Psychotherapy with HIV-Positive Gay Men:

A Psychodynamic Perspective
JEFFREY J. WEISS, Ph.D."
This paper examines psychotherapy with HIV-positive gay men from a
psychodynamic perspective. The themes of loss, uncertainty, identity, and
meaning are put forward as central in this therapeutic work. A range of
interventions (from counseling to dynamically oriented psychotherapy) are
discussed in relation to characteristics of the HIV-positive gay men who
present for psychological treatment.
INTRODUCTION
Numerous articles and books have been published which have focused on
psychotherapy with HIV-positive gay men.l-l1 In this article, psycho-
therapy with HIV-positive gay men is discussed from a psychodynamic
perspective. This discussion is based on individual psychotherapeutic work
with over 50 HIV-positive gay men, as well as group work, conducted by
the author from 1988 to 1993 in public and private hospital settings in a
large midwestern city in the United States.
While this article is based on psychotherapy conducted with American,
HIV-positive gay men, the concepts discussed are relevant not only to this
group, but can provide a basis for modification and application to other
groups of HIV-positive persons who differ in terms of sexual orientation,
gender, lifestyle factors, or nationality.
HIV-positive persons are concerned with becoming ill and dying as are
persons with any life-threatening illness. There are aspects of HIV illness,
however, which make it unique and, therefore, different from other
illnesses. The appreciation of these differences by the psychotherapist will
enhance the efficacy of treatment.
Being a gay man in America in the 1990's has become inevitably linked
with the concept 'HIV/AIDS'.12 HIV/AIDS is the defining event for gay
men living in the United States at this time. Among gay men, the relation-
ship to HIV/AIDS is undoubtedly present and takes on varying forms-

*Clinical Psychologist, The Helen Dowling Institute for Biopsychosocial Medicine. Mailing ad-
dress: Mathenesserlaan 183,3014 H A Rotterdam, Netherlands.
AMERICAN
JOURNAL OF PSYCHOTHERAPY,
Vol. 51, No. 1, Winter 1997
AMERICAN JOURNAL O F PSYCHOTHERAPY

being positive, being negative, not having been tested, fearful of having
been infected, fearful of becoming infected, guilt-ridden for being infected,
guilt-ridden for not being infected, caring for those who are infected, and
mourning those who have died. HIV/AIDS plays a role in many of the
decisions made by gay men (for example, where to live, whom to become
intimate with, and whom to tell that they are gay).
The impact of HIV/AIDS on society's view of the gay man is complex.
O n the one hand, it has dramatically increased the level of discussion and
openness in the mainstream press and in society regarding aspects of gay
lifestyles and gay sexuality,13 and it has increased public images of gay men,
the gay community, and gay relationships.14 O n the other hand, as gay men
have become more visible, the incidence of antigay violence, prejudice, and
discrimination has also increased15;and HIV/AIDS has resulted in a partial
remedicalizing of homosexuality.l6

Loss
Finding out that one is HIV-positive can be conceptualized as a series of
losses. Some of these losses are immediately experienced at the time of
diagnosis (sense of self as physically healthy, sexual freedom, and normal
life span); others are experienced as feared losses (normal cognitive func-
tioning, financial security, social support, and independence).
The adjustment process required after finding out one is HIV-positive
can thus be conceptualized as one of coping with loss. Factors that
moderate the relationship between loss and subsequent mental health
problems are life stressors, coping strategies, social support, and personal-
ity. The assessment of how all four of these areas have led to and continue to
contribute to the HIV-positive person's presenting problem is central in
psychotherapy treatment planning.
As the HIV-positive person confronts his or her own feelings about the
losses experienced due to being HIV-positive, unresolved feelings related
to past losses often emerge. In this way, being HIV-positive provides the
person with the impetus to address these unresolved feelings from the past
in order to better cope with his current circumstances.
HIV-positive men often feel that they have no control over the course of
their illness. They feel as though HIV infection is something which is
happening to them and they are left to passively wait and see what havoc it
wreaks on their bodies and their lives. It is often effective to intervene at a
cognitive level when confronted with this type of passive response from the
HIV-positive person. The client is encouraged to consider that he can play
.t Psychotherapy with HIV-Positive Gay Men

