The meeting of two narratives

The post-modern paradigms, particularly regarding the nature of reality, are fast coloring our ideas regarding our client's truths. We now have an expanded understanding about the flexibility and dynamic nature of truth, and therefore of clients' narratives. Another narrative, however, that must be taken fully into account is the narrative of the therapist. In fact, what we have in a clinical hour is the meeting and blending of two narratives, that of the client and that of the therapist. This paper summarizes some of the recent thinking regarding narrative, and the nature of truth, as well as pointing to implications for clinical practice.     

The importance of volitional narrative in treatment: An ethnographic case study in a work progran

The revised theory of the model of human occupation expands the concept of volition to include volitional narrative. This paper focuses on the application of this theory of volition to a client's experience in a work program. This ethnographic case study describes the volitional narrative and life world of one client who attended the occupational therapy work based program. For fifteen months the client was the subject of narrative interviews, participant observation, videotapes and telephone contacts. The findings will illustrate how knowledge of a client's volitional narrative and life world can shed critical light on understanding treatment conflicts. Finally, the discussion will underscore how important it is for work based programs to be designed to encourage therapists to adapt their treatment approaches to maximize the opportunities to seek out the client's volitional narratives and to create meaningful experiences that are consistent with the client's life world.     

The Adolescent Sexual Development of African American Gay Men with AIDS: Implications for Community-Based Practice

ABSTRACT

This qualitative study describes the adolescent sexual development of ten African American gay men living with AIDS. The informants retrospectively describe the challenges of being a gay adolescent in a mostly heterosexist and homophobic environment. They report unsupportive homophobic and heterosexist family members, community members and school officials. They also describe their burgeoning sexual orientation, sexual initiation as well as consensual and non-consensual sexual experiences with their peers. Additionally, several informants describe seeking sexual experiences with adult men. Later they suggest the adult men became their primary sources of emotional and psychological support. Implications for community practice, intervention and research with both African American gay adolescents and adult men living with AIDS are discussed.     

Career Issues and Concerns for Persons Living With HIV/AIDS

As the perception of HIV/AIDS continues to shift from a terminal illness to a manageable disease, persons living with HIV/AIDS (PLWHAs) are able to reenter the workforce or remain in their current jobs for a longer period of time. Although this change is positive, it also raises many career concerns for PLWHAs. Using an ecological approach and the theory of work adjustment (Lofquist & Dawis, 1969, 1991), the authors provide suggestions for working with PLWHAs on career‐related issues. A case vignette is presented to demonstrate how this approach may be applied.     

Narrative interaction and the development of client autonomy in clinical practice

Data from a psychoanalytic case are used to explore the development of client autonomy in clinical treatment. The client's narratives and the talk about them in which narrative meaning is formulated and reformulated are selected as one series of interactions in which the development of client autonomy can be studied. Discourse analysis methods are adapted to document and describe specific shifts in the structure of client narratives and talk about them which reflect the development of client autonomy over the course of treatment. Implications for casework treatment are discussed.     

The client's affective impact on the therapist: Implications for therapist responsiveness

Affective authenticity, a modulated, shaded registration of a client's affective impact on the therapist, may provide one component of a reparative opportunity in therapy. Building on infant studies that indicate early forms of sociability and empathy, the author argues that having an impact is a lifelong need. She draws on feminist critiques of abstinence to support her view that therapy can repeat the power imbalances characterizing many clients' historical contexts, if the therapist does not respond to her client's affective influence in an attuned way. A case example of a client with AIDS illustrates some of these ideas.     

Experience of Older Gay and Bisexual Men Living with HIV/AIDS

Although HIV/AIDS definitely impacts gay and bisexual men of all ages, the impact on people in their later years has not been actively investigated. This exploratory study obtained detailed narratives from 14 adults between the ages of 51-72, all of whom were infected with HIV. Ten of the participants were potentially infected through male to male sexual contact. The subjects reported living with HIV for substantial periods with an average of 13 years of life since diagnosis, estimating a duration of HIV seropositivity from 1-20 years. Most had significant health problems, which may be related to aging, in addition to a number of HIV-related symptoms. They expressed community identification as people living with HIV; some were highly identified as gay men, while other were closeted or in denial regarding their same-sex activity. Half felt to some extent bisexual, and described relationships with wives or other women. Although many participants maintained active social lives, others expressed feelings of loneliness and isolation. This group was minimally active sexually and several of the participants expressed reservations about safer sex, especially condom usage. A strong theme was the sense of having lived a full life, which may help the individual cope with his diagnosis. The findings suggest the need to examine the diversity among older gay and bisexual men living with HIV, how these experiences vary by race and ethnicity, and identification of issues related to prevention and services.     

