Substance Abuse and AIDS: Report from the Front Lines (The Impact on Professionals)
Working with chemically dependent people and working with people with HIV Spectrum Disease both present great challenges to the health care practitioner. Aside from the major professional challenges of locating scarce resources and quality medical care, drug treatment or psychosocial services, there are issues of stigma, discrimination and fears which add more difficulty and stress to the social worker or counselor's job. The nature of HIV Spectrum Disease and chemical dependency bring up many emotional reactions in the worker which can interfere with optimal delivery of services to clients. These reactions, which are called countertransference, must be acknowledged and resolved as much as possible in order to prevent their impacting negatively on the services being delivered and their reception by the client.
The importance of being aware of one's reactions is particularly crucial when working with individuals who are both gay or lesbian and chemically dependent, for these clients have multiple risks and often complex issues to resolve. Gay men may have risk from sexual behavior and present or former drug use behaviors. Gay men in recovery, who may have given up risky drug related behaviors years ago, can find a new pull toward drug use due to their anxieties about HIV. For those who have not been HIV tested and do not know their status, there may be fears about both past sexual and past drug related activities. And, if gay men in recovery had a history of working in the sex industry, there is even higher risk. For those who have tested HIV negative, there are still fears about the future and there may also be survivor's guilt for people who participated in high risk behaviors and didn't get HIV. Gay men and lesbians in general have suffered many losses since the HIV pandemic began and grief overload can be a pull toward drugs as a coping mechanism. Lesbians who have been drug injectors have often had to resort to selling sex to men in order to survive in the illegal and expensive world of drugs. Their risk then, is threefold: sex with women, sex with men and sharing injection equipment. Often, HIV education has not focused on behaviors and many lesbians have been unaware of their risk, thinking that their "group" cannot get HIV infection. It is important to add that since any use of mood altering substances (even legal ones, like alcohol) prior to sex often results in unsafe sex, gay men and lesbians do not have to be addicted or chemically dependent to have risk associated with their recreational drug use.
The authors have worked in both fields -- AIDS and substance abuse -- and have drawn many parallels between these fields. Workers in both areas of practice often complain of feeling overwhelmed and burdened by countertransference which, if not dealt with in an adaptive fashion, can lead to burnout. In an effort to guide practitioners through the process of identifying countertransference and coping adaptively, the authors will present some of their own experiences and some of the ways they were able to work through their feelings so that the goal of assisting the client to achieve a better quality of life could be achieved.
"Countertransference reactions refer to the health care provider's conscious or unconscious behavioral, cognitive, or emotional reactions to the circumstances, emotions, or behaviors presented by the client" (Macks, 1988). Objective countertransference refers to feelings induced by the client that would be induced in any worker as, for example, when a client behaves in a hostile manner and threatens a worker verbally. Any worker would be afraid of an aggressive threat. Subjective countertransference refers to feelings which come from the worker's history or unconscious which are not universal feelings the client would induce in any worker but particular to that worker, for example, the worker is homophobic and has difficulty working with gay clients. In general, objective countertransference is grist for the therapeutic mill -- that is, it can be used to reflect back to the client how his or her behavior induces reactions in others and can be helpful in developing the client's observing ego. Subjective countertransference, on other hand, must be recognized by the worker and resolved so that it does not impact negatively upon the client (Luban and Salon, 1981-84).
Substance abuse treatment is often seen as a hopeless task. Drug treatment modalities are not successful with many of the clients they serve. The drug-free therapeutic communities struggle with the issue of retention in treatment, as many of their entrants leave before treatment is completed; the methadone maintenance system, fares better with retention, but finds a large percentage of its clients abusing drugs while in treatment (Sorrel, 1990). Detoxification, largely misunderstood as a treatment modality when it is at best a medical intervention required in many cases before treatment can begin, has been proven to be extremely unsuccessful with addicts (NIDA, 1981). The Pilot Needle Exchange Study in New City reports that of one group of 56 of its program participants who were referred to and entered drug treatment (methadone maintenance or drug free program) 34 (64%) remained in treatment longer than 60 days and 20 (36%) remained less than 60. Thirty-eight of the group had previous drug treatment experiences which had obviously not been successful (NYC Department Health, 1989).
