IN THE SHADOW OF THE EPIDEMIC CHAPTER 2: THE PSYCHOLOGICAL EPIDEMIC The density of the
CHAPTER 2: THE PSYCHOLOGICAL EPIDEMIC
The density of the
In the winter of 1992, I was asked to speak to a group of San Francisco psychotherapists, all of whom worked with people with AIDS and their lovers and
families. I began with a question: What did each count on, what assumptions did he hold, that allowed him to hope that any gay man in San Francisco - who did not die of AIDS itself - might have the resources or resilience to
survive the epidemic in any relatively healthy or happy way? All sat silently. These men are bearing witness to an epidemic of psychological distress that, in its own way, often seems as hopeless as the AIDS epidemic itself. Driving to work the other morning, I watched people in a gas station pumping gas and putting air in their tires, and I
thought, "It's amazing that people can still do things like that." It's like when I was a little kid, and my father would
come home drunk and start yelling and throwing things around, and my mother would stand in the kitchen polishing the toaster. That's what it reminds me of - the world is crumbling around you and you don't even know if you can
exist, and other people are putting gas in their car like nothing's happening. I think to myself, "How do we do this?
How are we getting through this? Why do we keep going instead of just lying down and dying on the spot?"
If the AIDS epidemic itself, and the psychological issues of those with HIV, were not so necessarily overshadowing, it would
surely be obvious that the psychological condition of uninfected men is a crisis that places in peril the health, mental health - and lives - of millions of men, and that threatens the future of gay communities as a whole.
Psychological Development In psychological and social senses, human life changes throughout its course. These changes can be described as "stages" of
development, and the work of psychologist Erik Erikson (2), is one such description, a scheme of eight relatively progressive
stages of development, each with a central "task." The stages proceed in sequence, and an adequate - though often
incomplete - mastery of the task of one stage allows the individual to approach the task of the following stage. It should be
said that Erikson was the first to warn that such schemes must not be taken too rigidly, for they lack, as one example, the predictability and precision of biological models of development.
Driving to work the other morning, I watched people in a gas station pumping gas and putting air in their tires, and I thought, "It's amazing that people can still do things like that." It's like when I was a little kid, and my father would come home drunk and start yelling and throwing things around, and my mother would stand in the kitchen polishing the toaster. That's what it reminds me of - the world is crumbling around you and you don't even know if you can exist, and other people are putting gas in their car like nothing's happening. I think to myself, "How do we do this? How are we getting through this? Why do we keep going instead of just lying down and dying on the spot?"
If the AIDS epidemic itself, and the psychological issues of those with HIV, were not so necessarily overshadowing, it would surely be obvious that the psychological condition of uninfected men is a crisis that places in peril the health, mental health - and lives - of millions of men, and that threatens the future of gay communities as a whole.
In psychological and social senses, human life changes throughout its course. These changes can be described as "stages" of development, and the work of psychologist Erik Erikson (2), is one such description, a scheme of eight relatively progressive stages of development, each with a central "task." The stages proceed in sequence, and an adequate - though often incomplete - mastery of the task of one stage allows the individual to approach the task of the following stage. It should be said that Erikson was the first to warn that such schemes must not be taken too rigidly, for they lack, as one example, the predictability and precision of biological models of development.
While we generally progress psychologically and socially through developmental stages, human life does not proceed on tracks - or even a trajectory. We frequently return to earlier, incompletely mastered developmental tasks, and sometimes become fixed in one that we are not able to adequately master. Such common diversions in our development are referred to by psychologists as regression and fixation - meaning, respectively a return to earlier developmental issues and getting stuck in an issue.
When we return to an earlier stage of development, this means that relatively satisfactory solutions to the task of that stage were accomplished when the stage was first transmitted. Under stress, however the individual may "return" to that stage, meaning that he experiences the kinds of conflicts, and responds to them with the kinds of solutions that were available to him at that time. Such familiar, though largely outgrown, solutions to conflict provide one with a sense of safety, as they did at the time the developmental phase was first being transmitted. We see this commonly, as one example, in the adult who sulks in response to conflict with a partner - perhaps not the most adult response, but one that is developmentally familiar and seems to offer safety from an otherwise unmanageable situation.
