about the AIDS crisis? In the near future an entire community stands to lose half of its Population. Furthermore this special Population despite recent shifts in attitude remains the subject of unrelenting social and political discrimination. In some cities instances' homophobia and attendant gay-bashing have increased as a result if fears engendered by AIDS.
Unfortunately, scientists still remain helpless about critical aspects of the AIDS virus and its manifestations. Although life ' has been prolonged for many of those with the disease, many of the individual ailments continue to resist treatment. There appears to be no natural history of the disease; as it unfolds, the individuals infected with the virus often suffer repeated hospitalizations, possibly accompanied by wasting, severe disfigurement, blindness, paralysis, madness.
As a psychotherapist during this period I have treated a number of men who have died, their partners, their friends and some of their families. I have not treated any women or children with AIDS, which is an artifact of my clientele. But I believe my work with gay men is equally relevant to the treatment of women. The traditional practice of psychotherapy needs to be altered because of the special aspects of AIDS and the remaining material is devoted to explicating these changes.
In thirty years of office practice I have encountered only one patient who died while I was treating him, a man with cancer. Subsequently, during the last twelve years approximately one hundred men of my acquaintance have either died or are known to be to infected with the HIV virus. I led a therapy group composed of gay men for more than twenty years. Forty-six percent of this group have by now died or are known to be infected. Illness and mourning have become the staples of my therapeutic work with gay men. What are the implications of these harsh facts for treatment? First, I have shifted my concept of what treatment is. Previously I strove to enable individuals to take control of their lives, to overcome traumas from the past and find suitable ways to enjoy their future, to feel in charge of their destiny. I often quoted Freud's statement, "History is not destiny." However, today a history of HIV- infection does indicate destiny. Those infected will surely die in the not too distant future. Their days are truly numbered. Although a few men may survive twelve years from the original infection, the majority now live only two to three years.
Today, therapists can no longer entertain the hopeful premise that through their efforts the infected will come to lead a happy, healthy, prosperous life. Instead, we have the melancholy enterprise of seeing a individual through to his untimely death, offering whatever means are available so that he can live as good a life as is possible under the sentence of painful illness and premature death.
Although I can offer traditional therapy in overcoming a response related to anxiety, guilt, depression, paranoia or denial,.yet I can restore the individual to health, and for this I feel a sense of failure. It is not my own grandiosity that is at stake here, but my failure to adapt to the changed circumstances of the therapy. I am dealing not with patients who can look forward to life, but to those who must face their death, along with their anxiety, guilt, depression, paranoia and denial.
In addition to my major focus in dealing with psychological issues, I have enlarged immensely the amount of energy I expend in offering support to my clients. I have also added an entirely new dimension, that of witness. I want to comment on these departures, but first let me deal with the psychological dimensions I have referred to: anxiety, guilt and depression, fear and paranoia,
Anxiety
Almost everyone experiences anxiety. The fear of not succeeding in a career, of being abandoned, of having a love affair turn sour, of moving to a new location. Occasionally someone experiences existential anxiety about his death, usually in association with guilt and depression. Similarly an individual finds himself hypochondriacally involved with fears of the loss of his own health or reports somatic symptoms which are psychogenic. For those who are HIV positive, it is not surprising that all of these responses are heightened. Moreover, their fears are often grounded in reality rather than in anxiety. The patient is very likely to develop any number of symptoms and to be looking for a rash, the swelling of the lymph nodes, night sweats, loss of weight, exhaustion. I find that I spend an enormous amount of time in sessions discussing actual symptoms, trying to sort out which are located in fear and anxiety, and how to deal with those which are real.
A special subset of anxiety hovers around the terror of discovering if an individual actually is host to the virus. "Should I or should I not take the test?" Is it better to be ignorant and live my life as if healthy, rather than to discover that I am infected with a terrible disease for which there is no cure?" This struggle to determine whether or not to take the test can be complicated by the fear that a punitive government or a homophobic public will demand that anyone infected with the HIV virus be rounded up and placed in detention camps. Lest this seem too obviously a paranoid response, let me remind you that there are similar discussions about what to do with individuals who develop virulent tuberculosis in New York City.
