Initial Assessment
When I saw Jose for the first time in the early 1990s, he appeared anxious, tense, worried, and very fearful. Jose’s symptoms at the time of assessment included worries and fears about contracting HIV, a steady weight loss of about 25 pounds over the previous 6 months, difficulty in falling asleep, lack of concentration, tension, and fatigue. He was quite concerned about his steady weight loss, lack of concentration, sleep difficulties, and his feeling tired most of the time. He noted that his loss of weight and fatigue had started about 6 months earlier; the rest of his symptoms had developed over the previous 4–5 months and had become progressively worse during the past 3–4 months. It was around this time that Jose began to think that he might have become infected with the HIV virus.
Before living with his steady partner, Jose had been very conscientious in protecting himself during his homosexual encounters. However, after 1 year or so of steady living together, Jose and his partner saw no reason to protect themselves any longer, since they both had previously tested negative for HIV and were fully committed to each other.
Jose denied any history of psychiatric illness in his family or himself and also denied any history of surgical procedures or serious medical illness. He also denied any current drug use. During his high school years, he had occasionally experimented with marijuana while socializing with his peers. His drinking pattern was limited to occasional social gatherings. He described his childhood as a happy one, devoid of any substantial trauma or major negative events. He also denied any sexual abuse as a child.
Jose noted that even though he had lost about 25 pounds in the last 6 months, his appetite had not diminished. While he reported difficulties in falling asleep—it sometimes took up to 2 hours—he did not experience early morning wakening. He denied having crying spells or suicidal ideation. He also denied having hallucinatory experiences or delusions. He did not appear confused and was oriented to time, place, and person. Some cognitive difficulties were noted in that he initially had trouble subtracting seven from 100, but he was finally able to do so toward the end of the assessment interview after he was more relaxed and calm. He was able to think abstractly, and his recent memory and remote memory were intact. He recalled three objects after 5 minutes without difficulties; his judgment was good. He showed no loosening of associations, and neither ambivalence nor autism was detected, but he displayed an anxious mood. While he demonstrated very good insight, he also was demonstrating considerable denial vis-à-vis his situation and condition. His fund of knowledge was excellent, and he appeared to be quite intelligent and intellectually driven. He denied having phobias or experiencing panic attacks or obsessive-compulsive manifestations. He denied ever having problems with the law.
I thought that Jose was suffering from generalized anxiety disorder. I told him that I was willing to see him in individual therapy and that I would not be prescribing him any medications at that time. I also told him that it was more important that he have another HIV test. He was very concerned about confidentiality issues, potential problems at work, difficulties with his family, and relationship problems with his partner. He was also greatly concerned about his potential death. I provided him with understanding, empathic listening, active support, and extensive education, at a professional-peer level, about HIV and AIDS. I also referred him to an infectious disease specialist whom I knew well as a result of previous collaborations with HIV and AIDS cases. I told Jose that the infectious disease specialist would confidentially report the results of the HIV test to me and that I would personally report the results to Jose. I thought that the already developing doctor-patient relationship and therapeutic alliance would put me in a better position to communicate to him any possible untoward news.
Course of Treatment
At the next session, he addressed his concerns about disappointing his family vis-à-vis his homosexuality. He was the oldest child and only son. Throughout Jose’s life his father had demonstrated high expectations for Jose: a good marriage, a nice wife, wonderful children, and a family-oriented life similar to his own. His mother also frequently told Jose that she wanted to have several grandchildren and live close to them during her golden years. These were some of the reasons Jose left home several years ago without ever telling his family about his homosexual orientation. Jose always thought that he could keep his real sexual identity hidden by living in a big city while occasionally visiting his family at home.
After two or three weekly sessions with Jose, I learned from the infectious disease specialist that two serial HIV tests had shown that Jose was HIV-positive. By that time, the therapeutic alliance with Jose had been well established, and he showed much trust in me. I told him about the results of the HIV tests, counseled him about it, discussed his treatment options and therapeutic plans, referred him back to the infectious disease specialist, and underlined the fact that I would continue to treat him as needed. By the end of the session, I noted that he was in many ways more calm and relaxed, as if he knew all along that he was, in fact, HIV-positive. I thought that perhaps what he had primarily needed was empathy while he confronted the realities of his situation.
During the next several sessions, Jose was both angry and disappointed with his partner. At times, he was numb; at other points he would express disbelief and anger at the whole world. During these times I listened empathetically and underlined the fact that we were all “human beings,” each with our own strengths and weaknesses. Slowly, Jose began to accept his condition, his limitations, his realities, and his options. On two to three occasions I met with him and his partner and helped them settle ambivalent feelings and emotions. I also noted that despite the fact that his partner had infected Jose with HIV, they still cared a lot for each other. By this time his partner had also been retested for HIV, and the results had been positive. He had contracted HIV during an out-of-town business trip when he attended a party at a friend’s apartment while under the “heavy” influence of cocaine. By this time, Jose and his partner were under the care of the infectious disease colleague for their HIV infection.
