Many people living with HIV have a history of drug or alcohol use, or other practices that can lead to addiction. It may not be problematic or no longer an issue in their life -- or it may be an ongoing struggle. For some, dealing with a recent HIV diagnosis can bring the urge to resume troubling practices of the past, or even trigger a relapse. Or it may be time to look at how the use of substances affects their capacity to integrate HIV treatment into daily life. With all the strain that can come with being newly diagnosed, the misinformation and judgment around addiction, relapse and recovery can be extra hard to bear. So TheBody.com talked with Scott Kramer, a therapist who specializes in supporting people living with HIV, about his non-stigmatizing approach to helping people who are facing addiction issues along with HIV.
Can you tell us about where you work and what kind of clients you see?
I am a therapist in private practice, which means I work on my own, out of an office in the West Village [in New York City]. I'm a social worker by training. My client base is the LGBT community, with a specific focus on gay men, with an even more specific focus on gay men living with HIV.
Some of them have addiction issues. Some of them are currently using substances, and some of them identify as being in recovery. Some of them identify as having stopped, and not having any issues with those substances that they once had issues with before.
How do people find you to access your services?
People find me through a variety of different sources. It could be their doctors. Sometimes, if they test positive for HIV, their doctors will refer them. Or if a gay man might be having an issue with depression, anxiety, substance use, a doctor may also refer them to me.
Other places that refer to me are larger AIDS service organizations, like GMHC. I also get referrals from colleagues, friends and my current and former clients.
How do you usually deal with people who are HIV positive who are also living with an addiction?
It can be difficult. It depends, really, on which issue is presenting itself as the one that is affecting the client and their lives in a more significant way.
You have to really work with the client where they're at. If they come in and say, "I have HIV and I'm concerned about my drinking, because I seem to be drinking too much," I would say to them, "Which one of those two things do you feel like is a priority in your therapy? Which one, on a scale of 1 to 10, affects your life in a negative way more?"
Whatever they say is the one that we work on first, because it's their life. They could be totally well adjusted to their HIV status, but it's the, say, alcoholism that is affecting their life in a negative way because maybe they can't get to work. Maybe they are spending all their money on alcohol, or whatever substance it is, so they can't pay their rent. So that would be the most pressing issue.
If they come in and say, "I drink a little too much, but I'm so nervous about people finding out that I am living with HIV, and I'm really worried about that. It has me to the point where I can't go out, and I don't talk to any of my friends. I just go to work and come home." Then, the HIV is the thing that we have to talk about first.
But always the most important thing is safety. If somebody is using substances and doing things that are physically harmful to themselves -- like, if they tell me that they are drinking so much, or using a substance so much, that they are stumbling in the street and almost get hit by a car every night -- then that is a safety concern and that has to be dealt with immediately, no matter what.
Do you feel like a lot of people come to you because they had addiction issues first, and then they contracted HIV? Or that they had an addiction issue afterwards because of their diagnosis?
In my practice, if people are living with an addiction issue and HIV, the addiction issue generally precedes the HIV diagnosis. What I mean by that is, people will have their addiction issue prior to, or before, their HIV diagnosis. It generally doesn't happen the other way around, at least from what I've seen.
Now, I guess, the next logical question is: Does the addiction get worse after diagnosis? I would say not really. I would say that people use different coping skills to deal with stress and anxiety and fear and isolation. And so I don't think that I can really say one way or the other if an addiction becomes worse after HIV diagnosis. One way to avoid an addiction becoming worse after diagnosis is to figure out effective ways to cope with mental health issues that come from an HIV diagnosis. And that can be by therapy, and going to groups, and things like that.
From what I understand, addiction is a mental health issue. And people with mental health issues are often at high risk for HIV infection. And so an HIV infection or diagnosis, being a life-altering event, can often trigger a mental health issue to come to the surface. Right?
Absolutely. It certainly can. Even though many addictions can be considered coping issues -- "I drink because I feel sad" -- the mental health issues that I've seen that come from a diagnosis would be depression, anxiety, isolation, those types of things. I don't see the trigger of increased addictive behaviors happening after diagnosis. But that's just what I've seen. I don't have research to back that up.
When individuals present to you with an addiction, and they're newly diagnosed, how do you treat them? Is it more important that they start HIV medications, or that they deal with their addiction first?