Getting "stuck" or fixated in a developmental task - as opposed to regressing to it - is usually a matter of degree. The adult who typically responds to relationship problems by sulking might be described as fixated in the developmental stage - around 18 to 36 months - when sulking is an expected and normal "solution" to conflict because the child does not have other resources. The adult is expected to have other resources, like the capacity to talk about and negotiate problems. If, as a small child, he substantially failed to develop these more mature solutions, he will have difficulty mustering them as an adult. When the failure is substantial in one developmental phase, subsequent development tasks may also be affected. The three-year-old who has not learned to discuss problems, rather than sulk, will be handicapped in solving other, later tasks that require discussion.
Fixation and regression are useful concepts for understanding the impact of the AIDS epidemic on all gay men, including uninfected men. In understanding psychological distress, it is helpful to have a sense of how it has originated, developmentally speaking. Is withdrawal in the face of loss, for example, purely a reaction to the epidemic in a man who rarely uses it in adult life? Has the man regressed to responding with withdrawal in the face of loss as he sometimes has with other significant loss? Or is this a man who characteristically uses withdrawal in the face of loss - or threatened loss - and always has, and for whom the epidemic is simply another reason to withdraw from others? The answer will depend on the individual. The epidemic certainly has the power to induce difficulty into the lives of men with no significant history of loss; and it has the power to exacerbate preexisting vulnerabilities or refocus serious lifelong problems. The idea that many men's psychological issues may have preexisted the epidemic is moot, but it is nevertheless often used to deny the importance of the event. Such individuals are all the more vulnerable to the epidemic. That the devastation of whole communities by AIDS has "merely" profoundly entrenched long-standing vulnerabilities is in no way reassuring.
The Psychological Problems Men Are Experiencing
Many are not really familiar with a clear description of common psychological problems, and denial, as well as the "normalization" of psychological distress among gay men in the age of AIDS, keeps many from noticing the most obvious features of their experience. Therefore I will briefly describe each of the psychological conditions most commonly experienced in the epidemic. Those familiar with these psychological concepts may wish to pass over this section.
Depression is commonplace in the lives of gay men. Before the epidemic, depression was often rooted in both ordinary
sources, such as childhood loss, and in the often severe psychological and social pressures of growing up homosexual.
These special developmental pressures often result in isolation and loneliness in adolescence that serve as a foundation for
depression in later life. But depression may also grow out of the losses, isolation, and loneliness of adult life, and out of an
adult sense of helplessness and hopelessness. The AIDS epidemic provides all of these adult experiences, and many gay
men living in the epidemic have manifested developmentally unprecedented depression in response to the epidemic; have
returned to familiar, developmentally rooted depression; or have refocused their lifelong depression on new loss and trauma.
Much of the depression we see is a variable, synergistic, and destructive mix of old developmental problems and a reaction to current events.
1. A depressed or sad mood.
2. A diminished interest or loss of pleasure in daily activities.
3. Chronic anorexia or overeating or, in acute depression, a change in appetite or eating habits that results in significant weight change.
4. Difficulty sleeping, especially awakening early in the morning and being unable to go back to sleep; or oversleeping.
5. Either physical agitation (often experienced as anxiety) or physical slowing and inactivity.
6. A lack of energy or chronic fatigue.
7. Poor self-esteem, a sense of worthlessness, or inappropriate guilt.
8. Difficulty paying attention, concentration, and remembering.
9. Recurrent thoughts about death, being dead, or suicide.
10. A chronic feeling of being out of control of one's life, or more acute feelings of helplessness and hopelessness.
11. An effort at "self-medication," either with alcohol or other depressants such as benzodiazepines (Valium, Xanax, Dalmane, Halcion, etc.), all of which usually exacerbate depression; or with stimulants such as cocaine or amphetamines (methamphetamine, Dexedrine, etc.), which provide a subjective, temporary relief from the depression but exacerbate it as their effects diminish ("rebound" depression). (Much of the substance abuse in gay communities rests on underlying mood disorders.)
12. A loss of interest in sex, or the inability to function sexually due to problems with arousal, erection, or attaining an orgasm.
13. Increased isolation due to reduced energy, loss of interest in social activities, a desire to conceal one's mood from others, or the avoidance of potentially sexual situations. Isolation exacerbates depression, which may in turn deepen the isolation.
Some features of depression, including a depressed or sad mood, are often so long-standing and familiar, that an individual may not even recognize the problem - precisely because it is chronic. When other expressions of depression - like anxiety or substance use - are perceived in themselves, they may not be understood as aspects of depression, and the possibility of a mood problem may be entirely overlooked.
