Hatherleigh Continuing Education
for Psychologists
1994
Volume 4, Number 15

By Walt Odets

Now that the AIDS epidemic has spanned more than a decade, one hears a great deal about "survivor guilt" among mental health practitioners working with gay men.  Nevertheless, the term has remained too imprecisely defined to be very useful to the clinician diagnostically, and it offers, per se, neither a clear conceptualization of the problem nor a useful approach to psychotherapeutic treatment.  Despite the imprecision of the term, this author is convinced that survivor guilt is one of the clinical cornerstones of a psychological epidemic that is sweeping the surviving, HIV-negative gay male community.  Survivor guilt is a particularly destructive component of this psychological epidemic for many reasons, including the unconscious prohibitions it erects against the survivor's perception, acknowledgment, and communication of his psychological distress of all kinds.

The psychotherapist working with gay men in the age of AIDS is working not only with an individual, his development, and the psychological products of his life experience, but with a complex, subtle, and powerful psychosocial situation that has resulted from the gay community's decade-long experience with a devastating epidemic.  A simple fact may place this psychosocial force in perspective for the psychotherapist not familiar with the importance of the AIDS epidemic:  by 1990, more San Franciscans had died of AIDS than died in the four wars of the 20th century, combined and tripled (Agnos, 1990)  It should be clear to any psychotherapist that the psychological tasks of the survivors of such a situation could not be simple.  Unfortunately, the very real needs of HIV-positive men and men with AIDS have obscured the needs of HIV-negative survivors within the gay community.  The provision of services for HIV-negative men has become a deeply conflicted political issue in the gay community that colludes with the HIV-negative man's natural denial of his psychological problems.  Feelings that needed care is being taken from HIV-positive men in attending to the needs of HIV-negatives, that HIV-negatives are the fortunate ones in the gay community, and guilt about surviving are all social, political, and psychological  forces that have contributed to a largely unaddressed - and now uncontrolled - psychological epidemic among HIV-negative gay men.  Neither the community, nor the HIV-negative individual can easily acknowledge psychological problems despite overwhelming evidence of their existence.

Psychological denial, without accompanying survivor guilt, may include denial of the personal and social impact of the HIV epidemic on the gay community in general, denial about the complexity of feelings connected to "safer" (more properly protected) and unsafe (unprotected) sex, and denial of the likelihood that the epidemic may take an irreparable psychological toll from many survivors, especially those with multiple losses.  Many, even in mental health services within the gay community, continue to refer to psychologically troubled HIV-negative men as "the worried well."  But it is inconceivable that the survivors of such an event might accurately be described as merely "worried" or as "well."  A study of 745 New York gay men (Martin, 1988) found there was "a direct dose-response relation between bereavement episodes and the experience of traumatic stress response symptoms, demoralization symptoms, and sleep disturbance symptoms" (p. 858).  Recreational drug use and sedative use also increased in relation to bereavement episodes (p. 860), and men with one or more bereavements were four to five times more likely to seek mental health assistance in connection with concerns and anxiety about their own health than were men who suffered no bereavements (pp. 859-860).  In another New York study (Dilley & Boccellari, 1989), 139 asymptomatic gay men were involved, as controls, in a study with 236 AIDS and ARC patients.  It was discovered in structured interview that fully 39% of this "healthy" control group qualified for a DSM-IIIR Axis I diagnosis of Adjustment Disorder with Depressed or Anxious Features.

Depression, anxiety, substance use and abuse, and sexual, interpersonal, and occupational dysfunctions are all now commonly observed by the psychotherapist working with an HIV-negative gay male populations.  Such signs and symptoms, however, are seen in individuals both with and without survivor guilt, and the clinician must be able to identify and clarify survivor guilt, where it appears to exist, within such complex presentations.

Depression, anxiety, substance use and abuse, and dysfunction of all types may be an essentially "direct" (reactive) response to the HIV epidemic.  We commonly see loss, and consequent anger and helplessness resulting in depression.  Fear for one's own health and that of loved ones may result in chronic generalized or specific anxiety.  In other individuals, however, survivor guilt may be an important mediating element in the development of depression and anxiety.  Such guilt is largely unconscious and is generally denied or rationalized by the patient.  It is virtually never an explicit part of the presenting complaint.  If psychotherapists - a group, as will be discussed shortly, perhaps themselves particularly prone to feelings of survivor guilt - collude with the patient in ignoring or denying the issue of guilt, the outcome of the therapy will be unsatisfactory.  Such therapies appear to "stall" to the bewilderment of therapist who remains unaware of  the major unaddressed issue of guilt that is underlying what is being treated as a traditional reactive "bereavement" problem.