ANTICIPATORY AND ACTUALIZED IDENTITIES: A Cultural Analysis of the Transition from AIDS Disability to Work

Throughout the course of their lives, many people living with HIV/AIDS have prematurely retired onto AIDS disability. A new trend, however, has swept across the nation. Where once people were getting sick, leaving work, and embracing inevitable death, now, with advances in medical technology, many people with HIV/AIDS are renewing their lease on life and discovering a desire to go back to work. To learn how gay men's identities are impacted as they transition from AIDS disability back to the labor market, I conducted three months of fieldwork at an employment placement agency in San Francisco. During fieldwork I distributed informal questionnaires to 120 gay men and then formally interviewed 10 additional gay men who had either transitioned or were considering transitioning from AIDS disability back to work. Analyses reveal that cultural, structural, and medical contradictions typify the return to work. As gay men experience and live through these contradictions, their identities split into anticipatory and actualized components. By facilitating a reassessment of meanings and values, anticipatory identities cognitively and emotionally prepare individuals as they brave the road back to work. This version of identity represents a romanticized confluence of worker (role) identity, gay (status/master) identity, and overall sense of self (self-concept). Personal experiences with stigma, shame, and discrimination along with complexities of the workplace and medical services, however, prevent the maturation of anticipatory identities when seeking reemployment. This results in loosely coupled and situationally informed actualized identities . The relationship between these two identities suggests that many people living with HIV/AIDS—and indeed others who experience stressful life transitions—face complex choices between quality-of-life issues and the ability to survive according to external cultural and structural constraints.     

Gay Affirmative Psychotherapy: A Phenomenological Study

There is a need for gay and lesbian affirmative psychotherapy in a society in which gay men and lesbians endure prejudice and discrimination. Using a phenomenological model informed by feminist methodology, this study investigated the gay male client's experience of gay affirmative therapy. The participants shared their experiences in in-depth interviews. Phenomenological analysis revealed certain therapist qualities which were experienced as affirmative. Findings showed that with sensitivity, imagination, and experience, the heterosexual therapist can be gay affirmative; the gay therapist may more readily serve as a role model. Results are compared with other research, and recommendations are offered for future inquiry.     

Job coaching for persons with mental disabilities

The effectiveness of job coaching for persons with mental challenges at the Yokohama City Comprehensive Care Continuum is examined through case records. The immediate intervention with the client, as well as improved working conditions through consultation with the company are recognized as crucial for the client's optimum adjustment at the work site. On the other hand, in a case where the client quit the job, we can see that the inadequacy is in the assessment of the client and of the working conditions. Improved assessments are needed. Using the principle and the strategies of supported employment developed in America, the goal of job coaching at Y.C.C.C. is to form an adequate support system for the client, both at the workplace and in other living and social situation which influence the client in the workplace.     

HIV/AIDS Projects with and for Gay Men in Northern Thailand

Abstract

In this paper I look at three HIV/AIDS projects which were run by and for gay men, transsexuals and men who have sex with men (MSM) in northern Thailand in the early 1990s. These three projects were very different in format and in context, ranging from a rural village AIDS association to an urban drag beauty contest. The projects were located in settings as different as gay bars and cruising areas, shopping malls and rural villages. Aspects of the three Thai projects have important implications for those working in HIV/AIDS prevention and in the care and support of people living with HIV/AIDS (PLWHAs) across cultures, particularly in relation to education, outreach and counselling programs.     

Aging with HIV: Historical and Intra-Community Differences in Experience of Aging with HIV

Gay men living with HIV/AIDS face a complex of health issues, including those associated with the aging process, long-term HIV infection (25 years or more), and side effects from Highly Active Anti-Retroviral Therapy (HAART). If aging can increase marginalization, this is more likely for the aging HIV positive gay man, who is already marginalized for being queer and living with a stigmatizing disease. This article presents findings from a study of a long-running HIV support group. It locates the members, all gay men living with HIV, in a specific historical and political context to explore how feelings of loss and the struggle to sustain community affect long-term survivors and other older HIV+ gay men. We identify specific challenges presented by aging for men who contracted HIV early in the epidemic, contrasting them with those faced by men infected with the virus later in life. While both groups appear to struggle with a vision of what life could have been, had AIDS not forced loss and change, they also celebrate the community their shared plight has enabled.     