My counsel has always been to get tested and find out what one's health is. I recommended this to the Gay Men's Health Crisis, based on some early work I did for them over six years ago, but at that time it is was ignored because it was politically incorrect. In my practice I continue to make this recommendation to patients. So far, only one continues to resist the suggestion. He agrees with the idea, but his anxiety is so great that he cannot bear to contact his doctor. He considers if he will call his doctor from my office, if he will arrange to receive the test results when he is in a session, if he will agree to getting only a reading of his T-cells. To date, the debate continues. He is symptom free, and he knows that his lover of eight years is HIV negative. However, this patient also had at least fifteen friends who have died, and he has been a major caretaker to many of them.
I consult myself about this patient and his situation. Supposing he was worried about whether or not he had lung cancer. His father had been a heavy smoker and died from the same illness twenty years ago. Suppose my patient had also been a heavy smoker, but had given it up three years ago. He currently has no overt symptoms, but he is plagued by the thought that he has lung cancer. What would I do?
I believe I would feel confident in formulating the following diagnosis and treatment plan. The patient is suffering from some residual survivor guilt about his father's death, and as a result of his identification with his father he hypothesized his own death. I would explore these ideas with my patient, role play with him, acting his father, his doctor, and then shift roles and have him play his doctor and his father. I would discuss the possibility of successful treatment for lung cancer, based on early detection, and explore his sense of survivor's guilt.
With my current patient I have reason to be far less confident about predicting his physical diagnosis. Furthermore I am not prepared to accept the responsibility for insisting he take the test to determine his HIV status. In this human interaction, with this particular individual, I am unwilling to attempt to force him to take a step which he resists in order to come to learn that he is faced with his own death. I am willing to go along with him and j joke and laugh at his hypochondriasis , but I am not willing to pressure him beyond a certain point where I run the risk of stating, that I want him to find out whether or not he is infected with.this deadly virus. My thinking goes like this: if you learn that you are infected, I am not prepared to take the blame you will offer me for urging you to learn about your health. If he were indeed to learn that he is HIV-positive, I recognize that I am protecting myself from my own guilt as acting as a leader urging an action that he wished to avoid taking.
Suppose he were my best friend, what would I do? I would ask him if he wanted me to go to the doctor's office with him,just as I offered to accompany a patient to an abortion, since she was so ashamed and humiliated by her condition, as the result of a casual sexual encounter, that she insisted on going to the abortion unaccompanied. Yet my frightened patient has no symptoms and has good reason to believe that he is negative, I reach my own limits with him, accepting that at this moment he is not ready to submit to a test, and I am unwilling to take the responsibility for pushing him to learn his fate.
This brief treatment episode illustrates the level of anxiety present for both the therapist and the patient in dealing with HIV status. Both continuously face issues of life and death, of illness and pain and suffering. I cannot take them lightly with impersonal, clinical distance or professional remoteness. My training as a therapist included the injunction to be authentic, genuine and in contact with my patient, using Buber's model of the I-thou relationship. I continue to act in view of this proviso; in working with HIV-posifive patients the toll is great.
I often use the analogy of the Holocaust. Perhaps half of Europe's Jews perished during the Holocaust, which lasted approximately five years. Perhaps half of America's male homosexuals will perish. How does one learn to survive during this indefinite Holocaust? Denial is one answer. The use of denial relates to another psychological response of my patients, and so I continue my account of defensive responses.
Denial
Denial is one of the earliest and most primitive defenses. According to Freud, denial is opposed to the reality principle and as the child grows and develops, his ego strengthens and he is able to face the pain of reality. Most therapists align themselves against the use of denial in working with adult patients. It is crude, thin, superficial, related to the infantile sense of omnipotence, often present in psychotic behavior. I have learned to become an ally of denial and to recognize several dimensions.
One patient, a young singer with little gift for introspection and a great deal of fantasy, entered therapy because of a broken love affair. Within two months, for his own reasons, he decided to be tested and learned that he was HIV positive. I have never seen anyone accept this diagnosis with such apparent calm. It was certainly not my intention to increase his anxiety or fear. However, I raised questions about the changes this made in his life. He was quite certain that he would not die, that he would find means to survive and was certain that the possibilities of life were still open to him. I considered this Massive Denial. I believed he had some difficult therapeutic work in front of him to come to terms with his compromised health. Shortly thereafter, he accepted an offer to sing in a world-wide revival of "The King and I". He left treatment spuming an offer to stay in touch while on tour.