The psychotherapist working with gay men must attempt to distinguish between "simple" reactive depression and anxiety on the one hand and guilt-mediated depression and anxiety on the other.  Seen in the context of the AIDS epidemic, both present with some combination of depression, anxiety, and dysfunction; and both appear to involve a struggle to separate from the lost object.  There are however, important differences between simple reactive bereavement and bereavement complicated by survivor guilt.  Simple reactive depression and anxiety are integral parts of "normal" grieving, but the addition of guilt is a complication that may seriously inhibit or stall the entire process.  It is the author's belief that normal grieving does not, simply by definition, include survivor guilt, and that survivor guilt is most clearly understood as a serious, adjunctive complication of a normal grieving process. 

Some differences between simpler grieving and that complicated by survivor guilt will become apparent with careful observation.  In simple reactive grief, depression and anxiety are seen to be largely about the loss; in guilt-mediated grief the feelings will also be about the loss, but clarification will reveal significant additional feelings not seen in simple reactive grief alone.  These may include feelings that one would like to take the dead person's place, bewilderment or anger at having survived the deceased, irrational feelings that one is responsible for the death of the deceased, that one may die himself (possibly as punishment), or feelings that one is not worthy of survival.  Such feelings create an inordinate extension of the grieving process in which the mourner is apparently unable to let go of the lost object.  This extension of the grieving process occurs partly because much of the remorse is not about the loss of the object - an event that is in reality finished - but about the survivor's survival, an ongoing event that cannot be grieved because it is not over.

Feelings of anger or their absence may also be useful in making the distinction between simple reactive grief and guilt-mediated grief.  Anger at the deceased for leaving the survivor behind is a common experience in normal grieving.  It is rarely among the feelings of the person experiencing survivor guilt.  Rather, there is remorse and sadness at being left behind, the survivor often feeling it is his fault, rather than the deceased's, that this has occurred.  Finally, those experiencing simple reactive grief usually wish the deceased back in life, while those experiencing survivor guilt more often wish to join the dead.

Psychotherapeutic approaches for the grieving psychotherapy patient will differ depending on whether the individual's experience includes survivor guilt.  Survivor guilt is a feature that can substantially complicate, inhibit, or completely arrest the mourning process, and it often increases the risk of self-destructive behaviors in the author's experience.

Simple reactive depression and anxiety, depending on the severity of the stressor and psychological resilience of the patient, may or may not persist in the face of therapeutic intervention.  The author has no doubt that many gay men in the United States have now suffered such severe, repeated losses that a psychological "recovery"  (by non-epidemic standards), even with a therapy-assisted assimilation of the losses,  is unlikely or impossible.  On the other hand, guilt-mediated depression and anxiety are often responsive to psychotherapeutic intervention precisely because they are less the consequence of a reaction to real world events than of psychological processes that are partly unrelated to current reality.  Guilt, and thus the depression, anxiety, and dysfunction that it produces, may be ameliorated by clarification and interpretation, often producing substantial improvements in the experience and functioning of the patient.  The following session notes illustrate the guilt-mediated toll that the AIDS epidemic is taking on many gay men.  The patient thought himself HIV-negative at the time of this session, though he has since died of complications of AIDS.  A long-term therapy patient, and a professional writer, "Alan" speaks here about a visit with a former lover and close friend who had been diagnosed with AIDS a few months earlier. 

John was tired and was on the bed napping.  I was watching him, from across the room, staring at him, and suddenly I imagined I could actually see the virus, like tiny dust particles, pumping through his veins and lodging in muscles and other parts of his body - contaminating him.  I suddenly felt so completely repulsed, as if he had actually become physically repulsive - can you imagine, John, who was once so beautiful to me?  This panic just swept over me, and I felt like running out of his apartment.  I started feeling so awful about these thoughts, of fearing him, of finding him repulsive, and of thinking about abandoning him while he was sick, that the idea came to me that I could be sick myself, or that I should be, that I could talk John into infecting me or do something else to get infected so that I would not have to feel torn between these feelings.  I had the idea that if I lay down on the bed beside John, to take a nap with him, that would do it, and it seemed irresistible.  I would just lie down and nap with him and not wake up.