a larger role in how his illness progresses than he might currently feel to be
the case.
Some things which the HIV-positive person can control, which may
impact upon his physical health, are: his diet, exercise, recreational drug
use, maintenance of safe sexual behavior, compliance with medical appoint-
ments and recommended medical treatment, accessing of social support,
setting of realistic goals, and working on feelings and attitudes in psycho-
therapy and elsewhere.
Many clients respond quite well to this type of intervention. They do
not, on their own, realize that there are so many things that they do have
control over. Once this has been discussed in psychotherapy, they readily
begin to work at improving their functioning in these areas of their lives.
This approach works best when the discussion takes place in the context of
an empathic acknowledgement by the therapist of the many ways in which
aspects of the HIV-positive client's life truly are out of his control.

UNCERTAINTY
As progress is made in the medical treatment of HIV illness, HIV-
positive persons are living longer. The illness increasingly becomes some-
thing to live with, to adjust to; rather than an illness one quickly dies of.
Being HIV-positive introduces an enormous amount of uncertainty into the
person's life: "What will my course of HIV Illness be like?" It becomes very
difficult to plan for the future, not knowing how many years of life are yet
to come. Often a part of doing psychotherapy with an HIV-positive person
is helping him to accept and adjust to this uncertainty.
It is common for people, soon after finding out they are HIV-positive, to
assume that everything they feel, physically and emotionally, is related to
their HIV infection. Headaches, stomach aches, fatigue, and depression are
immediately assumed to be HIV related.
An illustration of this is a psychotherapy client of mine who was taking a
combination of two anti-HIV medications (zidovudine and didanosine).
He developed severe stomach pain and was hospitalized. I saw him shortly
after he was admitted and we both assumed that he was experiencing
pancreatitis, a known potential side effect of didanosine treatment. It
turned out to be a case of acute appendicitis, unrelated to his HIV infection
or to his medications. It is important to keep in mind that our HIV-positive
clients' physical and psychological problems should not be automatically
assumed to be HIV-related.
Clients should be encouraged to make use of the information about
HIV/AIDS which is available in that it can help to minimize their level of
AMERICAN JOURNAL O F PSYCHOTHERAPY

uncertainty regarding how being HIV-positive is impacting their lives. If a

client is not adequately educated about HIV illness, I will help him to
become so. This can provide relatively quick relief from many of the fears
that result from a lack of information or incorrect information. For
example, the client who has just been told he is HIV-positive and is now
distressed because this means to him that he can no longer play with his
t w ~ - ~ e a r - onephew
ld for fear of infecting him, needs education prior to any
other type of intervention.
WHOPRESENTS FOR PSYCHOTHERAPY
The stress of being diagnosed as HIV-positive and living with HIV
infection is likely to cause a disruption in the functioning of the self. While
some individuals have the necessary resources to manage this disruption,
many others would benefit from assistance while they are going through
this adjustment process.
The HIV-positive persons who do come to psychotherapy are a select
group. They have responded to feelings of distress by initiating contact
with a psychotherapist or exhibiting behavior which has led them to one. If
self-referred, these clients often express a sense of urgency and a motivation
to resolve certain issues prior to becoming ill and to dying. Sometimes they
are ready to work on changing themselves in psychotherapy in ways in
which they are not likely to have been motivated to do if it had not been for
their HIV infection.
Examples of this include a client who worked in psychotherapy on
feelings related to sexual abuse that occurred 20 years earlier; a 20-year-old
client who struggled to stop a six-year history of prostitution and cocaine
use; and a client whose primary source of narcissism, his physical appear-
ance, had been taken away from him by his HIV illness and who began in
therapy to look at previously ignored aspects of his self that might serve as
new sources of self-esteem.
WHATTYPE OF TREATMENTTO OFFER
HIV/AIDS has had a complex impact on the progress in psychothera-
peutic work with gay men. While HIV/AIDS has resulted in increased
interest in gay men as a specific psychotherapeutic treatment group,17Js at
times in the discussion of two related issues (gay-affirmativepsychotherapy
and HIV-specific psychotherapy), the necessary distinctions between the
two are blurred.
Few clinicians writing about their psychotherapy work with gay clients
have identified themselves as gay19; fewer yet working with HIV-positive
clients have identified themselves as HIV-positive.*OWhat is important in
Psychotherapy with HIV-Positive Gay Men