How do workers in the field cope with the low success rates in the treatment of substance abuse? One of the ways, particularly for those in methadone maintenance, is to redefine success. Successful drug treatment is often seen as abstinence. In fact, our abstinence bias has created a stigmatization of methadone maintenance as a modality. Workers hear their colleagues asking, "How can you work in methadone; all you're doing is substituting one drug for another." Although there are many models for chemotherapy relative to other diseases (e.g., insulin treatment for diabetes) those who do not acknowledge chemical dependency as a disease are unable to see methadone as a viable treatment which allows clients to leave the street world of crime and the unhealthy lifestyle produced by the illegality of drugs and their high cost.
Likewise, in AIDS work, many people cannot see how workers can take on a job that will end in the premature death of the client despite improved medical treatments. If a worker is "cure" oriented in either the substance abuse field or the AIDS field, hopelessness, helplessness and burnout will certainly follow. By redefining success, not as curing the client of the disease, but as enhancing and improving the clients' quality of life for whatever time they have left, workers can eliminate the hopeless feeling and feel good about their work. A methadone client who is no longer being arrested and incarcerated for crimes undertaken to get money for drugs, whose family is rejoined, who is able to obtain permanent housing and a more stable income, can be seen as a success in treatment. The fact he or she may remain on methadone is inconsequential. A person with AIDS who is able to continue working for several years after diagnosis, take vacations, complete important life tasks and enjoy friends and family, who can continue to contribute to the community until shortly before death by adopting a "Living with AIDS" model rather than allowing needless debilitation, marks a success in treatment. By redefining the markers of success, both workers and clients can feel that their work together is helpful and positive.
Working with people in crisis can produce feelings of frustration and a sense of running around in circles and never getting to the long term goals set by the worker and the client. Clients in drug treatment and People With AIDS often move rapidly from one crisis to another. People involved with HIV are often on emotional roller coasters due to mental and physical status that can fluctuate from day to day and even hour to hour. Drug treatment clients coming to the program intoxicated may also produce negative feelings in the worker. The worker needs to be prepared to accompany the client through each new medical, interpersonal, intrapsychic or practical emergency that may emerge, without getting on the emotional roller coaster with the client. Constant crisis states give the work a rushed quality and make the worker feel like he/she is applying band-aids rather than getting to the core of the client's problem. Many of the crises involve concrete issues and entitlements, which some workers feel are less important than counseling or therapy and prefer not to deal with them. Perhaps one way to avoid burnout is to see crisis work as very important to the client and the re-stabilization of his or her life as a primary goal that must be reached before any other work can begin. From the client's perspective, case management and the provision of concrete services and entitlements may be the most important roles practitioners can assume.
The worker must be flexible and professionally creative while still remaining "appropriate." It is difficult to maintain one's boundaries, particularly during times when the client is regressed due to crisis and an inability to cope. The profound human suffering and tragedy experienced by those with HIV spectrum disease and those involved with drugs often provokes a strong emotional response on the part of the worker. Most of us enter the "helping professions" because of our compassion and desire to help others. The work constantly tugs on the strings of our hearts. Many of us have a giant rescue fantasy and parental feelings towards clients. We feel we are going to make the client's life better. We need to look at this grandiosity and see it as disempowering to the client. Only the client can make his or her life better. We can facilitate the process, but only if we are aware of our limitations. AIDS and chemical dependency are two diseases which humble us as workers.