It's important to do both at the same time. But, medically speaking, they need to follow their doctor's advice regarding any kind of HIV prescriptions and medications. The current thinking now is that as soon as someone is diagnosed, medication is indicated, no matter what their CD4 or viral load is. And so the patient or client will have to navigate with their own medical doctor on how they feel about that, and what to do in that regard.
Certainly, I will work with them around issues in starting medication. If their doctor says it's time to start medication but maybe they don't feel they're ready yet, we can explore those issues as to why they're not ready -- whether that's fear of people seeing them take medication and finding out, or not being able to get mail-order at their apartment so they have to have it delivered somewhere else, or fear of side effects, or fear of not being able to take a pill at the same time every day (or several pills, depending on what regimen they're on).
And then the addiction part is really important at the same time. Because if someone is actively using, they might be less likely to be adherent to their medication regimen. And if that happens, if they're not compliant, then the virus can become resistant and the medication may not work. That can lead to a whole host of issues down the road.
I defer to the medical doctor to deal with the medications. And then I deal with the addiction issues.
What are some symptoms people should look out for if they think they might be candidates for accessing mental health care to deal with an addiction?
If somebody feels like their addiction is having negative consequences on their life -- so, for example, if someone is spending so much money on alcohol that they can't afford their rent, or food -- then they should think about seeking mental health services. If somebody is having issues with sex addiction, and they are missing work, being late to work, having some physical manifestations of sex addiction like STDs, that might be an indication of a need to seek mental health services. Anything that is having a negative impact on their life that they can see and feel in a real way is an indication for seeking mental health services.
Also, if someone is blacking out and can't remember what happened the night before, that's a definite indicator. If someone is forgetting to take their medications, their HIV meds, because their addiction is making them lose track of time, then that's also a big indicator to seek mental health services.
Would you say that relapse as part of recovery is common, or normal? And is it a part of the recovery process?
Relapse is part of the recovery process. It can be expected. It just is part of what someone needs to go through to get to the level of sobriety that they would like. And not everybody needs the same level of sobriety. And not everyone needs the same level of support. But the expectation of relapse as part of recovery is something that needs to be expected, and also, to be planned for -- if that's possible.
That's really interesting, that you say "planned for." Because there's already so much stigma around addiction and recovery issues. But I think there's even a greater stigma around relapse. It feels like failure -- but it's actually a normal, expected part of the process for mental health professionals.
Absolutely. And, while we're talking about addiction issues, you could think about it in terms of diet. Many people have been on diets before. Sometimes you can be on a diet that is very restrictive, so you can't eat what you want to eat. And then all of a sudden, you feel like you want to indulge and have cake, or pizza, or something that may not be on your food plan.
Then the next day you say to yourself, "Well, crap. I screwed that up. Now it's time to get back on, and eat healthy again." You could say that. Or you could say, "Well, I screwed that up, so I might as well just keep eating cake and pizza for the next week."
It's the same thing with substances. You can either say, "All right, I had too much to drink last night. And now I know I need to maybe get myself to my counselor, or a therapist, and talk about this, and see what triggered it and why it happened, and how I can try and cope with it so that I don't drink for the rest of the week." Or someone might say to themselves, "Well, I screwed up. It kind of felt OK. I think I'm going to drink this week -- and then maybe I will get back on the wagon, and contact whoever to help me out."
Is there a difference between the way you treat substance versus non-substance addiction? For instance, someone can be a sex addict, but then they also would want sex to be a normal part of their lives, post-addiction, or while they're in recovery -- as opposed to someone with a meth addiction whom you want to get off meth, or using meth as little as possible.
That's a really good question. Sex is generally going to be a part of life. But it really all comes down to the behavior. If somebody has a sex addiction and their behavior is preventing them from living a happy and successful life, then maybe there needs to be a change in thinking about what sex means for them. Maybe at some point they can have sex, but not the same kind of sex that they were having before -- or maybe not for the same reason that they were having it before.
That is very different than, say, crystal meth. Because, depending on the client, the client may say, "Well, I never want to do crystal meth again." And that's possible. It's actually possible to never do crystal meth again. It's illegal. It's hard to stop. And it's not necessary for life, in the same way that, sort of, sex is. That's something that happens between two people, or between people in a relationship. And so how do we navigate through that process?
I think it's really up to the client as to how they need and want to feel and behave and think about the things that they're doing in order to not have those behaviors again become a negative part of their life.
This transcript has been edited for clarity.