doing psychotherapy with gay clients is not that the psychologist be gay, but
rather that he or she work from a gay-affirmative frame of reference,
implying an acceptance and understanding of gay lifestyles. The same
would apply to doing psychotherapy with HIV-positive persons. It is not
necessarily an HIV-positive therapist who is needed, but rather one with
the knowledge and insight required to appreciate the experiential world of
the HIV-positive person. The therapist ideally creates a treatment setting
which optimizes the freedom of the client to explore his own feelings
regarding homosexuality and HIV infection, unencumbered by the thera-
pist's opinions, sexual preference, or HIV serostatus.
Before recommending or beginning psychotherapy, the therapist should
conduct a diagnostic assessment to determine whether psychotherapy is
indicated and, if so, what form of therapy and with what treatment goals.
Aside from individual psychotherapy,other recommended treatments might
include group, couples, or family therapy and/or pharmacotherapy.
Among those who do seek professional help on their own, many would
likely in time have found their own way without this help; it just might have
taken longer or been a more difficult and/or lonely road. In these cases, the
psychosocial intervention needed might best be labeled counseling.
Counseling is aimed at individuals going through an "uncomplicated"
adjustment process, with no significant blocks interfering with this process.
These people have successfully coped with severe stress in the past and,
even though they may be experiencing some difficulty with the current
adjustment process, they can be expected to successfully work through the
crisis without psychotherapeutic assistance. Nevertheless, they can still
benefit from education about the adjustment process, help with problem
solving, facilitation of the expression of emotions, advice about their
unique concerns, and guidance regarding decision making during a challeng-
ing time.21
Many clients will not be adequately helped after education has been
provided and ways of adjusting to the uncertainty and losses inherent in
HIV illness are discussed. The psychological functioning of the self of these
clients has been thrown off balance by HIV illness. This is when psycho-
therapy is indicated. In these instances, the person usually has personality,
developmental, or emotional issues that have not been resolved prior to the
HIV-positive diagnosis, which are surfacing at the present time; and/or
there are current circumstances which are complicating the adjustment
process.
A distinction can be made between varying forms of psychodynamic
psychotherapy: from the most supportive to the most insight oriented and
AMERICAN JOURNAL OF PSYCHOTHERAPY

exploratory. Supportive therapy primarily focuses on symptoms and behav-

ior change through support of the clients' adaptive defenses and environ-
mental resources. Transference is not addressed, nor are attempts made to
modify personality or resolve unconscious conflicts.22 In contrast, in
dynamically oriented psychotherapy, the transference is at times used and
connections are drawn between current relationships and aspects of the
client's early upbringing and past.23 When psychotherapy is indicated, I
will begin working dynamically in the absence of any counterindications
(history of major psychotic for example).
Once a dynamically oriented treatment is under way, the work at times
has little explicitly to do with being HIV-positive. There are unique issues,
however, that can arise in the treatment due to the client's having a physical
illness. These include his missing appointments due to illness, the counter-
transference feelings evoked by his coming to sessions feeling ill; and the
change in the relationship which occurs as a result of visiting the client
when he is hospitalized, which can often lead to meeting family members
and partners, and the need to at times interact with the client in a manner
which differs from that of being in the therapist's office.

Identity refers to the experience of who one is in the world.25 One's

identity is made up of the various aspects of the self to which one attributes
meaning and gives significance. For the HIV-infected gay man, being gay
and being HIV-infected are likely to be important components of identity.
First Coming Out
For the majority of gay men, the realization as a youth of being
homosexual is problematic. There is an awareness that homosexuality is
devalued and rejected by society at large, including one's parents, peers,
and teachers. The gay youth often experiences this perceived rejection of
his sexuality as a narcissistic blow. He will also to some degree internalize
negative feelings about being gay based on his exposure to these views in
others (internalized homophobia). Having to keep his true sexuality a
secret, the young gay man is deprived of admiration and recognition from
others for this essential aspect of his self. This often results in a loss of
self-esteem.
A vital role of the coming-out process is to heal this narcissistic injury
and restore integrity and strength to the injured self. Belonging to a gay
community and finding gay role models can also serve as healing self-
objects for the gay "Coming out" as gay is a developmental process
that takes place on several levels: first, telling oneself that one is gay;
Psychotherapy with HIV-PositiveGay Men