Clearly there are many useful interpretations that could be made of Alan's powerful story.  Alan's appears to attempt an introjection of John to ward off mourning, a desire to "merge" with John and thus prevent his loss.  But guilt is a very important unconscious feeling here and should also be opened to interpretation.  The introjection serves not only to prevent John's loss, but to make Alan "like" John, to allow Alan to share John's medical condition and thus have nothing to be guilty about.  Characteristically, Alan had no explicit sense of guilt at this point in the therapy.  He simply felt bad about John.  Also noteworthy is the subjective unacceptability of Alan's ambivalence about John, and Alan's fatal solution to that ambivalence.  Alan will share John's fatal illness and will not be a survivor.

Indications of such guilt are also seen outside of psychotherapy.  An HIV-positive antibody test or AIDS diagnosis results in a decrease of anxiety symptoms in some patients (Dilley, et. al., 1989, p. 171).  Conversely, one often sees significant distress in response to negative blood test results at HIV test sites, and negative results often exceed positive results in producing psychological trauma (Walton, 1989).  This psychological trauma according to Walton is typically expressed by four "paradoxical" responses:  "My lover is positive, now what am I going to do?"; "If anyone deserved it, it is me."; "All my friends are positive, how can I relate to them?"; and "Now I'm going to have to deal with my life."  At the HIV test site in Berkeley, California he supervised, Walton reported, that "crisis" responses requiring special psychological intervention by a supervisor were generated by negative test results by approximately a three to one margin over positive tests.

Other expressions of guilt among seronegative men include many irrational - if psychologically intelligible - behaviors.  Binges of unprotected sex, especially after the death of a friend or lover, are a phenomenon not uncommonly reported in therapy sessions conducted by the author.  Other self-destructive behaviors now seen commonly in gay men may also be indicators of guilt about surviving the epidemic: substance abuse, self-generated financial problems, difficulty planning for the future, and the avoidance of life-sustaining relationships are among those mostly commonly seen be the author in his psychotherapy practice.

Guilt is a complex phenomenon that pervades the work of psychotherapy.  Though survivor guilt, as one form of guilt, has been partially clarified previously in examining its relationship to grief, it will be useful to the psychotherapist to conceptually refine some of its distinctive elements.  The following description of survivors by psychiatrist, Michael Friedman (1985), will be familiar to those living in the AIDS epidemic - although the description is actually about survivors of the Holocaust.  Friedman discusses the work of  Niederland:

Typically, after struggling to begin a new life and often succeeding, these people succumbed to a variety of symptoms like depression, anxiety, and psychosomatic conditions . . . .  Niederland believed these symptoms to be identifications with loved ones who had not survived.  His patients often appeared and felt as if they were living dead.  Niederland believed that these identifications were motivated by guilt, which he called survivor guilt.  The survivors experienced an "ever present feeling of guilt . . . for having survived the very calamity to which their loved ones succumbed." (p. 520)

Friedman expands this understanding by describing survivor guilt as including not only guilt about the fact of having survived, but also feelings that one

could have helped but failed. . . . It is a guilt of omission.  It is the guilt of people who believe they have better lives than those of their parents or siblings.  The greater the discrepancy between one's own fate and the fate of the loved person one failed to help, the greater the empathic distress and the more poignant one's guilt.  (p. 532)

In Alan's life guilt entered the developmental picture because Alan, working to be husband, and sometimes parent to his younger siblings, understandably failed at the task.  Alan, the eldest son, had been "given" to his mother by the family in exchange for his father's freedom from emotional responsibilities and guilt about his "failure" to his wife.  Through identification with his father, Alan also bore his father's guilt as well as his own about failing his mother and younger siblings as substitute spouse and father.  Elements of such a family organization are seen in the history of many gay men in the author's clinical experience.  Also seen in Alan's history are a number of other developmental events common seen by the author among gay men that exacerbate problems with guilt.  These include the guilt about abandonment of the family necessitated by the need to live homosexually - "going out to California" - and guilt about others who are affected when the gay man "comes out," abandoning his substantially false heterosexual self and those to whom it was cathected.  