Living with the stigma of AIDS

This article uses interview data to explore how 23 gay and bisexual men who had AIDS were affected by and managed stigma. The article describes how stigma affects the relationships of persons with AIDS to their families, friends, lovers, colleagues, and health care providers. It explores how persons with AIDS avoid or reduce stigma by concealing their illnesses, learning when and to whom they should reveal their illnesses, changing their social networks, educating others about AIDS, developing nonstigmatizing theories of illness causation, and using bravado to convince others that they are still functioning social beings.     

“And then AIDS came along”: A life course turning point and sub-cohorts of older gay men

Research on life course turning points focuses on heterosexuals. Scholars acknowledge that the early AIDS epidemic was a period of crisis for current older gay men, and that this period has shaped and will likely continue to impact their lives. However, few studies have considered the range of early AIDS-related experiences within this group. In this article, I use a life course perspective and in-depth interviews with 40 gay men (60+) in Atlanta to address the following questions: (1) How did current older gay men's experiences vary during the AIDS years? (2) What social factors shaped this variation? I identified three AIDS-related sub-cohorts, which were defined by how participants' social and spatial relationships to urban gay communities influenced their experiences of personal loss, community loss, personal support, and community support between 1981 and 1996. The results suggest that scholars and service providers interested in how early life experiences impact later life should consider the divergent early AIDS-related experiences within the group “older gay men.”     

THE CLIENT'S INTERVIEW OF THE THERAPIST

This paper presents a framework for thinking about interactions between client and therapist systems in terms of the participants' personal explanatory systems and models of reality. The therapist's contribution to forming structures throughout the therapy is examined. The elements of a covert interview of the therapist performed by the client system are described. A model is presented for training therapists to think systemically about client/therapist fit in the context of the client's interview. A case presentation illustrates the value of the interview.     

Sexual Behavior Changes as a Result of a Concern About AIDS:

This survey assessed the impact of a concern about acquiring AIDS upon the thinking and sexual behavior of persons of different sexual orientations and gender in 1986. A questionnaire assessing sexual behavior changes over time was administered to both gay and heterosexual bar patrons in Greenwich Village, New York. Among individuals, concern about AIDS had affected the sexual behavior of almost all gay men, a majority of gay women, over half of heterosexual women, but only a quarter of heterosexual men. Across all the groups, the most frequent behavioral response involved the elimination or decrease of casual sex and the ascertaining of sexual histories. Only gay men were using condoms to any appreciable degree. This study occurred before the Surgeon General's report recommending condoms appeared. A follow-up study assessing sexual behavior changes since then is underway.     

Using Psychodynamic, Cognitive-Behavioral, and Solution-Focused Questioning to Co-Construct a New Narrative

The narrative and social construction metaphors are used as the conceptual frame for the clinical work with a client who felt trapped in an emotionally abusive relationship. To help the client deconstruct a problem-saturated narrative, questions were asked which drew from psychodynamic, cognitive-behavioral, and solution-focused models. The rationale for the use and timing of deconstructive questions from the various models is discussed. The problem-saturated story during the time of intake is presented, as is the change process that led to a more solution-focused narrative. An effective short-term treatment was created through the use of interventions drawn from multiple clinical models. Effectiveness was judged by client's improved emotional state, and the ability of the client to imagine and pursue identified solutions.     

Chapter 6: Gay Latinos and AIDS:

AIDS education, prevention strategies, and support services for gay and bisexual Latinos have traditionally been inadequate, even though surveillance data demonstrate that the risk of contracting AIDS is two and one-half times greater for gay or bisexual Latino men than for their white counterparts. Language, culture, disproportionate poverty, and different definitions of gay or bisexual identity in Latino communities must be considered when addressing AIDS issues among Latino groups in the United States. It should not be assumed that outreach, education and prevention programs which may be appropriate for whites or African Americans will be appropriate for Latinos. This article offers a theoretical framework for developing a culturally-sensitive AIDS prevention program for gay and bisexual Latino men.     

Managing impressions of an AIDS service organization: Into the mainstream or out of the closet?

Organizations, like individuals, can be discreditable and potentially stigmatized. This can affect both the members of the organization and its operation. This study examines how workers in an AIDS service organization in Ontario, Canada, manage its public image as a way of dealing with the stigma which surrounds much of their work. Using data from in-depth interviews with staff members and volunteers, the study describes worker concerns about the appearance of being too closely associated with the local gay and lesbian community and documents some of the strategies they employed to manage the organization's public image. The paper concludes with a discussion of the relationship between organizational impression management and viability in the context of the stigma and uncertainty which surrounds the HIV epidemic.