second, telling others in a gay-affirmative environment; and, third, telling

the wider and usually "straight" society of family, friends, and colleague^.^^
Although the experiencing of internalized homophobia is likely to be
most strongly felt early in the coming-out process, it is unlikely that these
negative feelings about the self will completely disappear even after the
person accepts his homosexuality. As a result of the enduring impact of
early socialization experiences and the continued exposure to anti-
homosexual attitudes, internalized homophobia remains present to some
extent in the gay person's psychological adjustment throughout life.28
Second Coming Out
One of the challenges facing the person after being diagnosed as
HIV-positive is with whom to share this information and how and when to
do so. There is still widespread fear of, and discrimination against, HIV-
positive persons. Acknowledging membership in this group is quite diffi-
cult in and of itself, but even more difficult when it will also lead to
identifying oneself as a member of another stigmatized group, homosexu-
als, if this had previously been kept hidden.
Gay men have a template for how to think about sharing their HIV-
positive identity. Their positive and negative experiences in the process of
coming out as gay will influence their willingness and the skills they have to
share their HIV serostatus. For those gay men who have been open with
others about being gay, it is often relatively easy to identify those who will
be accepting of their being HIV-positive. They are able to successfully avail
themselves of the support of others in this way.
For those gay men who have not come out to others as gay, it is
extremely difficult to come out as HIV-positive. A supportive response of
the other cannot be assumed. There is great fear that the double disclosure
will result in the loss of relationships. The difficulty many HIV-positive
persons have in sharing their HIV serostatus with others limits their ability
to avail themselves of social support.
It is imperative for the therapist to be aware of and sensitive to the
earlier narcissistic injury (related to being gay) which is often reawakened
by the losses that accompany finding out that one is HIV-positive. The
twice-injured, gay, HIV-positive man entering psychotherapy may use the
therapist as an affirming self-object and, in time, find other affirming
self-objects within the gay and HIV/AIDS ~ o m m u n i t i e s . ~ ~
HIV Identity
Being HIV-positive can become a central aspect of the HIV-positive
person's identity. I recall being quite surprised the first time I heard a client
AMERICAN JOURNAL O F PSYCHOTHERAPY

refer to himself as "HIV" as opposed to "HIV-positive." H e said, "Being

HIV, it's hard for me to . . ." While this could be seen as a mere speech
abbreviation, it may also be more significant than this. The use of the
adjective "HIV," in place of "HIV-positive," to describe one's self, may
reflect a heightened degree to which the individual feels his self is defined
by the infection with the HIV virus.
Examining the language used by HIV-positive persons to talk about
their illness is one way to explore how the subjective experience of being
HIV-positive may differ from the experience of having other life-
threatening illnesses. I posit that what distinguishes the HIV-positive
person from those with other life-threatening illnesses is a greater tendency
to define the self by the HIV infection. A striking illustration of this is
the gay, HIV-positive, 19-year-old client of a colleague, who shortly after
learning his HIV serostatus, had a hazardous waste symbol tatooed on
his arm.
Why would it be so that HIV infection in the gay man is more so linked
to identity than are other life-threatening medical illnesses in other groups?
I propose that this results from the direct link between being infected and
its cause: homosexual behavior. The feelings the gay man has regarding
being HIV-positive are undoubtedly intertwined with his feelings regarding
his sexual orientation, a fundamental aspect of his identity. The more
conflict which is present regarding being gay, the more problematic will be
the process of accepting being HIV-positive.
Sexuality
More so than with other illnesses, there is a sense among HIV-positive
gay men of their having played an active role in acquiring their illness. Their
being HIV-positive is linked to their past sexual behavior with men.
Feelings of guilt, shame, and self-loathing for being gay that are present can
result in the feeling that HIV infection is a deserved punishment.
After finding out that he is HIV-positive, the gay man often has
thoughts, fantasies, and feelings about when he was infected and by whom.
H e often wonders whether he has infected partners with the HIV virus
prior to his finding out that he was HIV-infected. H e knows that he is now
capable of infecting others through sexual relations.
For most gay men who know they are HIV-infected, the emotional
experience of having sexual relations cannot be kept separate from feelings
regarding being HIV-infected. This can result in problems with sexual
interest, pleasure, erection, and orgasmic functioning. HIV-infected gay
men often encounter messages, some subtle, some quite direct, that they
Psychotherapy with HIV-Positive Gay Men