Men with such developmental backgrounds often grow up with a pervasive sense of unworthiness, failure, and guilt about relationships in general .  Their guilt about their sexuality is aggravated not only by the broad, nearly exclusive societal support of heterosexuality, but by feelings that their homosexuality is the source of their failure of their families.  One consequence of such a developmental history is the feeling of guilt in such men about making for themselves lives that are less lonely and depressed than those of their parents or siblings - in other words guilt about having successful relationships.  These are all aspects of survivor guilt, and this guilt provides a predisposition that, given the synergistic support of real-world adult circumstances like the Holocaust or the AIDS epidemic, can become a devastating, often fatal experience.

Other long-standing or developmental problems also interact with and exacerbate the psychological resilience of seronegative men living in the AIDS epidemic.  Psychological histories of mood disorders, especially difficult conflicts about sexuality, and long-standing personal isolation, including schizoid character trends, will all interact destructively with the psychological pressures of the AIDS epidemic.  At the most destructive end of this interactive spectrum, are men with lifelong histories of depression, serious conflict about their sexuality, or deeply established schizoid trends.  These men, living through the AIDS epidemic, often find new reasons for remaining  depressed or isolated (and perhaps sexually dysfunctional) and AIDS may be enlisted unconsciously to displace conflict from the subjective and private to the objective and public sphere. 

In the middle of the spectrum are men with similar developmental issues that were either less severe (or were better worked through in adulthood), and for them the AIDS epidemic may be a test of psychological "progress" or may entail some regression.  Still other men, nearer the benign end of the developmental spectrum, may find themselves with historically and developmentally unprecedented issues of depression, guilt, isolation, or sexual dysfunction that are largely reactive to the epidemic.  For these men such problems are more easily addressed than those of men in the first two groups.  Finally, at the least problematic end of the spectrum, are many men, possessing a fortuitous combination of relatively benign development, a good psychological "constitution,"  and perhaps a relatively fortuitous experience of the epidemic that combine to allow for a weathering of the AIDS epidemic with a minimum of serious disturbance.

The psychotherapeutic approach to gay men suffering from survivor guilt is relatively straightforward, for much "ordinary" psychotherapy outside the epidemic is about survivor guilt.  Most psychotherapies work with conflict and guilt about separation from the family, ambivalence about success, and a sense of inadequacy in relationships.  These issues always entail the clarification of what is, in the broadest sense, survivor guilt.

In general, the defenses against experiencing guilt about the current events must be clarified and the patient's pain about that clarification (expressed as "resistance")  interpreted.  Few gay men have any conscious experience of guilt about surviving per se , and the more serious the unconscious guilt, the more powerful will be the resistance to recognizing it or having it described clearly.  This is the case because simple recognition of the guilt is, itself, experienced as a danger to the object of the guilt.  Typically, those suffering most seriously from guilt about survival will deny any experience of it, presenting with some combination of depression, anxiety, hypochondriasis, and social, occupational, or sexual dysfunction.  Such men may acknowledge some question about why they are among the survivors - "the 'Why not me?' question," said a patient of the author - and they will often be found to be engaging in unconsidered unprotected sex, substance abuse, or other self destructive behaviors.

Such men are often strongly identified with particular HIV infected men, perhaps partners or best friends; with HIV positive men in general; or simply with the gay community, which is perceived to be "mostly" HIV-infected.  They may feel that their seronegative statuses have created a rift in their own "mixed-antibody" relationships, represent a violation of their allegiances or responsibilities to the gay community, or threaten their identities as gay men.  These feelings are summed up strikingly by a number of psychotherapy patients of the author who, in the process of "coming- out," have felt that they would be truly gay and part of the gay community only when they had contracted HIV.  Such feelings can be profound and compelling even as they are perceived as irrational, and they are especially common in older men coming out later in life, many of whom feel they have betrayed the gay community by life "in the closet."  A psychotherapy patient of the author in his mid-forties stated it succinctly.