Somewhat later, Jose began to show a lot of guilt about his family and religion. Actually, he had slowly been developing a moderate major depressive episode, with symptoms of early morning wakening, depressed mood for most of the day, diminished interest for almost all daily activities, strong feelings of guilt and worthlessness, difficulties in concentrating, crying spells, and mild suicidal ideations but no definite plan of action. Up to then, I had been prescribing for him a regimen of oral lorazepam, 1 mg t.i.d., on an as-needed basis for treatment of his anxiety or insomnia. At this point, I added a regimen of oral bupropion, which I slowly titrated up to 300 mg/day. After 5–6 weeks, Jose’s depression improved; I discontinued bupropion treatment after about 1 year, and Jose never showed any signs of relapse.
After close to 2 years of providing HIV treatment to Jose, the infectious disease specialist informed me that Jose was not responding well and that there were signs of deterioration in Jose’s illness. Likewise, I also had begun to note that Jose was suffering from mild signs of memory impairment, some language disturbances, and mildly impaired judgment. When Jose was first given zidovudine, his HIV infection was quite advanced, since he had been infected for some time before the treatment began. In addition, zidovudine treatment resulted in severe bouts of nausea and headaches. These side effects led to periods of noncompliance that, in turn, worsened the HIV infection. This clinical deterioration required higher doses of zidovudine, which resulted in severe hematological reactions, primarily granulocytopenia. Later on, Jose received treatment with dideoxyinosine and dideoxycytidine, but both medications produced severe pancreatitis.
During this period, I focused Jose’s treatment on family and work concerns. Jose felt that it was time to begin settling issues with his family and also time to go on medical leave from work. He expressed his desire that I be present when he told his parents about his sexual orientation and illness. I consented. I met with Jose, his father, and his mother in my office. It was a difficult moment for everyone involved, including myself. Jose’s father showed complete denial and disbelief, even anger at Jose. His mother was devastated and in shock. I decided to see them both daily for several sessions, sometimes with Jose and sometimes without him. The treatment process was certainly not an easy one. In the beginning, the parents were thinking more about themselves than about Jose. At times I had to be mildly confrontational with them, since education and empathic listening were not enough to break their denial and resistance. Finally, they began to accept the reality of the situation and, eventually, started to provide emotional support for Jose. Later on, Jose’s sister and her family were apprised of the situation; they were more understanding of Jose’s major life challenges.
After 2–3 months, Jose began to think again about suicide. This time, however, the suicidal thoughts were more realistic in nature, more existential, and not at all related to any signs of depression. He also became more “spiritual,” and the topics of religion, faith, and dying were openly addressed. By this time, Jose’s partner was feeling very guilty, not only because he had infected Jose with HIV but also because Jose’s illness was getting worse while his own illness had stabilized. At Jose’s request, I saw both of them together on many occasions. During this time, I referred Jose to a self-help religious/spiritual HIV/AIDS group. He began to feel better and was more able to cope with the deterioration caused by his illness and the dying process.
A few months later, Jose developed Pneumocystis carinii pneumonia; he had to be hospitalized and almost died. A full-blown AIDS illness had developed. Upon his discharge from the hospital, Jose addressed his work situation in several of his therapy sessions. His cognitive functions were not getting any better. He proceeded to go on medical leave from work, which was then followed by a disability leave. At this point, I prescribed a regimen of oral methylphenidate, 30 mg/day, in consultation with and with the approval of the infectious disease specialist. Over the next several sessions, Jose’s legal situation was addressed; obviously, it was time for Jose to put his legal affairs in order. A lawyer was consulted, life and disability insurance were reviewed, Jose’s properties were inventoried, and a will was drafted and signed. Jose decided to leave part of his estate to his partner, the rest to his family.
A few months later, Jose’s AIDS had worsened. It was difficult for him to be ambulatory. He was concerned about not being able to continue to come to see me for his therapy sessions. His concern and despair about the situation were quite clear. I told him that I would continue our therapy sessions at his home. He felt more relaxed when he heard that. During the home therapy sessions, death was discussed at length. By this time, denial, projection, and rationalization were no longer needed. Jose had slowly mastered his fate, his destiny. During one of the home therapy sessions, his parents were visiting him. At one point, Jose’s father said that he had bought a family burial site, and that he and his wife wanted Jose to be buried there. Jose consented and said nothing else; he then looked at me and peacefully smiled; it was obvious to me that Jose had finally found peace within himself and about his own identity. During our next session, Jose asked me if I would attend his eventual funeral. I said I would.
About 2 months later, the infectious disease specialist told me that death was imminent for Jose and that Jose’s partner and family had been informed. It was late in the afternoon, about 6:00 p.m., when I arrived at Jose’s apartment. Jose’s father was holding one of Jose’s hands; Jose’s partner was holding the other; Jose’s mother was quietly praying in front of a picture of a Catholic saint in Jose’s bedroom. I sat near her in a chair and reflected for a while on what it meant to live and to die with HIV and AIDS. About 1 hour later, Jose was dead.
Two days later, I attended a Catholic mass held in memory of Jose as well as his funeral, both of which were held in Jose’s parents’ town. While in church during the mass, Jose’s father delivered a brief eulogy. In this eulogy, Jose’s father said, “We are all, especially me, very proud of Jose’s life; Jose lived in accordance to his principles and his identity. While dying, Jose achieved self-actualization. Because of it, he died in peace. Jose will always be an ideal role model for all of us.”