should stop having sexual relations due to their ability to infect others with
the HIV virus. It is therefore often quite difficult for HIV-positive gay men
to discuss their problems in sexual functioning with others and in psycho-
therapy.
In order for psychotherapy to optimally help the gay, HIV-infected
client, he must feel that the therapist accepts him as a sexual being and that
the therapist responds to his concerns regarding his sexual functioning no
differently than he responds to concerns about other areas of functioning.
Whereas the gay man struggling with "coming out" needs a therapist who
accepts his homosexuality, the HIV-infected gay man struggling with being
HIV-infected needs a therapist who also accepts his sexuality.
For the gay man, sexuality is at the core of the experience of being
HIV-infected. Attention to sexuality in psychotherapy with the HIV-
infected gay client is likely to impact adaptation beyond the domain of
sexual functioning. Addressing the client's feelings relating to his sexuality
can serve to identify past unresolved conflicts (feelings about having
become HIV-infected) and present concerns (feelings about living with
HIV illness). This is illustrated in the following vignette from a weekly
psychotherapy group of HIV-positive men.
Clinical Example 1
There were three members of the group: a doctor, a lawyer, and a
banker; all gay, Caucasian, attractive, successful men. They were all open at
their work about being gay, were in or had been in long-term gay
relationships, were involved in the local gay community, and were seem-
ingly quite comfortable with being gay. A new group member who was gay
and Caucasian, but had not achieved the professional or social status of
these other men was introduced into the group. When asked by the banker
if he had a partner, the new group member explained that for him what was
exciting was the continual search for new sexual partners. H e began talking
unapologetically about how he finds his partners in bath houses, parks, and
leather bars. The three other group members seemed to become increas-
ingly uncomfortable as he went on talking. Eventually, the lawyer angrily
said, "It's because of people like you that we have to deal with AIDS." H e
gasped and then said, "I can't believe I just said that. I sound like some gay
hater."
Up until this group session, the feeling that the three group members
had that they were to blame for their HIV infection had gone unarticulated.
None of them consciously identified with the media portrayal of the
promiscuous, gay man; an image which the new group member elicited.
AMERICAN JOURNAL O F PSYCHOTHERAPY

The new group member confronted them with the link between their HIV
serostatus and their past sexual behavior. They all had some degree of
internalized homophobia and felt at some level that their HIV infection was
a punishment for their homosexuality. Their presentation as self-accepting
gay men, however, masked these feelings prior to this group session.

Taylor has discussed the benefit to persons with cancer of their being
able to find meaning in their illness.*9 The search for this meaning is quite
pronounced among HIV-positive persons in psychotherapy. Clarifying with
the client, the specific threats and losses posed by the HIV infection to him,
sharpens the understanding of the psychological stress he is experiencing,
and can restore a sense of order and reason to his life.
While the illness does not always have a clear and profound meaning for
each HIV-positive person, the process of exploring the possible meanings
the illness does have can serve to anchor the HIV-positive person. It makes
the HIV illness something which has to do with the self-one's history and
identity, rather than something foreign and intrusive. It fosters in the client
an acceptance, rather than rejection, of being HIV-positive. The goal in
psychotherapy is to help the client find a way to integrate being HIV-
positive into the fabric of the self; so that he can live as one whole, neither
defined by, nor in disavowal of, being HIV-positive.
Clinical Example 2
Steven is a 32-year-old, white, gay man who requested to be evaluated
for psychological services four weeks after learning that he was HIV-
positive. H e was diagnosed with a Major Depressive Episode. Once weekly
psychotherapy and antidepressant medication were recommended and
begun.
His chief complaints were feeling sad and hopeless, being unable to
sleep for more than three hours a night, having frequent nightmares, and
contemplating suicide as "a form of euthanasia." H e had never been in
psychotherapy despite having made two suicide attempts (at ages 8 and 19)
and having a history of bulimia and addiction to sleeping pills.
Steven is the oldest of seven children and was given a parental role in his
family at a young age. H e experienced his mother as "hot and cold;"
sometimes very loving and at other times quite cruel. The "love" was her
letting him know how desperately she needed him; the cruelty came in her
frequently telling him things such as that she cried for days when he was
born because of how ugly he was and how embarrassed she felt of him. H e
never felt anything other than hatred from his father. The one positive
Psychotherapy with HIV-Positive Gay Men