Manic responses, broadly speaking, span a range of intensity, but are all unconscious efforts to stimulate oneself out of depression with activity. They are thus a kind of psychological equivalent to stimulant drugs like cocaine and amphetamines, which are often used to "self-medicate" depression. The specific features of full, clinical mania include some or all of the following features.5 Hypomania (less intense than full mania) and hyperactivity (still less intense) will also include some of these features, though perhaps with less intensity. (5)
1. Periods of elevated, expansive, or irritable mood.
2. Inflated self-esteem or grandiosity, often involving feelings that one is especially gifted or protected by some transcendent force.
3. In more acute cases, a decreased need for sleep.
4. Talkativeness, pressured speech, racing thoughts, and distractibility.
5. Physical agitation and an increased need for physical activity.
6. An increase in goal-directed activity, socially, occupationally, or sexually.
7. Exaggerated engagement in pleasurable activities with potential for pain, including buying sprees and sexual "indiscretions."
8. A general foreclosure on psychological experience, including a denial of feelings (especially painful ones), a loss of empathy for others, and an inability to engage intimately with others.
Manic responses, their personal significance for many gay men living in the epidemic, and their social implications for gay communities as a whole are important. The idea of mania provides some insight into a psychotherapy patient, Pat, who suffered multiple deaths at work, lost four friends in a single month, and yet continued to conduct a normal day's activities. The loss and loneliness Pat was experiencing were rarely the overt topic of conversation during therapy hours, and he only rarely subjectively experienced depression. Instead, we usually talked about the stresses involved in his twelve-hour workdays at a San Francisco AIDS services agency; his series of troubling and, for him, consistently unintelligible relationships; his inability to spend time alone or to sleep alone; his sudden, unaffordable shopping sprees; his sometimes twice daily aerobics classes; and, often, his inability to have any sense at all of what he was feeling about a person, event, or moment.
Periodically, however, Pat would collapse into an immobilizing depression, and would express puzzlement about its origins. During one session he described a sudden feeling of hopelessness and exhaustion the morning before.
"Do you have any idea why this happened Tuesday morning?" I wondered.
As the preceding conversation suggests, manic responses rely heavily on denial, and Pat is partly working in the session to counter depression by denying the emotional meaning of the events of Monday. This denial also entails a fantasy of omnipotence, of being beyond the epidemic both physically and psychologically. While it is also true that denial is an aspect of normal psychological functioning, and is often a helpful adaptation to an overwhelming event, it is a psychological defense that entails great costs. Denial distorts both external and internal realities. With regard to external reality, there are facts that are problematic or dangerous to deny: Engaging in unprotected sex, substance abuse, and other self-destructive behaviors can be serious consequences of manic denial.
The distortions brought to internal realities by denial are more subtle but also costly. Manic defenses work partly by helping one deny his internal life of reflection and feeling, including depression. While depression may be the "target" feeling, the denial of feelings is intrinsically indiscriminate. Sustained manic defenses against depression will broadly inhibit an individual's capacity to experience feelings in general. Ultimately, mania relies on a denial of one's whole internal life, including feelings of genuine happiness and of empathy for others. Unfortunately, such feelings serve as the basis for intimacy, and the denial that isolates the person from himself finally isolates him from others.
The developmental problems usually encountered by gay men often result in a tendency to deny feelings, to isolate, and to avoid intimacy. Most gay men have grown up with fantasies and feelings that include forbidden, homosexual ones. The internal conflict arising over such feelings that include forbidden, homosexual ones. The internal conflict arising over such feelings is often resolved with isolation from others - or from anything that might evoke feelings of any kind. Manic defenses, marshaled against feelings arising out of the epidemic, unfortunately collude with such developmental predispositions.
Manic defenses and the isolation that result from them are a significant danger to gay communities. The few decades prior to the epidemic provided political and social freedoms that have allowed important psychological growth for gay men and women. The stresses of the AIDS epidemic may well reverse much of that. The important point about manic solutions is that many gay men are becoming isolated not only in the familiar and more recognizable form of depression, but in manic forms as well. Profound and ultimately painful isolation may lurk invisibly but destructively in the energetic man, busy in the world, and socially connected. In human terms, such a man may be disconnected from himself, from others, and from his capacity for intimacy.