Sometimes AIDS teaches us to throw the book away. Admonitions not to ever touch a client are often simply not relevant. In a situation in which a 30 year old black woman diagnosed with AIDS Related Complex had spent three months in a hospital without ever being touched by human hands (without latex gloves), the patient was experiencing stimulus hunger and craved the feeling of a caring hand. The social worker found her crying in her bed one day, and the client said she realized that "no one is ever going to touch me again as long as I live." The client felt toxic and untouchable. Initially the worker heard her supervisor's "tapes" playing in her head, "Never touch a client." With her guilt mounting, the worker reached out to take the client in her arms. The worker learned that the new disease AIDS brings new rules. Now, it is important for workers to touch clients to counteract stimulus hunger, belie the feeling of toxicity and provide caring interventions in a way that will help the client. Similarly, crying with a client has been considered "inappropriate" for a worker in traditional settings. Sometimes a genuine empathic response to the client's situation needs to be expressed for both the worker and the client. How much grief can a worker absorb and sit on?
There are many old admonitions which need to be re-examined. For example, one of the reasons given for not touching clients is that it might eroticize the transference. In the case above discussed, the worker was a heterosexual female and the client was a lesbian. Hugging and touching the client did in fact eroticize the transference. The following day the client gave a seductive smile to the worker and said, "Let's go to a hotel and fool around." The worker felt she had made a mistake and felt guilty, but went on to process the issue with the client. They discussed the role of the worker in the client's life and the fact that the worker, whether sexually attracted to the client or not, could not ignore the professional boundaries inherent in the client-worker relationship. The client understood the boundary and knew that no romance or sex could occur between them. However, she asked the worker if the worker minded a little flirting because no one else was visiting her and there was no opportunity for her to feel like a sexual being. The worker was amenable to the flirting, which then continued for a few days and eventually stopped. No harm was done and, in fact, once the issue was out in the open, both client and worker felt more comfortable.
Substance abuse workers are instructed never to work with a client while he or she is under the influence of mood altering substances. We stop counseling sessions, whether group or individual, to reflect to the client that he/she is high and needs to reschedule the session for a time when the client will be sober. Active drug and alcohol users with HIV infection and/or illness desperately need counseling, support, case management and assistance in countless areas of their lives. Therefore, workers must reevaluate the conventional wisdom of not working with a client who is high. Committed long term drug users will receive no HIV related services if that position is taken during the AIDS epidemic. Of the 260,000 drug addicts in New York State, only about 50,000 or approximately one-fifth can enter treatment due to the lack a treatment slots (N.Y.S.D.S.A.S., 1989). The other 210,000 who are at high risk for HIV deserve the same assistance as those who are in treatment. Drug users may never make the decision to give up drugs; certainly the point of an ARC or AIDS diagnosis is not a good time to try to force abstinence on a long time user with few other coping mechanisms. The first rule of social work, "Start where the client is at" demands that we offer help to the intoxicated client. Workers must look at their own issues about drug use and their understanding of the problem. Chemical dependency is a disease, not a moral issue. Discrimination based on what disease a person has is unacceptable, as is homophobic or racist discrimination.
Many people view dying and death in a highly romanticized. way. They have the idea that as people die they become transformed into spiritual beings. For some people this is the case, but most people die in character. Not every dying person is nice or even likeable. Working with dying people who are angry, hostile, demanding or manipulative can be particularly difficult for the worker who may already be stressed by the fact that the client dying. The reality is that dying does not usually transform people into accepting, serene people who have resolved their issues and are gracefully closing their lives. The worker must accept the client as he or she is and put the fantasies from the movies aside.
One of the most difficult pieces of countertransference workers suffer from is over-identification with the client. While this can occur in any setting, it is particularly devastating in AIDS and in substance abuse when the client is the same age or younger, maybe is in the same ethnic group as the worker or has the same sexual orientation as the worker. Perhaps the worker has abused drugs in the past or is in recovery now. Workers in both fields may have the same high risk factors for HIV infection as the clients. One of the writers is a gay man who is infected with HIV. The other writer is a former heroin addict who had been involved in prostitution. One aspect of this work that is particularly stressful is that it causes the worker to face issues in his or her own life and behaviors, past history and mortality. Many gay men and many recovering drug users find they are not able to deal with issues around HIV in their practice because they have been unable to resolve their own issues and fears. Others may push ahead to confront these issues in their practices in the unconscious hope that it will keep AIDS away from them. Clinical supervision is essential to help workers identify their own boundary weaknesses and magical thinking and take steps to counteract them.