figure in his early life was his maternal grandmother who had died six
months prior to his beginning psychotherapy.
When Steven began psychotherapy he was in the habit of relieving the
intense anxiety he felt after frequent fights on the telephone with his
mother by going out and finding anonymous sexual partners. During the
course of therapy, he stopped this behavior and instead began calling an
HIV/AIDS hot line at these times.
Steven was certain that there was something from his past, perhaps
having been sexually abused, which he could not remember. H e felt he had
to remember this event if he were to get better. The possibility of some
forgotten incident emerging was not initially discounted by the therapist;
however, Steven's continued obsessive focusing on this in sessions was
eventually interpreted as a way for him to disavow his feelings regarding the
many painful incidents from childhood which were fully conscious.
In response to this interpretation, Steven began to discuss his feelings
relating to these remembered incidents. He would experience intense
anger toward his parents and siblings as he discussed these events. As his
level of anger increased, his level of depression subsided. A cycle began in
the therapy of his feeling intense anger, being frightened by this and
backing away from it, and then daring once again to feel his rage.
After five months in psychotherapy, Steven revealed that he was certain
as to when he had been HIV infected. After a fight with his mother, during
the time when his grandmother was very close to her death, he went out
and purposely tried to get HIV infected by having passive, unprotected
anal intercourse with several anonymous partners. In this session, he was
able to connect his feelings to his actions. It was the first time he had cried
in session. He said through tears, "I thought maybe if I was dying too then
my mother would finally love me. Now I realize even this isn't enough."
This realization seemed to us both to be the hidden knowledge for
which he had been searching earlier on in the psychotherapy. With this
realization, he was able to begin mourning and letting go of the fantasy that
there was something he could do to acquire his mother's unambivalent
love. In the months after this session, he became less involved with his
family and his past and began to feel less depressed, closer to his partner,
and to do volunteer work for an HIV/AIDS organization.
While Steven had feelings of sadness and regret at having "gotten myself
infected with HIV," the understanding of the meaning of his illness in the
context of his relationship with his mother, allowed him to accept his HIV
infection and to redirect the focus of his energy from his past to his life in
the present.
AMERICAN JOURNAL O F PSYCHOTHERAPY

The dynamics of the self adjusting to being HIV-positive exist beyond

the individual, intrapsychic level; the cultural and subcultural context are
also essential to consider. Discussing the impact of prior life events on a
person's ability to deal with a major loss, Wortman30 and her colleagues
write:
Some people may have something in place beforehand-perhaps a religious or
philosophical orientation or a certain view of the world-that enables them to
be less vulnerable to the effects of loss (p. 249). People who appear to have
considerable coping resources-successful, control-oriented people who have
a history of accomplishment and who have generally been rewarded for their
efforts-may be particularly vulnerable to certain kinds of sudden, undesirable
life events. Such people may be more devastated by a loss that challenges the
view that efforts are generally rewarded than those who possess considerably
fewer coping resources (p. 251).
I have found support for this statement in contrasting the HIV-positive
clients I have worked with in two hospital settings-one private and one
public. The public-hospital clients were typically from a much lower social
class and more likely to be members of a minority group than the
private-hospital clients. There is considerable difference in the typical life
experiences of these two groups in terms of major life stressors. This is not
to say that the private-hospital men have led lives without stress. The way I
would characterize the difference, however, is that for this group, life
stresses have been isolated events that have occurred at distinct points in
time. There is a sense of these events having been dealt with and then
moved on from. For example, it might be part of the client's history that a
sister died of cancer or that his parents divorced.
For the public-hospital clients, however, life stressors are more chronic.
There is less of a clear beginning or end to the stress; it is a part of daily life
and the expectation is that it d continue to be so. There is therefore also
no sense of having coped with the stress and moved on from it. Typical
daily stresses include lack of money for adequate food, clothing, housing,
and medical care; living in an environment where violence and crime are
prevalent; and feeling discriminated against and victimized by society
based on having a minority status (in addition to that of being gay).
I have observed that the task of coping with being HIV-positive in
general seems less acutely jarring to the clients at the public hospital as
opposed to the clients at the private hospital. The experience of major life
stress is more familiar to the public-hospital clients. HIV illness is viewed as
one more thing to cope with in the midst of so many other major life
8 Psychotherapy with HIV-Positive Gay Men