I have spoken about depression as an important response to the epidemic, but in men with certain kinds of problematic childhood development we often see a "depressive" response that is characterized more by anxiety, agitation, anger, or boredom than by a typically sad or depressed mood. (6) In such men, anxiety may be a kind of substitute for depression, or, in others, it may be the more usually expected direct response to anxiety provoking features in life - which are abundant in the epidemic. Anxiety is usually more easily recognized than depression and is experienced as nervousness or fear, sometimes accompanied by obsessive (repetitive, senseless) thoughts, usually about all the things that might go wrong. Anxiety may be completely unfocused on specific things or events, or it may be narrower but still generalized, as in fear of leaving the house or being in crowds. It may also have a very specific focus, as in the fear of bridges or elevators. All forms of anxiety may be experienced in discrete, very severe episodes known as panic attacks . As elements of character - rather than as discrete problems - anxiety is familiar in the very compulsive person who habitually checks his door lock three or four times on returning home at night. Anxiety may include some or all of the following. (7)
1. An unrealistic or "excessive" subjective experience of agitation, anxiety, or worry.
2. Motor tension, which may include trembling, feeling shaky, muscle tension, restlessness, or easy fatigability.
3. Autonomic activity ("fight or flight" arousal), including shortness of breath, accelerated heart rate, sweating, dry mouth, dizziness or lightheadedness, nausea, diarrhea or other abdominal distress, frequent urination, or trouble swallowing (a "lump" in the throat).
4. Vigilance and scanning, including feeling on edge, an exaggerated startle response, and difficulty concentrating.
5. Difficulty falling asleep or staying asleep.
7. Panic attacks, which are discrete periods of intense fear or discomfort that include autonomic activity as described above and often a sense of depersonalization, a fear of dying, a fear of going crazy, or of being out of control in public.
8. Post traumatic stress disorder, which includes anxiety symptoms connected with the reexperiencing of an extremely stressful event, or the effort to avoid reexperiencing it. Additional features may include an estrangement from others, a restricted range of emotion, and the sense of a foreshortened future.
In her research with HIV-negative gay men in San Francisco, psychologist Rachel Schochet has found a high incidence of psychological distress that includes both severe episodes of anxiety and chronic depression. She feels it is consistent with the concept of posttraumatic stress syndrome, a diagnostic idea developed to describe the experience of returning Vietnam veterans, many of whom suffered such problem with an onset long after the traumatic event. Many other researchers also believe that anxiety disorders are the most common psychiatric complications among uninfected gay men. (8) During life in an epidemic, some anxiety is an expected and realistic response. But anxiety may become chronic and severe, and it can be a crippling source of reclusiveness and isolation, occupational dysfunction, and sexual dysfunction. Like depression, anxiety is both a cause of isolation and dysfunction and is in turn aggravated by them. Anxiety may keep us in the house, and the more we are isolated from social interaction, the more anxiety its anticipation evokes. How anxiety among gay men living in the epidemic should be interpreted is a difficult question. While anxiety experienced by uninfected men is, indeed, often appropriate and realistic under the circumstances, it is also often psychologically debilitating and, in any nonepidemic times would be the appropriate object of psychological attention. In clinical practice today, anxiety is considered problematic when it appears to be in excess of group norms, or when it is the basis of severe and "unusual" levels of dysfunction. Unfortunately, our standards have been radically altered by the epidemic.
Hypochondriasis is anxiety focused on the fear of serious disease. Such fear is supported by the interpretation of physical signs and symptoms, and the anxiety continues despite medical reassurance to the contrary. Like other forms of anxiety, it is often difficult to know in a particular instance whether the anxiety should be considered "problematic" or expected and appropriate among men who are living in an epidemic - and, no doubt, at real risk for disease. In the case of anxiety about HIV, we now often make the judgment by evaluating the individual's likelihood of actually having been at risk of infection. Regardless of what it is now called , what would have been perceived as true hypochondriasis before the AIDS epidemic is now commonly experienced by gay men. Greg, a 28-year-old psychotherapy patient, related his experience to me during a psychotherapy session:
With all of my friends it started with the skin: there was always some little thing that didn't look like much, and then, pow you would find out they had AIDS. I mean, I don't even look at myself in the mirror any more, and I never look at my skin. I'm terrified that one day I'll find some little spot and the next thing you know, I'll be dead. I have just freaked out when I got a bruise or saw a birthmark I'd forgotten about, and I just don't look anymore. I used to look, and I'd run off to the doctor and it would be nothing. That was early on in the epidemic. And though I have the idea that these things don't bother me anymore, the truth is that I never look.