In our death-denying culture each of us carries around an illusion of our own immortality. Working with clients who are in the final stages of their lives shatters this illusion and forces us to confront the reality of our own vulnerability. If left unexamined by the worker this can result in emotional distancing from the client. This distancing will negatively affect the client's ability to discuss subjects about which they can talk to no one else. By allowing the client to discuss death and dying and issues of mortality, the worker will eventually become less afraid and can be helpful to the client and to him/herself in becoming more comfortable with death.
Physical and mental deterioration in a young client brings up many feelings. The AIDS dementia complex that many HIV clients manifest often brings a premature geriatric-type state that may have a rapid and sudden onset or appear in a gradual progression. Helping clients manage memory loss, confusion and violent mood swings while they adjust to the physical deterioration and disfigurement of their illness takes a toll on both client and worker. Many times the worker dreads seeing the once-healthy client in an emaciated, weak and unattractive state. For those unfamiliar with work in medical settings, walking into a hospital room to see one's client hooked up to machines and tubes, smelling bad and looking extremely ill can be a traumatic experience. Many workers avoid visiting their clients in hospitals for this reason. Yet the continuity of care that a worker provides in making such visits is crucial to the client's quality of life. Workers need to desensitize themselves by placing themselves in hospitals and among People With AIDS so they can become inured to the sights, sounds, and smells of illness.
A particularly difficult period for the therapist occurs when exploring with a terminally ill client his/her feelings about wanting to terminate medical treatment or end his/her own life. The complex emotional, ethical and legal questions this raises for the worker can be particularly taxing when the client is sane and discussing suicide rationally. How one deals with suicidal ideations and plans as a worker has always been extremely clear. One does everything in one's power to prevent suicide. Before AIDS, we always did. Now the certainty of how to handle a suicidal client has become somewhat blurred. A terminally ill client who feels he/she has no quality of life and who is in severe pain and emotional anguish, who may be unable to relate to those who love him/her and whom they love, who may be demented or showing signs of neuropsychiatric deterioration, or who may be blind or unable to move and who considers suicide, is often making a rational choice. They need to discuss that option with their worker without being rushed to the Psychiatric Emergency Room or put on psychotropic medication or in some way prevented from making their decision and acting on it. In the experience of the writers, very few clients attempt suicide, but almost all of the PWAs we've worked with have needed to hold it as an option and think of it when they felt they could not go on. It is very difficult for a well trained health care professional to sit and rationally discuss suicide with a client and not run for a psychiatric consult. Often when clients discuss suicide they are feeling particularly unloved or burdensome to those they love and need reassurance from care partners and family that they are still loved and valued as people.
A client in a residential drug treatment facility in upstate New York was diagnosed with AIDS. He told his counselor he was going to leave treatment and go home to spend the remainder of his life fishing and relaxing with his family. The worker knew that the client would go back to drugs since treatment had only just begun and the client's sobriety was shaky. The worker still agreed with the client, saying, "That's what I would do if I had AIDS." The worker was giving up on the client and later admitted to being relieved at not having to work with the client and watch him suffer and die. The worker colluded with the client's denial and actually supported the client in giving up. The client left treatment and returned to drug use, shortening his life and destroying the quality of whatever time he had left. In working with clients, what we would do is not to be pushed upon the client. We have a professional role to fulfill with the client and we need to keep our objectivity. One way of preventing the intrusion of the worker's choices into the client's treatment is to conduct all counseling with the goal of fulfilling the needs of the client. There are no absolutes in terms of right and wrong in dealing with the human condition. The worker's values, beliefs and goals are secondary in importance to those of the client. When a client states a decision, the worker's job is to explore that decision with the client to insure that the client feels that it is the best choice under the circumstances. If both client and worker agree that it is, the worker should help the client achieve the aims the client has established. If the worker has reservations about the client's decision, those reservations should be presented; the client's decision must still be respected and supported.