stresses as opposed to the one negative stress which has intruded on an

otherwise relatively stress-minimal life. The therapist's appreciation of the
way in which stress is experienced in the client's social setting can strengthen
his empathic link with the client.

SUMMARY
This paper examines psychotherapy with HIV-positive gay men from a
psychodynamic perspective. Adjustment to being HIV-positive is conceptu-
alized as an ongoing process of confrontation with loss and uncertainty.
Interventions offered to HIV-positive gay men range from counseling,
indicated in response to an "uncomplicated" adjustment process; to dynami-
cally oriented psychotherapy, indicated when the functioning of the self has
been thrown off balance by HIV illness. The client's process of accepting
his HIV illness is shaped and colored by the degree to, and manner in,
which he has accepted being gay and integrated this into his identity.
Sexuality is a core theme in psychotherapy with this population. It often
plays a prominent role in the past unresolved conflicts (feelings about
having become HIV-infected) as well as present concerns (feelings about
living with HIV illness) which the client has come to therapy to address.
The process of addressing the meanings being HIV-positive holds for the
client in therapy can promote acceptance of the illness and cohesiveness of
the self. Cultural and subcultural differences in how life stress is experi-
enced must also be taken into account by the therapist in order to fully
appreciate the client's concerns.

REFERENCES
1. Mulder, C. L., & Antoni, M. H. (1994). Acquired immunodeficiency syndrome (AIDS) in
homosexual men: Psychological distress and psychotherapy Clinical Psychology and Psycho-
therapy, 1, 68-81.
2. Zegans, L. S., Gerhard, A. L., & Coates, T. J. (1994). Psychotherapies for the person with HIV
disease. Psychiatric Clinics of North America, 17, 149-162.
3. Sanver, D. B., & Crawford, I. (1994).Therapeutic considerations for work with persons with HIV
disease. Psychotherapy, 31, 262-269.
4. Adler, G., & Beckett, A. (1989).Psychotherapy of the patient with an HIV infection: Some ethical
and therapeutic dilemmas. Psychosomatics, 30, 203-208.
5. Winiarski, M. G. (1991).AIDS-related psychotherapy. New York: Pergamon Press.
6 . Blechner, M. J. (1993).Psychoanalysis and HIV disease. Contemporary Psychoanalysis, 29, 61-80.
7. Markowitz, J. C., Klerman, G. L., &Perry, S. W. (1992).Interpersonal psychotherapy of depressed
HIV-positive outpatients. Hospital and Community Psychiatry, 43, 885-890.
8. Hildebrand, H . P. (1992).A patient dying with AIDS. International Review of Psycho-Analysis, 19,
457-469.
9. Bemstein, G., & Klein, R. (1995). Countertransference issues in group psychotherapy with
HIV-positive and AIDS patients. International Journal of Group Psychotherapy, 45, 91-100.
10. Cadwell, S. A,, Burnham, R. A. Jr., & Forstein, M. (Eds.) (1994). Therapists on the front line:
Psychotherapy with gay men in the age ofA1DS. Washington, D.C.: American Psychiatric Press.