If I'd been honest about who I was when I was younger, I'd have AIDS too.  Sometimes I feel like [contracting HIV] is the least I could do to make up for all my years dishonesty.  Guys my age who had more courage about being gay are all dead, and I've got to say that I have a lot of admiration for them.  They went out and acted on their feelings, and I hid out.  That's one of the reasons I'm sometimes embarrassed to tell people I'm [HIV-] negative.

When signs and symptoms of guilt have been clarified, the job of interpreting the meaning of the guilt may then be approached.  This will involve helping the patient weave together an understanding of the current guilt with longer-standing developmental issues and conflicts.  As in all therapies, this connection-making, when supported by genuine insight, is powerful and convincing and is the basis for reducing the subjective "rightness" - the transparency and inevitability - of conflicting or self-destructive feelings.  When it is understood that guilt about surviving those who have been lost to AIDS is irrational and unrealistic and that the feelings of guilt are compelling because they connect unconsciously to earlier guilt, the patient may then begin to feel that he has a right to have the best life he can within the bounds of his realities.  He will know that trying to do so is not violence against, betrayal, or abandonment of those less fortunate, for he will understand that "to a degree not generally recognized, psychopathologies are pathologies of loyalty" (Friedman, 1985, p. 530). 

In closing, a word about survivor guilt and counter-transference is needed. Those in the helping professions, including psychotherapists, have chosen lifework that provides an opportunity to help repair patients - and self - to an extent they were unable to accomplish as daughter, son, or sibling.  Such motivation is surely near the core of the "curative" impulse.  But the psychotherapist may also use his work to remain attached to failed parents and siblings - and thus to his or her own failure - by remaining inordinately attached to the troubled lives of patients.  The adult therapist thus avoids the abandonment of mother, father or siblings for a better life of his or her own, and the exacerbation of guilt that such an abandonment would induce.  Such acting out of survivor guilt in the counter-transference is evident in psychotherapy practices that are overburdened with HIV-related problems and by the psychotherapist who seems unable to maintain any reasonable separation from the despair and hopelessness of his patients.  Just as life itself feels a betrayal of the dead, a life happier than that of one's dying patients can feel intolerable.  This is sometimes the psychological foundation of "burnout" and it is, in all cases, an approach with limited psychotherapeutic utility.

There are many particular - as opposed to broadly humanistic - reasons that it is now crucial that we address survivor guilt in the gay community.  At the most pragmatic (and least guilt-provoking) level, healthier survivors make better caretakers of those with AIDS, and today this is important work in the gay community.  Additionally, there are the issues of survivors themselves.  Many potential survivors will not ultimately survive because of the self-destructive behaviors that guilt, depression and anxiety motivate.  For those who will survive in a biological sense, there is already an immense amount of psychological damage wrought by the HIV epidemic.  The psychological futures of countless survivors, as well as the future of the gay community as a whole, depend partly on the ability of mental health providers to deal with the intense issues arising in both seropositive and seronegative men.  If we are not able to adequately address the issues of seronegative men the costs may be unendurable and we may find ourselves in the future grimly predicted by a twenty-three year old, two weeks after an HIV positive blood test.  "I'm sometimes glad to think," he said, "that I won't be around in ten years because by then the only gay people left will be those whose lives were ruined by watching the rest of us die."

NOTES

Agnos, Art: Plenary address to the sixth international conference on AIDS.  San Francisco, 1990.

Baker, R., Moulton, J., & German, M.: An Epidemic of Loss: AIDS in San Francisco's Gay Male Community, 1988 to 1992. San Francisco: San Francisco AIDS Foundation, 1992.

Dilley, J. & Boccellari, A: Neuropsychiatric complications of HIV infection, in Face to Face, a Guide to AIDS Counseling .  Edited by Dilley, Pies, & Helquist. San Francisco:  AIDS Health Project University of California San Francisco, 1989.

Friedman, M: Toward a reconceptualization of guilt . Contemporary Psychoanalysis 21:501-547, 1985.

Martin, J. L: Psychological consequences of AIDS-related bereavement among gay men.  Journal of Consulting and Clinical Psychology 56: 856-862.

Walton, Scott:  In a personal communication, 1989.  Walton was the Executive Director of the Pacific Center for Human Growth which provided HIV-test site counseling for the city of Berkeley, California.

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