I found a similar kind of denial present in a consultation I had with an architect. Although aware that he was HIV positive, he told no one about his status: no friend, no lover, no family member, no co-worker. I questioned him about his reasons for keeping this important information to himself. He spoke of his shame in revealing his homosexuality, his not wanting to burden his friends with his condition, his feeling of being in good health. So long as he was the only one privy to his HIV status, he felt no need to face the significance of the disease.
Another patient developed what I would call Rational Denial. He accepted the threat to his health that AIDS represented, but he decided that he could overcome the illness. He consulted herbalists, followed a macrobiotic diet, engaged masseurs, underwent acupuncture. His aim was not merely to live a better life, but to conquer the illness through the use of Alternative Medicine. With regard to his disease, his stance was, "Yes, I am infected, but I can defeat it." His belief permitted him to live out his last days with hope. He also chose to leave therapy as he perused alternative treatments, and frankly I was grateful that I was not party to sustaining his commitment to Rational Denial, even though I would have made no efforts to pierce his denial.
Other patients pursue what I call Functional Denial.-.Their formulation states, "I know I am going to die. All of us will die, but probably I will die sooner. Living with this knowledge is threatening. How can I manage to live as good a life as possible without being overwhelmed by this terrifying Information? If I live in partial denial, then each day is easier. However, in order to take care of my health and make plans for the future, at times I must return and destroy my denial."
Functional Denial moves between the poles of Massive Denial I'm OK, I can manage this - and Massive Terror - why don't I just kill myself and get it over with and be rid of the horror of the inevitable. The individual struggles to find an acceptable balance which works for a limited time, then a new crisis intervenes, for example, a significant drop in the number of T- cells, followed by the process of finding a new balance.
Paranoia
Recently on national television Spike Lee voiced the opinion that the creation of the AIDS virus and its proliferation among gays, blacks and Hispanics might be sponsored by the US government. He then went on to cite other forms of government sponsored research and actions which in the past had been cruel and callous toward blacks. Certainly Lee is correct about the past actions of the government, but I doubt that this is responsible for the AIDS epidemic. Yet homosexuals, blacks and Hispanics are frightened by the recognition that they are over-represented among those with AIDS, and in their willingness to find an explanation or to locate someone to blame, the government is available. Certainly the recent administrations of Reagan and Bush have been inhospitable to all three groups. However it is a far step from disapproving of how gays, blacks or Hispanics behave to inaugurating a policy of genocide.
My understanding is that since the AIDS virus is primarily spread among drug addicts by sharing needles with contaminated blood, and since homosexuals who engage in anal intercourse are also in high risk groups, that by projecting the blame for the disease on a hostile government the individuals are able to escape looking at how their own behavior was involved in their contacting the disease. I am not speaking here of blaming anyone for becoming infect ' ed. Back in the period before 1981, when no one knew of the existence of the AIDS virus, addicts shared needles and homosexuals practiced anal intercourse, if that was their choice. Unfortunately no one knew what these behaviors meant. Now it may be convenient to blame the government, but I hope drug addicts are smart enough not to share needles and that homosexuals are wise enough to practice safer sex. (My emphasis on safer sex comes from the recognition that condoms are either defective or break nearly ten percent of the time. In other contexts, the result of a defective condom may result in an unwanted pregnancy or contracting a socially transmitted disease which can be cured. In the case of AIDS, the consequences are more deadly.)
A few patients have told me that they b elieve the AIDS epidemic results from government policy. They can read this point of view in various publications or hear it on TV As a therapist,my responsibility is to determine the importance of a paranoid thought to a patient. Ordinarily I would work to enable the patient to own his projections. Now, if the patient is not obsessed with this idea, I am content to downplay the symptom. I clearly state my own thinking that the virus is a new mutant which only became recognised in the last ten years, and that it probably was around for a number of years before that as it grew in strength and came to be lodged among populations which just happened to be susceptible to becoming a host. However, I also point out that many heterosexuals, whites, women, children and hemophiliacs are infected, and I doubt that this too is government policy. And then I drop the topic. I am not eager to underscore a difference between myself and my patient based on the truth or falsity of opinion about the origin of the virus. I honestly don't know the origin. More to the point, unless the paranoia is strongly present it is not too important to remove such thoughts in order to help a patient find a way to live with his illness. I reserve the right to select which symptoms I will concentrate on. And it is wise to remember that even paranoids have ' enemies. A great deal of the medical community has its own shameful history of paranoid responses to patients infected with the AIDS virus.