Similarly, another psychotherapy patient, John, in his early twenties, talks of his anxiety about AIDS and his insight into a hypochondriacal process. During this session he was recovering from a cold that had kept him in bed for a few days.
"Lying in bed, I was just filled with these aches and pains, and I decided I had AIDS. I've asked all my friends and
they say the same thing, that they get sick with anything and that's the first thing they think. I know I bitch a lot, but
when I was lying there, I was really scared, and I was thinking, you know, I don't want to die, I don't want to die, I really don't."
Such hypochondriacal feelings have become a familiar, critical component of "AIDS anxiety," a phenomenon widely
recognized - if often simplistically conceptualized - by mental health providers now working with gay men. The existence of
unrealistic hypochondriacal anxiety is clearly seen in men who have tested HIV-negative but who so doubt the results that
they test repeatedly to no rational purpose. Although medical personnel are beginning to discourage the practice, I have had psychotherapy patients test as many as six times in a year.
Although convincing figures are unavailable because of anonymous testing and, in my impression, because of a decline in repeated testing, a large number of gay men in the US - perhaps 40 percent - may still be untested or not recently tested for HIV antibodies and do not know their antibody status. We have "safer sex" guidelines, but they, as well as HIV antibody tests, provide only reassurance - not insurance and, often, not assurance - either emotionally or medically. The epidemiology and biology of AIDS are immensely complex, and they are filled with contradictions, inconsistencies, and anomalies. Thus it is not only hypochondriacal anxiety, but a mix of irrational and rational ideas and feelings that contribute to many men's continuing doubt and anxiety about their health, whether the feelings are conscious or not. Hypochondriacal anxiety and reasonably founded doubt are now part of the experience of virtually all gay or bisexual men who have had sexual contact with other men in the last 15 or so years, who continue to have such contact, or who contemplate it, regardless of how "safely" the contact was or might be contacted.
The extend to which gay men have become involved in psychological distress about physical health and the complexity of that distress, is illustrated by an incident involving a psychotherapy patient, Bill. He was in a monogamous relationship and both men were uninfected.
Bill developed distributed itching of the skin, and the symptom became increasingly disturbing and severe. Much speculation was made about the cause, he made visits to his general practitioner and a dermatologist, and the
medical consensus was that this was a case of dry skin. The diagnosis was called into question, however, when Bill's
lover developed similar, though less severe, symptoms, and when Bill's condition continued to worsen despite the
use of prescribed and unprescribed skin moisturizers. Finally, Bill was using sedatives several times a week to sleep,
and was having to undress in the middle of the day to apply moisturizers to his entire body. He was preoccupied with the problem and spoke, not entirely seriously, but with genuine distress, of suicide.
While the cause of Bill's skin problem is not certain, the possible role of the anti-inflammatory suggests that Bill's lover, as well as the lover's gay physician, might well have been participating in the metaphor of illness too. The physician, beleaguered by AIDS-related problems and concerned about the unprotected sex of the two men, seemed to have landed easily on the idea that his patient had been "infected" by another man. The scabies diagnosis seemed so obvious to him that he had conducted no microscopic examination of skin scrapings, a common procedure if there is doubt, which there was, because Bill did not have the expected scabies "tracks" on his hands.
As is almost always the case between gay lovers now, the two men both feared - partly unconsciously and partly not - being infected and infecting the other. They thus readily accepted the notion of mutual infection with scabies, for it was a diagnosis that expressed metaphorically important and preoccupying fears. That Bill's lover "contracted" the problem is an expression of his fears that he had been "infected," his identification with his lover, and his identification with the gay community and the important role that illness now plays in it.
I am using the term sexual dysfunction in its traditional sense. It encompasses a number of specific, familiar problems.
These include a loss of interest in or aversion to sex, the inability to have an erection or to maintain one, and the inhibition or
absence of orgasm. Gay men now commonly experience such problems, although they are rarely the reason for seeking
psychotherapeutic attention in the age of AIDS. They are now too familiar to gay men and too well accepted to appear to
warrant attention. Furthermore, it feels very difficult for any gay man to seek attention for problematic sex when others have contracted HIV or are dying from it.
1. Keith Waldrop, The Ruins of Providence (Providence, RI: Copper Beech Press, 1983), p. 37.