Abandonment is an issue for workers when clients disappear or die. Often there is no opportunity to formally terminate with clients, either because a sudden decision is made to relocate the client elsewhere, e.g., to their family in another state or to a hospital or nursing home, or the client disappears from outpatient treatment with no notice of where he/she is going or dies suddenly and unexpectedly. The stress of being left and not knowing what has happened and the stress of incomplete work can lead to a feeling of incompetence on the part of the worker. This is not a new phenomenon to drug treatment workers. Clients may suddenly disappear due to overdose, violent death, incarceration or running from the authorities or criminal underworld. Not infrequently the worker never finds out what happened and thinks about the client on and off for years, wondering. Sometimes the worker later finds out what happened to the client. Workers whose client contact is abruptly aborted need good clinical supervision to deal with the inability to know or to finish up with these clients. Workers need the termination phase of treatment as much as clients do. Both suffer when termination does not occur.
When a client dies, regardless of the setting or the reason, workers need to have structures and methods for grieving. Sometimes a "post-mortem" case conference can help workers look at the case and put some closure on it. Sometimes agencies ignore the need for workers to grieve and in fact regard grieving workers as inappropriate. Where workers can openly mourn their clients, burnout is reduced and other clients see the real care and concern that workers have for them. Attending wakes, funerals and memorial services for clients is very important for workers who wish to do so. Many drug treatment programs have a practice of posting a photograph of a deceased client with a small statement about the person where everyone can see it, allowing both staff and clients to talk openly about the death and their loss of the person. Staff support groups and staff meetings where feelings about loss of clients can be explored are very helpful. Whatever structures an agency devises, it is important to talk about the client's death and the loss and sadness felt by the workers who cared for that client. When workers are overcome with grief, they need to be given time off to sit with their feelings rather than rush on to the next piece of work.
When a chemically dependent client relapses, most workers ask themselves, "What else could I have done that might have made a difference? Did I screw up with this client?" Many of these are the same questions that get asked by the worker whose clients are dying, as irrational as that may sound. When clients in recovery from drug or alcohol abuse relapse, workers get angry. The countertransference reaction may be that "the client is making me look bad." It may be anger that the client allows him/herself to indulge in drugs while the worker has had to "renounce these infantile cravings" (Imhof et al., 1983). Compound the situation with an HIV involved client who relapses and the anger is increased. Practitioners working with PWAs sometimes get angry at how much beyond their control the client's deterioration is, or "How come I can't get him or her to do intrapsychic exploration?" "What's the sense of confronting denial, drinking, drugging, etc., since this person is going to die soon anyway?" Good work can only take place where there is common ground between the services the practitioner wants to provide and the services the client wishes to receive.
Anger prevents the worker from being empathic with the client. What many substance abuse professionals have done is to accept relapse as part of the disease of chemical dependency and, rather than being caught off guard and shocked by it, they plan for it and are prepared when it happens. A similar attitude must be maintained when a healthy PWA experiences a new or repeat opportunistic infection. Both situations are often outside of the locus of control of either client or worker.
Despite all the difficult emotions and countertransference reactions of workers in substance abuse and in AIDS it is possible for professionals to survive and thrive while doing this difficult and important work. It is also possible, although difficult, to remain centered and not burn out. It is crucial for workers to have support, both from clinical supervision and from their colleagues and peers. Both writers have also found their own psychotherapy to be extremely helpful in working through their own issues which lead to subjective countertransference. Time needs to be built in for grieving, mourning and for workers taking care of their own needs. Humor and lightheartedness are essential if one is to survive, hence all the AIDS jokes that AIDS services providers and PWAs tell each other. Questions of spirituality, the client's and the practitioner's, often arise during the course of treatment. Those workers who are involved in twelve-step self help groups like Alcoholics Anonymous find them to be an essential component of their support systems. Human service professionals must strive to take care of their own health and watch their own diet, exercise and assess their own intake of mood altering substances. They also need to put time aside to let the child in them come out and have fun now and then.