Depression
Before discussing depression, I want to review briefly the difference between feelings of sadness and depression.. As you know, sadness is a healthy emotional response to a Situation involving loss, grief, mourning, disappointment, failure. Life after all is not all smiles or a bowl of cherries.
Depression, in contrast is a neurotic or psychotic disorder not necessarily triggered by real loss. The continuum of emotions between happiness and sadness is vital and significant. P anna, the Glad Girl, represents false optimism and false hope, just as the Sad Sack or Linus in Peanuts with a perpetual cloud over his head represents neurotic gloom and depression.
In dealing with patients I need to distinguish among those who are genuinely mourning the loss of their health, the threat to their life, the death of friends, the end of their careers and those who become neurotically attached to the idea of suffering and guilt and who in reaction then become lost in depression. With those who are authentically sad, I share my own sadness and accept the legitimacy of their feeling. I do not attempt to take away their sadness. I think it is appropriate and healing, an accurate recognition of what their situation is and emotionally sensible.
I treat those lost in their suffering and depression, no longer able to distinguish the cause of their sadness from a sense of being hopeless and helpless, as I would any depressed patient. However, in my heart, I can also feel the terror of depression. Ultimately both of us are helpless against the ravages of the disease. But even with compromised health, it is possible to live a rewarding, although limited life, and we, patient and therapist take this opportunity to find the means to do so. Later, when an AIDS patient reaches the point where his life is largely torment, he may consider suicide, and I am content to support his decision. I have not worked with any patient who has made this choice, but I know that others have opted for suicide, and I can accept their decision. The last stages of AIDS can be grueling, entailing endless medical procedures with little help for relief from final suffering. I believe a choice to die is as important as a choice to live, and that in these instances it is appropriate and commendable.
Guilt
Guilt is a psychological response familiar to anyone treating homosexuals. Despite the volumes written about the subject, we still do not know how and by what means an individual resolves his sexual identity. A simple-minded explanation is that an individual makes this choice freely. In fact no one consciously chooses his sexual orientation. It is formed long ago and far away in the mysterious penumbra of childhood. What is chosen is what behavior to follow, once one becomes aware of his sexual identity. Moreover, one of the issues which the AIDS epidemic has revealed is that the choices are not only exclusively homosexual or heterosexual, but that a significant number of men are bi-sexual.
With the advent of the AIDS epidemic, the guilt quotient of homosexual men is vastly increased. The emotional equation that homosexual sex equals sin and results in death becomes for many a reality. Either they see friends who are infected as a result of their sexual activities or they find themselves ill. Since much of their early training has led them to judge themselves as sick or sinful, it is easy for them to take the next step and interpret that a wrathful God is punishing them. Residual aspects of fundamentalist religion continue to exist in many an apparent bon vivant. Indeed, I would assert that one of the many reasons for the large numbers of sexual partners which are fairly common among homosexual men is because they are reluctant to make a commitment to one person and face societal disapprobation for their public choice to live with another man. Many furtive encounters pursued in sleazy bars or bathhouses pen-nit both the satisfaction of sexual impulses and accompanying large doses of guilt to help atone for the sin.
Often, those infected turn away from sexual experience. Sexual acts led to their current plight; now, therefore sex is to be avoided. I have been remarkably unsuccessful in finding means to overcome this dread of sex, this phobia of sexual pleasure. No matter how many discussions I have had with patients, many of them remain celibate, asexual, solitary. Reason and desire shrivel in their lustre against the enormity of their illness and its source.
I do not mean to suggest that all men who are HIV positive lose their ability to lead active sexual lives. The newspapers are filled with too many lurid stories of infected individuals going on to infect others in resentful rage. However I am stating that in my own work I have been impressed with how ineffective I have been in seeing that my patients have some form of a successful sexual life, albeit safe for themselves and their partner. Guilt over sexual acts becomes even more reinforced as a result of the infection that sex becomes permanently tainted and taboo. On three different occasions individual patients have come to a session, drenched in guilt because they have had unsafe sex while intoxicated. I am almost as upset as they are. They are risking becoming more infected and in infecting others. The act has already taken place. It cannot be undone. I do my best to ask the patient to look at the serious nature of what has happened. I try not to blame or induce further guilt. I work to see that in future safe sex becomes embedded as a form of behavior, that the individual guards against his use indiscriminate use of alcohol and drugs, but I also tremble for what can easily become destructive behavior related to guilt and rage.