43
AMERICAN JOURNAL O F PSYCHOTHERAPY

11. Hudson, R., & Cornett, C. (1993). The process of dynamic psychotherapy with gay men living with
H N . In C. Cornett (Ed.),Afirmative dynamicpsychotherapy with gay men. Northvale, NJ: Jason
Aronson, pp. 151-176.
12. Odets, W. (1995). In the shadow o f the epidemic: Being- HIV-negative in the age - of
. AIDS. Durham:
Duke University Press.
13. Paul, J. P., Hays, R. B., & Coates, T. J. (1995). The Impact of the HIV epidemic on U.S. gay male
communities. In A. R. D'Augelli & C. T. Patterson (Eds.), Lesbian, gay and bisexual identities
over the lifespan: ~ s ~ c h o l o ~ i c a ' i ~ e r s ~ eNew
c t ~ York:
e s . Oxford university Press, pp. 347-397.
14. Adam, B. D. (1992). Sex and caring among men. In K. Plummer (Ed.), Modern homosexualities:
Fragments of lesbian and gay experience. London: Routledge, pp. 175-183.
15. B e d , K. T. (1992).Anti-gay violence and victimization in the United States: An overview. In G . M.
Herek & K. T. Berrill (Eds.), Hate crimes: Confronting violence against lesbian and gay men.
Newbury Park, CA: Sage.
16. Plummer, K. (1992). Speaking its name. In K. Plummer (Ed.), Modern homosexualities: Fragments
of lesbian and gay experience. London: Routledge, pp. 3-25.
17. Cornett, C. (Ed.) (1993). Affirmative action psychotherapy with gay men. Northvale, NJ: Jason
Aronson.
18. Hancock, K. A. (1995). Psychotherapy with lesbians and gay men. In A. R. D'Augelli & C. J.
Patterson (Eds.),Lesbian, gay and bisexual identities over the lifespan: Psychologicalperspectives.
New York: Oxford University Press, pp. 398432.
19. Isay, R. A. (1993).The homosexual analyst: Clinical considerations. In C. Cornett (Ed.),Afirmative
dynamic psychotherapy with gay men. Northvale, NJ: Jason Aronson, pp. 177-198.
20. Shernoff, M. (1994). Therapists' disclosure of HIV status and the decision to stop practicing: An
HIV-positive therapist responds. In S. A. Cadwell, R. A. Burnham, Jr., & M. Forstein (Eds.),
Therapists on the front line: Psychotherapy with gay men in the age of AIDS. Washington, D.C.:
American Psychiatric Press, pp. 549-559.
21. Cook, A. S., & Dworkin, D. S. (1992). Helping the bereaved: Therapeutic interventions for
children, adolescents, and adults. New York: Basic Books.
22. Conte, H. R. (1994).Review of research in supportive psychotherapy: An update. AmericanJournal
of Psychotherapy, 48, 494-504.
23. Goldstein, W. N. (1995). The borderline patient: Update on the diagnosis, theory and treatment
from a psychodynamic perspective. American Journal of Psychotherapy, 49,3 17-337.
24. Dewald, P. A. (1994). Principles of supportive psychotherapy. American Journal of Psychotherapy,
48,505-518.
25. Galatzer-Levy, R. M., & Cohler, B. J. (1993). The psychological significance of others in adoles-
cence: Issues for study and intervention. In P. H . Tolan & B. J. Cohler (Eds.), Handbook of
clinical research and practice with adolescents. New York: John Wiley & Sons, pp. 63-94.
26. Gonsiorek, J. C. (1995). Gay male identities: Concepts and issues. In A. R. D'Augelli & C. J.
Patterson (Eds.),Lesbian, gay and bisexual identities over the lifespan: Psychologicalperspectives.
New York: Oxford University Press, pp. 2 4 4 7 .
27. Edwards, R. (1992). The AIDS dialectics: Awareness, identity, death, and sexual politics. In K.
Plummer (Ed.), Modern homosexualities: Fragments of lesbian and gay experience. London:
Routledge, pp. 151-183.
28. Meyer, I. H . (1995). Minority stress and mental health in gay men. Journal of Health and Social
Behavior, 36,38-56.
29. Taylor, S. E. (1983). Adjustment to threatening events: A theory of cognitive adaptation. American
Psychologist, 38, 1161-1173.
30. Wortman, C. B., Sheedy, C., Gluhoski, W., & Kessler, R. (1992). Stress, coping and health:
Conceptual issues and directions for future research. In H. S. Friedman (Ed.),Hostility, coping
& health. Washington, D.C.: American Psychological Association, pp. 227-256.