There are incredible rewards that come from working in AIDS or in substance abuse. The worker has the opportunity to evaluate the meaning and quality of his or her own life and work and establish true priorities. In the midst of the suffering, pain and sadness, an intensely intimate relationship often develops between the client and the worker that results from being allowed to accompany clients on their journeys in recovery or during the final phase of their lives. The intensity of the therapeutic relationship increases the pain felt by the worker when the client deteriorates and either relapses to drug use or dies of AIDS. One challenge for the professional is to learn how to tolerate all of these feelings, keep a professional objectivity, but not emotionally distance from the client. By not shutting down to these painful and sad feelings a tremendous benefit accrues to the worker that is carried over into a profoundly altered professional as well as personal life. The way one works with all clients is profoundly affected and enhanced by work with substance abusers and with people with HIV Spectrum Disease.
The writers have experienced a tremendous humbling of their own self-images through contact with clients. Creating a balance between the personal and professional spheres of one's life in response to the emotional demands of the work is critical but can be difficult when one's clients are getting AIDS and falling into the mire of drug use and one's friends are getting AIDS and falling into the mire of drug use. Working with two chronic, progressive diseases for which there are no cures and no vaccines and finding ways to instill hope in the clients and in ourselves is no easy task. And working with the gay or lesbian client who has multiple risks and complex issues around sex and drug use can test the worker's ability to work holistically, for one can't separate the issues into compartments, but must deal with the whole person all at once.
Professionals can make a major difference in helping clients to cope with pathology -- be it AIDS or substance abuse related. We must learn not to judge our competence by what the outcome is for the client. We must judge our work by the quality of our skills and the depth of our caring. All individuals must choose their own paths and we have to be mature enough to allow our clients to live their lives as they need to and not necessarily as we would want them to. In this work we are sometimes fortunate enough to accompany a client on his or her chosen path toward growth, serenity, improved functioning and enhanced human relationships. At other times we are simply accompanying them through the chaos and pain of their existence. In either case our lives can become permanently enriched as a result of being along on the ride.
_Imhof, J., Hirsch, R., & Tercnzi, R.E. (1983). Countertranstcrential and attitudinal considerations in the treatment of drug abuse and addiction. The International Journal of the Addictions 18(4), 491-510.
Luban, S. & Salon, R., 1981-84. Clinical Supervision, Van Etten Drug Treatment Program (discussions and seminars).
Macks, 1. (1988). Women and AIDS: Countertransference issues. Social Casework: AIDS-A Special Issue 69, (6), 34~347.
National Institute on Drug Abuse Services Research Report. (1981). Comparative effectiveness of drug abuse treatment modalities (DHHS Publicadon No. ADM 81-1067) Washington, D.C.: U.S. Government Printing Office.
The pilot needle exchange study in New York City: a bridge to treatment, a report on the first ten months of operation. (1989). New York City Department of Health.
New York State Division of Substance Abuse Services (1989). Telephone conversation with Office of Communications.
Sorrell, S. (1990). Personal communication. Dr. Sorrell believes that approximately 50% or more of the clients in his methadone maintenance program at Roosevelt Hospital are using various drugs while in treatment. One third show positive urine toxicologies for substances of abuse, however he observes signs of abuse in about 20% of the patients whose urine tests are negative.
Michael Shernoff, MSW is a psychotherapist and author in Manhattan who is also adjunct faculty at Hunter College Graduate School of Social Work. He coedited (with Walt Odets) The Second Decade of AIDS: A Mental Health Practice Handbook, and has just completed editing an anthology entitled Gay Widowers Speak: Surviving the Death of a Partner to be published in 1998 by Harrington Park Press. He can be reached via e mail at firstname.lastname@example.org or at his home page http://www.gaypsychotherapy.com
Edith Springer, MSW is clinical director of the New York Peer AIDS Education Coalition.
©1992 Michael Shernoff & Edith Springer.
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