Another type of guilt to which both my patients and I are prone is survivor's guilt. When someone we care for dies, we are all shaken by the loss. Often the question arises, "Why him? Why not me?" "Why did he deserve to die? Why do I deserve to live?" Naturally there are no valid answers to these questions, but the survivors feel depressed and guilty, in part as a means of coping with their loss and their inability to find a satisfactory, rational explanation for the death. A related response to guilt is the fear and panic located in the thought, "I'll be next. I am just as guilty as the one who has recently died. " Repeatedly I have found this response among healthy men who have been tested and know that they are not infected. Indeed some people take the test over and over again in order to reassure themselves that they are not infected, even though they have been practicing safe sex or have had no sex at all. They cannot believe that they have escaped the fate of their friends and lovers.
Some gays have been in perpetual mourning since the age of AIDS began thirteen years ago. One patient recently said, "When Peter died, I looked in my phone book to see who I would call to tell, and I found that all the others were dead too. " Another patient who works in the entertainment industry comes in about once a month and tells me about another friend or acquaintance who has just died. He also has very few friends left, and recently he has begun speaking about leaving his job in the treater and becoming a mortician.
What do I do in these instances? I cannot dismiss the mountain of deaths looming over the lives of these men; we cannot ask them to turn away form their grief. What I do is share my pain with them and hope, as we mourn our losses together, that some healing will take place. A pall hangs over our lives. One response to the endless list of deaths is to become numb. I am reminded of the tales of what happened to soldiers in the trenches in the first world war. -At Verdun, at Amiens, where hundreds of thousands perished, those living in the trenches became emotionally anesthetized. If they felt the full horror of what was happening they might not have been able to go on. In Eliot's "Murder in the Cathedral" the Chorus chants, "Many have perished. More will." When there are so many deaths, it becomes too much to continue to react to each with feeling. I often wonder how nurses on a children's cancer ward manage to do their work without burning out. We are burned out and sometimes black humor or gallows black humor helps relieve the tension, but sometimes numbness is a blessing, just as when a part of the body is wounded, at some point the pain ceases and numbness takes its place. After the eightieth person you know dies, how much can you genuinely feel for the eighty-first?
Well, I must say that this all sounds pretty gloomy, and it is. Yet I also want to state that I have been vastly impressed with how much dignity and strength these men have shown. The stereotype of the gay man would point toward a shallow, superficial response to life. Actually, I think that some of this stereotype is based on the reality that one means for homosexuals to cope with their ostracism is to play at being light-hearted and "gay". However once the epidemic began the homosexual community has reacted with great maturity and strength, and so have the men with whom I work. I hear about how some individuals have not reacted with such dignity and honor, and I feel I am privileged that this has not been my experience. No matter how dizzy or ditsy some of my patients may have appeared on the surface, after confronting the reality of their circumstances, the majority manage to live with nobility and maturity.
At times I feel that I am sitting in the witness box of history during this terrible period. I look forward to the end of the trial and the closing of the case. Many years ago I said that I wanted to see two things happen during my lifetime. (1) women gaining the right to a legal abortion; (2) the breaking up of the Soviet Empire. Expressing these hopes forty years ago, I felt fanciful and unrealistic. But lo, they have both come to pass. Now I add, I would like to witness the end of the Age of AIDS.
Daniel Rosenblatt, Ph.D.
was born 1925 in Detroit/ Michigan. He studied psychology at Harvard and Cambridge. He was teached Gestalt Therapy by Laura Perls. After working as a scientist in psychology for many years he started his private practise as a psychotherapist in New York. He maintains it for about 40 years. Daniel Rosenblatt is fellow of the New york Gestalt institut and he also was the president of this institute. He is giving training groups in the U.S., in Europe, Australia and Japan. His book "Opening Doors. What Happens in Gestalt Therapy" was published by the Gestalt Journal Press, Inc. His book "The Gestalt Therapy Primer" was republished by Yurisha Press. The Gestalt Institute of Cologne printed a German version of this book: "Gestalttherapie für Einsteiger".
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